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Trans-esophageal & Intra-cardiac Echocardiography

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Presentation on theme: "Trans-esophageal & Intra-cardiac Echocardiography"— Presentation transcript:

1 Trans-esophageal & Intra-cardiac Echocardiography
Himal raj Sr cardiology

2 HISTORY Side and Gosling (1971) - TEE for CwD of cardiac flow
Frazin et al (1976) - TEE M mode echo Hisanaga et al (1977) - illustrated use of cross sectional real time imaging

3 introduction TEE uses sound waves to create high-quality moving pictures of heart and its blood vessels involves a flexible tube or probe with a transducer at its tip probe is guided down throat and esophagus more 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 vessels 3D TEE helps to diagnose heart problems like: Congenital heart disease Heart valve disease and To assist with heart surgery Types of TEE : 2-Dimensional (2D) 3-Dimensional (3D) Standard TEE pictures are 2D

5 Transesophageal Echocardiography (TEE)

6 tee

7 TEE: Advantages Transducer - 2- 3 mm from heart
Closer to posterior structures - Better visualization of LA, LAA, PV, MV, LV, Aorta Far from surgical area - Intra-operative monitoring High 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, instrumentation needs orientation and expertise

9 Indications -common Assessment of prosthetic valves; infective endocarditis ; native valve disease Assessment of a suspected cardioembolic event Assessment of cardiac tumors Assessment of atrial septal abnormalities Assessment of aortic dissection, intramural hematomas Evaluation of CHD; CAD ;pericardial disease Evaluation of critically ill patients Intraoperative monitoring Monitoring during interventional procedures Stress echocardiography Nondiagnostic TTE

10 Contraindications ABSOLUTE Oesophageal stricture or obstruction
Suspected or known perforated viscus Instability of cervical vertebrae GI bleeding not evaluated RELATIVE Esophageal varices or diverticula Cervical arthritis Oropharyngeal distortion Bleeding diathesis or over-anticoagulation

11 procedure 4- 6 hours fasting Written consent
Intravenous line ; oxygen ; suction equipment ; Remove denture or devices ; 2% lidocaine spray ECG must be monitored throughout Left lateral position Introduce the probe with some anteflexion through a bite block

12 procedure Routine 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 bronchospasm Congestive heart failure or pulmonary edema Sustained ventricular tachycardia

15 complications MINOR Excessive retching or vomiting Sore throat
Hoarseness Minor pharyngeal bleeding Blood tinged sputum Non sustained or sustained supraventricular tachycardia Atrial fibrillation Nonsustained ventricular tachycardia Bradycardia or heart block Transient hypotension Transient hypertension Angina Transient hypoxia Parotid swelling Tracheal intubation

16 TEE PROBE Modification of standard gastroscope, with transducers in place of fibreoptics Conventional rotary controls with inner and outer dials Inner dial guides anteflexion and retroflexion Outer dial controls medial and lateral movement Multiplane probe has a lever control to guide rotation

17 Tee probe

18 TEE Transducer TEE Transducer Relation of TEE transducer with heart

19 TEE PROBE Monoplane TEE - provides images in horizontal plane only
Biplane TEE - orthogonal longitudinal plane also Multiplane 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 PROCEDURE Proceed 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
[1] Advancement/withdrawal (for inferior or superior structures respectively) [2] Rotation (clockwise to view rightward structures and counter- clockwise for leftward structures)

25 Transducer manipulation options
[3] Anteflexion and retroflexion of the probe shaft (to view structures towards the heart base or towards the apex) [4] Leftward and rightward flexion of the probe shaft (used infrequently with the advent of multiplane probes)

26 Transducer manipulation options
[5] Electronic image plane rotation (0–1800)


28 By convention, in TEE, tip of 2D sector is displayed on top of screen and left-sided cardiac structures appear on right side of display.


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 examination But 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 symmetric Imaging plane is directed thru the right pulmonary artery to image the proximal ascending aorta in LAX. For: aortic pathology, pericardial effusion, pulmonary embolus

40 ME Asc A LAX ( 90°)

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

42 ME Asc A SAX (0°)

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

44 ME AV SAX (30-45°)

45 ME RVIO View (60-75°) From ME AV SAX (30-60°) rotate omniplane angle to ° Optimize TV leaflets, open up RVOT, Bring PV + main PA into view For : P valve / PA / RVOT /TV pathology /VSD

46 ME RVIO View (60-75°)

47 ME BCV ( 90°) From ME 2 C (90°), Turn entire probe right Change angle or rotate probe slightly to image both IVC (left) and SVC (right) simultaneously For : ASD (secundum, sinus venosus), atrial pathology, lines/wires,Venous cannula (SVC, IVC)

48 ME BCV ( 90°)

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

50 TG mid SAX (0°)

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 display Decrease depth to 5cm; advance + withdraw probe Near field image of the circular aorta represents the right anterior wall of the aorta For :Aortic pathology , Color flow reversal: AI severity, IABP position

52 ME DA SAX (0°)

53 ME DA LAX (90°) From ME DA SAX…. Rotate to 900 … aortic walls appear in parallel Distal aorta is to the display left and the proximal aorta to the display right

54 ME DA LAX (90°)

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 symmetric Assess : 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 horizontal Imaging 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 commissures Views MV (with A3 & P3) that is parallel to the annulus For : 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 display For: paravalvular leak prosthetic aortic valve ; AV gradient spectral 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 horizontal Imaging 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 right Imaging 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 angle to 60-90°…. Bring the pulmonic valve and pulmonary artery in view Imaging 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 TEE Main advantages of Real-time three-dimensional (RT3D) TEE during catheter-based interventions: Ability to visualize the entire lengths of Intracardiac catheters, including the tips of all catheters and the balloons Devices they carry, along with a clear depiction of the positions in relation to other cardiac structures To demonstrate certain structures in an ‘‘en face’’ view RT3D TEE is a powerful new imaging tool May become the technique of choice and the standard of care for guidance of selected percutaneous catheter- based procedures Gila Perk, et al. J Am Soc Echocardiogr 2009;22:865-82


68 Intracardiac Echocardiography
An imaging technique that helps to guide percutaneous interventional procedures Probe can be inserted under local anaesthesia Principally used during closure of atrial septal abnormalities

69 Intracardiac Echocardiography


71 Intracardiac Echocardiography
The 1st generation ICEs were introduced in 1980s They provided high resolution imaging Tissue penetration limited due to high frequency of the transducers (20–40 MHz) Anatomic intracardiac overviews not properly obtained Recently the development of steerable phased array ultrasound catheter systems with low frequency and Doppler qualities has expanded the clinical use of ICE M 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 TTE Patient discomfort is less Availability of direct online information on the position of catheters and devices General anaesthesia not needed The possibility of direct monitoring of acute procedure related complications such as: Communication with the patient during the procedure possible as compared to TEE Thrombus formation Pericardial effusion etc M 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 as Ports for guidewires Therapeutic devices and pressure The phased array catheters are expensive and for single use only Phased array ICE provides only monoplane image sections Difficult for operators to obtain the same views No 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 procedures Evaluation of intracardiac thrombus Transseptal puncture Atrial septal defect/patent foramen ovale closure Interventional electrophysiological procedures Pulmonary vein ablation in patients with atrial fibrillation Atrial flutter ablation Ventricular tachycardia ablation Other applications Diagnosis/biopsy of intracardiac masses Balloon mitral valvuloplasty Atrial appendage occlusion Visualisation of coronary sinus

75 Closure of an ASD under ICE guidance

76 ICE: Technical Requirements
Mechanical ultrasound tipped catheter: Can be used for both Intravascular Intracardiac imaging For intracardiac use 9 MHz single element transducer is incorporated in an 8 French catheter A Piezoelectric crystal is rotated at 1800 rpm in the radial dimension perpendicular to the catheter shaft Provides cross sectional images in a 360˚ radial plane The ICE catheter needs to be filled with 3–5 ml sterile water before it is connected to the ultrasound machine M R M Jongbloed, et al. Heart 2005;91:981–990.

77 ICE: Technical Requirements
Phased array ultrasound tipped catheter system uses A 10 French ultrasound catheter Positioned in the right atrium (RA) or right ventricle (RV) via a femoral approach Through a 10 French introducer Measurements of haemodynamic and physiologic variables can be made using Doppler imaging Catheter is connected to an ultrasound system M R M Jongbloed, et al. Heart 2005;91:981–990.

78 ICE Future Advances Higher resolution
Are more reproducible and more flexible than piezoelectric ceramic They are extremely reproducible and can be made from masks like integrated circuits Electrophysiology- Enabled Devices for Imaging and Therapy Integration of ultrasound imaging with mapping technologies, fusion, and overlay images Ziyad M. Hijazi, et al. Circulation. 2009;119:

79 REFERENCES OTTO – The practice of clinical echocardiography – 4th edition FEIGENBAUM’S Echocardiography – 7th edition Basic perioperative TEE – A consensus statement of ASE and SCA – S.T Reeves – J Am Soc Echo 2013 Recommendations for TEE: update 2010 – Flachskampf - European Journal of Echocardiography 2010 TEE Multimedia Manual - André Y. Denault, Pierre Couture TEE Study Guide and Practice Questions-Dr Andrew Roscoe Virtual TEE Website – University of Toronto

80 mcqs 1)The number of most relevant views for a basic perioperative TEE examination according to current guidelines by ASE and SCA – 20 views 15 views 12 views 11 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
60˚ 90˚ 120˚

84 5)Principal use of ICE is in
Evaluation of intracardiac thrombus Balloon mitral valvuloplasty ASD closure Pulmonary vein ablation


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