TEE

INSTRUMENTATION & BASIC VIEWS

Dr. Sony Manuel MSenior Resident

MCH KOZHIKODE

References :

1. Recommendations for Performing TEE …. A. Flachskampf… euje.2000

2. A systematic approach to performing a comprehensive TEE…A call to order…. Avinash A et. al …. BMC Cardiovascular Disorders 2009

3. TEE Multimedia Manual .. André Y. Denault, Pierre Couture

4. TEE….. Partho P Sengupta …..HEART 2005

5. TEE Study Guide and Practice Questions ….Dr Andrew Roscoe

6. Virtual TEE Website … Toronto general hospital

7. Otto: The Practice of Clinical Echocardiography

8. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for TTE & TEE…..jacc 2007

HISTORY

Side and Gosling (1971) …. TEE for CwD of cardiac flow

Frazin et al (1976) …. TEE M mode echo

Hisanaga et al (1977) illustrated the use of cross sectional real time imaging

• Invasive technique

• USG probe closer to heart & great vessels … allows the use of high frequency transducers [better resolution]

• Monoplane Biplane Multiplane

• Focus initially on the primary area of interest & then do a comprehensive examination [except in emergency settings]

• Almost all views obtained by TTE can be duplicated by TEE

ADVANTAGES OF TEE

• 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]

DISADVANTAGES:

• semi invasive procedure: chances of injury ;

• needs special setup, technique, preparation, instrumentation

• needs orientation and expertise

INDICATIONS

• 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;

• Evaluation of CHD; CAD ;pericardial disease

• Evaluation of critically ill patients

• Intraoperative monitoring

• Monitoring during interventional procedures

• Nondiagnostic TTE

CONTRAINDICATIONS

ABSOLUTE

• Oesophageal stricture or obstruction

• Suspected or known perforated viscus

• Instability of cervical vertebrae

• GI bleeding not evaluated

RELATIVE

o Esophageal varices or diverticula

o Cervical arthritis

o Oropharyngeal distortion

o Bleeding diathesis or over-anticoagulation

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 block

• Routine antibiotic prophylaxis before TEE is not advocated [ risk of IE is extremely low]..Recommended in high risk patients ….prosthetic valves, multivalvar 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 safety

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.

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 rotation

Monoplane TEE provides images in horizontal plane only

With biplane 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

Standard imaging plane levels (from the incisors):

• upper or high esophageal (25–28 cm)

• mid-esophageal (29–33 cm)

• gastroesophageal junction (34–37 cm)

• transgastric (38–42 cm)

• deep-transgastric (>42 cm)

• 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].

A complete TEE exam usually takes 15–20 min.

An abbreviated or problem-focused TEE study may be appropriate in unstable or uncooperative patients…..

Transducer manipulation options: [video…tee simulation]

[1] Advancement/withdrawal (for inferior or superior structures respectively)

[2] Rotation (clockwise to view rightward structures and counter- clockwise for leftward structures)

[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)

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

TEE probe orientation :

By convention, in TEE, the tip of the 2D sector is displayed on top of the screen and left-sided cardiac structures appear on the right side of the display.

BASIC VIEWS

ASE & SCA recommend 20 views for a comprehensive TEE.

Mid Esophagus 4C (0°):

position the probe in the mid-esophagus behind the LA. The imaging plane is directed thru the LA, center of the MV and apex of the LV

Assess :

Chamber size; Ventricular function; Mitral Valve disease; Tricuspid Valve disease; Atrial Septal Defect; Pericardial Effusion

ME 2C(90°):

From ME 4C : Keep the probe tip still and the 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

‘Coumadin

ridge’…

between

LAA & LUPV

ME Mitral Commissural View(60°):

From 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 the LA, MV and LV apex.

The MV is imaged with the P3 scallop (left), P1 scallop (right) and AMVL (usually A2) in the middle forming the intermittently seen "trap door".

Assess : MV disease, LV function, LA pathology.

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 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 LAX(120°) :

From ME AV SAX (30-60°), rotate to 120 -150°

LVOT, AV, proximal ascending Aorta line up.

Optimize aortic annulus and make the sinuses of Valsalva symmetric

Assess : MV disease, AV disease, Aortic Root dimensions & pathology,

LVOT pathology, VSD

ME RVIO (60-75°)View:

From ME AV SAX (30-60°)

Rotate the 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 BCV(90°) :

Find ME 2 C (90°)

Turn the entire probe right

Change angle or rotate probe slightly to image both the IVC (left) and SVC (right) simultaneously

For : ASD (secundum, sinus venosus), Atrial pathology, Lines/wires,

Venous Cannula (SVC, IVC)

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 probe

Near field image of the circular aorta represents the right anterior wall of the aorta

For :

Aortic Pathology

Color flow reversal: AI severity

IABP position

ME DA LAX(90°) :

Fro m 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.

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 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

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 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

MCQs

(1)TEE – multiplane probe @ 1350 roughly corresponds to :

a)Parallel to the ascending aorta

b)Parallel to Long-axis view of cardiac structures (LV and LVOT)

c)Parallel to Cardiac short axis

d)Parallel to probe long axis

(2)Identify the structure marked as ‘X’

(a)Asc aorta

(b)Des aorta

(c)Arch of aorta

(d)Pulmonary artery

(3)Identify this view :

(a)UE Aortic arch LAX

(b)ME Asc Aorta LAX

(c)ME Asc Aorta SAX

(d)UE Aortic arch SAX

(4)Identify the view :

(a)ME 2C

(b)ME LAX

(c)ME mitral commissural

(d)ME RV inflow

(5)Identify the valve marked as ‘X’:

(a)Mitral

(b)Tricuspid

(c)Aortic

(d)Pulmonary

(6)Identify the structure :

(a)Asc aorta

(b)Desc aorta

(c)Aortic arch

(d)MPA

(7)Identify the ventricular wall :

(a)Anterior

(b)Inferior

(c)Anteroseptal

(d)Anterolateral

(8)Not a contraindication for TEE :

(a)Stricture esophagus

(b)Patient on anticoagulation

(c)Esophageal diverticulum

(d)Clear fluids taken with in 2 hrs of TEE

(9)TEE won’t show you a part of :

(a)Asc aorta

(b)Aortic root

©Arch of aorta

(d)Descending thoracic aorta

(10)The structure which is indicated by ‘X’ :

(a)RPA

(b)Subclavian artery

(c)SVC

(d)IVC

THANK YOU