(BQ) Part 2 book Board stiff tee - Transesophageal echocardiography presents the following contents: Left ventricular systolic function, the 17 segment model, congenital heart disease, artifacts and pitfalls, related diagnostic modalities, sonographic formulas, test questions,...
CHAPTER 13 Left Ventricular Systolic Function Eric W Nelson For some reason there is a lot of focus on the left ventricle and its evaluation on TEE, both in the operating room and on the boards This most likely has to with the fact that it’s pumping blood to the entire body, thus keeping you alive The easiest way to start your evaluation of the left ventricle is to know what a normal left ventricle looks like The shape of the LV should look somewhat like a football If you drop a TEE probe in someone and the heart is closer to a basketball than a football, something is wrong So, now you know how to eyeball the heart and tell grossly if it’s normal or not, but what about an actual measurement? LV function is typically measured numerically by the ejection fraction (EF) That is, how much blood that goes into the LV goes out through the aorta? Good Bad EF can be calculated by measuring the fractional area of change (FAC) of the left ventricle A true long- or short-axis cross section is required being careful not to foreshorten Foreshortening is a term commonly used by echocardiographers to describe the heart when it is compressed because of the viewpoint taken With modern TEE machines all you have 123 124 Board Stiff TEE to is outline the end-diastolic area and the end-systolic area and the machine will crunch the numbers FAC = (end-diastolic area – end-systolic area)/end-diastolic area You can also estimate EF via the eyeball method, which is what most people On the test you should be able to look at an image and determine the difference between an EF of 25% and 55% Which is pretty easy! One thing to keep in mind whether using the eyeball method or doing an actual measurement is don’t jump to conclusions based on one view A single slice may look great, but remember it’s only part of the heart and another part may not look so good Also, if you are foreshortening or not getting a “true” cut of the LV your read is going to be off Make sure you eyeball the LV with multiple omniplane angles and also in both the transgastric and midesophageal views ABNORMAL LV SYSTOLIC FUNCTION Naturally, the first thing that comes to mind is ischemia…if this wasn’t your first thought you may want to retake your boards There are also a lot of other things that may cause abnormal LV function n Ischemia, just can’t say it enough n Ventricle—infiltrative diseases that cause restrictive physiology such as amyloidosis cause global impairment n Pericardial space—tamponade either from an effusion or blood TEE is great at not only making this diagnosis, but also locating where the effusion is around the heart and whether it is loculated n Pleural space—tension pneumothorax causes decreased venous return thus decreasing preload and ventricular function n Metabolic—hypoxemia, hypoglycemia, anemia, hyperkalemia, and a vast array of other metabolic abnormalities CARDIOMYOPATHIES Hypertrophic There are four different types of hypertrophic cardiomyopathies, although the most famous is septal hypertrophy leading to subaortic stenosis or “hypertrophic obstructive cardiomyopathy”, which all the cool kids just call HOCM (pronounced hokum) HOCM is an inherited cardiomyopathy It is autosomal dominant with limited penetrance, unless of course you are the patient then it is a very penetrating diagnosis! Chapter 13 Left Ventricular Systolic Function With hypertrophic cardiomyopathies systolic function typically is not the problem, rather the heart has a hard time relaxing, like that one attending we’ve all had with the vein in his forehead that seems to keep growing and may pop at any minute! An important point about HOCM is the picture you see on TEE Some people call this the “dagger sign” When a continuous wave Doppler is placed across the left ventricular outflow tract, or LVOT, and the AV the outflow pattern will resemble a dagger rather than the nice rounded appearance of someone without this problem This is secondary to the ventricle being so empty at the end of systole and the septum being so huge an obstruction actually occurs HOCM AS Keep in mind that patients with HOCM are also more prone to SAM or systolic anterior motion of the mitral valve Since the outflow tract is already narrow, it’s easy for the anterior leaflet to get sucked in and impede flow The definitive answer to relieving HOCM is surgical resection of the septum TEE plays an important role here in order to determine preop if the surgery is necessary and postop if there was enough septum resected, not enough, or too much If not enough was taken the obstruction will remain, but if the surgeon got a little greedy the patient may end up with a VSD Also remember that there are conduction fibers running through the septum It’s not uncommon to have a heart block after this type of surgery Too Little Too Much Just Right 125 126 Board Stiff TEE Medical management of HOCM involves keeping the heart full; remember that the obstruction occurs when the heart is empty; and also decreasing contractility Restrictive Sometimes the only way to tell the difference between a hypertrophic and restrictive cardiomyopathy is by looking at the posterior basal wall of the heart This is best appreciated in the transgastric short-axis views Remember, in hypertrophic cardiomyopathies the posterior basal wall is spared, but in restrictive cardiomyopathies it is not Oh yeah, don’t forget that a good history and physical can also help determine the type of cardiomyopathy as well Restrictive Hypertrophic Alright, we’ve determined that we have a restrictive cardiomyopathy, but where’d it come from? Well, the list is long and distinguished There are a lot of things that can “sneak” into the myocardium and cause restriction: n amyloid n sarcoid n glycogen from patients with glycogen storage disease n eosinophils from eosinophilic myocarditis (also known as Loffler’s) Like hypertrophic cardiomyopathies, restrictive cardiomyopathies mainly present a problem in diastole that is the heart does not relax well enough to accept blood Remember to go over the various diastolic E/A patterns and pulmonary venous flow because these show up on the test! Patients with restrictive heart disease are also prone to thrombus formation even without a wall motion abnormality Thrombi are typically found in the apex Remember, the apex of the heart is best visualized in the mid-esophageal 2-chamber view and the mid-esophageal 4-chamber view Thrombi may also form under the posterior mitral valve leaflet, which may lead to a bit of mitral regurgitation Chapter 13 Left Ventricular Systolic Function Dilated Remember at the beginning of this chapter when I mentioned that the heart shouldn’t look like a basketball? Well that’s exactly what this type of heart looks like It’s big, the walls are thin, and it really isn’t doing much at all Keep your eye out for thrombi, as there isn’t much going on so clot formation is possible Clot Like everything else there is a list of what causes dilated cardiomyopathy n Ischemic n Post viral n Peripartum n Alcohol n Idiopathic (a doctor’s way of saying “I just don’t know”) n And numerous others QUESTIONS Which wall is spared in hypertrophic cardiomyopathy? A Inferiolateral B Posterior basal C Septal D Apical anterior E Anteroseptal Which of the following may cause cardiomyopathy? A Pregnancy B Ischemia C Alcohol D Virus E All of the above F B and D 127 128 Board Stiff TEE Where is the most likely place to find thrombus in the LV? A Apex B LVOT C Basal septal wall D Lateral wall Treatment for HOCM includes all of the following except: A Surgical resection B Alcohol C Beta blockade D Inotropic agents E Increased preload What causes hemodynamic compromise in patients with HOCM? A Anatomic outflow tract obstruction B Physiologic outflow tract obstruction C Decreased EF D Restrictive myocardium Which of the following causes restrictive cardiomyopathy? A Concentric hypertrophy B Alcohol C Ischemia D Iron overload E Celiac disease Which of the following patients are prone to LV thrombus formation: A Atrail fibrillation B Hypertrophic cardiomyopathy C Restrictive cardiomyopathy D Pericardial tamponade E Severe MR A problem in which of the following spaces may affect LV systolic function? A Pericardium B Pleura C Ventricle D Metabolism E A, B, and C F All of the above True or false: It is possible to evaluate the ejection fraction of the heart by one view on TEE A True B False 10. Which view is the best to evaluate HOCM A Mid-esophageal chamber B Mid-esophageal chamber C Deep transgastric D Transgastric short axis E A and C Chapter 13 Left Ventricular Systolic Function ANSWERS B E A D B D C F B 10 E 129 This page intentionally left blank CHAPTER 14 Segmental Left Ventricular Systolic Function John C Sciarra and Christopher J Gallagher MYOCARDIAL SEGMENT IDENTIFICATION Hear ye, hear ye The Office of Homeland Security is not going to shoot me for revealing any state secrets here You will need to know these segments and you will need to know which coronaries feed which walls and which segments I kid thee not I speak not with forked tongue This is a for sure on the test The first time you see it you’ll quasi freak, because it looks so complex, but when you think of all the other stuff you memorized to get this far, it’s not so bad Plus there’s a logic to it, so don’t go off the deep end First, the whole thing, then we’ll back up and break it down A SEGMENTS—DON’T FREAK B DONUT AT EACH SLICE I Basal Mid S Apical Not in apical C Not in apical P WHICH LEVEL IS DONUT? Basal? (see MV) D L AS A WHICH WALL IS WHICH? Septal ME 4-Chamber Mid? (see Paps) Apical (nothing) Lateral Inferior ME 2-Chamber Anterior ME LAX Posterior Anteroseptal 131 132 Board Stiff TEE I found it easiest to start with the cross sections That way you can at least always know what’s “directly across” from you Then you can take the long views and start to put it together So, think of three of these lying on top of each other, starting at the top of the ventricle, right next to the mitral valve Three layers of six: The basal segments are next to the mitral valve The middle segments are next down, at the level of the papillary muscles The lower, or apical, segments come next BUT WAIT! Though it would make sense to 6/6/6, the SCA (perhaps fretting about the demonic number 666 from The Omen), only recognizes four segments in the ever-narrowing apex Lose the posterior and the anteroseptal segments there In the apical, you just have inferior, anterior (across from each other, remember), and septal and lateral (across from each other too) Now, put it back together, piece by piece, until it makes sense If you are still confused, stay tuned for the 17 segment chapter CORONARY ARTERY DISTRIBUTION AND FLOW REAL WORLD NOTE Major, major importance that you know this This ties in with the extremely practical dilemma that you face on a daily basis: “Is the new graft working?” If a wall fed by, say, the right coronary graft was working, and now is not working, hey, look at the graft for kinks, disconnects, clots, dissections It’s a hell of a lot easier to recognize the problem and fix it now than to find out later and lose a chunk of myocardium TEST NOTE Vintage testable material here, folks A little brutal memorization (come on, there are only three vessels, it’s not that bad) and you should nail these questions Chapter 24 Test Questions C Offers a better assessment of individual patient anatomy D Allows enhanced real-time velocity determinations 20-2 3D TEE probes utilize: A 128 piezelectric crystals B 2500 active elements C A trapezoidal image D Movement of the transducer to create images 20-3 True concerning 3-D TEE A Dispersion is the technique when data are converted to Cartesian coordinates B Extrapolation is the technique used to fill in data between the coordinates C Data acquisition takes place, followed by RAM storage, conversion, and interpolation D 2-D echoes are interpolated to form 3-D echoes 20-4 In 3-D imaging techniques, the poorest temporal resolution is associated with: A Live B Live zoom C Full volume 20-5 True about 3-D imaging: A Volume techniques can be generated in one heartbeat B Current systems allow line measurements within a 3-D volume C A grid of dots can currently be overlaid on a 3-D image to estimate length ANSWERS | Chapter 20: Intraoperative 3-D Echocardiography 20-1 D 20-2 B 20-3 C 20-4 B 20-5 C QUESTIONS | Chapter 21: The Structured TEE Examination 21-1 In the ME chamber view; the following walls of the left ventricle are seen: A Anteroseptal and posterior B Anterior and inferior 269 270 Board Stiff TEE C Septal and basal D Posteroseptal and lateral 21-2 The ME commissural view of the mitral valve (60 degrees) is most notable in that: A Only the a2 leaflet of the mitral valve is seen B P3 of the posterior, a2 of the anterior, and p1 of the posterior are the most frequently seen cusps C Only the posterior leaflets are seen D The LV is seen in short axis 21-3 The view used to create the most parallel and precise continuous wave assessment of velocity of blood flow in the ascending aorta is: A AV sax B Deep transgastric C AV lax D Epiaortic sax 21-4 The best view for simultaneous assessment of the tricuspid valve and pulmonic valve is: A ME sax B ME lax C RV inflow outflow D TG short axis 21-5 The best view for identifying coronary sinus, IVC, SVC, and the foramen ovale is: A 4-chamber degrees B 2-chamber 60 degrees C ME lax 135 degrees D ME bicaval view ANSWERS | Chapter 21: The Structured TEE Examination 21-1 B 21-2 B 21-3 B 21-4 C 21-5 D QUESTIONS | Chapter 22: Sonographic Formulas 22-1 Stroke volume equals: A AVA × peak vel B AVA × TVIav Chapter 24 Test Questions C AVA × TVIlvot D CSAlvot × TVIav 22-2 All true about PHT except: A Rate of decline in pressure through a valve over time B Time for peak pressure in a system to decline to ½ C Time of PHT = peak velocity/square root of D Equal to 0.29 × DT 22-3 MVA for stenotic valve: A 220/.29 × DT B 220 × PHT C PHT/220 D 0.29 × DT 22-4 All true for PISA determination of MVA except: A Angle correction of alpha/180 is used because the mitral valve is “tented” when closed and the isovelocity figure measured is less than hemisphere in size B pi r2 is the area of a hemisphere C ‘r’ is measured at the first isovelocity line D The determination is made during systolic ANSWERS | Chapter 22: Sonographic Formulas 22-1 B 22-2 A 22-3 A 22-4 D 271 This page intentionally left blank Epilogue: Smooth Sailing “Nothing ever happens on my voyages.” Edward Smith Captain of the Titanic There you have it TEE in a nutshell Now, whether you decide to make TEE a part of your OR, ER, or ICU practice, I wish you smooth sailing, just like Captain Smith had (At least for the first half of his trip.) If you decide to take the PTEeXAM, best of luck I hope this simplified introduction helped to clarify a point or two about the groovalacious world of transesophageal echocardiography See you under a bridge somewhere! Christopher J Gallagher 2013 273 This page intentionally left blank Index Note: Page numbers followed by “f ” and “t” refers to figures and tables respectively A A (atrial) wave 73, 93 Abdominal aorta 84 Acoustic imaging, assumptions 174 Air dilemma Air, intracavity 153 Aliasing 30–31, 30f, 31f ‘Alphabet’, transesophageal echocardiography (TEE) 68f, 204f, 207f Aneurysms aortic 87, 87f, 89 left ventricular 135–136 sinus of Valsalva 87, 167 ruptured 167 Angiosarcoma 117 Anterior wall 68f, 71 Anteroseptal wall 71 Aorta anatomy 84–86, 85f, 86f pericardial layers 82 see also Ascending aorta; Descending aorta Aortic annulus 100–101, 101f calcification 102t dilation 102t Aortic arch (AA) 78–79, 85 dissections 89 imaging 208, 208f descending short axis (SAX) view 208, 208f Aortic cannula 150 Aortic conditions aneurysm 87, 87f, 89 inflammation/coarctation/infection 91 plaque 89–90 pseudoaneurysm 87–88 surgery 89 thrombus 91 trauma 90–91 Aortic dissection 88–89 classification 88–89 Aortic root 77–78, 77f, 84 Aortic valve (AV) 72, 98–100, 107 annulus 84 area, calculation 215–217, 228–229, 242, 244 bicuspid 98, 98f, 169 gradient, calculation 217–218 imaging 100–101, 206–207, 206f deep transgastric views 62, 68f, 108–109, 109f, 206–207, 206f ME AV LAX view 68f, 100–101, 101f, 107–108, 206–207, 206f ME AV SAX view 68f, 107, 206, 206f insufficiency 78, 102t, 108, 110 leaflets 107–108 left ventricle assist device (LVAD) 151–152 left ventricular outflow (LVOT) 62–63 M-mode 40–41, 40f normal 110, 110f problems, causes 99t regurgitant fraction, calculation 231 regurgitant orifice area, calculation 231–232 regurgitant volume, calculation 230–231 repair 159 stenosis 98, 102t, 107–108, 108f, 110–111, 110f classification 109 senile calcific 98, 98f, 107–108, 108f stroke volume, calculation 244 systolic blood velocities 97 Arrays 12–13, 13f Artifacts 173 attenuation errors 182–185, 183f, 184f Doppler 185–186, 186f mimics 116, 186–188, 186f, 187f, 188f multiple echoes 176–180, 177f, 178f, 179f types 174–185 US beam characteristics 174–176, 175f, 176f velocity errors 180–182, 181f, 182f Ascending aorta 78–79, 84 dissections 89 views, ME long axis (LAX)/short axis (SAX) 68f Atheromas 90 Atherosclerosis 89–90 Atherosclerotic plaque 90 Atrial cannula 150 Atrial reversal 61 Atrial septal defects 163, 167–168 primum 168 secundum 168 sinus venosus 168 Atrio-ventricular valve 166 Atrium anatomic variants 115–116 imaging 207–208, 207f ME bicaval view 208, 208f 275 276 Index Attenuation 6, 174, 182 errors, artifacts 182–185, 183f, 184f Axial resolution 12, 12f Azygos vein 78, 94 B BART (blue away red towards) acronym 28 Beam angle 32–36, 32f characteristics 174–176, 175f, 176f focal zone 12, 12f formation 11 width 175, 175f, 185–186, 186f Bernoulli equation 50, 214, 217, 236–237, 245 modified 100, 110–111 Bicuspid aortic valve 98, 98f, 163, 169 Biplanes, 3-D guided 200 Björk–Shiley valve 157 Blalock–Taussig operation 165 Blood flow reversal 106 B-mode 15, 16f, 27, 27f Bounce technology Breast cancer 118 Breathing, spontaneous 83 Bypass assessment 149, 153 see also Coronary artery bypass graft (CABG) C Calcifications 88 leaflet 102t senile aortic stenosis 98, 98f, 107–108, 108f senile degeneration 98 Calculations see Measurements Cancer breast 118 lung 118 Carbomedics valve 157–158, 157f Carcinoid 118 Carcinoma, renal cell 118 Cardiac anatomy 67 imaging planes 67–71, 68f Cardiac arrest, unexpected intraoperative 91 Cardiac chambers anatomy 68f, 71–72, 72f collapse 84 pressures 50–51, 51f Cardiac cycle 72–74 Cardiac devices 149–150, 150f circulatory assist 150–153, 151f, 152f see also Cardiac masses Cardiac index, calculation 214, 241–242 Cardiac masses 115 atrial anatomic variants 115–116 benign primary 116–119 common, schematic representation 118–119, 118f imaging modalities 118–119 malignant primary 117–118 metastatic 118 mimics 115–116 valvular anatomic variants 116 ventricular anatomic variants 116 Cardiac output, calculation 213–214, 227, 232, 241–242, 244, 246 Cardiac surgical techniques 149–155 bypass/cardioplegia assessment 149 cannulas/devices 149–150, 150f circulatory assist 150–153, 151f, 152f cardiopulmonary bypass, minimally invasive 153 intracavity air 153 off-pump 153–155 Cardiac valves anatomy 72 variants 116 area 49–50, 97 gradients 49–50 imaging 205–207 normal values 98f pathology 97, 99t, 102t surgery 156–158 repair 159–160 systolic blood velocities 97 valve types 156 see also specific valves Cardiac walls, anatomy 68f, 71–72, 72f Cardioplegia assessment 149 Cardiopulmonary bypass, minimally invasive 153 Cardiovascular instability 156 coronary artery bypass graft (CABG) 155 Carotid arteries 78 left 85 Carpentier–Edwards valve 158, 158f Case studies 211 Celiac trunk 79, 85 Central venous pressure (CVP) 73, 147 Chiari network 115, 188 Chronic pulmonary vasculature strain 91 Cine loop technology 43 Circulatory assist devices 150–153, 151f, 152f Clotted blood 80–81 CME Unlimited Coarctation of aorta 163 Color flow Doppler (CFD) 28, 98–100, 102t, 186 Comet tail artifact 178 Comprehensive Review of Intraoperative Echocardiography (echo meeting) Compression 3, 6f Congenital heart disease 163 atrial septal defects 167–168 bicuspid aortic valve 169 communication, intraoperative 165–166 findings 149–150 history 149–155 left ventricular outflow abnormalities 169 Index operation names 149–150 patent ductus arteriosus 169 perimembranous 167 persistent left superior vena cava (PLSVC) 168 pulmonary valve stenosis 168 terminology 163–164 tricuspid valve, Ebstein’s abnormality 170 venous blood flow 165 see also Ventricular septal defect (VSD) Connective tissue disorders 87 Constrictive pericarditis 84 Continuity equation 100, 215, 234–235 essence of 50f Continuous wave (CW) Doppler 28, 28f, 47, 98–100, 107 Contrast echocardiography 119, 192 Conversion, raw data 197 Coronary angiography vs transesophageal echocardiography (TEE) 192 Coronary arteries 85 anatomy 143 distribution 132–133, 133f, 143f flow 132–133, 133f memory helper 133 sinus, unroofed 168 surgical techniques 155 Coronary artery bypass graft (CABG) 156 off-pump 153 on-pump 155 Coumadin ridge 115, 187 Crista terminalis 115, 188 Crystal thickness 10 D D (diastolic) wave 61, 93 Dagger sign 124–125 Damping 11 Damus Kaye Stansel operation 165 Data processing 197 Data storage, temporary 197 Deceleration time (DT) 61 Deep transgastric (TG) plane 68 long axis (LAX) view, aortic valve (AV) 62, 68f, 108–109, 109f, 206–207, 206f Depth 14 gain compensation 14 Descending aorta 84–85 long axis (LAX) view 68f short axis (SAX) view 68f aortic arch (AA) 208, 208f thoracic 78, 84–85 Devices see Cardiac devices Diagnostic modalities 191 Diastole 51, 51f Diastolic function, assessment 55, 62t aortic valve (AV)/left ventricular outflow (LVOT) 62–63 history 59 left atrium, size 59 mitral valve (MV)/left ventricular inflow 57–58, 57f non-valvular flow 63–64 pulmonary valve/right ventricular outflow 56–57, 56f pulmonary veins inflow 60, 60f, 63–64 tricuspid valve/right ventricular inflow 55–56, 56f Valsalva maneuver 59–60 see also Heart Diastolic pressure left ventricular, calculation 232–233 pulmonary artery 235 Dilated cardiomyopathy 127 Dimensionless index 110–111 Displays 15, 15f Distraction 13 Doppler Effect 100 Doppler shift equation 25–26 derivation 32–35, 32f, 34f Doppler ultrasound, principles 25 artifacts/pitfalls 185–186, 186f B-mode 27, 27f beam angle 32–36, 32f color flow Doppler 28, 98–100, 102t, 186 continuous wave (CW) 28, 28f, 47, 98–100, 107 high pulse repetition frequency (HPRF) mode 31–32 M-mode 27, 27f Nyquist limit/aliasing 30–31, 30f, 31f, 35 profiles 55 pulse wave (PW) 29, 29f, 35, 47, 98–100 quantitative 47 range ambiguity 29–30, 29f tissue reconstruction 26–27 two dimensional (2-D) images 27, 27f Double envelope 110–111 Down’s syndrome 167 Dropout phenomena 176 E Ebstein’s anomaly of tricuspid valve 163, 170 Echo probes 19 cleaning 20–22 insertion 21 matrix array 197 problems 20–21 three dimensional (3-D) 196–198 transportation 20 use 21 Edge components, M-mode 39 recognition, M-mode 39 shadow 176, 176f Eisenmenger syndrome 167 Ejection fraction (LVEF), left ventricular 43, 123 277 278 Index Electrocardiography (ECG) 72 vs transesophageal echocardiography (TEE) 192 Electronic interface 185 Embolism 159 Endocarditis 159 Epicardial pacing 188 Epicardial scanning 191 Equipment 19–20 cleaning 20–22 ergonomics 21–22 see also Echo probes Esophagus 78–79, 80f Eustachian valve 115, 188 Examination, transesophageal echocardiography (TEE) 203 preliminary checks 203 structures 207–208 valves 205–207 ventricular function 203–205 Expiration, spontaneous 83 F False chords 116 False lumens 88 Fenestrations 88 Fibroelastoma, papillary 117 Fibroma 117 Fish mouth 68f, 169, 205–206 Fluid pericardial 81–82 transesophageal echocardiography (TEE) 80, 81f Focusing 11, 11f Fontan, defined 165 Foreign bodies atrial 116 ventricular 116 Four-chamber view 71 see also Midesophageal (ME) Chamber view Frequency 3, 4f, 14 G Gain 14 Gastric lining 80 Gastric window 94 ‘Gate’ 93–94 Gebode defect 167 Ghosting 186 Glenn operation 165 Gologorsky method 191 Gradient essence 51f tissue valves 159 Grating lobes 174 Great vessel pressures 50–51, 51f H Hancock valve 158, 158f Heart see also Cardiac entries cross section 141f disease see Congenital heart disease images 142f, 143f impaired filling 58–59, 58f, 61f normal 58, 58f, 60, 61f pseudonormal 58f, 59–61, 61f restrictive flow 29f, 32–36, 61f transplantation 160 valves see Cardiac valves Hepatic veins 55–56, 64, 92–95 flow 101 Hepato-renal space 94 High pulse repetition frequency (HPRF) mode 31–32 High-frame rate-Doppler 47–48 Holodiastolic aortic flow reversal 110 Hologram displays 198 Hypertension 169 Hypertrophic obstructive cardiomyopathy (HOCM) 124–127, 125f, 126f Hypertrophy, lipomatous 116 Hypotension 147–149, 156 causes 147–148, 148f coronary artery bypass graft (CABG) 155 I Image display 3D 197 hologram 198 stereoscopic 198 Impella 152, 152f Incorrect gain 185 Inferior vena cava (IVC) 77, 77f, 79, 92–95, 93f Inferior wall 68f, 71 Innominate artery 84–85 Innominate vein 78–79 Inspiration, spontaneous 83–84 Instrumentation 13–15 Insufficiency, valves 97–98 aortic valve (AV) 78, 102t, 108, 110 causes 99t mitral valve (MV) 101 tricuspid valve 101 Interatrial septum, lipomatous hypertrophy 116 Intercostals 85 Internal jugular veins 78 Interpolation, raw data 197 Intra-aortic balloon pump 150–151, 151f Intra-cardiac masses see Cardiac masses Intracavity air 153 Ischemia 124 Isovolumic relaxation time (IVRT) 61 J Jugular veins, internal 78 Index K M Kidney 78–79, 94 Malignant melanoma 118 Marfan’s disorder 87 Matrix array 196–197 probe 197 Measurements case studies 211 M-mode 42–44 valve 49–50, 50f velocity 47 volumetric 48, 48f Mechanical ventilation 83–84, 84f Medtronic–Hall valve 157 Melanoma, malignant 118 Memory wall motion abnormality 134 Mercedes Benz sign 56, 206 Mesothelioma 117 Metabolic abnormalities 124 Metastatic cardiac masses 118 Midesophageal (ME) Chamber view 68f atrium 208 left ventricle 204, 204f mitral valve (MV) 205–206, 205f Midesophageal (ME) Chamber view 68f, 103, 103f atrium 208 left ventricle 203–204 mitral valve (MV) 205, 205f right ventricle 204–205 tricuspid/pulmonary valve 207, 207f Midesophageal (ME) aortic valve (AV) long axis (LAX) view 68f, 100–101, 101f, 107–108, 206–207, 206f short axis (SAX) view 68f, 107, 206, 206f Midesophageal (ME) ascending aortic view long axis (LAX) 68f short axis (SAX) 68f Midesophageal (ME) bicaval view 68f atrium 208, 208f Midesophageal (ME) left ventricle long axis (LAX) view 203f, 204 Midesophageal (ME) mitral commissural view 68f, 205–206, 205f Midesophageal (ME) plane 68 long axis (LAX) view 68f Midesophageal (ME) RV inflow-outflow view 68f atrium 208 right ventricle 204–205, 204f tricuspid/pulmonary valve 207, 207f Mimics artifacts 186–188, 186f, 187f, 188f cardiac masses 115–116 Minimally invasive cardiopulmonary bypass 153 Mirror images, artifacts 174, 179–180, 179f, 186 L Lambl’s excrescences 116, 187, 187f Lanimetry 109 Lateral resolution 12, 12f Latex 19 Leaflet calcification 102t Leaflet motion 102t Lecompte maneuver 164 Left atrium pressure, calculation 245 size 59 Left carotid artery 85 Left subclavian artery 85 dissections 89 Left ventricle (LV) assessment 200 assist device (LVAD) 151–152, 151f ejection fraction (LVEF) 43, 123 end-diastolic pressure, calculation 232–233 hypertrophy (LVH) 102t imaging 203–204, 203f, 204f regional function/wall motion 200 shape dilated 123–124, 123f normal 123, 123f, 125 systolic pressure, peak 218 volume 200 Left ventricular inflow, mitral valve (MV) 57–58, 57f, 61f Left ventricular outflow tract (LVOT) 49–50 abnormalities 169 aortic valve (AV) 62–63 stroke volume, calculation 219–220, 229–230, 241, 246 Left ventricular systolic function 123 abnormal 124 cardiomyopathies 124–127 segmental see Segmental left ventricular systolic function Leukemia 118 Ligamentum arteriosum 84 Lipoma 117 Lipomatous hypertrophy, interatrial septum 116 Liver 78–79, 94 left lobe 80 transplantation 161 Lumens false 88 true 88 Lung 78–79, 94–95 atelectasis 94 cancer 118 right 95 transplantation 160–161, 161f Lymphoma 118 279 280 Index Mitral valve (MV) 72, 98–100, 103, 166 area calculation continuity equation 234–235 PISA (proximal isovelocity surface area) 238 pressure half-time 104, 234, 237 gradient, calculation 236–237 imaging 205–206, 205f ME 4C view 103, 105 ME AV LAX view 100–101 three dimensional (3-D) 199–200 inflow patterns 103–104 insufficiency 101 leaflet 100–101, 101f left ventricular inflow 57–58, 57f, 61f M-mode 41, 41f problems, causes 99t regurgitation 64, 94, 102t, 103–106, 105f regurgitant fraction, calculation 221, 240 regurgitant orifice area, calculation 221–222, 240 regurgitant volume, calculation 221, 238–240 repair 159, 159f stenosis 98, 102t, 103–104, 104t stroke volume, calculation 220, 230, 238 systolic blood velocities 97 M-mode 16, 16f, 27, 27f aortic valve (AV) 40–41, 40f edge components 39 edge recognition 39 measurements/calculations 42–44 mitral valve (MV) 41, 41f quantitative 39 temporal resolution 40 ventricular wall assessment 42, 42f Moderator band 116, 186, 186f Morrison pouch 94 Multiple echoes, artifacts 176–180, 177f, 178f, 179f Mustard procedure 149, 164 Myocardial perfusion scanning 191 Myocardial segment identification 131–132, 131f Myocardial velocity 51 Myxoma 117 N Near field clutter 185 Nodules of Arantius (nodulus arantii) 116, 187, 187f Nyquist limit 30–31, 30f, 31f, 107–108 derivation 35 O Overriding aorta 163 defined 163–164 P P wave 72 Papillary fibroelastoma 117 Papillary muscles 116 Patent ductus arteriosus 169 Peak aortic valve (AV) area, calculation 215–217 Peak aortic valve (AV) gradient, calculation 217–218 Peak left ventricular systolic pressure, calculation 218 Peak right ventricular systolic pressure 214–215, 227–228, 247 Peak trans-mitral pressure gradient, calculation 236–237 Pectinate muscles 116, 187–188, 188f Pericardial space 124 effusion 82–83, 83f, 148f fluid 81–82 reflection 80 sac thickening 84 Pericardial-cardiac filling pressures 83 Pericarditis 82 constrictive 84 restrictive 84 Pericardium, anatomy/pathology 77–84, 77f, 80f, 81f, 82f, 83f, 84f Perioperative events/problems 147 cardiovascular instability 147–149 coronary surgical techniques 155 transplantation 160–162 see also Cardiac surgical techniques Persistent left superior vena cava (PLSVC) 168 Phased array 13 Piezoelectric crystals 196–197 Piezoelectric effect 9–10, 9f, 10f PISA (proximal isovelocity surface area) 47, 47f, 50, 106 PISA (proximal isovelocity surface area) calculations 222–223 area 237–238 mitral valve (MV) area 238 regurgitant flow rate 223 regurgitant fraction 224–225 regurgitant orifice area 224 regurgitant volume 224 Planimetry 215 Pleural space 78–79, 94–95, 124 effusions 94–95, 160–161, 161f, 187 Pneumothorax 94 Posterior wall 71 Potts operation 165 A Practical Approach to Transesophageal Echocardiography (Perrino & Reeves) Pressure half-time calculation, mitral valve (MV) area 234, 237 Primum, atrial septal defect 168 Probes see Echo probes Problems see Perioperative events/ problems Index Pseudoaneurysm 87–88, 136, 136f PTEeXAM 1, 11 see also Examination, transesophageal echocardiography (TEE) Pulmonary artery 79, 166 blood flow, calculation 247 diastolic pressure, calculation 235 main 77, 77f, 79 pathology 91–92 pericardial layers 82 right 79 shunt fraction, calculation 247 stroke volume, calculation 246 systolic pressure, calculation 242–243 Pulmonary embolism 91 Pulmonary (pulmonic) valve 55, 56f, 72, 106 continuous wave Doppler (CWD) 107 imaging 207, 207f ME AV SAX view 107 problems, causes 99t regurgitation 106 repair 160 right ventricular outflow 56–57, 56f stenosis 106–107, 163, 168 systolic blood velocities 97 Pulmonary veins 77, 77f, 79 flow 61, 61f, 101 inflow pattern 60, 60f, 63–64 right upper 79 systolic flow 102t Pulse repetition frequency (PRF) 47 Pulse wave (PW) Doppler 29, 29f, 35, 47, 98–100 Pulsus paradoxus 83 PV-Ar (atrial reversal part of pulmonary vein flow) 61 Q QRS complex 73 R Range ambiguity 29–30, 29f, 47, 185 Rarefaction 3, 6f Rastelli, defined 165 Reeves, Scott T Reflection 5, 6f Refraction 6, 6f, 174, 180–181 artifact 182, 182f Regional wall motion abnormality (RWMA) 196 Regional Wall Motion Unknown (tape) 134 Regurgitant flow rate, PISA (proximal isovelocity surface area) calculation 223 Regurgitant fraction, calculation aortic valve (AV) 231 mitral valve (MV) 221, 240 PISA (proximal isovelocity surface area) 224–225 Regurgitant orifice area, calculation aortic valve (AV) 231–232 mitral valve (MV) 221–222, 240 PISA (proximal isovelocity surface area) calculations 224 Regurgitant volume, calculation aortic valve (AV) 230–231 mitral valve (MV) 221, 238–240 PISA (proximal isovelocity surface area) 224 Regurgitation 98–100, 105 blood flow 106 mitral valve (MV) 64, 94, 102t, 103–106, 105f pulmonary valve 106 regurgitants 106, 106f tricuspid valve 64, 94, 104–106, 105f Renal arteries 85 Renal cell carcinoma 118 Rendering techniques 197–198 Resonance 10 Restrictive cardiomyopathy 126, 126f Restrictive pericarditis 84 Retrograde cannula 149–150, 150f Reverberation 174 artifact 176–178, 178f linear 178, 178f Rhabdomyoma 117 Rhabdomyosarcoma 117 Rheumatic heart disease 98, 98f Right ventricle (RV) 166 assessment 200 imaging 204–205, 204f strain 92 systolic pressure, peak 214–215, 227–228, 247 Right ventricular inflow, tricuspid valve 55–56, 56f Right ventricular outflow obstruction 163 pulmonary valve 56–57, 56f Ring down artifacts 178–179, 178f, 179f Ross procedure 158–159 RT3D software 201 S S (ventricular systole) wave 93–94 Safety 19–20 St Jude valve 157–158, 157f Sampling theory 29–30, 30f Sampling volume 93–94 Savage, Robert Scatter Secundum, atrial septal defect 168 Segmental left ventricular systolic function 131 aneurysm 135–136 assessment, methods 133–134 confounding factors 135 coronary artery distribution/flow 132–133, 133f differential diagnosis 134–135 rupture 136, 136f segment identification 131–132, 131f 281 282 Index Segmentation 197–198 Senile calcific aortic stenosis 98, 98f, 107–108, 108f Senile calcific degeneration 98 Septal hypertrophy 124 17 segment model 139, 139f, 140f, 141f transesophageal echocardiography (TEE) planes 144, 144f Shadowing 182 Shunt fraction, calculation 247 Side lobes 174–175, 176f Signal processing 16 Sinotubular junction 84 right 89 Sinus of Valsalva 84 aneurysms 87, 167 ruptured 167 Sinus venosus, atrial septal defect 168 Snell–Descartes law 180–181 Society of Cardiovascular Anesthesiology 1, 149 Sonographic formulas 209 Sound beam see Beam Speed displacement artifact 180 Spinal cord 78 Spine 78, 94 Spleen 78–79, 94 Spontaneous breathing 83 expiration 83 inspiration 83–84 ST segment 73 Starr–Edwards valve 156–157, 159 Stenosis, valves 97–98 aortic valve (AV) 98, 102t, 107–108, 108f, 110–111, 110f senile calcific 98, 98f, 107–108, 108f causes 99t mitral valve (MV) 98, 102t, 103–104, 104t pulmonary valve 106–107, 163, 168 subaortic 169 tricuspid valve 103 Stereoscopic display 198 Stomach 78–79, 94 Straddling, defined 163–164 Stress echocardiography 191 Stroke volume, calculation 212, 226–227 aortic valve (AV) 244 left ventricular outflow tract (LVOT) 219–220, 229–230, 241, 246 mitral valve (MV) 220, 230, 238 pulmonary artery 246 Subaortic stenosis 169 Subclavian artery, left 84–85, 89 Subdiaphragmatic area 94 Superior mesenteric artery 85 Superior mesenteric artery (SMA) 79 Superior vena cava (SVC) 77, 77f, 79, 92–95, 93f persistent left (PLSVC) 168 Surface rendering 198 Swan–Ganz catheter (SGC) 43, 73, 147, 155, 167, 185, 193 vs transesophageal echocardiography (TEE) 193 Systole 51, 51f Systolic blood velocities 97 Systolic function see Left ventricular systolic function Systolic pressure left ventricular 218 pulmonary artery 242–243 right ventricular, peak 214–215, 227–228, 247 Systolic pulmonary vein flow 102t T Tamponade 84, 148 Tandem heart 152, 152f TEE: An Interactive Board Review (CD) TEE ‘alphabet’ 68f, 204f, 207f TEE on CD: An Interactive Resource Temporal resolution, M-mode 40 Tethering 135, 135f Textbook of Clinical Echocardiography (Otto) Thebesian valve 188, 188f Thoracic aorta distal 79 mid 79 proximal 79 Three dimensional (3-D) images 195 cardiac masses 118 functions 195 left ventricle (LV) assessment 200 volume 200 limitations 199 mitral valve (MV) 199–200 modes 198–199, 198t probes 196–198 rendering technique 197–198 right ventricle (RV), assessment 200 Thrombus 117 formation 126, 127f Thymus 78, 94 Time-velocity integral (TVI) 48–50, 48f Tissue characterization 6–7 impedance interactions 5–6 propagation velocity reconstruction 26–27 Tissue Doppler 51, 51f, 61f Tongue 78 Trabeculations 116 Trachea 78–79, 94 Transducers Transgastric (TG) Chamber view 68f, 203–204 Transgastric (TG) basal short axis (SAX) view 68f left ventricle (LV) 105 mitral valve (MV) 205–206 Transgastric (TG) long axis (LAX) view 68f Index Transgastric (TG) plane 68 view 71, 79 Transgastric (TG) RV inflow view 68f, 204–205 Transgastric (TG) short axis (SAX) view 203–204 mid 68f, 80–81, 203f Transplantation 160–162 Transposition 164 Transthoracic echocardiography (TTE) vs transesophageal echocardiography (TEE) 192 Transverse sinus 79 Trauma, aortic 90–91 Tricuspid inflow velocity 84 Tricuspid valve 64, 72, 103 causes, problems 99t Ebstein’s anomaly 163, 170 imaging 207, 207f ME AV SAX view 107 ME4C view 103 insufficiency 101 regurgitation 64, 94, 104–106, 105f repair 160 right ventricular inflow 55–56, 56f stenosis 103 systolic blood velocities 97 True lumens 88 Two dimensional (2-D) images 16, 16f, 27, 27f, 39, 196 cardiac masses 118 Two-chamber view 71 see also Midesophageal (ME) Chamber view U Ultrasound, principles attenuation compression/rarefaction frequency/wavelength/tissue propagation velocity reflection 5, 6f refraction 6, 6f scatter tissue characterization 6–7 interactions 5–6 waves, properties see also Beam; Doppler ultrasound, principles Upper abdominal aorta 78–79 Upper esophageal (UE) aortic arch (AA) long axis (LAX) view 68f, 208 short axis (SAX) view 56, 56f, 68f, 208 atrium 207f Upper esophageal (UE) plane 68 Upper lung 79 V V ascent 73 Valsalva maneuver 59–60 Valves see Cardiac valves Valvular regurgitation see Regurgitation Vegetation, bacteremic 117 Velocity errors, artifacts 180–182, 181f, 182f measurement, types 47 Vena cava see Inferior vena cava (IVC); Superior vena cava (SVC) Vena contracta 106, 110 Venous blood flow 165 Ventilation, mechanical 83–84, 84f Ventricle anatomic variants 116 diseases 124 see also Left ventricle (LV); Right ventricle (RV) Ventricular septal defect (VSD) 163, 166 natural history 166–167 pitfalls 167 Ventricular systole 93 Ventricular wall assessment, M-mode 42, 42f Vertebral disks 78 Volume rendering 198 Volumetric analysis 200 data collection 197 measurements/calculations 48, 48f W Wall motion abnormality 188 Wall pairs, cross section 141f Waterston operation 165 Wavelength 3, 4f Waves, ultrasound Wireframe rendering 198 X X descent 73 Y Y descent 73 283 ... 124 Board Stiff TEE to is outline the end-diastolic area and the end-systolic area and the machine will crunch the numbers FAC = (end-diastolic area – end-systolic area)/end-diastolic... WHICH WALL IS WHICH? Septal ME 4-Chamber Mid? (see Paps) Apical (nothing) Lateral Inferior ME 2- Chamber Anterior ME LAX Posterior Anteroseptal 131 1 32 Board Stiff TEE I found it easiest to start... 12 16 11 10 Basal anterior Basal anteroseptal Basal inferoseptal Basal inferior Basal inferolateral Basal anterolateral Mid-anterior Mid-anteroseptal Mid-inferoseptal 10 Mid-inferior 11 Mid-inferolateral