TRANS-ESOPHAGEAL & INTRA-CARDIAC ECHOCARDIOGRAPHY

HIMAL RAJ

SR CARDIOLOGY

HISTORY

Side and Gosling (1971) - TEE for CwD of cardiac

flow

Frazin et al (1976) - TEE M mode echo

Hisanaga et al (1977) - illustrated use of cross

sectional real time imaging

2

INTRODUCTION

TEE uses sound waves to create high-quality moving

pictures of heart and its blood vessels

involves a flexible tube or probe with a transducer at its

tip

probe is guided down throat and esophagus

more detailed pictures of heart as esophagus is directly

behind heart

3

TEE: TYPES

• Types of TEE :

1. 2-Dimensional (2D)

2. 3-Dimensional (3D)

• Standard TEE pictures

are 2D

• 3D pictures provide more

details about

• Structure and function of

heart and Its blood vessels

• 3D TEE helps to diagnose

heart problems like:

• Congenital heart disease

• Heart valve disease and

• To assist with heart surgery

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TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)

5

TEE

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TEE: ADVANTAGES

Transducer - 2- 3 mm from heart

Closer to posterior structures - Better visualization

of LA, LAA, PV, MV, LV, Aorta

Far from surgical area - Intra-operative monitoring

High 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]7

TEE: DISADVANTAGES

• semi invasive procedure: chances of injury ;

• needs special setup, technique, preparation,

instrumentation

• needs orientation and expertise

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INDICATIONS -COMMON• Assessment of prosthetic valves; infective endocarditis ;

native valve disease

• Assessment of a suspected cardioembolic event

• Assessment of cardiac tumors

• Assessment of atrial septal abnormalities

• Assessment of aortic dissection, intramural hematomas

• Evaluation of CHD; CAD ;pericardial disease

• Evaluation of critically ill patients

• Intraoperative monitoring

• Monitoring during interventional procedures

• Stress echocardiography

• Nondiagnostic TTE

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CONTRAINDICATIONS

ABSOLUTE

Oesophageal stricture or obstruction

Suspected or known perforated viscus

Instability of cervical vertebrae

GI bleeding not evaluated

RELATIVE

Esophageal varices or diverticula

Cervical arthritis

Oropharyngeal distortion

Bleeding diathesis or over-anticoagulation 10

PROCEDURE

4- 6 hours fasting

Written consent

Intravenous line ; oxygen ; suction equipment ;

Remove denture or devices ; 2% lidocaine spray

ECG must be monitored throughout

Left lateral position

Introduce the probe with some anteflexion through

a bite block11

PROCEDURE

Routine 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 safety12

COMPLICATIONS

Majority 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.

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COMPLICATIONS

MAJOR

Death

Esophageal rupture

Laryngospasm or bronchospasm

Congestive heart failure or pulmonary edema

Sustained ventricular tachycardia

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COMPLICATIONS

MINOR

Excessive retching or

vomiting

Sore throat

Hoarseness

Minor pharyngeal bleeding

Blood tinged sputum

Non sustained or sustained

supraventricular tachycardia

Atrial fibrillation

Nonsustained ventricular

tachycardia

Bradycardia or heart block

Transient hypotension

Transient hypertension

Angina

Transient hypoxia

Parotid swelling

Tracheal intubation15

TEE PROBE

Modification of standard gastroscope, with

transducers in place of fibreoptics

Conventional rotary controls with inner and outer

dials

Inner dial guides anteflexion and retroflexion

Outer dial controls medial and lateral movement

Multiplane probe has a lever control to guide

rotation16

TEE PROBE

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TEE TRANSDUCER

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TEE Transducer Relation of TEE transducer with heart

TEE PROBE

Monoplane TEE - provides images in horizontal

plane only

Biplane TEE - orthogonal longitudinal plane also

Multiplane 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 19

STANDARD IMAGING PLANE LEVELS (FROM THE INCISORS)

upper or high esophageal (25–28 cm)

mid-esophageal (29–33 cm)

transgastric (38–42 cm)

deep-transgastric (>42 cm)

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PROCEDURE

Proceed 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 finally slow withdrawal of the probe for

complete scan of the thoracic aorta [from high

esophageal views].

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PROCEDURE

A complete TEE exam usually takes 15–20 min.

An abbreviated or problem-focused TEE study may

be appropriate in unstable or uncooperative

patients

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TRANSDUCER 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] Anteflexion and retroflexion of the probe shaft (to

view structures towards the heart base or towards the apex)

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

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TRANSDUCER MANIPULATION OPTIONS

[5] Electronic image plane rotation (0–1800)

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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 examination

• But current guidelines recommend that a basic PTE

examination should focus on encompassing the 11 most

relevant views.

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CROSS-SECTIONAL VIEWS OF THE 11 VIEWS OF THE ASE AND SCA BASIC PTE EXAMINATION.

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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

ME 4 CHAMBER VIEW

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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 VIEW

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

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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 symmetric

Imaging 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°)

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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 0°Imaging 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°)

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ME RVIO VIEW (60-75°)From ME AV SAX (30-60°) rotate omniplane angle to 60-75°

Optimize TV leaflets, open up RVOT,

Bring PV + main PA into view

For : 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 right

Change angle or rotate probe slightly to image both IVC (left)

and SVC (right) simultaneously

For : 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

parallel

Distal 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 -150°LVOT, 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 horizontal

Imaging 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 commissures

Views MV (with A3 & P3) that is parallel to the annulus

For : LV size, function ; VSD ; MV planimeter orifice area

TG LAX (110-120°)

From TG 2 chamber (90°) … rotate omniplane angle to 110-120°

Imaging 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 horizontal

Imaging 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

UE AORTIC ARCH LAX (0°)

From ME(0°)… ME descending aorta SAX (0°) view… Withdraw probe until aorta changes into oval

shape…

Turn probe slightly to the right

Imaging 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 view

Imaging 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 TEE

Main 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 balloons

Devices they carry, along with a clear depiction of the positions in

relation to other cardiac structures

To demonstrate certain structures in an ‘‘en face’’ view

RT3D TEE is a powerful new imaging tool

May 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;22:865-82

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INTRACARDIAC ECHOCARDIOGRAPHY

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INTRACARDIAC ECHOCARDIOGRAPHY

An imaging technique that helps to guide

percutaneous interventional procedures

Probe can be inserted under local anaesthesia

Principally used during closure of atrial septal

abnormalities

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INTR

AC

AR

DIA

C

EC

HO

CA

RD

IOG

RA

PH

Y

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INTRACARDIAC ECHOCARDIOGRAPHY

• The 1st generation ICEs were introduced in 1980s

• They provided high resolution imaging

• Tissue penetration limited due to high frequency of the

transducers (20–40 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

ICE

M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981–990.

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ICE: ADVANTAGESNo radiation is needed

Patient discomfort is less

General anaesthesia not

needed

Communication with the

patient during the

procedure possible as

compared to TEE

Not necessary to position a

transducer in a sterile field

as compared to TTE

Availability of direct online

information on the position

of catheters and devices

The possibility of direct

monitoring of acute

procedure related

complications such as: Thrombus formation

Pericardial effusion etc

M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981–990.

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ICE: LIMITATIONS Considerable shaft size (10 French)

Lack of additional catheter features, such as Ports for guidewires

Therapeutic devices and pressure

The phased array catheters are expensive and for single

use only

Phased array ICE provides only monoplane image sections

Difficult for operators to obtain the same views

No 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): 981–990.

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ICE: CLINICAL IMPLICATIONS Applications of intracardiac echocardiography (ICE) in

interventional procedures

Evaluation of intracardiac thrombus

Transseptal puncture

Atrial septal defect/patent foramen ovale closure Interventional

electrophysiological

procedures Pulmonary vein ablation in

patients with atrial fibrillation

Atrial flutter ablation

Ventricular tachycardia

ablation74

Other applications Diagnosis/biopsy of

intracardiac masses

Balloon mitral valvuloplasty

Atrial appendage occlusion

Visualisation of coronary

sinus

CLOSURE OF AN ASD UNDER ICE GUIDANCE

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ICE: TECHNICAL REQUIREMENTS

Mechanical ultrasound tipped catheter: Can be used for both

Intravascular

Intracardiac imaging

For intracardiac use 9 MHz single element transducer is incorporated in an 8 French

catheter

A Piezoelectric crystal is rotated at 1800 rpm in the radial

dimension perpendicular to the catheter shaft

Provides cross sectional images in a 360˚ radial plane

The ICE catheter needs to be filled with 3–5 ml sterile water

before it is connected to the ultrasound machine

M R M Jongbloed, et al. Heart 2005;91:981–990.

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ICE: TECHNICAL REQUIREMENTS

Phased array ultrasound tipped catheter system

uses A 10 French ultrasound catheter

Positioned in the right atrium (RA) or right ventricle (RV)

via a femoral approach

Through a 10 French introducer

Measurements of haemodynamic and physiologic

variables can be made using Doppler imaging

Catheter is connected to an ultrasound system

M R M Jongbloed, et al. Heart 2005;91:981–990.

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ICE FUTURE ADVANCES

Higher resolution Are more reproducible

and more flexible than

piezoelectric ceramic

They are extremely

reproducible and can be

made from masks like

integrated circuits

Electrophysiology-

Enabled Devices for

Imaging and Therapy Integration of ultrasound

imaging with mapping

technologies, fusion,

and overlay images

Ziyad M. Hijazi, et al. Circulation. 2009;119:587-596

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REFERENCES

OTTO – The practice of clinical echocardiography – 4th edition

FEIGENBAUM’S Echocardiography – 7th edition

Basic perioperative TEE – A consensus statement of ASE and

SCA – S.T Reeves – J Am Soc Echo 2013

Recommendations for TEE: update 2010 – Flachskampf -

European Journal of Echocardiography 2010

TEE Multimedia Manual - André Y. Denault, Pierre Couture

TEE Study Guide and Practice Questions-Dr Andrew Roscoe

Virtual TEE Website – University of Toronto

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MCQS

1)The number of most relevant views for a basic

perioperative TEE examination according to current

guidelines by ASE and SCA –

a) 20 views

b) 15 views

c) 12 views

d) 11 views

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2) In ME 2 chamber view , the omniplane angle is

a) 135˚

b) 120˚

c) 90˚

d) 60˚

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3) In ME LAX view, the omniplane angle is

a) 45˚

b) 60˚

c) 90˚

d) 120˚

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4) In desc aortic LAX view, the omniplane angle is

a) 0˚

b) 60˚

c) 90˚

d) 120˚

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5)Principal use of ICE is in

a) Evaluation of intracardiac thrombus

b) Balloon mitral valvuloplasty

c) ASD closure

d) Pulmonary vein ablation

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