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Transesophageal echocardiography(TEE)

A transesophageal echocardiogram, or TEE, is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. It has several advantages and some disadvantages compared with a transthoracic echocardiogram.

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Transesophageal echocardiography(TEE)

  1. 1. Awadhesh Sharma ,MD ,DM,FSCAI,FACC LPS Institute of Cardiology Kanpur
  2. 2.   Dr. Awadhesh Kumar Sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical College Jhansi. Then he did his superspecilization degree DM in Cardiology from PGIMER & DR Ram Manohar Lohia Hospital New Delhi. He had excellent academic record with Gold medal in MBBS, MD and first class in DM. He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Hon. Mayawati in 2009.He is also receiver of GEMS international award. Recently he received best interventional cardiologist award from central health minister Hon Ashwini Chaubey ji. He was also awarded with prestigious fellowships of American College of Cardiology (FACC) and FSCAI. He had many national & international publications. He had special interest in both invasive & non invasive cardiology. He had performed more than 10000 invasive cardiac intervention procedures successfully till date including coronary angiography, simple & complex angioplasty, peripheral vessels angiography & angioplasty, carotid angiography & angioplasty, ASD, PDA device closures, Mitral & pulmonary valvotomy. He is also in editorial board of many national & international journal- Journal of clinical medicine & research (JCMR),Clinical cardiology update, United Journal of Cardiology and Cardiovascular Medicine, EC Pulmonology and Respiratory Medicine. He is also active member of reviewer board of many journals. He is active member of many professional bodies including Indian Medical Association, Cardiological Society of India, APVIC, ICC, API. He had worked as Intervention Cardiologist at RML Hospital, New Delhi(2011- 2014),NABH Accredited Grecian Hospital, Mohali (2014-2016). Currently he is working as Assistant Professor of cardiology at Prestigious LPS Institute of Cardiology, GSVM Medical college, Kanpur (UP),Centre of excellence under Govt of UP. He is actively involved in teaching of 30 postgraduates (DM Cardiology) and 100 paramedical students.
  4. 4.  TEE- ultrasound diagnostic technique using an esophageal window.  TEE utilizes an electronically steered high- frequency ultrasound transducer (5-7MHz) mounted on an endoscope  The higher resolution , coupled with anatomic proximity of the transducer to the posterior cardiac structures, delivers superior images quality when compared with TTE, particularly of posterior cardiac structures
  5. 5.  In 1976, Frazin et al. described their initial experience with a single-crystal ultrasound transducer attached to a coaxial cable that was passed into the esophagus  Accurate positioning of this probe was difficult, and the device was not used frequently  A major breakthrough in TEE came in the early 1980s, when phased-array transducers connected to more flexible endoscopes were introduced and made even smaller
  6. 6.  Atrial fibrillation  Suspected endocarditis  Cardiac source of embolism  Valvular heart disesase  Prosthetic valve evaluation-Assessing the structural complications such as myocardial abscess, fistulas, mycotic aneurysm, valvular aneurysms or perforations, flail leaflets, or prosthetic valve dehiscence  ASD assessment  Assessment of acute aortic syndromes, and cardiac masses
  7. 7.  To assess adequacy of valve repair.  To assess Prosthetic Valve or Ring Regurgitation  To monitor LV function  To evaluate removal of air from the heart  To assess the adequacy of repair of congenital heart disease
  8. 8. Evaluate for contraindications  Esophageal pathology  Dysphagia, odynophagia, recent esophageal bleeding Evaluate for factors affecting intravenous conscious sedation risk:  Poor ability to cooperate  Impaired ability to protect airway  Sleep apnea  Systemic illness  Nothing by mouth for 4–6 h
  9. 9.  Evaluate oropharynx for airway patency.  Informed consent  Establish peripheral IV with 3-way stopcock  Topical anesthesia  Lidocaine 2% viscous solution or spray
  10. 10.  Probe insertion  Dental trauma  Oropharyngeal trauma  Esophageal/gastric bleeding  Esophageal laceration/perforation  Vagal reaction  Conscious Sedation  Hypoventilation and hypoxia  Hypotension  Aspiration  Topical anesthetic  Methemoglobinemia (benzocaine)  Allergic reaction
  11. 11.  From the level of T1 to T4, the esophagus has lung on the left and right side, the trachea anteriorly and vertebrae posteriorly, and so no image is obtained.  At the level of T4, the aortic arch is anterior to the esophagus and (sometimes with the left brachiocephalic vein and distal right pulmonary artery) can be visualized with appropriate probe manipulation.  The superior vena cava is anterior and to the right at this level but cannot be visualized due to the interposition of the trachea.
  12. 12.  Between T4 and T8 ,the ascending aorta, superior vena cava, pulmonary trunk, and right pulmonary artery lie anterior to the esophagus and are usually the first images seen as the probe is advanced without need for further manipulation (upper esophageal window).  The left pulmonary artery is also anterior to the esophagus at this level, but is obscured by the left main bronchus.
  13. 13.  From about the level of T8 to the level of T12 the left atrium is immediately anterior to the esophagus, thus allowing unimpeded visualization of all the intracardiac structures (mid esophageal window).  Posterior to the esophagus from T4 to T12 is the descending aorta; this is usually imaged at the end of the study by complete rotation (clockwise or anticlockwise) and subsequent slow withdrawal of the probe.  Below the diaphragm the stomach is directly inferior to the ventricles and these can be visualized by flexing the probe tip to bring it into apposition with the lesser curvature of the stomach (transgastric window).
  14. 14.  Upper Esophageal-approx. 20–30 from the incisors  Mid Esophageal-approx.30–40 from the incisors  Trans Gastric -approx.40–50 cm from the incisors
  15. 15.  0 Degree(transverse Plane)- Oblique view of upper esophageal basal structures, the mid esophageal four chamber view or basal transgastric short axis view can be obtained from this position by reteroflexion and Anteflexion of transducer tip.  45 Degrees- Short axis view of the aortic valve
  16. 16.  90 Degrees- Longitudinal transducer orientation, produce images oblique to the long axis of the heart.  135 Degrees- True long axis of the LA and left ventricular outflow tract(LVOT)
  17. 17. With transducer array at 90 degrees, the plane is Sagittal to the body and oblique to the long axis of the Heart. 1. Counterclockwise rotation of the probe-two chamber left ventricular inflow view 2. Slight clockwise rotation of probe from first view, produce long axis of right ventricular outflow tract(RVOT)
  18. 18. 3.Further clockwise rotation-Long axis view of proximal ascending aorta. 4.Further clockwise rotation-Long axis view of the Vena Cava and Atrial septum.
  19. 19.  With the transducer tip in fundus of the stomach (about 40-45cm from the incisors)  The transducer array at 0 degree produces the short –axis view of LV and RV.  Anteflexion or slight withdrawl of the tip of transducer optimizes the basal short-axis view of the ventricles.  Retroflection of tip produces more apical short-axis view.
  20. 20.  Sequential rotation of multi plane transducer provides the primary trans gastric views of the LV  0 degree, short-axis view of LV and RV  70-90 degree- longitudinal two-chamber view of the LV  110-135 degree- trans gastric view of the LVOT and aortic valve
  21. 21.  The mitral valve is so named due to its appearance that resembles a bishops’ miter.  Trans esophageal echocardiography and the mitral valve (that sits only 5–10 cm from the transducer with nothing but blood between them)
  22. 22.  The posterior leaflet has clefts that divide it into 3 scallops (P1, P2, and P3);  The anterior leaflet has no such scallops, but is described as having three regions that reflect those of the posterior leaflet (A1, A2, and A3 respectively).  In addition to the points of apposition along the leaflets, there are anterior (adjacent to A1/P1) and posterior (adjacent to A3/P3) commissures.  The non leaflet apparatus consists of the saddle-shaped mitral annulus, the chordae tendinae (primary chordae attached to the free edges of the leaflets, secondary and tertiary chordae attached to body of leaflets), and papillary muscles (anterior: chordae attached to lateral aspects of leaflets; posterior: chordae attached to medial aspects of leaflets).
  23. 23.  The fully developed human left atrium (LA) consists of the true atrial septum, a superior smooth walled portion, and an inferior trabeculated portion  The smooth walled portion is larger and originates embryologically from the pulmonary veins that combine to form a common pulmonary vein before becoming integrated with the inferior portion of the left atrium.  The trabeculated portion of the adult LA is confined to the appendage (LAA) and is all that remains is of the primitive left atrium.
  24. 24.  The postero-superior wall of the LA is adjacent to the mid esophagus, and all mid esophageal views image the left atrial cavity by default.  There are therefore no specific left atrial views
  25. 25.  Purpose of the left atrial appendage (LAA) is not fully understood.  LAA acts as a capacitance chamber allowing sudden changes in LA volume to be accommodated without marked increases in left atrial pressure (LAP)  The LAA acts as a cul-de- sac with a high incidence of thrombus especially in the presence of atrial fibrillation (AF).  The orifice of the neck of the appendage curves around the lateral aspect of the LA between the left upper pulmonary vein (LUPV) (posteriorly) and the junction of the LA and pulmonary trunk (anteriorly).
  26. 26.  In LAA/LA clot except type Ia- most of the interventionalist usually defer PTMC.  For LA/LAA clot assessment we image LAA in mid esophageal 0 degree and 90-110 degree.  Second image is obtained by slightly withdrawing TEE probe till visualization of aorta and image LAA in 0 degree and 90-110 degree angle with slight counter clock wise probe rotation.
  27. 27.  Severe rheumatic MS specially with associated AF, dilated LA(>4.5 cm),dense spontaneous ECHO contrast and LAA emptying velocity <25 cm/sec is associated with LAA/LA clot.  AS per classification by Manjunath et al it is classified as follows- 1. Type Ia: LA appendage clot confined to appendage. 2. Type Ib: LA appendage clot protruding into LA cavity. 3. Type IIa: LA roof clot limited above the plane of fossa ovalis. 4. Type IIb: LA roof clot extending below the plane of fossa ovalis 5. Type III: Layered clot over the IAS 6. Type IV: Mobile clot which is attached to LA free wall or roof or IAS 7. Type V: Ball valve thrombus (free floating).
  28. 28. Type Ib Type Ib
  29. 29. Type Ib Type Ib
  30. 30. Type Ib LAA clot Type IV LAA Clot
  31. 31.  Evaluation of the right sided veins is usually straight forward.  From the mid esophageal 4 chambers view the probe is rotated to the right (with the image sector angle at 0–30° and depth at about 10 cm) such that the inter-atrial septum is horizontal and in the centre of the screen .  Color Doppler is added to the left side of the screen and the probe is advanced slowly until 2 distinct pulmonary infows are seen ; the more horizontal flow is from the RLPV and the more vertical fow is from the RUPV.  The RUPV can also be seen by maintaining the probe depth, rotating the image sector plane to the bicaval view at 80–120° , and then manually rotating the probe clockwise/to the right .  This latter view of the RUPV is especially useful in patients’ with atrial septal defects (ASD) when excluding anomalous pulmonary venous drainage (most commonly the RUPV) and when assessing the distance betweenthe rim of the ASD and the RUPV prior to considering percutaneous closure.
  32. 32.  The left upper pulmonary vein (LUPV), which enters the LA just lateral to the LAA from an anterior to posterior trajectory, is identified by withdrawing slightly and turning the probe to the left.  The left lower pulmonary vein (LLPV) is then identified by turning slightly farther to the left and advancing 1 to 2 cm. The LLPV enters the LA just below the LUPV, courses in a more lateral to medial direction, and is less suitable for Doppler quantification of pulmonary venous blood flow velocity being nearly perpendicular to the ultrasound beam.  In some patients, the LUPV and LLPV join and enter the LA as a single vessel
  33. 33.  Valve Structure-  The valve itself consists of 3 cusps (right, left, and noncoronary) attached to a fibrous annulus, and unlike the atrio-ventricular valves,  It does not have any anchoring supports (e.g., chordae tendinae) to maintain the integrity. The integrity is dependant mainly on the annulus geometry and the ratio of annulus: cusp area.  The annulus geometry is affected by the inter-ventricular septum and proximal aortic root, and pathologies of either can alter the annular shape and cause incompetence of the valve.  There is about 30% overlap of each cusp with its neighbour, and the total cusp area must exceed the cross sectional area of the annulus in order to maintain competency with a normal ratio being greater than 1.6:1;  Any pathology that decreases cusp area or increases annular area will therefore lead to incompetence and regurgitation through the valve.
  34. 34.  Starting in the mid esophagus (ME) and having briefly imaged the 4 chambers (4Ch) view the probe is withdrawn slightly to obtain the 5 chambers (5Ch) view;  The image sector depth is then reduced in order to visualize the valve close up in 2D, and with color Doppler.  In this view the noncoronary cusp (NCC) or left coronary cusp (LCC) is seen superiorly with the right coronary cusp (RCC) seen inferiorly
  35. 35.  Maintaining this esophageal level the image plane angle is slowly rotated between 40° and 80°, whilst gently manually rotating the probe clockwise (to the right) to obtain the AV short axis (SAX) view.  In order to remain spatially orientated it is best to undertake these manipulations at a greater image sector depth so as to have more landmarks to guide.  Once the AV SAX view is obtained the image sector depth can be reduced once more for closer evaluation of the valve.  The probe depth may need to be adjusted and some degree of lateral flexion applied in order to get a perfect “en face” view of the valve, and once achieved, it will allow an exquisite view of all 3 cusps
  36. 36.  The third mid esophageal view recommended for AV assessment is the (AV) long axis (LAX) view; this is similar to the left ventricular LAX view but may require further manipulation to ensure the appropriate cut through the valve and proximal aortic root (i.e., with the root being imaged in as close to horizontal projection as possible).  Starting from the SAX view the image sector depth is again increased to assist orientation.  The image plane angle is then rotated between 120° and 160° (although image may be acquired at angles 100–120°) with or without some manual anticlockwise rotation being applied. Then the sector depth is reduced to give a close up of the valve and proximal root .
  37. 37.  The most consistently attainable view is the TG LAX ; in order to optimize visualization of the valve rotating the probe to the right can be helpful.  The second transgastric view is the deep transgastric view found at 0–40° by first obtaining the TG SAX view of the LV and then advancing the probe. It should be noted that it is not always possible to get the deep TG view and patients’ tend to find it quite uncomfortable, so can be ommited.
  38. 38.  The coronary ostia are well seen in the mid esophageal AV short (left [LCA] and right [RCA]) and AV long (RCA) axis views.  In the SAX view the left main stem (LMS) and proximal portion of the anterior descending (LAD) and circumflex (LCx) branches can be seen
  39. 39.  Aortic dissection is a clinical emergency that is challenging to diagnose.  TEE and CT angiography are the two most commonly employed imaging modalities for aortic dissection.  Multiple studies have demonstrated the high sensitivity and specificity of both modalities for diagnosing type A dissections.  The sensitivity and specificity of TEE have been reported as 90% to 100% and 94% respectively .
  40. 40.  Trans catheter closure of ASD is an effective alternative to surgery in most patients with ostium secundum ASD.  Factors that decide suitability for trans catheter closure include size of the defect and presence of adequate tissue rims around the defect.  Accurate imaging of the anatomic features of the ASD is critical for case selection, planning, and guidance during the procedure.
  41. 41.  The rims of a secundum ASD are labeled as - 1. Aortic or (anterosuperior), 2. Atrio ventricular (AV) Valve ,mitral or (inferoanterior), 3. Superior vena caval (SVC or posterosuperior), 4. Inferior vena caval (IVC or posteroinferior) 5. Posterior or superrior 6. Coronary sinus By conventional definition, a margin 5 mm is considered to be adequate.Deficient aortic rim (42.1%).
  42. 42. Bicaval view SVC & IVC Rims
  43. 43. Aortic rim (down) Posterior rim(UP)
  44. 44.  In order to remain spatially orientated it is best to undertake these manipulations at a greater image sector depth so as to have more landmarks to guide you.  When optimizing the image, whatever you do, do it slowly; then, if the image looks worse do the opposite.  The ME 4Ch view is the easiest to obtain and recognize and so can be used to orientate the operator. If you get “lost” during a study, return to this view and start again.
  45. 45.  TEE represents a valuable and generally safe diagnostic and monitoring tool for the evaluation of cardiac performance and structural heart disease and can favorably influence clinical decision making.  Although complications associated with TEE probe placement and manipulation can occur, these events are rare.  Awareness of the possible complications, proper identification, and careful assessment of patients is very important.
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A transesophageal echocardiogram, or TEE, is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. It has several advantages and some disadvantages compared with a transthoracic echocardiogram.


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