This page intentionally left blank Transoesophageal Echocardiography Transoesophageal echocardiography (TOE/TEE) in cardiac patients is now almost routine Its use in cardiac monitoring has also extended to include critically ill patients for non-cardiac surgery and the intensive care setting Specific accreditation is required prior to practice of TOE/TEE involving a written examination and a documented logbook of experience This book has been specifically designed to help candidates pass the written exam and has been structured around the syllabus Providing a summary of all relevant information, this is an invaluable study aid Lists of further reading material are provided with every topic, including guidelines and safety, cardiomyopathies, heart disease, haemodynamic calculations and many more Each chapter ends with a series of exam-style questions for self-assessment An extremely useful book for trainee anaesthetists, intensivists, trainee cardiologists and cardiac surgeons Andrew Roscoe is a consultant in cardiothoracic anaesthesia at Wythenshawe Hospital in Manchester, UK Transoesophageal Echocardiography Study Guide and Practice Questions Dr Andrew Roscoe, F.R.C.A Consultant in Cardiothoracic Anaesthesia Wythenshawe Hospital, Manchester, UK CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521689601 © Cambridge University Press 2007 This publication is in copyright Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published in print format 2007 eBook (EBL) ISBN-13 978-0-511-27815-0 ISBN-10 0-511-27815-2 eBook (EBL) paperback ISBN-13 978-0-521-68960-1 paperback ISBN-10 0-521-68960-0 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this publication to provide accurate and up-todate information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn fromactual cases, every effort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free fromerror, not least because clinical standards are constantly changing through research and regulation The authors, editors and publishers therefore disclaimall liability for direct or consequential damages resulting fromthe use of material contained in this publication Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use Contents List of abbreviations Foreword page vii xiii Physics of ultrasound Basic principles Transducers Imaging Doppler Artefacts 1 13 22 29 35 Guidelines and safety Indications Safety 44 44 46 Normal anatomy and physiology Chambers Valves Vessels Septa 50 50 53 63 69 Ventricular function LV systolic function LV diastolic function RV function 75 75 80 85 Cardiomyopathies Hypertrophic obstructive cardiomyopathy Dilated cardiomyopathy Restrictive cardiomyopathy 89 89 90 91 vi Contents Valvular heart disease Mitral valve Aortic valve Tricuspid valve Pulmonary valve Valve surgery 94 94 101 105 107 108 Cardiac masses Tumours Thrombus Pseudomasses Vegetations 115 115 118 118 120 Congenital heart disease Valve defects Ventricular defects Great vessels ASD VSD 122 122 123 124 126 128 Extracardiac anatomy Pericardium Aortic disease 132 132 136 10 Haemodynamic calculations Doppler equation Bernoulli equation Intracardiac pressures Flow Aortic valve Mitral valve 140 140 140 140 141 141 141 MCQ answers 144 References 147 Index 149 viii List of abbreviations DF DT EF ERO ET fD FD FO FS HOCM HV HVLT I IAS ICU IHD IPP IRC ITC IVC IVRT IVS LA LAA LAD LAP LARRD LATA LAX LBBB LCA LCC LCCA LCx LGC duty factor deceleration time ejection fraction effective regurgitant orifice ejection time Doppler frequency focal depth foramen ovale fractional shortening hypertrophic obstructive cardiomyopathy hepatic vein half value layer thickness intensity interatrial septum intensive care unit ischaemic heart disease intrapericardial pressure intensity reflection coefficient intensity transmitted coefficient inferior vena cava isovolumic relaxation time interventricular septum left atrium left atrial appendage left anterior descending coronary artery left atrial pressure longitudinal resolution lateral resolution long axis view left bundle branch block left coronary artery left coronary cusp left common carotid artery left circumflex coronary artery lateral gain compensation List of abbreviations LLPV LPA LSCA LSE LUPV LV LVEDP LVEDV LVESV LVH LVIDd LVIDs LVM LVOT LVP LVSP MAPSE MG MI MM MR MRI MV MVA MVC MVL MVO NCC P PA PADP PAP PD PDA PE left lower pulmonary vein left pulmonary artery left subclavian artery left sternal edge left upper pulmonary vein left ventricle left ventricular end diastolic pressure left ventricular end diastolic volume left ventricular end systolic volume left ventricular hypertrophy left ventricular internal diameter in diastole left ventricular internal diameter in systole left ventricular mass left ventricular outflow tract left ventricular pressure left ventricular systolic pressure mitral annular plane systolic excursion mean gradient myocardial infarction motion mode mitral regurgitation magnetic resonance imaging mitral valve mitral valve area mitral valve closes mitral valve leaflet mitral valve opens non-coronary cusp power pulmonary artery pulmonary artery diastolic pressure pulmonary artery pressure pulse duration patent ductus arteriosus pulmonary embolism ix x List of abbreviations P/E PFO PG PHT PI PISA PM P/M PMVL PRF PRP PS PV PVs PW PWD PZT-5 RA RAP RBBB rbc RCA RCC RF RLN RLPV RPA RSE RUPV RV RVH RVOT RVP RVSP RWMA piezo-electric patent foramen ovale pressure gradient pressure half-time pulmonary incompetence proximal isovelocity area papillary muscle postero-medial posterior mitral valve leaflet pulse repetition frequency pulse repetition period pulmonary stenosis pulmonary valve pulmonary veins pulse wave pulse wave Doppler lead zirconate titanate – right atrium right atrial pressure right bundle branch block red blood cell right coronary artery right coronary cusp regurgitant fraction recurrent laryngeal nerve right lower pulmonary vein right pulmonary artery right sternal edge right upper pulmonary vein right ventricle right ventricular hypertrophy right ventricular outflow tract right ventricular pressure right ventricular systolic pressure regional wall motion abnormality List of abbreviations SAM SAN SAPA SATA SATP SAX SBP SCA SLE SPL SPPA SPTA SPTP STJ SV SVI SVR TA TAA TAPSE TAPVD TB Td TDI TGA TGC TMF TOE TR TS TTE TTF TV TVA TVC systolic anterior motion sino-atrial node spatial average, pulse average spatial average, temporal average spatial average, temporal peak short axis view systolic blood pressure sickle cell anaemia systemic lupus erythematosus spatial pulse length spatial peak, pulse average spatial peak, temporal average spatial peak, temporal peak sino-tubular junction stroke volume stroke volume index systemic vascular resistance truncus arteriosus thoracic aortic aneurysm tricuspid annular plane systolic excursion total anomalous pulmonary venous drainage tuberculosis time delay tissue Doppler imaging transposition of great arteries time gain compensation transmitral flow transoesophageal echocardiography tricuspid regurgitation tricuspid stenosis transthoracic echocardiography transtricuspid flow tricuspid valve tricuspid valve area tricuspid valve closes xi xii List of abbreviations TVL TVO TX U/S Vcf VSD VTI WPW Z tricuspid valve leaflet tricuspid valve opens transducer ultrasound velocity of circumferential fibre shortening ventricular septal defect velocity–time integral Wolfe–Parkinson–White syndrome impedance xiv Foreword (BSE) to establish an accreditation process in TOE with its first examination held in the UK in 2003 Since then the European Association of Cardiothoracic Anaesthesiologists (EACTA) and the European Society of Echocardiography (ESE) produced its own European TOE examination and accreditation process in 2005 In 2004, the Japanese Society of Cardiovascular Anesthesiologists launched their first TOE competency examination The purpose of these accreditation processes is to enable recognition of special competence in perioperative echocardiography against an objective standard, and all of them consist of two parts With the practical part, the candidate must demonstrate adequate training and competency through a supervised residency program or logbook The theoretical part requires the successful completion of a multiple choice and image clip examination With his experience in learning, practicing and teaching perioperative echocardiography in North America and in the UK, the author fills a certain niche with this book It is not intended to be a comprehensive reference book In contrast to the vast amount of information on echocardiography already available both in print and online, this book provides the aspiring echocardiographer with a valuable summarized resource to prepare for any of the perioperative echocardiography examinations It gives any examination candidate a convenient framework onto which further knowledge can be added Both the American and the European perioperative TOE examination syllabus is well covered in a concise manner The Perioperative Transoesophageal Echocardiography Exam Notes contains all the critical physics equations, standard values and plenty of diagrams in a highly absorbable way Each chapter also concludes with a series of exam-style self-assessment questions to emphasize important facts and practice for the exam Cardiac surgery and anaesthesia have come a long way since the late 1970s when TOE was introduced into the perioperative arena The development of many surgical procedures and the reduction in perioperative morbidity and mortality can be directly related to the use Foreword of TOE There rests a great responsibility on any clinician performing a diagnostic perioperative TOE This book will certainly contribute not only to help preparation for the examinations, but also to raise the standard of our practice and patient care Steve Konstadt Justiaan Swanevelder xv ... Vegetations 11 5 11 5 11 8 11 8 12 0 Congenital heart disease Valve defects Ventricular defects Great vessels ASD VSD 12 2 12 2 12 3 12 4 12 6 12 8 Extracardiac anatomy Pericardium Aortic disease 13 2 13 2 13 6 10 Haemodynamic... published in print format 2007 eBook (EBL) ISBN -13 978-0- 511 -27 815 -0 ISBN -10 0- 511 -27 815 -2 eBook (EBL) paperback ISBN -13 978-0-5 21- 68960 -1 paperback ISBN -10 0-5 21- 68960-0 Cambridge University Press has... equation Intracardiac pressures Flow Aortic valve Mitral valve 14 0 14 0 14 0 14 0 14 1 14 1 14 1 MCQ answers 14 4 References 14 7 Index 14 9 viii List of abbreviations DF DT EF ERO ET fD FD FO FS HOCM