TRANS ESOPHAGEAL ECHOCARDIOGRAPHY
-
Upload
unnikrishnan-p -
Category
Health & Medicine
-
view
9.139 -
download
0
description
Transcript of TRANS ESOPHAGEAL ECHOCARDIOGRAPHY
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
POWERFUL DIAGNOSTIC TOOLDECREASE MORBIDITYINCREASE SURVIVAL
http://www.ppt-to-video.com
ANESTHETISED PATIENT’S PHYSIOLOGY IS DIFFERENT; WE KNOW IT BETTER!
WE ARE CLOSELY LINKED WITH THE PERIOPERATIVE CARE
http://www.ppt-to-video.com
LUNGS AND RIBS DON’T INTERFERELUNGS AND RIBS DON’T INTERFEREONLY ESOPHAGEAL WALL AND PERICARDIUM IN ONLY ESOPHAGEAL WALL AND PERICARDIUM IN BETWEENBETWEENWONT DISRUPT SURGERYWONT DISRUPT SURGERYTRANS THORACIC IS DIFFICULT IN:TRANS THORACIC IS DIFFICULT IN: OBESITY/EMPHYSEMA/ABNORMAL CHEST WALLOBESITY/EMPHYSEMA/ABNORMAL CHEST WALL
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
tissue insonated with sound tissue insonated with sound above audible range, >20000 above audible range, >20000 HzHz
Most use 2.5-7.5 HzMost use 2.5-7.5 Hz
Transducer composed of Transducer composed of piezoelectric crystalspiezoelectric crystals
http://www.ppt-to-video.com
Electrical signal applied to the Electrical signal applied to the crystal crystal vibrate vibrate sound sound absorption/reflection/refractioabsorption/reflection/refraction/scatteringn/scattering reflected reflected ultrasound wave ultrasound wave crystal crystal receive the reflected wave receive the reflected wave convert it back to electrical convert it back to electrical signalsignal
http://www.ppt-to-video.com
v = v = f x f x λλ
Ultrasound travels at 1540 Ultrasound travels at 1540 m/secm/sec
Hence v constantHence v constant
As f increase, As f increase, λλ decrease decrease
v,f and v,f and λλ known known
Time find outTime find out
Hence depth find outHence depth find out
http://www.ppt-to-video.com
FF more more absorption more absorption more resolution moreresolution more
λλ less less attenuation more attenuation more penetration lesspenetration less
http://www.ppt-to-video.com
Water, muscle, blood Water, muscle, blood less less impedance impedance less attenuation less attenuation
Air , bone Air , bone high impedance high impedance ultrasound traverse poorlyultrasound traverse poorly
http://www.ppt-to-video.com
DOPPLER PRINCIPLE: “WHEN A WAVE OF A GIVEN FREQUENCY,STRIKES A MOVING TARGET,IT WILL BE REFLECTED AND THE REFLECTED WAVE WILL SHOW A FREQUENCY SHIFT PROPORTIONAL TO THE VELOCITY OF THE TARGET WHICH IS PARALLEL TO THE PATH OF THE EMITTED WAVE”
http://www.ppt-to-video.com
If target is moving away from If target is moving away from the emitted wave, the the emitted wave, the frequency of the reflected wave frequency of the reflected wave will be lowerwill be lower
If the target is moving towards If the target is moving towards the transducer, the frequency the transducer, the frequency of the reflected wave will be of the reflected wave will be higherhigher
http://www.ppt-to-video.com
RBCs act as excellent reflectorsRBCs act as excellent reflectors
Measuring the RBC flow velocity Measuring the RBC flow velocity in the heart is the application in the heart is the application used hereused here
accurate when the transmitted accurate when the transmitted beam and the velocity vector beam and the velocity vector are parallel [ at least within 20º]are parallel [ at least within 20º]
http://www.ppt-to-video.com
http://www.ppt-to-video.com
..
http://www.ppt-to-video.com
Most basic modeMost basic mode
Waves transmitted as a single Waves transmitted as a single beambeam
Only tissues which come in this Only tissues which come in this narrow path are displayednarrow path are displayed
Only a limited area is visualizedOnly a limited area is visualized
Waves transmitted and Waves transmitted and received back in 0.001 sec received back in 0.001 sec
http://www.ppt-to-video.com
So 1000 frames/sec = REAL So 1000 frames/sec = REAL TIMETIME
High resolution : even subtle High resolution : even subtle changes in motion/dimension changes in motion/dimension are well pickedare well picked
Hence finer analysis best done Hence finer analysis best done with this modewith this mode
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Amplitude of returning waves Amplitude of returning waves are displayed as shades of are displayed as shades of brightnessbrightness
Blood filled chambersBlood filled chambers no no reflected wavesreflected waves BLACK BLACK
Valve tissue and myocardium Valve tissue and myocardium high reflected wave activityhigh reflected wave activity grey/whitegrey/white
..\pdfnotes\Pocket Atlas of ..\pdfnotes\Pocket Atlas of Echocardiography.pdfEchocardiography.pdf
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Obtained by rapid repetitive Obtained by rapid repetitive scanning along multiple beam scanning along multiple beam lines within an area in the lines within an area in the shape of a fan (sector), 60-shape of a fan (sector), 60-90°wide90°wide
Done by phased array Done by phased array technologytechnology
Sector contains approx. 100 Sector contains approx. 100 scan linesscan lines time consuming time consuming
Information updated 30-60 Information updated 30-60 times times
http://www.ppt-to-video.com
Desired view is obtained by 2D Desired view is obtained by 2D echo echo Doppler beam Doppler beam superimposedsuperimposed
Cursor is positioned as parallel Cursor is positioned as parallel as possible to the assumed as possible to the assumed direction of blood flowdirection of blood flow
Quantify stenosis , Quantify stenosis , regurgitationregurgitation
Demonstrate shuntsDemonstrate shunts
..\videos\video.flv..\videos\video.flv
http://www.ppt-to-video.com
PULSED WAVE DOPPLERPULSED WAVE DOPPLER
CONTINUOUS WAVE DOPPLERCONTINUOUS WAVE DOPPLER
COLOR FLOW DOPPLERCOLOR FLOW DOPPLER
http://www.ppt-to-video.com
a single crystal intermittently a single crystal intermittently transmits and receives ultra transmits and receives ultra sound signals sound signals analyzed for analyzed for frequency shiftsfrequency shifts
Cursor placed on an updated 2D Cursor placed on an updated 2D image and reflected wave from image and reflected wave from only that portion analyzedonly that portion analyzed
http://www.ppt-to-video.com
We can contract or expand the We can contract or expand the interrogated areainterrogated area
Problem : there is a velocity Problem : there is a velocity limit (.8-1 m/sec) for the wave, limit (.8-1 m/sec) for the wave, beyond which a phenomenon beyond which a phenomenon known as “aliasing” or known as “aliasing” or “wraparound” occurs “wraparound” occurs ambiguous velocity and time ambiguous velocity and time informationinformation
http://www.ppt-to-video.com
Allows a flow disturbance to be Allows a flow disturbance to be localized precisely or blood localized precisely or blood velocity from a small region to velocity from a small region to be measured correctlybe measured correctly
e.g. mitral inflow, tricuspid e.g. mitral inflow, tricuspid inflowinflow
http://www.ppt-to-video.com
One transducer continuously One transducer continuously emit signalsemit signals
Another one continuously Another one continuously receive reflected signalsreceive reflected signals
Very high velocities can be Very high velocities can be reliably detectedreliably detected
Since no lag betweenSince no lag between
emission and reception emission and reception
http://www.ppt-to-video.com
i.e. extremely high sampling i.e. extremely high sampling frequency frequency minimize aliasing minimize aliasing
problem : reflected signals problem : reflected signals returning from all points are returning from all points are analyzed.. Cant localize a signal analyzed.. Cant localize a signal preciselyprecisely
http://www.ppt-to-video.com
Useful for: measuring high Useful for: measuring high velocities e.g. intracardiac velocities e.g. intracardiac shunts , regurgitant jet, flow shunts , regurgitant jet, flow across stenotic valves like ASacross stenotic valves like AS
Velocities up to 600-800 cm/ Velocities up to 600-800 cm/ sec can be measuredsec can be measured
http://www.ppt-to-video.com
Uses pulsed wave technology to Uses pulsed wave technology to measure blood flow at multiple measure blood flow at multiple sitessites
Real time blood flow is shown Real time blood flow is shown in colorsin colors
While also showing 2D images While also showing 2D images in black and whitein black and white
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Velocities and directions of Velocities and directions of blood flow are color encodedblood flow are color encoded
Velocity away Velocity away blue blue
Velocity towards Velocity towards red “BART” red “BART”
High turbulence High turbulence green green
As velocity increase intensity of As velocity increase intensity of color also increasecolor also increase
http://www.ppt-to-video.com
Aliasing occurs Aliasing occurs color mosaic color mosaic
But as 2D image is there, But as 2D image is there, direction of this aliased signal direction of this aliased signal can be determined easilycan be determined easily
Assess valvular Assess valvular
abnormalities , shunts, aortic abnormalities , shunts, aortic dissectiondissection
http://www.ppt-to-video.com
Transducer fitted to the distal, Transducer fitted to the distal, flexible end of a gastroscopeflexible end of a gastroscope
Adult : above 20-25 KgAdult : above 20-25 Kg
Pediatric : above 3.5- 4 KgPediatric : above 3.5- 4 Kg
Adult @ 5 MHz Pediatric @7.5 Adult @ 5 MHz Pediatric @7.5 MHzMHz
2D—M-mode—PWD—CWD--COLOR2D—M-mode—PWD—CWD--COLOR
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Two rotary knobsTwo rotary knobs
One for anteflexion and One for anteflexion and retroflexionretroflexion
One for rightward and leftward One for rightward and leftward flexionflexion
http://www.ppt-to-video.com
Can rotate the angle plane Can rotate the angle plane without movement of the probewithout movement of the probe
Good view of LA,MV..Good view of LA,MV..
..\pdfnotes\iadt07i4p324.pdf..\pdfnotes\iadt07i4p324.pdf
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
ADVANCED/WITHDRAWNADVANCED/WITHDRAWN
RIGHT/LEFTRIGHT/LEFT
ANTEFLEXED/RETROFLEXED-90°ANTEFLEXED/RETROFLEXED-90°
LATERAL FLEXION-70°LATERAL FLEXION-70°
http://www.ppt-to-video.com
Single plane Single plane 0° 0°
Biplane Biplane one transducer: 0°one transducer: 0°
one transducer 90°one transducer 90°
Multiplane probes Multiplane probes 0-180° 0-180°
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
HISTORY: dysphagia/ HISTORY: dysphagia/ hemetemesis/ previous hemetemesis/ previous surgeries on GIT/ cervical spine surgeries on GIT/ cervical spine diseasedisease
Fasting for 4-6 hrsFasting for 4-6 hrs
Remove denturesRemove dentures
Airway/ oxygen delivery Airway/ oxygen delivery systems / bite block/ suction / systems / bite block/ suction / intubation cart / IVAintubation cart / IVA
http://www.ppt-to-video.com
TOPICAL : lignocaineTOPICAL : lignocaine
SEDATIONSEDATION
ANTIXYLAGOGUEANTIXYLAGOGUE
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Orogastric tubeOrogastric tube
Supine / left lateralSupine / left lateral
Operator stands as in for L’scopyOperator stands as in for L’scopy
ETT securedETT secured
Probe in unlocked position Probe in unlocked position align with natural anatomyalign with natural anatomy
Lubricated Lubricated
Bite block on probeBite block on probe
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Thumb of left hand placed on Thumb of left hand placed on patient’s tonguepatient’s tongue
Left hand used to pull jaw Left hand used to pull jaw upwardupward
Pass probe tip through bite Pass probe tip through bite guard , over tongue , guard , over tongue , maintaining it in midline maintaining it in midline ( transducer facing anteriorly) ( transducer facing anteriorly) and to the left of ETTand to the left of ETT
http://www.ppt-to-video.com
Mild resistance felt @ pharyngo Mild resistance felt @ pharyngo esophageal junction [ neonate: esophageal junction [ neonate: 10 cm from lip, adult : 20 cms]10 cm from lip, adult : 20 cms]
If doubt : done under If doubt : done under laryngoscopylaryngoscopy
no hot water no hot water 1-2 hrs 1-2 hrs
Not to eat Not to eat 1-4 hrs 1-4 hrs
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Inspected for defectsInspected for defects
Enzymatic solution to remove Enzymatic solution to remove secretionssecretions
Gluteraldehyde for 20 minsGluteraldehyde for 20 mins
Tap water dry for 20 minsTap water dry for 20 mins
http://www.ppt-to-video.com
Apex of the sector scan is Apex of the sector scan is shown at the top of the echo shown at the top of the echo screen which displays posterior screen which displays posterior parts of the heart ( part close parts of the heart ( part close to probe)to probe)
http://www.ppt-to-video.com
In the transverse imaging In the transverse imaging plane, left of image is towards plane, left of image is towards patients right and right of the patients right and right of the image is towards patients leftimage is towards patients left
http://www.ppt-to-video.com
In the vertical imaging plane, In the vertical imaging plane, left side of the image is inferior left side of the image is inferior and point towards patient’s and point towards patient’s feetfeet
Right side of the image is Right side of the image is anterior and points towards anterior and points towards patients headpatients head
..\pdfnotes\iadt07i4p324.pdf..\pdfnotes\iadt07i4p324.pdf
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Once we centre a cardiac Once we centre a cardiac structure in one image plane,it structure in one image plane,it will continue to remain there as will continue to remain there as the transducer is rotated from the transducer is rotated from 0-180°,facilitating the 3D 0-180°,facilitating the 3D assessment of that particular assessment of that particular structurestructure
http://www.ppt-to-video.com
Markedly abnormal ventricular Markedly abnormal ventricular functionfunction
Extensive MIExtensive MI
Large air emboliLarge air emboli
Severe valvular dysfunctionSevere valvular dysfunction
Large mass or thrombiLarge mass or thrombi
Large effusionLarge effusion
Major lesions of great vesselsMajor lesions of great vessels
http://www.ppt-to-video.com
20 views 20 views comprehensive comprehensive examinationexamination
8 out of 20 needed to meet 8 out of 20 needed to meet these goalsthese goals
http://www.ppt-to-video.com
Upper esophageal(20-30 cm)Upper esophageal(20-30 cm)
Mid esophageal(30-40 cm)Mid esophageal(30-40 cm)
Transgastric (40-45 cm)Transgastric (40-45 cm)
Deep transgastric (45-50 cm)Deep transgastric (45-50 cm)
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Aortic valve short axis—SAXAortic valve short axis—SAX
Aortic valve long axis—LAXAortic valve long axis—LAX
RV inflow-outflowRV inflow-outflow
BicavalBicaval
Ascending aorta—SAXAscending aorta—SAX
Ascending aorta—LAX Ascending aorta—LAX
http://www.ppt-to-video.com
4 chamber4 chamber
2 chamber2 chamber
CommissuralCommissural
Long axisLong axis
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
The probe is advanced into the The probe is advanced into the stomach and ante flexed ( to stomach and ante flexed ( to keep it apposed to the keep it apposed to the diaphragmatic surface of diaphragmatic surface of stomach)stomach)
http://www.ppt-to-video.com
Mid SAXMid SAX
Two chamberTwo chamber
Basal SAXBasal SAX
LAXLAX
RV inflowRV inflow
http://www.ppt-to-video.com
http://www.ppt-to-video.com
TG mid SAX view is particularly TG mid SAX view is particularly used by the anesthetist in the used by the anesthetist in the assessment of LV function, assessment of LV function, Ejection Fraction and Volume Ejection Fraction and Volume statusstatus
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Probe further advanced , slowly Probe further advanced , slowly withdrawn with tip sharply withdrawn with tip sharply anteflexed until it contacts the anteflexed until it contacts the diaphragmatic surface of diaphragmatic surface of stomach wallstomach wall
LAX view shows all 4 chambers, LAX view shows all 4 chambers, aortic valve and LV outflow tractaortic valve and LV outflow tract
Estimates velocity via aortic Estimates velocity via aortic valve and COvalve and CO
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
Images aortic arch and Images aortic arch and descending aorta descending aorta
http://www.ppt-to-video.com
http://www.ppt-to-video.com
http://www.ppt-to-video.com
..\videos\video.flv..\videos\video.flv
http://www.ppt-to-video.com
Intraoperative assessment of Intraoperative assessment of acute, life threatening acute, life threatening hemodynamic disturbanceshemodynamic disturbances
Valve repairValve repair
Congenital heart disease Congenital heart disease surgerysurgery
Repair of HOCMRepair of HOCM
http://www.ppt-to-video.com
Intraoperative use- endocarditisIntraoperative use- endocarditis
Pre operative use in unstable Pre operative use in unstable patients with suspected thoracic patients with suspected thoracic artery aneurysm / dissectionartery aneurysm / dissection
Intraoperative assessment of Intraoperative assessment of aortic valve function during aortic valve function during repair of aortic dissectionrepair of aortic dissection
Pericardial window proceduresPericardial window procedures
http://www.ppt-to-video.com
Use in ICU patients with Use in ICU patients with unexplained hemodynamic unexplained hemodynamic disturbances/valve disturbances/valve diseases/thrombotic diseases/thrombotic complicationscomplications
http://www.ppt-to-video.com
ConfirmConfirm
Localize Localize
ReassessReassess
LA clotLA clot
LV functionLV function
Associated abnormalitiesAssociated abnormalities
Congenital heart diseaseCongenital heart disease
http://www.ppt-to-video.com
Prosthetic valve: leakProsthetic valve: leak
Too small?Too small?
Moving normally?Moving normally?
Deairing adequate?Deairing adequate?
Adequacy of repair: Residual Adequacy of repair: Residual VSD?VSD?
PA pressurePA pressure
Trouble in coming out of bypass?Trouble in coming out of bypass?
http://www.ppt-to-video.com
Ventricular fillingVentricular filling
EjectionEjection
Systolic functionSystolic function
Diastolic functionDiastolic function
Hypotension : low cardiac Hypotension : low cardiac output Vs low SVRoutput Vs low SVR
Guide for administration of Guide for administration of fluid, inotropes and fluid, inotropes and vasopressorsvasopressors
http://www.ppt-to-video.com
RWMARWMA
Differential diagnosisDifferential diagnosis
MyocarditisMyocarditis
Myocardial stunningMyocardial stunning
http://www.ppt-to-video.com
PAC Vs TEEPAC Vs TEE
TEE TEE Real time, directly Real time, directly visualizing, amount of visualizing, amount of information moreinformation more
PAC PAC CO,LVEDP rough CO,LVEDP rough estimates, indirect methodsestimates, indirect methods
Cost?Cost?
http://www.ppt-to-video.com
LA clot before BMV?LA clot before BMV?
ASD device closureASD device closure
Aortic dissection : trans Aortic dissection : trans thoracic Vs TEEthoracic Vs TEE
ThrombusThrombus
Abnormal thoraxAbnormal thorax
http://www.ppt-to-video.com
Preoperative assessment of Preoperative assessment of ventricular function in high risk ventricular function in high risk patientspatients
During placement of LV assist During placement of LV assist devicedevice
Positioning of cannulaePositioning of cannulae
As a substitute of PACAs a substitute of PAC
Deployment of intravascular Deployment of intravascular devicesdevices
http://www.ppt-to-video.com
ThermalThermal
Pressure over heartPressure over heart
Compression of structures Compression of structures adjacent to esophagus adjacent to esophagus
http://www.ppt-to-video.com
HypertensionHypertension
HypotensionHypotension
Arrhythmias Arrhythmias
LaryngospasmLaryngospasm
BronchospasmBronchospasm
HypoxiaHypoxia
http://www.ppt-to-video.com
Perforated esophagusPerforated esophagus
Previous esophagectomyPrevious esophagectomy
Severe esophageal obstructionSevere esophageal obstruction
Active upper GI bleedActive upper GI bleed
http://www.ppt-to-video.com
Esophageal Esophageal stricture,tumour,diverticula,varicestricture,tumour,diverticula,varicess
SclerodermaScleroderma
Previous esophageal surgeryPrevious esophageal surgery
Previous gastric surgeryPrevious gastric surgery
Mediastenal irradiationMediastenal irradiation
Unexplaind swallowing difficultiesUnexplaind swallowing difficulties
http://www.ppt-to-video.com
Echo machine kept in standby Echo machine kept in standby mode when not in usemode when not in use
When not imaging, probe When not imaging, probe should be left in neutral should be left in neutral unlocked position, to avoid unlocked position, to avoid prolonged pressure in prolonged pressure in esophagusesophagus
http://www.ppt-to-video.com
..
http://www.ppt-to-video.com
..
http://www.ppt-to-video.com