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 First published in print format ISBN-13 978-0-521-68960-1 ISBN-13 978-0-511-27815-0 © Cambridge University Press 2007 Every effort has been made in preparing this publication to provide accurate and up-to- date 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. 2007 Information on this title: www.cambridge.org/9780521689601 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 p ermission of Cambrid g e University Press. ISBN-10 0-511-27815-2 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 g uarantee that any content on such websites is, or will remain, accurate or a pp ro p riate. Published in the United States of America by Cambridge University Press, New York www.cambridge.org paperback eBook (EBL) eBook (EBL) paperback Contents List of abbreviations page vii Foreword xiii 1Physics of ultrasound 1 Basic principles 1 Transducers 13 Imaging 22 Doppler 29 Artefacts 35 2 Guidelines and safety 44 Indications 44 Safety 46 3 Normal anatomy and physiology 50 Chambers 50 Valves 53 Vessels 63 Septa 69 4Ventricular function 75 LV systolic function 75 LV diastolic function 80 RV function 85 5 Cardiomyopathies 89 Hypertrophic obstructive cardiomyopathy 89 Dilated cardiomyopathy 90 Restrictive cardiomyopathy 91 vi Contents 6Valvular heart disease 94 Mitral valve 94 Aortic valve 101 Tricuspid valve 105 Pulmonary valve 107 Valve surgery 108 7 Cardiac masses 115 Tumours 115 Thrombus 118 Pseudomasses 118 Vegetations 120 8Congenital heart disease 122 Valve defects 122 Ventricular defects 123 Great vessels 124 ASD 126 VSD 128 9Extracardiac anatomy 132 Pericardium 132 Aortic disease 136 10 Haemodynamic calculations 140 Doppler equation 140 Bernoulli equation 140 Intracardiac pressures 140 Flow 141 Aortic valve 141 Mitral valve 141 MCQ answers 144 References 147 Index 149 viii List of abbreviations DF duty factor DT deceleration time EF ejection fraction ERO effective regurgitant orifice ET ejection time f D Doppler frequency FD focal depth FO foramen ovale FS fractional shortening HOCM hypertrophic obstructive cardiomyopathy HV hepatic vein HVLT half value layer thickness I intensity IAS interatrial septum ICU intensive care unit IHD ischaemic heart disease IPP intrapericardial pressure IRC intensity reflection coefficient ITC intensity transmitted coefficient IVC inferior vena cava IVRT isovolumic relaxation time IVS interventricular septum LA left atrium LAA left atrial appendage LAD left anterior descending coronary artery LAP left atrial pressure LARRD longitudinal resolution LATA lateral resolution LAX long axis view LBBB left bundle branch block LCA left coronary artery LCC left coronary cusp LCCA left common carotid artery LCx left circumflex coronary artery LGC lateral gain compensation List of abbreviations ix LLPV left lower pulmonary vein LPA left pulmonary artery LSCA left subclavian artery LSE left sternal edge LUPV left upper pulmonary vein LV left ventricle LVEDP left ventricular end diastolic pressure LVEDV left ventricular end diastolic volume LVESV left ventricular end systolic volume LV H left ventricular hypertrophy LVIDd left ventricular internal diameter in diastole LVIDs left ventricular internal diameter in systole LV M left ventricular mass LVOT left ventricular outflow tract LV P left ventricular pressure LVSP left ventricular systolic pressure MAPSE mitral annular plane systolic excursion MG mean gradient MI myocardial infarction MM motion mode MR mitral regurgitation MRI magnetic resonance imaging MV mitral valve MVA mitral valve area MVC mitral valve closes MVL mitral valve leaflet MVO mitral valve opens NCC non-coronary cusp P power PA pulmonary artery PADP pulmonary artery diastolic pressure PAP pulmonary artery pressure PD pulse duration PDA patent ductus arteriosus PE pulmonary embolism [...]... 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 19 70s when TOE was introduced...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... 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... 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... 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... 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... 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 . format ISBN -1 3 97 8-0 -5 2 1- 6 896 0 -1 ISBN -1 3 97 8-0 - 51 1-2 7 81 5-0 © Cambridge University Press 2007 Every effort has been made in preparing this publication to provide accurate and up-to- date information. University Press. ISBN -1 0 0-5 1 1-2 7 81 5-2 ISBN -1 0 0-5 2 1- 6 896 0-0 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites. 11 8 Pseudomasses 11 8 Vegetations 12 0 8Congenital heart disease 12 2 Valve defects 12 2 Ventricular defects 12 3 Great vessels 12 4 ASD 12 6 VSD 12 8 9Extracardiac anatomy 13 2 Pericardium 13 2 Aortic disease 13 6 10