Normal TTE/TEE Examinations

Transcription

1 Normal TTE/TEE Examinations Geoffrey A. Rose, MD FACC FASE Sanger Heart & Vascular Institute Before you begin imaging... Obtain the patient s Height Weight BP PLAX View PLAX View Is 9-10 o clock? If not, change interspace Image at end diastole Check ECG Impression of left pleural effusion? (See arrow.) Reduce gain to artifact Is the RV big? View descending thoracic aorta (large arrow) Coronary sinus evident? (small arrow) Enlarged CS + nl RV = Persistent L- PLAX View PLAX View Assess LV cavity shape. Do septum and inferolateral walls converge toward apex? Overall wall thickness? Septal and inferolateral walls symmetric in thickness? Do aortic leaflets coapt centrally? Anything in LVOT? Mitral valve morphology? Diastolic Evaluation Screen for bicuspid Ao valve 1

2 PLAX View PLAX View: M-mode Do aortic leaflets dome during systole? Anything in LVOT? MV geometry? Prolapse? Tethering? Systolic Evaluation AoV MV Pap Level Perpendicular to LV long axis? Pap IL wall Screen for bicuspid Ao valve Sweep: Aortic valve to Pap Muscle tips PLAX View: M-mode PLAX View: 2D measurements Box-like opening? AoV MV E + A waves? SAM? Uncorrected M-mode measurements would overestimate LV cavity size and wall thickness (dotted line) Premature AoV closure? Diastolic fluttering? Diastolic Evaluation PLAX View: 2D measurements PLAX View: Color Doppler Note that LA measurement should be perpendicular to LA long axis (dotted line) Reduce width and length of color sector PRF > ±50 cm/sec Laminar flow vs turbulent flow in LVOT? Systolic Evaluation 2

3 RV Inflow View RV Inflow View Anterior TV leaflet Imaging Plane Anterior TV leaflet Only view to assess coaptation of anterior and posterior tricuspid leaflets May see Chiari network in plane (dark arrow) between and Coronary Sinus Posterior TV leaflet Septal Leaflet Plane CS Ant TVL Post TVL Posterior TV leaflet RV Inflow View RVOT View Anterior TV leaflet Posterior TV leaflet RVOT Prominent Eustachian valve may appear as a mass (dark arrow) Turbulent flow in RVOT? Diastolic color flow in LPA? Think PDA. LPA RPA RVOT View: Doppler Short Axis: Base Parabolic flow profile Max velocity ~ 1 m/sec RVOT Determine bicuspid vs trileaflet morphology during systole Raphe w/ bicuspid valve can make it appear trileaflet N R L Ao Valve 3

4 Short Axis: Base Short Axis: Base Bicuspid Valve Trileaflet Valve Leaflets should open completely as a circle (not oval) if valve is indeed trileaflet N R L Ao Valve Short Axis: Base Short Axis: Mitral Valve Look for ostia of Right and L Main coronary arteries Set Doppler color ±20 cm/sec N R L Ao Valve Note orientation of segments of mitral leaflets Use color Doppler to localize MR jet in medial-lateral plane Medial A3/A2/A1 P3/P2/P1 Lateral Short Axis: Papillary Level Short Axis: Apical Level LV circular shape should become a smaller circle Assess septal roundedness in both systole and diastole PM AL This is our first view of the LV apex! Note: counterclockwise twist. 4

5 Apical: 4 chamber view Apical: 5 chamber view Be certain you are imaging through true apex. Take note of length L1. Normal RV area is ~1/3 to 1/2 of LV area L1 Think of the LVOT as a staircase from LV to Ao valve. In this view, you are looking down the stairs. You can t estimate accurately the length of the staircase. Limited spatial resolution within LVOT in this view. LAA LUPV RLPV RUPV Apical: 4 chamber view Apical: 4 ch Tissue Doppler Adjust color gate & image depth so that color Doppler velocity range > ±50 cm/s to assess MR. Pulse Doppler at mitral valve tips Pulse Pulmonary vein E S Expect E L > E S E L Apical: 4 chamber view Assess TR Assess atrial septal mobility View is of limited use to assess septal integrity Chiari network in Right Atrium Embryologic remnant of R valve of Sinus Venosus Not ASD/PFO. Color Artifact. 5

6 Apical: 4 chamber view Apical: 2 chamber view LA volume index: 8 (A4C * A2C)/3 L L is the shorter of the LA lengths in 4ch and 2 ch views Image obtained at maximal LA area (end-systole) Remember LV L1 from 4 ch view L= 5.3 cm L2 LA volume index: 8 (A4C * A2C)/3 L Image obtained at maximal LA area (end-systole) Normal: 22±6 ml/m 2 L= 4.7 cm Apical: 2 chamber view Mitral leaflets move more as a piston than as a gate Apical: 2 chamber view 4ch: Ant ML on left side of image 2ch: Ant ML center of image No Ao or RV in should be image P1 P3 A2 P3 ApLAX: Ant ML on right side of image Apical: Long-axis view Subcostal views Best view of pulse Doppler LVOT VTI Better spatial discrimination Remember LV L1 from 4 ch view L3 and hepatic vein flow blue as flow is away from transducer Aortic flow orange and should be laminar Continuous flow in visceral arteries 6

7 Subcostal views Aortic Arch views RA and RV are anterior Look for pericardial effusion Notice liver Good view of interatrial septum RA LA RV LV Circle is where head is Large arrow points where coarctation would be Small arrow: pulmonary artery Doppler flow in desc Ao TEE A2 and P2 of Mitral Valve Invasive test: address clinical concern first Systematic assessment of IAS, LAA, pulmonary veins 4 ch LV at Aorta (A1/P1), mid (A2/P2), and deep (A3/P3) PA/Ao/Bicaval/RUPV are all at 120 degrees with counterclockwise rotation of probe TEE: 4 chamber view 0 view A2 P2 TEE: 4 Chamber and 2 Chamber views Mitral Valve Prolapse Reconciling 3D Surgical View with Standard 2D View 7

8 60 view P3 A1 and A2 Mitral Valve Prolapse Reconciling 3D Surgical View with Standard 2D View TEE Long Axis view CTA to guidetee RUPV Aorta Pulm Artery Esophagus TEE: Long Axis view 0 TEE: Bicaval view TEE: Bicaval view 8

9 TEE RUPV TEE: Bicaval Q-tip sign or Warfarin ridge separating LAA from LUPV TEE: Left Atrial Appendage Assessment Use Biplane Views TEE: Left Atrial Appendage Assessment Don t be fooled by fat in the transverse sinus A3 P3 A2 A1 P1 P2 TEE: transgastric images Remember 12 0 clock is the inferior wall TEE: transgastric images Remember 12 0 clock is the inferior wall 9

10 Typically only see 4-5 cm of ascending aorta A3 P3 A2 P2 A1 P1 TEE: transgastric images Localize MR in medio-lateral plane Aortic TEE Images Ascending aorta and Aortic arch 10