Breakout Session: Transesophageal Echocardiography Doris Ockert, MD Andrew Schroeder, MD University of Wisconsin School of Medicine and Public Health Jutta Novalija, MD, PhD Medical College of Wisconsin 1 Financial Disclosures No disclosures or conflicts of interest Doris Ockert, MD Andrew Schroeder, MD Jutta Novalija, MD, PhD 2 Objectives Discuss indications/contraindications to TEE Understand TEE probe manipulation Review 11 basic views Anatomic structures Basic diagnostic uses Obtain basic TEE images 3 Unexplained hypotension Hypovolemia, LV dysfunction, low SVR rtic dissection, tamponade, pulmonary embolus Cardiac surgery CABG, valve, thoracic aorta, heart and lung transplantation, congenital HD Anticipated hemodynamic instability ASA practice guidelines for perioperative transesophageal echocardiography, Anesthesiology 2010 4
Textbook: Esophageal pathology Prior esophageal surgery Patient refusal Guidelines: TEE may be used for patients with oral, esophageal, or gastric disease, if the expected benefit outweighs the potential risk, provided the appropriate precautions are applied. ASA practice guidelines for perioperative transesophageal echocardiography, Anesthesiology 2010; 112:1 5 A practical approach: Screen for risks Document your screening questions and answers Assess risk vs. benefit Consider other imaging modalities Consider GI consult Minimize risk Experienced echocardiographer Limited the exam and avoid unnecessary probe manipulations Pediatric probe 6 Morbidity 2-5:1,000 Dental damage Dysphagia GI bleeding Hemodynamic changes Dislodged ETT Mortality 1:10,000 Esophageal perforation Reeves et al, JASE 2013 7 Probe Muscle relaxant Suction stomach to remove air Ultrasound gel Mouth guard Direct laryngoscopy or blind insertion Jaw thrust, slight anteflexion, advance gently into esophagus 8
Prepare the Machine On button Enter patient information Connect probe Connect EKG Choose mode Adjust gain and depth 9 Probe Manipulation Advance/Withdraw Turn Left/Right Omniplane (0-180 ) Anteflexion/ Retroflexion Lateral flexion (Left/ Right) Image from: Shanewise et al, Anesth Analg 1999 10 GI Stations Relative positions of esophagus and stomach to heart and aorta Image from: Reeves et al, JASE 2013 11 Mid Esophageal 12
Machine Manipulation GI Stations 11 View Exam Transgastric Machine Manipulation GI Stations 11 View Exam 13 Deep Transgastric Machine Manipulation GI Stations 11 View Exam 14 Upper Esophageal Machine Manipulation GI Stations 11 View Exam 15 Upper Esophageal 16
Machine Manipulation GI Stations 11 View Exam 11 View Basic Exam Image from: Reeves et al, JASE 2013 ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX 17 SAX X Midesophageal 4 Chamber RA IAS MV TV RV LV IVS Left ventricle (LV) Septal wall Lateral wall Mitral valve (MV) ME 4Ch ME 2Ch ME X Right atrium (RA) Right ventricle (RV) Tricuspid valve (TV) Interatrial septum (IAS) Interventricular septum (IVS) ME Asc X ME Asc SAX Chamber size LV systolic function LV regional wall motion RV systolic function ME AV SAX ME RV In Out MV pathology pathology effusion ASD/VSD TV Pericardial 18 Bicaval TG SAX SAX X Midesophageal 2 Chamber CS MV LV Left ventricle (LV) Anterior wall Inferior wall Mitral valve (MV) Coronary sinus (CS) Left atrial appendage (A, not shown) LV systolic function LV regional wall motion MV pathology A thrombus 19 ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Midesophageal Long Axis AV MV LVOT IVS RV LV Left ventricle (LV) Anteroseptal wall Inferolateral wall Mitral valve (MV) Left ventricular outflow tract (LVOT) rtic valve (AV) rtic root and ascending aorta () Interventricular septum (IVS) LV systolic function LV regional wall motion MV pathology AV pathology rtic dissection VSD Dynamic LVOT obstruction 20
ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Midesophageal Ascending rta Long Axis RPA Ascending aorta () Right pulmonary artery (RPA) rtic dissection rtic aneurysm rtic atheroma PAC in RPA Pulmonary embolism in RPA 21 ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Midesophageal Ascending rta Short Axis RPA SVC PA Ascending aorta () Main pulmonary artery (PA) Right pulmonary artery (RPA) Pulmonic valve (PV) Superior vena cava (SVC) rtic dissection rtic aneurysm rtic atheroma Pulmonary embolism 22 ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Midesophageal rtic Valve Short Axis IAS RA L N R RV Right atrium (RA) Interatrial septum (IAS) rtic valve Non (N), right (R), and left (L) cusps AV pathology AV morphology size ASD 23 ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Midesophageal Right Ventricular Inflow-Outflow IAS RA AV TV PA PV RV Interatrial septum (IAS) Right atrium (RA) Tricuspid valve (TV) Right ventricle (RV) Pulmonic valve (PV) Main pulmonary artery (PA) rtic valve (AV) TV pathology PV pathology RV systolic function ASD 24
ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Midesophageal Bicaval IAS IVC RA SVC Interatrial septum (IAS) Right atrium (RA) Superior vena cava (SVC) Inferior vena cava (IVC) ASD Confirm central venous line/cannula placement 25 ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Transgastric Midpapillary Short Axis RV IAS LV Left ventricle (LV) Right ventricle (RV) Interventricular septum (IVS) Papillary muscles LV size LV systolic function LV regional wall motion LV preload LV hypertrophy Septal motion RV volume overload RV pressure overload VSD 26 ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Descending rtic Short Axis Descending aorta () Left lung and pleura (not shown) rtic dissection rtic aneurysm rtic atheroma Confirm aortic wire/cannula/iabp placement Pleural effusion 27 ME 4Ch ME 2Ch ME X ME Asc X ME Asc SAX ME AV SAX ME RV In Out Bicaval TG SAX SAX X Descending rtic Long Axis Descending aorta () rtic dissection rtic aneurysm rtic atheroma Confirm aortic wire/cannula/iabp placement Grade aortic insufficiency 28
Degraded images electrical interference too much gain too little gain air artifact reverberation comet tail Erroneously perceived structures mirror image Misplaced structures side lobes beam width Missing structures acoustic shadow dropout poor focus 29 References 1.!Reeves ST, et al. Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Journal of the American Society of Echocardiography. Elsevier Inc; 2013 May 1;26(5):443 56. 2. American Society of Anesthesiologists: Practice guidelines for perioperative transesophageal echocardiography. Anesthesiology 112:1084-1096, 2010. 3. Shanewise JS, et al: ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 89:870 84, 1999. 30