2 HISTORY Side and Gosling (1971) - TEE for CwD of cardiac flow Frazin et al (1976) - TEE M mode echoHisanaga et al (1977) - illustrated use of cross sectional real time imaging
3 introductionTEE uses sound waves to create high-quality moving pictures of heart and its blood vesselsinvolves a flexible tube or probe with a transducer at its tipprobe is guided down throat and esophagusmore detailed pictures of heart as esophagus is directly behind heart
4 TEE: Types 3D pictures provide more details about Types of TEE : Structure and function of heart and Its blood vessels3D TEE helps to diagnose heart problems like:Congenital heart diseaseHeart valve disease andTo assist with heart surgeryTypes of TEE :2-Dimensional (2D)3-Dimensional (3D)Standard TEE pictures are 2D
7 TEE: Advantages Transducer - 2- 3 mm from heart Closer to posterior structures - Better visualization of LA, LAA, PV, MV, LV, AortaFar from surgical area - Intra-operative monitoringHigh resolution images : [Absence of intervening lung or bone tissue - Better signal to noise ratio and decreased image depth – allows use of higher freq (5 and 7 MHz) transducers – enhances image quality]
8 TEE: DISADVANTAGES semi invasive procedure: chances of injury ; needs special setup, technique, preparation, instrumentationneeds orientation and expertise
9 Indications -commonAssessment of prosthetic valves; infective endocarditis ; native valve diseaseAssessment of a suspected cardioembolic eventAssessment of cardiac tumorsAssessment of atrial septal abnormalitiesAssessment of aortic dissection, intramural hematomasEvaluation of CHD; CAD ;pericardial diseaseEvaluation of critically ill patientsIntraoperative monitoringMonitoring during interventional proceduresStress echocardiographyNondiagnostic TTE
10 Contraindications ABSOLUTE Oesophageal stricture or obstruction Suspected or known perforated viscusInstability of cervical vertebraeGI bleeding not evaluatedRELATIVEEsophageal varices or diverticulaCervical arthritisOropharyngeal distortionBleeding diathesis or over-anticoagulation
11 procedure 4- 6 hours fasting Written consent Intravenous line ; oxygen ; suction equipment ; Remove denture or devices ; 2% lidocaine sprayECG must be monitored throughoutLeft lateral positionIntroduce the probe with some anteflexion through a bite block
12 procedureRoutine antibiotic prophylaxis before TEE is not advocated [ risk of IE is extremely low].Recommended in high risk patients - prosthetic valves, multivalvular involvement or those with a past h/o IE]Persistent resistance to advancing the instrument mandates termination of TEE and endoscopy should be performed before re-examination.After each TEE - Disnfect ; Check for any damage - ensure electrical safety
13 complications Majority are minor. Major complications [death, laryngospasm, sustained VT & CHF occur in ≈ 0.3% of patients]Cardiac complications include SVT or AF, VT, bradycardia, transient hypotension or hypertension, angina ,CHF and pulmonary edema.
14 complications MAJOR Death Esophageal rupture Laryngospasm or bronchospasmCongestive heart failure or pulmonary edemaSustained ventricular tachycardia
15 complications MINOR Excessive retching or vomiting Sore throat HoarsenessMinor pharyngeal bleedingBlood tinged sputumNon sustained or sustained supraventricular tachycardiaAtrial fibrillationNonsustained ventricular tachycardiaBradycardia or heart blockTransient hypotensionTransient hypertensionAnginaTransient hypoxiaParotid swellingTracheal intubation
16 TEE PROBEModification of standard gastroscope, with transducers in place of fibreopticsConventional rotary controls with inner and outer dialsInner dial guides anteflexion and retroflexionOuter dial controls medial and lateral movementMultiplane probe has a lever control to guide rotation
18 TEE TransducerTEE TransducerRelation of TEE transducer with heart
19 TEE PROBE Monoplane TEE - provides images in horizontal plane only Biplane TEE - orthogonal longitudinal plane alsoMultiplane TEE transducer :single array of crystals [phased array transducers with piezoelectric elements]that can be electronically and mechanically rotated in an arc of 180 °to produce a continuum of transverse and longitudinal images from a single probe position
20 Standard imaging plane levels (from the incisors) upper or high esophageal (25–28 cm)mid-esophageal (29–33 cm)transgastric (38–42 cm)deep-transgastric (>42 cm)
22 PROCEDUREProceed systematically - from mid esophagus [≈35 cms from the incisors] to gradually more distal esophagus, fundus of the stomach after gentle advancement across the cardia [≈40-50 cms from incisors] and ﬁnally slow withdrawal of the probe for complete scan of the thoracic aorta [from high esophageal views].
23 PROCEDURE A complete TEE exam usually takes 15–20 min. An abbreviated or problem-focused TEE study may be appropriate in unstable or uncooperative patients
24 Transducer manipulation options  Advancement/withdrawal (for inferior or superior structures respectively) Rotation (clockwise to view rightward structures and counter- clockwise for leftward structures)
25 Transducer manipulation options  Anteﬂexion and retroﬂexion of the probe shaft (to view structures towards the heart base or towards the apex) Leftward and rightward ﬂexion of the probe shaft (used infrequently with the advent of multiplane probes)
30 Prior guidelines developed by the ASE and the SCA have described the technical skills for acquiring 20 views in the performance of a comprehensive intraoperative multiplane transesophageal echocardiographic examinationBut current guidelines recommend that a basic PTE examination should focus on encompassing the 11 most relevant views.
31 Cross-sectional views of the 11 views of the ASE and SCA basic PTE examination.
32 ASE & SCA recommend 20 views for a comprehensive TEE.
33 Mid Esophagus 4C ( 0°)Position probe in mid-esophagus behind LA. depth 14cm,angle 0-10°. Image all 4 heart chambers. Optimize LV apex by slight retroflexion of probe tip. Ensure no part of AV or LVOT is seen. Aim to maximize TV diameter, and adjust depth to view entire LV.Assess :chamber size; ventricular function; mitral valve disease; tricuspid valve disease; ASD; pericardial effusion
35 ME 2C ( 90° )From ME 4C : keep probe tip still and MV in the center; rotate omniplane angle forward to °; RA + RV disappear,LAA appears.Retroflex probe tip for true LV apex; adjust depth to see entire LV apex.Assess : LAA mass/thrombus; LV size and function; MV disease (A1, A2 & P3 scallops); MV annulus measurement‘
37 ME LAX (120°)Rotate omniplane angle forward to °Imaging plane is directed thru the LA to image the aortic root in LAX and entire LV. The more cephalad structures are lined up on the display right.The LV anteroseptal + inferolateral walls & MV segments, A2 and P2 are seen.Assess : LV function, MV disease, AV and aortic root disease, IVS pathology.
39 ME Asc A LAX ( 90°)Find the ME AV LAX (120°). Withdraw the probe to bring the right pulmonary artery in view Decrease omniplane angle slightly by 10-20° to make the aortic wall symmetricImaging plane is directed thru the right pulmonary artery to image the proximal ascending aorta in LAX.For: aortic pathology, pericardial effusion, pulmonary embolus
41 ME Asc A SAX (0°)From ME AV LAX (120°) OR from ME AV SAX (30°)…. Withdraw probe (asc aorta ), Rotate the omniplane angle back to 0°Imaging plane is directed slightly above the aortic valve thru the RPA(seen in LAX), ascending aorta (seen in SAX) and SVC (SAX).For : PA pathology, pulmonary embolus, ascending aorta pathology ,PDA, swan-ganz in SVC
43 ME AV SAX (30-45°)From ME 4C (0°) withdraw cephalad to obtain the ME 5C(0°) [imaging plane is directed thru the LA and aligned parallel to the AV annulus] rotate to 30-45°; center aortic valve and aim to make 3 aortic valve cusps symmetric. Withdraw probe for coronary ostia.Advance probe for LVOT.Assess : AV disease, OS ASD, LA size, coronary artery pathology
49 TG mid SAX (0°)Advance probe until you see stomach (rugae) or liver. anteflex to contact stomach wall and inferior wall of heart .center LV by turning probe R or L . image both papillary muscles .imaging plane transversely thru the mid inferior wall of the LV with all 6 mid LV segments viewed at once from the stomach.For: Left ventricle size, function, IVS motion, VSD, pericardial effusion
51 ME DA SAX (0°)Insert the probe to the ME, sector depth 10-12cm, angle 0°;Turn probe to left to find the aorta; put aorta in middle of displayDecrease depth to 5cm; advance + withdraw probeNear field image of the circular aorta represents the right anterior wall of the aortaFor :Aortic pathology , Color flow reversal: AI severity, IABP position
55 ME Mitral Commissural View (60°) Find the ME 4C : keep the probe tip still and MV in the center;rotate omniplane angle forward to 45-60°;RA,RV disappear, retroflex slightly for LV apex;Imaging plane is directed thru the LA to image LA, MV and LV apex.Assess : MV disease, LV function, LA pathology.
56 ME AV LAX (120°)From ME AV SAX (30-60°), rotate to °LVOT, AV, proximal ascending aorta line up.Optimize aortic annulus and make sinuses of valsalva symmetricAssess : MV disease, AV disease, aortic root dimensions & pathology, LVOT pathology, VSD
57 TG 2C (90° )From mid TG SAX (0°) .. rotate omniplane angle to 90° Anteflex until LV is horizontalImaging plane ….Transversely thru the inferior wall of the LV and subvalvular structures of the mitral valve from the stomach.For : LV function , mitral valve subvalvular pathology
58 TG Basal SAX(0°)From TG mid SAX view … withdraw the probe until MV is seen in SAX … aim to see symmetric MV commissuresViews MV (with A3 & P3) that is parallel to the annulusFor : LV size, function ; VSD ; MV planimeter orifice area
59 TG LAX ( °)From TG 2 chamber (90°) … rotate omniplane angle to °Imaging plane is directed longitudinally thru the LV to image the aortic root in LAX.For : MV pathology ,VSD, LV systolic function, Aortic valve: spectral and color doppler, LVOT: spectral and color doppler
60 Deep TG LAX (0°)From mid or apical TG SAX view, anteflex and gently advance probe, hugging the stomach mucosa until the LV apex is seen at the top of the displayFor: paravalvular leak prosthetic aortic valve ; AV gradientspectral doppler ; LVOT gradient spectral doppler
61 TG RV inflow (90°)From mid TG SAX (0°) turn probe right to put RV in center …Rotate omniplane angle to 90°… anteflex until RV is horizontalImaging plane is directed longitudinally thru the posterior RV wall to reveal a long axis view of the RV, with the apex of the RV to the display left and the anterior free wall in the far field.For : RV function; tricuspid subvalvular /TV pathology
62 UE Aortic Arch LAX (0°)From ME(0°)… ME descending aorta SAX (0°) view… Withdraw probe until aorta changes into oval shape…Turn probe slightly to the rightImaging plane is directed thru the longitudinal axis of the transverse aortic arch. The circular shape of the DA changes to an oblong shape of the transverse aortic arch (0°)For : aortic pathology
63 UE Aortic Arch SAX (60-90°)From UE aortic arch LAX (0°) view…. Rotate the omniplane angleto 60-90°…. Bring the pulmonic valve and pulmonary artery in viewImaging plane is directed thru the transverse aortic arch in SAX and the pulmonary artery in LAX.For : Aortic arch pathology, Pulmonic valve disease, PDA
66 3 Dimensional TEEMain advantages of Real-time three-dimensional (RT3D) TEE during catheter-based interventions:Ability to visualize the entire lengths ofIntracardiac catheters, including the tips of all catheters and the balloonsDevices they carry, along with a clear depiction of the positions in relation to other cardiac structuresTo demonstrate certain structures in an ‘‘en face’’ viewRT3D TEE is a powerful new imaging toolMay become the technique of choice and the standard of care for guidance of selected percutaneous catheter- based proceduresGila Perk, et al. J Am Soc Echocardiogr 2009;22:865-82
68 Intracardiac Echocardiography An imaging technique that helps to guide percutaneous interventional proceduresProbe can be inserted under local anaesthesiaPrincipally used during closure of atrial septal abnormalities
71 Intracardiac Echocardiography The 1st generation ICEs were introduced in 1980sThey provided high resolution imagingTissue penetration limited due to high frequency of the transducers (20–40 MHz)Anatomic intracardiac overviews not properly obtainedRecently the development of steerable phased array ultrasound catheter systems with low frequency and Doppler qualities has expanded the clinical use of ICEM R M Jongbloed, et al. Heart July; 91(7): 981–990.
72 ICE: Advantages No radiation is needed Not necessary to position a transducer in a sterile field as compared to TTEPatient discomfort is lessAvailability of direct online information on the position of catheters and devicesGeneral anaesthesia not neededThe possibility of direct monitoring of acute procedure related complications such as:Communication with the patient during the procedure possible as compared to TEEThrombus formationPericardial effusion etcM R M Jongbloed, et al. Heart July; 91(7): 981–990.
73 ICE: Limitations Considerable shaft size (10 French) Lack of additional catheter features, such asPorts for guidewiresTherapeutic devices and pressureThe phased array catheters are expensive and for single use onlyPhased array ICE provides only monoplane image sectionsDifficult for operators to obtain the same viewsNo standard views for ICE are currently defined as compared to standard views for for TTE and TOE.M R M Jongbloed, et al. Heart July; 91(7): 981–990.
74 ICE: Clinical Implications Applications of intracardiac echocardiography (ICE) in interventional proceduresEvaluation of intracardiac thrombusTransseptal punctureAtrial septal defect/patent foramen ovale closureInterventional electrophysiological proceduresPulmonary vein ablation in patients with atrial fibrillationAtrial flutter ablationVentricular tachycardia ablationOther applicationsDiagnosis/biopsy of intracardiac massesBalloon mitral valvuloplastyAtrial appendage occlusionVisualisation of coronary sinus
76 ICE: Technical Requirements Mechanical ultrasound tipped catheter:Can be used for bothIntravascularIntracardiac imagingFor intracardiac use9 MHz single element transducer is incorporated in an 8 French catheterA Piezoelectric crystal is rotated at 1800 rpm in the radial dimension perpendicular to the catheter shaftProvides cross sectional images in a 360˚ radial planeThe ICE catheter needs to be filled with 3–5 ml sterile water before it is connected to the ultrasound machineM R M Jongbloed, et al. Heart 2005;91:981–990.
77 ICE: Technical Requirements Phased array ultrasound tipped catheter system usesA 10 French ultrasound catheterPositioned in the right atrium (RA) or right ventricle (RV) via a femoral approachThrough a 10 French introducerMeasurements of haemodynamic and physiologic variables can be made using Doppler imagingCatheter is connected to an ultrasound systemM R M Jongbloed, et al. Heart 2005;91:981–990.
78 ICE Future Advances Higher resolution Are more reproducible and more flexible than piezoelectric ceramicThey are extremely reproducible and can be made from masks like integrated circuitsElectrophysiology- Enabled Devices for Imaging and TherapyIntegration of ultrasound imaging with mapping technologies, fusion, and overlay imagesZiyad M. Hijazi, et al. Circulation. 2009;119:
79 REFERENCESOTTO – The practice of clinical echocardiography – 4th editionFEIGENBAUM’S Echocardiography – 7th editionBasic perioperative TEE – A consensus statement of ASE and SCA – S.T Reeves – J Am Soc Echo 2013Recommendations for TEE: update 2010 – Flachskampf - European Journal of Echocardiography 2010TEE Multimedia Manual - André Y. Denault, Pierre CoutureTEE Study Guide and Practice Questions-Dr Andrew RoscoeVirtual TEE Website – University of Toronto
80 mcqs1)The number of most relevant views for a basic perioperative TEE examination according to current guidelines by ASE and SCA –20 views15 views12 views11 views
81 2) In ME 2 chamber view , the omniplane angle is 135˚120˚90˚60˚
82 3) In ME LAX view, the omniplane angle is 45˚60˚90˚120˚
83 4) In desc aortic LAX view, the omniplane angle is 0˚60˚90˚120˚
84 5)Principal use of ICE is in Evaluation of intracardiac thrombusBalloon mitral valvuloplastyASD closurePulmonary vein ablation