Themidesophagealfour-chamberviewseenhereistheviewmostfamiliartonewlearnersofcardiacanesthesia.
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedCopyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.SCM6WhiteLabelFigureCopyright?ThePublisher.Allrightsreserved.HerethestructuresoftheheartasseenonthepreviousTEEimageareidentifiedincludingtherightatrium(RA),tricuspidvalve(TV),rightventricle(RV),leftatrium(LA),mitralvalve(MV),andleftventricle(LV).
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedFigure3Ademonstratesanepiaorticultrasonographic(EAU)imageofthenormalascending(Asc)aortaintheshort-axisview.Seenaretheanterior(A),posterior(P),rightlateral(RL),andleftlateral(LL)wallsoftheaorta.Therightpulmonaryartery(PA)andsuperiorvenacavaarealsoseen.The"standoff"isthatareaoffluidbetweenthehandheldEAUprobeandtheaorta.Figure3Bpresentsthelong-axisview.TEEcannotvisualizetheascendingaortaduetothepresenceoftheairway.(From:GlasKE.,SwaminathanM,ReevesST,etal.Guidelinesfortheperformanceofacomprehensiveintraoperativeepiaorticultrasoundexamination:recommendationsoftheAmericanSocietyofEchocardiographyandtheSocietyofCardiovascularAnesthesiologists;endorsedbytheSocietyofThoracicSurgeons.AnesthAnalg.2008;106(5):1227-1238,withpermission.)
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedAnepicardialleftventricle(LV)basalshort-axisview(SAX)seenhererevealstherightventricle(RV)andtheanterior(AL)andposterior(PL)leafletsofthemitralvalve.TheorientationofthehandheldprobeagainsttheheartisdemonstratedinpanelA.(From:ReevesST,GlasK,EltzschigH,etal.Guidelinesforperformingacomprehensiveepicardialechocardiographyexamination:recommendationsoftheAmericanSocietyofEchocardiographyandtheSocietyofCardiovascularAnesthesiologists.AnesthAnalg.2007;105(1):22-28,withpermission.)
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedTheAmericanSocietyofEchocardiography(ASE)andSocietyofCardiovascularAnesthesiologists(SCA)20recommendedviewsforacomprehensiveTEEexamination.Thecompassintherightuppercornerofeachviewapproximatestheangleoftheultrasoundsector.Viewsaredesignatedas:ME=midesophageal,LAX=longaxis,TG=transgastric,SAX=shortaxis,AV=aorticvalve,RV=rightventricle,Asc=ascending,Desc=descending,UE=upperesophageal.Thesestandardviewsprovidetwo-dimensionalwindowstoexaminethethree-dimensionalheart.(From:ShanewiseJS,CheungA,AronsonS,etal.ASE/SCAguidelinesforperformingacomprehensiveintraoperativemultiplanetransesophagealechocardiographyexamination;recommendationsoftheAmericanSocietyofEchocardiographyCouncilforIntraoperativeEchocardiographyandtheSocietyforCardiovascularAnesthesiologistsTaskForceforCertificationinPerioperativeTransesophagealEchocardiography.AnesthAnalg.1999;89:870-884,withpermission.)
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedTheviewshavenowbeengroupedtogetherbaseduponthelocationintheesophaguswheretheyareobtained,upperesophageal(UE),middleesophageal(ME),transgastric(TG),anddescendingaortic(DA).Majorcardiacstructuresarelabeledincluding:
rightatrium(RA)
leftatrium(LA)
mitralvalve(MV)
tricuspidvalve(TV)
rightventricle(RV)
leftventricle(LV)
leftatrialappendage(LAA)
aorta(AO)
anteriorleafletofthemitralvalve(ALMV)
posteriorleafletofthemitralvalve(PLMV)
ascendingaorta(AscAO)
rightpulmonaryartery(RPA)
superiorvenacava(SVC)
mainpulmonaryartery(MPA)
intraatrialseptum(IAS)
pulmonicvalve(PV)
rightventricularoutflowtract(RVOT)
non-coronarycuspoftheaorticvalve(NCC)
rightcoronarycuspoftheaorticvalve(RCC)
leftcoronarycuspoftheaorticvalve(LCC)
posteriorscallopsofthemitralvalveP1,P2,P3
anteriorscallopsofthemitralvalveA1,A2,A3
posteriormedialpapillarymuscle(Post/MedPM)
anteriorscallopsofthemitralvalveA1,A2,A3
posteriormedialpapillarymuscle(Post/MedPM)
anterolateralpapillarymuscle(Ant/LatPM)
inferiorvenacava(IVC)
descendingaorta(DescAO)
leftbrachiocephalicvein(BCV)
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedTheechoprobeismanipulatedbytheexaminerinmultiplewaystocreatethestandardimagesthatconstitutethecomprehensiveperioperativeTEEexamination.Atalltimesneverforcetheprobe.Ifresistanceisencounteredabandontheexamination.Echocardiographicinformationcanbeprovidedbyintraoperativeepicardialandepiaorticexamination.Advancingtheprobeintheesophaguspermitstheupper,mid,andtransgastricexaminations(A).Theprobecanbeturnedintheesophagusfromlefttorighttoexaminebothleft-andright-sidedstructures(A).Usingthebuttonlocatedontheprobepermitstheechocardiographertorotatethescanbeamthrough180degrees,therebycreatingvarioustwo-dimensionalimagingslicesofthethree-dimensionalheart(B).Lastly,panelsCandDdemonstratemanipulationofthetipoftheprobetopermitthebeamtobedirectedtobestvisualizetheimage.(Modifiedfrom:ShanewiseJS,CheungA,AronsonS,etal.ASE/SCAguidelinesforperformingacomprehensiveintraoperativemultiplanetransesophagealechocardiographyexamination;recommendationsoftheAmericanSocietyofEchocardiographyCouncilforIntraoperativeEchocardiographyandtheSocietyforCardiovascularAnesthesiologistsTaskForceforCertificationinPerioperativeTransesophagealEchocardiography.AnesthAnalg.1999;89:870-884,withpermission.)
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedAsthesectorbeamisrotatedfrom0to180degreesthetwo-dimensionalimagechangesorientation.At0degrees,thefour-chamberviewisseenwiththepatient''srightheartstructuresseenontheleftofthescreen.Theleftheart(shadeddarkerblue)occupiesthefullscreeninthetwo-chamberviewsobtainedat90degreesdisplayinganteriorandinferiorstructures.Completingthearcto180degreesmirrorstheimageobtainedatzerodegrees.Oneofthefirsttasksoftheechocardiographerwhenviewinganimageistotakenoteoftheangleofthesectorbeamsincethatdeterminestheimage.(Modifiedfrom:ShanewiseJS,CheungA,AronsonS,etal.ASE/SCAguidelinesforperformingacomprehensiveintraoperativemultiplanetransesophagealechocardiographyexamination;recommendationsoftheAmericanSocietyofEchocardiographyCouncilforIntraoperativeEchocardiographyandtheSocietyforCardiovascularAnesthesiologistsTaskForceforCertificationinPerioperativeTransesophagealEchocardiography.AnesthAnalg.1999;89:870-884,withpermission.)
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedTheabovegraphicdemonstratesthemidesophagealfour-chamberview(A),themidesophagealtwo-chamberview(B),themidesophageallong-axisview(C),andthetransgastricmidshort-axisview.Thedifferentviewsprovidetheopportunitytoobservethemyocardiumsuppliedbyeachofthethreemaincoronaryvessels,theleftcircumflex(Cx),theleftanteriordescending(LAD),andtherightcoronaryartery(RCA).Areasofimpairedmyocardialperfusionaresuggestedbytheinabilityofthemyocardiumtoboththickenandmoveinwardlyduringsystole.ImageDisveryusefulformonitoringintheoperatingroombecauseleftventricularmyocardiumsuppliedbyeachofthethreevesselscanbeseeninoneimage.(Modifiedfrom:ShanewiseJS,CheungA,AronsonS,etal.ASE/SCAguidelinesforperformingacomprehensiveintraoperativemultiplanetransesophagealechocardiographyexamination;recommendationsoftheAmericanSocietyofEchocardiographyCouncilforIntraoperativeEchocardiographyandtheSocietyforCardiovascularAnesthesiologistsTaskForceforCertificationinPerioperativeTransesophagealEchocardiography.AnesthAnalg.1999;89:870-884,withpermission.)
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedTheCarpentiersystemforidentifyingtheleafletsofthemitralvalveispresentedinthisschematic.Theanteriorleafletoccupiesthegreatestareaofthemitralvalve.Theposteriorleaflet,however,coversthegreatercircumference.Theposteriorleafletisdividedintothreescallopsextendingfromtheanterolateraltotheposteromedialcommissures.Theanteriorleafletiscontinuouswithfibrousattachmentoftheaorticvalveknownasthecruxoftheheart.Themitralannulusisafibrousringwhichprovidesthevalveitsshape.(Modifiedforpublicationfrom:ShanewiseJS,CheungA,AronsonS,etal.ASE/SCAguidelinesforperformingacomprehensiveintraoperativemultiplanetransesophagealechocardiographyexamination;recommendationsoftheAmericanSocietyofEchocardiographyCouncilforIntraoperativeEchocardiographyandtheSocietyforCardiovascularAnesthesiologistsTaskForceforCertificationinPerioperativeTransesophagealEchocardiography.AnesthAnalg.1999;89:870-884,withpermission.)
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedPWDopplerisemployedinthisdeeptransgastricviewinterrogationoftheleftventricularoutflowtrack(LVOT).BloodisflowingintheLVOTawayfromtheesophagus.Therefore,theflowvelocitiesappearbelowthebaseline.FlowvelocitythroughtheLVOTis46.5cm/s.ThisisasexpectedwhenthereisnopathologynotedasbloodisejectedalongtheLVOT.Tracingtheflowenvelope(dottedlines)identifiesthetime-velocityintegral(TVI).InthisexampletheTVIis14cm.
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedThemidesophageallong-axisviewisemployedinthisimagetoidentifyandtomeasurethediameteroftheLVOT.KnowingthediameteroftheLVOTpermitscalculationoftheLVOTarea(D2×0.785=LVOTarea).
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedIntracavitarypressurescanbecalculatedusingknownpressuresandtheBernoulliequationwhenregurgitantjetsarepresent.ThePAsystolicpressureisobtainedwhentricuspidregurgitationispresentandtherightatrialpressureknown.Assumingnopulmonicvalvedisease,therightventricularsystolicpressureandthepulmonarysystolicpressurearethesame.Theleftatrialpressurecanbesimilarlycalculatedifmitralregurgitationispresent.Again,assumingnovalvulardiseaseLVsystolicpressureshouldequalsystemicsystolicbloodpressure.Subtracting4V2fromtheLVSPestimatestheleftatrialpressure.
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedThemidesophagealfour-chamberviewseenherepermitsimagingoftherightatrium(RA),leftatrium(LA),rightventricle(RV),leftventricle(LV),tricuspidvalve(TV),andmitralvalve(MV).Notethesectorangleof0degreesintheupperrighthandcorner.Alwaysidentifythesectorangletohelptoidentifyrightfromleftandanteriorfrominferior(VideoA1).
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedThemidesophagealtwo-chamberviewseenhererevealsthemitralvalve(MV),leftatrium(LA),andleftventricle(LV)(VideoA2).
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedThemidesophagealaorticvalvelong-axisviewseenhereprovidesacloseexaminationoftheAOV,sinotubularjunction(STJ),ascendingaorta,andanteriorleafletofthemitralvalve(VideoA5).
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedThemidesophagealrightventricularinflow-outflowviewispresentedhere.Therightatrium(RA),leftatrium(LA),tricuspidvalve(TV),andrightventricularoutflowtrackareseen(RVOT).Ashort-axisviewoftheaorticvalve(AOV)islikewiseseen(VideoA7).
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedThemidesophagealascendingaortalong-axisviewispresentedhere.Boththeascendingaortaandtherightpulmonaryartery(incrosssection)canbeseen(VideoA9).
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedThetransgastricbasalshort-axisviewisseeninthisimage.Theleafletsofthemitralvalveappearasafish''smouthwhenexaminedinthisview(VideoA11).
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedRotatingthesectorplaneprovidesthedescendingaortalong-axisview.Aorticpathologyanddissectionscanbeseenwiththiswindow.
Citation:IntroductiontoPerioperativeEchocardiography,WasnickJD,HillelZ,KramerD,LittwinS,NicoaraA.CardiacAnesthesiaandTransesophagealEchocardiography;2011.Availableat:https://accessanesthesiology.mhmedical.com/content.aspx?bookid=418§ionid=43896235Accessed:June05,2018Copyright?2018McGraw-HillEducation.AllrightsreservedCopyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.Copyright?2012AmericanMedicalAssociation.Allrightsreserved.SCM6WhiteLabelFigureCopyright?ThePublisher.Allrightsreserved. |
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