Trans-esophageal & Intra-cardiac Echocardiography

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

HISTORYSide and Gosling (1971) - TEE for CwD of cardiac flowFrazin et al (1976) - TEE M mode echo Hisanaga et al (1977) - illustrated use of cross sectional real time imaging

2introductionTEE uses sound waves to create high-quality moving pictures of heart and its blood vesselsinvolves a flexible tube or probe with a transducer at its tipprobe is guided down throat and esophagus more detailed pictures of heart as esophagus is directly behind heart

3TEE: TypesTypes of TEE :2-Dimensional (2D)3-Dimensional (3D)Standard TEE pictures are 2D

3D pictures provide more details about Structure and function of heart and Its blood vessels3D TEE helps to diagnose heart problems like:Congenital heart disease Heart valve disease and To assist with heart surgery

4Transesophageal Echocardiography (TEE)5

tee

6TEE: AdvantagesTransducer - 2- 3 mm from heartCloser to posterior structures - Better visualization of LA, LAA, PV, MV, LV, Aorta Far from surgical area - Intra-operative monitoringHigh 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]

7TEE: DISADVANTAGESsemi invasive procedure: chances of injury ; needs special setup, technique, preparation, instrumentationneeds orientation and expertise

8Indications -commonAssessment of prosthetic valves; infective endocarditis ; native valve diseaseAssessment of a suspected cardioembolic event Assessment of cardiac tumors Assessment of atrial septal abnormalities Assessment of aortic dissection, intramural hematomasEvaluation of CHD; CAD ;pericardial diseaseEvaluation of critically ill patientsIntraoperative monitoringMonitoring during interventional proceduresStress echocardiographyNondiagnostic TTE

9Contraindications

ABSOLUTEOesophageal stricture or obstructionSuspected or known perforated viscusInstability of cervical vertebraeGI bleeding not evaluated

RELATIVEEsophageal varices or diverticulaCervical arthritisOropharyngeal distortionBleeding diathesis or over-anticoagulation

10procedure4- 6 hours fastingWritten consentIntravenous line ; oxygen ; suction equipment ; Remove denture or devices ; 2% lidocaine sprayECG must be monitored throughout Left lateral positionIntroduce the probe with some anteflexion through a bite block

11procedureRoutine 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 safety12complicationsMajority 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.

13complicationsMAJORDeathEsophageal ruptureLaryngospasm or bronchospasmCongestive heart failure or pulmonary edemaSustained ventricular tachycardia14complicationsMINORExcessive retching or vomitingSore throatHoarsenessMinor pharyngeal bleedingBlood tinged sputumNon sustained or sustained supraventricular tachycardiaAtrial fibrillation

Nonsustained ventricular tachycardiaBradycardia or heart blockTransient hypotensionTransient hypertensionAnginaTransient hypoxiaParotid swellingTracheal intubation15TEE PROBEModification of standard gastroscope, with transducers in place of fibreopticsConventional rotary controls with inner and outer dialsInner dial guides anteflexion and retroflexionOuter dial controls medial and lateral movementMultiplane probe has a lever control to guide rotation

16Tee probe

17TEE Transducer

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TEE TransducerRelation of TEE transducer with heartTEE PROBEMonoplane TEE - provides images in horizontal plane onlyBiplane TEE - orthogonal longitudinal plane alsoMultiplane TEE transducer : single array of crystals [phased array transducers with 64 -256 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

19Standard imaging plane levels (from the incisors)

upper or high esophageal (2528 cm)mid-esophageal (2933 cm)transgastric (3842 cm)deep-transgastric (>42 cm)

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PROCEDUREProceed 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 nally slow withdrawal of the probe for complete scan of the thoracic aorta [from high esophageal views].22PROCEDUREA complete TEE exam usually takes 1520 min.An abbreviated or problem-focused TEE study may be appropriate in unstable or uncooperative patients

23Transducer manipulation options

[1] Advancement/withdrawal (for inferior or superior structures respectively)[2] Rotation (clockwise to view rightward structures and counter- clockwise for leftward structures)

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Transducer manipulation options[3] Anteexion and retroexion of the probe shaft (to view structures towards the heart base or towards the apex)

[4] Leftward and rightward exion of the probe shaft (used infrequently with the advent of multiplane probes)

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Transducer manipulation options[5] Electronic image plane rotation (01800)

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TEE PROBE ORIENTATION

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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.

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BASIC VIEWS

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 examinationBut current guidelines recommend that a basic PTE examination should focus on encompassing the 11 most relevant views.30Cross-sectional views of the 11 views of the ASE and SCA basic PTE examination.31

ASE & SCA recommend 20 views for a comprehensive TEE.

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

33ME 4 CHAMBER VIEW34

ME 2C ( 90 ) From ME 4C : keep probe tip still and MV in the center; rotate omniplane angle forward to 80-100; 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

ME TWO-CHAMBER VIEW36

ME LAX (120) Rotate omniplane angle forward to 120-130Imaging 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.

ME LAX VIEW38

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

ME Asc A LAX ( 90) 40

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 0Imaging 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

ME Asc A SAX (0)

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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

ME AV SAX (30-45) 44

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

ME RVIO View (60-75)

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

ME BCV ( 90)

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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

TG mid SAX (0)

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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 probeNear field image of the circular aorta represents the right anterior wall of the aortaFor :Aortic pathology , Color flow reversal: AI severity, IABP position

ME DA SAX (0)

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

ME DA LAX (90)

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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.

ME AV LAX (120) From ME AV SAX (30-60), rotate to 120 -150LVOT, AV, proximal ascending aorta line up.Optimize aortic annulus and make sinuses of valsalva symmetricAssess : MV disease, AV disease, aortic root dimensions & pathology, LVOT pathology, VSD

TG 2C (90 )From mid TG SAX (0) .. rotate omniplane angle to 90.. Anteflex until LV is horizontalImaging 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

TG Basal SAX(0) From TG mid SAX view withdraw the probe until MV is seen in SAX aim to see symmetric MV commissuresViews MV (with A3 & P3) that is parallel to the annulusFor : LV size, function ; VSD ; MV planimeter orifice area

TG LAX (110-120) From TG 2 chamber (90) rotate omniplane angle to 110-120Imaging 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

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

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 horizontalImaging 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

61 UE Aortic Arch LAX (0)From ME(0) ME descending aorta SAX (0) view Withdraw probe until aorta changes into oval shapeTurn probe slightly to the rightImaging 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

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 viewImaging plane is directed thru the transverse aortic arch in SAX and the pulmonary artery in LAX. For : Aortic arch pathology, Pulmonic valve disease, PDA

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3 Dimensional TEEMain 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 balloonsDevices they carry, along with a clear depiction of the positions in relation to other cardiac structuresTo demonstrate certain structures in an en face viewRT3D TEE is a powerful new imaging toolMay become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based proceduresGila Perk, et al. J Am Soc Echocardiogr 2009;22:865-8266INTRACARDIAC ECHOCARDIOGRAPHY67Intracardiac EchocardiographyAn imaging technique that helps to guide percutaneous interventional proceduresProbe can be inserted under local anaesthesiaPrincipally used during closure of atrial septal abnormalities68Intracardiac Echocardiography

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70Intracardiac EchocardiographyThe 1st generation ICEs were introduced in 1980sThey provided high resolution imagingTissue penetration limited due to high frequency of the transducers (2040 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 ICEM R M Jongbloed, et al. Heart. 2005 July; 91(7): 981990. 71ICE: AdvantagesNo radiation is neededPatient discomfort is less General anaesthesia not neededCommunication with the patient during the procedure possible as compared to TEENot necessary to position a transducer in a sterile field as compared to TTEAvailability of direct online information on the position of catheters and devicesThe possibility of direct monitoring of acute procedure related complications such as:Thrombus formationPericardial effusion etcM R M Jongbloed, et al. Heart. 2005 July; 91(7): 981990.

72ICE: LimitationsConsiderable shaft size (10 French)Lack of additional catheter features, such asPorts for guidewiresTherapeutic devices and pressureThe phased array catheters are expensive and for single use onlyPhased array ICE provides only monoplane image sectionsDifficult for operators to obtain the same viewsNo standard views for ICE are currently defined as compared to standard views for for TTE and TOE.M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981990.

73ICE: Clinical ImplicationsApplications of intracardiac echocardiography (ICE) in interventional proceduresEvaluation of intracardiac thrombusTransseptal punctureAtrial septal defect/patent foramen ovale closure

Interventional electrophysiological proceduresPulmonary vein ablation in patients with atrial fibrillationAtrial flutter ablationVentricular tachycardia ablation

74Other applicationsDiagnosis/biopsy of intracardiac massesBalloon mitral valvuloplastyAtrial appendage occlusionVisualisation of coronary sinus

Closure of an ASD under ICE guidance

75ICE: Technical RequirementsMechanical ultrasound tipped catheter:Can be used for bothIntravascularIntracardiac imagingFor intracardiac use9 MHz single element transducer is incorporated in an 8 French catheterA Piezoelectric crystal is rotated at 1800 rpm in the radial dimension perpendicular to the catheter shaftProvides cross sectional images in a 360 radial planeThe ICE catheter needs to be filled with 35 ml sterile water before it is connected to the ultrasound machineM R M Jongbloed, et al. Heart 2005;91:981990.76ICE: Technical RequirementsPhased array ultrasound tipped catheter system usesA 10 French ultrasound catheterPositioned in the right atrium (RA) or right ventricle (RV) via a femoral approachThrough a 10 French introducerMeasurements of haemodynamic and physiologic variables can be made using Doppler imagingCatheter is connected to an ultrasound systemM R M Jongbloed, et al. Heart 2005;91:981990.

77ICE Future AdvancesHigher resolutionAre more reproducible and more flexible than piezoelectric ceramicThey are extremely reproducible and can be made from masks like integrated circuits

Electrophysiology-Enabled Devices for Imaging and TherapyIntegration of ultrasound imaging with mapping technologies, fusion, and overlay images

Ziyad M. Hijazi, et al. Circulation. 2009;119:587-59678REFERENCESOTTO The practice of clinical echocardiography 4th editionFEIGENBAUMS Echocardiography 7th editionBasic perioperative TEE A consensus statement of ASE and SCA S.T Reeves J Am Soc Echo 2013Recommendations for TEE: update 2010 Flachskampf - European Journal of Echocardiography 2010TEE Multimedia Manual - Andr Y. Denault, Pierre CoutureTEE Study Guide and Practice Questions-Dr Andrew RoscoeVirtual TEE Website University of Toronto

79mcqs1)The number of most relevant views for a basic perioperative TEE examination according to current guidelines by ASE and SCA 20 views15 views12 views11 views802) In ME 2 chamber view , the omniplane angle is 1351209060813) In ME LAX view, the omniplane angle is456090120824) In desc aortic LAX view, the omniplane angle is 06090120

835)Principal use of ICE is inEvaluation of intracardiac thrombusBalloon mitral valvuloplastyASD closurePulmonary vein ablation84