trans esophageal echocardiography

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POWERFUL DIAGNOSTIC TOOLDECREASE MORBIDITYINCREASE SURVIVAL

ANESTHETISED PATIENT’S PHYSIOLOGY IS DIFFERENT; WE KNOW IT BETTER!

WE ARE CLOSELY LINKED WITH THE PERIOPERATIVE CARE

LUNGS AND RIBS DON’T INTERFERELUNGS AND RIBS DON’T INTERFEREONLY ESOPHAGEAL WALL AND PERICARDIUM IN ONLY ESOPHAGEAL WALL AND PERICARDIUM IN BETWEENBETWEENWONT DISRUPT SURGERYWONT DISRUPT SURGERYTRANS THORACIC IS DIFFICULT IN:TRANS THORACIC IS DIFFICULT IN: OBESITY/EMPHYSEMA/ABNORMAL CHEST WALLOBESITY/EMPHYSEMA/ABNORMAL CHEST WALL

tissue insonated with sound tissue insonated with sound above audible range, >20000 above audible range, >20000 HzHz

Most use 2.5-7.5 HzMost use 2.5-7.5 Hz

Transducer composed of Transducer composed of piezoelectric crystalspiezoelectric crystals

Electrical signal applied to the Electrical signal applied to the crystal crystal vibrate vibrate sound sound absorption/reflection/refractioabsorption/reflection/refraction/scatteringn/scattering reflected reflected ultrasound wave ultrasound wave crystal crystal receive the reflected wave receive the reflected wave convert it back to electrical convert it back to electrical signalsignal

v = v = f x f x λλ

Ultrasound travels at 1540 Ultrasound travels at 1540 m/secm/sec

Hence v constantHence v constant

As f increase, As f increase, λλ decrease decrease

v,f and v,f and λλ known known

Time find outTime find out

Hence depth find outHence depth find out

FF more more absorption more absorption more resolution moreresolution more

λλ less less attenuation more attenuation more penetration lesspenetration less

Water, muscle, blood Water, muscle, blood less less impedance impedance less attenuation less attenuation

Air , bone Air , bone high impedance high impedance ultrasound traverse poorlyultrasound traverse poorly

DOPPLER PRINCIPLE: “WHEN A WAVE OF A GIVEN FREQUENCY,STRIKES A MOVING TARGET,IT WILL BE REFLECTED AND THE REFLECTED WAVE WILL SHOW A FREQUENCY SHIFT PROPORTIONAL TO THE VELOCITY OF THE TARGET WHICH IS PARALLEL TO THE PATH OF THE EMITTED WAVE”

If target is moving away from If target is moving away from the emitted wave, the the emitted wave, the frequency of the reflected wave frequency of the reflected wave will be lowerwill be lower

If the target is moving towards If the target is moving towards the transducer, the frequency the transducer, the frequency of the reflected wave will be of the reflected wave will be higherhigher

RBCs act as excellent reflectorsRBCs act as excellent reflectors

Measuring the RBC flow velocity Measuring the RBC flow velocity in the heart is the application in the heart is the application used hereused here

accurate when the transmitted accurate when the transmitted beam and the velocity vector beam and the velocity vector are parallel [ at least within 20º]are parallel [ at least within 20º]

Most basic modeMost basic mode

Waves transmitted as a single Waves transmitted as a single beambeam

Only tissues which come in this Only tissues which come in this narrow path are displayednarrow path are displayed

Only a limited area is visualizedOnly a limited area is visualized

Waves transmitted and Waves transmitted and received back in 0.001 sec received back in 0.001 sec

So 1000 frames/sec = REAL So 1000 frames/sec = REAL TIMETIME

High resolution : even subtle High resolution : even subtle changes in motion/dimension changes in motion/dimension are well pickedare well picked

Hence finer analysis best done Hence finer analysis best done with this modewith this mode

Amplitude of returning waves Amplitude of returning waves are displayed as shades of are displayed as shades of brightnessbrightness

Blood filled chambersBlood filled chambers no no reflected wavesreflected waves BLACK BLACK

Valve tissue and myocardium Valve tissue and myocardium high reflected wave activityhigh reflected wave activity grey/whitegrey/white

..\pdfnotes\Pocket Atlas of ..\pdfnotes\Pocket Atlas of Echocardiography.pdfEchocardiography.pdf

Obtained by rapid repetitive Obtained by rapid repetitive scanning along multiple beam scanning along multiple beam lines within an area in the lines within an area in the shape of a fan (sector), 60-shape of a fan (sector), 60-90°wide90°wide

Done by phased array Done by phased array technologytechnology

Sector contains approx. 100 Sector contains approx. 100 scan linesscan lines time consuming time consuming

Information updated 30-60 Information updated 30-60 times times

Desired view is obtained by 2D Desired view is obtained by 2D echo echo Doppler beam Doppler beam superimposedsuperimposed

Cursor is positioned as parallel Cursor is positioned as parallel as possible to the assumed as possible to the assumed direction of blood flowdirection of blood flow

Quantify stenosis , Quantify stenosis , regurgitationregurgitation

Demonstrate shuntsDemonstrate shunts

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PULSED WAVE DOPPLERPULSED WAVE DOPPLER

CONTINUOUS WAVE DOPPLERCONTINUOUS WAVE DOPPLER

COLOR FLOW DOPPLERCOLOR FLOW DOPPLER

a single crystal intermittently a single crystal intermittently transmits and receives ultra transmits and receives ultra sound signals sound signals analyzed for analyzed for frequency shiftsfrequency shifts

Cursor placed on an updated 2D Cursor placed on an updated 2D image and reflected wave from image and reflected wave from only that portion analyzedonly that portion analyzed

We can contract or expand the We can contract or expand the interrogated areainterrogated area

Problem : there is a velocity Problem : there is a velocity limit (.8-1 m/sec) for the wave, limit (.8-1 m/sec) for the wave, beyond which a phenomenon beyond which a phenomenon known as “aliasing” or known as “aliasing” or “wraparound” occurs “wraparound” occurs ambiguous velocity and time ambiguous velocity and time informationinformation

Allows a flow disturbance to be Allows a flow disturbance to be localized precisely or blood localized precisely or blood velocity from a small region to velocity from a small region to be measured correctlybe measured correctly

e.g. mitral inflow, tricuspid e.g. mitral inflow, tricuspid inflowinflow

One transducer continuously One transducer continuously emit signalsemit signals

Another one continuously Another one continuously receive reflected signalsreceive reflected signals

Very high velocities can be Very high velocities can be reliably detectedreliably detected

Since no lag betweenSince no lag between

emission and reception emission and reception

i.e. extremely high sampling i.e. extremely high sampling frequency frequency minimize aliasing minimize aliasing

problem : reflected signals problem : reflected signals returning from all points are returning from all points are analyzed.. Cant localize a signal analyzed.. Cant localize a signal preciselyprecisely

Useful for: measuring high Useful for: measuring high velocities e.g. intracardiac velocities e.g. intracardiac shunts , regurgitant jet, flow shunts , regurgitant jet, flow across stenotic valves like ASacross stenotic valves like AS

Velocities up to 600-800 cm/ Velocities up to 600-800 cm/ sec can be measuredsec can be measured

Uses pulsed wave technology to Uses pulsed wave technology to measure blood flow at multiple measure blood flow at multiple sitessites

Real time blood flow is shown Real time blood flow is shown in colorsin colors

While also showing 2D images While also showing 2D images in black and whitein black and white

Velocities and directions of Velocities and directions of blood flow are color encodedblood flow are color encoded

Velocity away Velocity away blue blue

Velocity towards Velocity towards red “BART” red “BART”

High turbulence High turbulence green green

As velocity increase intensity of As velocity increase intensity of color also increasecolor also increase

Aliasing occurs Aliasing occurs color mosaic color mosaic

But as 2D image is there, But as 2D image is there, direction of this aliased signal direction of this aliased signal can be determined easilycan be determined easily

Assess valvular Assess valvular

abnormalities , shunts, aortic abnormalities , shunts, aortic dissectiondissection

Transducer fitted to the distal, Transducer fitted to the distal, flexible end of a gastroscopeflexible end of a gastroscope

Adult : above 20-25 KgAdult : above 20-25 Kg

Pediatric : above 3.5- 4 KgPediatric : above 3.5- 4 Kg

Adult @ 5 MHz Pediatric @7.5 Adult @ 5 MHz Pediatric @7.5 MHzMHz

2D—M-mode—PWD—CWD--COLOR2D—M-mode—PWD—CWD--COLOR

Two rotary knobsTwo rotary knobs

One for anteflexion and One for anteflexion and retroflexionretroflexion

One for rightward and leftward One for rightward and leftward flexionflexion

Can rotate the angle plane Can rotate the angle plane without movement of the probewithout movement of the probe

Good view of LA,MV..Good view of LA,MV..

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ADVANCED/WITHDRAWNADVANCED/WITHDRAWN

RIGHT/LEFTRIGHT/LEFT

ANTEFLEXED/RETROFLEXED-90°ANTEFLEXED/RETROFLEXED-90°

LATERAL FLEXION-70°LATERAL FLEXION-70°

Single plane Single plane 0° 0°

Biplane Biplane one transducer: 0°one transducer: 0°

one transducer 90°one transducer 90°

Multiplane probes Multiplane probes 0-180° 0-180°

HISTORY: dysphagia/ HISTORY: dysphagia/ hemetemesis/ previous hemetemesis/ previous surgeries on GIT/ cervical spine surgeries on GIT/ cervical spine diseasedisease

Fasting for 4-6 hrsFasting for 4-6 hrs

Remove denturesRemove dentures

Airway/ oxygen delivery Airway/ oxygen delivery systems / bite block/ suction / systems / bite block/ suction / intubation cart / IVAintubation cart / IVA

TOPICAL : lignocaineTOPICAL : lignocaine

SEDATIONSEDATION

ANTIXYLAGOGUEANTIXYLAGOGUE

Orogastric tubeOrogastric tube

Supine / left lateralSupine / left lateral

Operator stands as in for L’scopyOperator stands as in for L’scopy

ETT securedETT secured

Probe in unlocked position Probe in unlocked position align with natural anatomyalign with natural anatomy

Lubricated Lubricated

Bite block on probeBite block on probe

Thumb of left hand placed on Thumb of left hand placed on patient’s tonguepatient’s tongue

Left hand used to pull jaw Left hand used to pull jaw upwardupward

Pass probe tip through bite Pass probe tip through bite guard , over tongue , guard , over tongue , maintaining it in midline maintaining it in midline ( transducer facing anteriorly) ( transducer facing anteriorly) and to the left of ETTand to the left of ETT

Mild resistance felt @ pharyngo Mild resistance felt @ pharyngo esophageal junction [ neonate: esophageal junction [ neonate: 10 cm from lip, adult : 20 cms]10 cm from lip, adult : 20 cms]

If doubt : done under If doubt : done under laryngoscopylaryngoscopy

no hot water no hot water 1-2 hrs 1-2 hrs

Not to eat Not to eat 1-4 hrs 1-4 hrs

Inspected for defectsInspected for defects

Enzymatic solution to remove Enzymatic solution to remove secretionssecretions

Gluteraldehyde for 20 minsGluteraldehyde for 20 mins

Tap water dry for 20 minsTap water dry for 20 mins

Apex of the sector scan is Apex of the sector scan is shown at the top of the echo shown at the top of the echo screen which displays posterior screen which displays posterior parts of the heart ( part close parts of the heart ( part close to probe)to probe)

In the transverse imaging In the transverse imaging plane, left of image is towards plane, left of image is towards patients right and right of the patients right and right of the image is towards patients leftimage is towards patients left

In the vertical imaging plane, In the vertical imaging plane, left side of the image is inferior left side of the image is inferior and point towards patient’s and point towards patient’s feetfeet

Right side of the image is Right side of the image is anterior and points towards anterior and points towards patients headpatients head

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Once we centre a cardiac Once we centre a cardiac structure in one image plane,it structure in one image plane,it will continue to remain there as will continue to remain there as the transducer is rotated from the transducer is rotated from 0-180°,facilitating the 3D 0-180°,facilitating the 3D assessment of that particular assessment of that particular structurestructure

Markedly abnormal ventricular Markedly abnormal ventricular functionfunction

Extensive MIExtensive MI

Large air emboliLarge air emboli

Severe valvular dysfunctionSevere valvular dysfunction

Large mass or thrombiLarge mass or thrombi

Large effusionLarge effusion

Major lesions of great vesselsMajor lesions of great vessels

20 views 20 views comprehensive comprehensive examinationexamination

8 out of 20 needed to meet 8 out of 20 needed to meet these goalsthese goals

Upper esophageal(20-30 cm)Upper esophageal(20-30 cm)

Mid esophageal(30-40 cm)Mid esophageal(30-40 cm)

Transgastric (40-45 cm)Transgastric (40-45 cm)

Deep transgastric (45-50 cm)Deep transgastric (45-50 cm)

Aortic valve short axis—SAXAortic valve short axis—SAX

Aortic valve long axis—LAXAortic valve long axis—LAX

RV inflow-outflowRV inflow-outflow

BicavalBicaval

Ascending aorta—SAXAscending aorta—SAX

Ascending aorta—LAX Ascending aorta—LAX

4 chamber4 chamber

2 chamber2 chamber

CommissuralCommissural

Long axisLong axis

The probe is advanced into the The probe is advanced into the stomach and ante flexed ( to stomach and ante flexed ( to keep it apposed to the keep it apposed to the diaphragmatic surface of diaphragmatic surface of stomach)stomach)

Mid SAXMid SAX

Two chamberTwo chamber

Basal SAXBasal SAX

LAXLAX

RV inflowRV inflow

TG mid SAX view is particularly TG mid SAX view is particularly used by the anesthetist in the used by the anesthetist in the assessment of LV function, assessment of LV function, Ejection Fraction and Volume Ejection Fraction and Volume statusstatus

Probe further advanced , slowly Probe further advanced , slowly withdrawn with tip sharply withdrawn with tip sharply anteflexed until it contacts the anteflexed until it contacts the diaphragmatic surface of diaphragmatic surface of stomach wallstomach wall

LAX view shows all 4 chambers, LAX view shows all 4 chambers, aortic valve and LV outflow tractaortic valve and LV outflow tract

Estimates velocity via aortic Estimates velocity via aortic valve and COvalve and CO

Images aortic arch and Images aortic arch and descending aorta descending aorta

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Intraoperative assessment of Intraoperative assessment of acute, life threatening acute, life threatening hemodynamic disturbanceshemodynamic disturbances

Valve repairValve repair

Congenital heart disease Congenital heart disease surgerysurgery

Repair of HOCMRepair of HOCM

Intraoperative use- endocarditisIntraoperative use- endocarditis

Pre operative use in unstable Pre operative use in unstable patients with suspected thoracic patients with suspected thoracic artery aneurysm / dissectionartery aneurysm / dissection

Intraoperative assessment of Intraoperative assessment of aortic valve function during aortic valve function during repair of aortic dissectionrepair of aortic dissection

Pericardial window proceduresPericardial window procedures

Use in ICU patients with Use in ICU patients with unexplained hemodynamic unexplained hemodynamic disturbances/valve disturbances/valve diseases/thrombotic diseases/thrombotic complicationscomplications

ConfirmConfirm

Localize Localize

ReassessReassess

LA clotLA clot

LV functionLV function

Associated abnormalitiesAssociated abnormalities

Congenital heart diseaseCongenital heart disease

Prosthetic valve: leakProsthetic valve: leak

Too small?Too small?

Moving normally?Moving normally?

Deairing adequate?Deairing adequate?

Adequacy of repair: Residual Adequacy of repair: Residual VSD?VSD?

PA pressurePA pressure

Trouble in coming out of bypass?Trouble in coming out of bypass?

Ventricular fillingVentricular filling

EjectionEjection

Systolic functionSystolic function

Diastolic functionDiastolic function

Hypotension : low cardiac Hypotension : low cardiac output Vs low SVRoutput Vs low SVR

Guide for administration of Guide for administration of fluid, inotropes and fluid, inotropes and vasopressorsvasopressors

RWMARWMA

Differential diagnosisDifferential diagnosis

MyocarditisMyocarditis

Myocardial stunningMyocardial stunning

PAC Vs TEEPAC Vs TEE

TEE TEE Real time, directly Real time, directly visualizing, amount of visualizing, amount of information moreinformation more

PAC PAC CO,LVEDP rough CO,LVEDP rough estimates, indirect methodsestimates, indirect methods

Cost?Cost?

LA clot before BMV?LA clot before BMV?

ASD device closureASD device closure

Aortic dissection : trans Aortic dissection : trans thoracic Vs TEEthoracic Vs TEE

ThrombusThrombus

Abnormal thoraxAbnormal thorax

Preoperative assessment of Preoperative assessment of ventricular function in high risk ventricular function in high risk patientspatients

During placement of LV assist During placement of LV assist devicedevice

Positioning of cannulaePositioning of cannulae

As a substitute of PACAs a substitute of PAC

Deployment of intravascular Deployment of intravascular devicesdevices

ThermalThermal

Pressure over heartPressure over heart

Compression of structures Compression of structures adjacent to esophagus adjacent to esophagus

HypertensionHypertension

HypotensionHypotension

Arrhythmias Arrhythmias

LaryngospasmLaryngospasm

BronchospasmBronchospasm

HypoxiaHypoxia

Perforated esophagusPerforated esophagus

Previous esophagectomyPrevious esophagectomy

Severe esophageal obstructionSevere esophageal obstruction

Active upper GI bleedActive upper GI bleed

Esophageal Esophageal stricture,tumour,diverticula,varicestricture,tumour,diverticula,varicess

SclerodermaScleroderma

Previous esophageal surgeryPrevious esophageal surgery

Previous gastric surgeryPrevious gastric surgery

Mediastenal irradiationMediastenal irradiation

Unexplaind swallowing difficultiesUnexplaind swallowing difficulties

Echo machine kept in standby Echo machine kept in standby mode when not in usemode when not in use

When not imaging, probe When not imaging, probe should be left in neutral should be left in neutral unlocked position, to avoid unlocked position, to avoid prolonged pressure in prolonged pressure in esophagusesophagus

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