Transcript Transesophageal Echocardiography Goal

TRANSESOPHAGEAL ECHOCARDIOGRAPHY
GOAL DIRECTED FLUID THERAPY DURING
ANESTHESIA
Dr Piyush Mallick MD
Consulatnt Anesthesia
& ICU
Al Zahra Hospital Sharjah
INTRODUCTION
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In 1976, Dr Leon Frazin - concept of TEE.
Echocardiography:- the heart and great vessels
probed with ultrasound (sound with frequency above
20 kHz).
Echocardiography uses ultrasound waves with
frequency of 2.5 – 7.5 MHz.
Ultrasound sent into thoracic cavity and partially
reflected by cardiac structures.
From these reflections: distance, velocity and
density of objects within the chest derived.
INDICATIONS FOR PERIOPERATIVE TEE
 Preoperative: hemodynamically unstable patients
with no definite diagnosis like suspected thoracic
aortic aneurysms, dissection, or undifferentiated
shock state
 Intraoperative:
 acute, persistent, and life-threatening hemodynamic
disturbances
 valve repair, CHD surgery for lesions requiring
cardiopulmonary bypass; repair of hypertrophic
obstructive cardiomyopathy; endocarditis; repair of
aortic dissections; pericardial window procedures.
INDICATIONS FOR PERIOPERATIVE TEE
 In ICU: unstable patients with unexplained
hemodynamic disturbances, suspected valve
disease, or thromboembolic problems.
 TEE guided CPR in ED cardiac arrest ( Both for
diagnosis & Monitoring whether effective CPR)
TEE….
TEE EQUIPMENT
 Monitor and TEE probe
 TEE probe: a minaturized
echocardiographic transducer (40mm
long, 13mm wide and 11 mm thick)
mounted on the tip of a gastroscpoe.
 Transducer: a phased array configuration
with 64 piezoelectric elements operating
at 3.7 to 7.5 MHz.
 2 knobs: one controls anteflexion and
retroflexion; other controls rightward and
leftward movement of the probe.
 One electronic switch to scan the heart in
various axial views .
PROCEDURE
 Induction of anaesthesia and
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tracheal intubation
Patient’s neck extended
Well lubricated TEE probe
introduced into the midline of
hypopharynx with transducer
facing anteriorly
Probe advanced into esophagus
During this manoeuvre, the
control knob must be in neutral
position.
Terminology used to describe transesophageal echocardiography probe
movements.
MULTIPLANE PROBE
I
III
II
I- UPPER ESOPHAGEAL
II- MID ESOPHAGEAL
III- TRANSGASTRIC
Transesophageal echocardiography cross sections in a comprehensive
examination.
WHAT ANESTHESIOLOGIST SHOULD
KNOW ?
EVALUATION OF LV FILLING :
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TEE reveals changes in left ventricular preload and
filling pressure.
It measures EDA (end diastolic volume).
EDA < 12cm2 - hypovolemia
Assessment of LV filling and function subjectively
with the “trained eye”: a valid method to guide fluid
administration.
CARDIAC OUT PUT WITH EACH BEAT
2. ESTIMATION OF CARDIAC OUTPUT:
• Real-time TEE images of LV filling and ejection
permits qualitative, immediate detection of extreme
changes in cardiac output.
• TEE quantify CO the velocity and the cross-sectional
area of blood flow.
• SV = v x ET x CSA
SV = stroke volume (ml)
v = spatial average velocity of blood flow (cm/sec)
ET = systolic ejection time (sec)
CSA = cross-sectional area of the vessel (cm2 )
SYSTOLIC & DIASTOLIC FUNCTION
3. Assessment of ventricular systolic function:
 Fractional area change (FAC) during systole: a
measure of global LV function.
 FAC = EDA – ESA / EDA
EDA : cross-sectional area at end diastole
ESA : cross-sectional area at end systole.
 Marked changes in FAC are apparent by simply
viewing the real-time images.
 Hallmarks of severe RV dysfunction: severe
hypokinesis , enlargement of RV , change in shape of
RV from crescent to round.
DIASTOLOGY FOR HFPEF
4. Assessment of ventricular diastolic function:
• TEE is an ideal tool for assessment of diastolic function
because of its unobstructed view of the mitral valve and
pulmonary veins.
• Normal flow across the mitral valve in diastole has
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E wave : an early higher-velocity component (generated by atrial
pressure and ventricular relaxation)
• A wave : lower-velocity component (generated by atrial
contraction)
• At slower heart rates, these two waves are separated by a
period of relatively little flow (diastasis).
TAPSE & S prime for RV function
 Video
Line drawings representing simultaneous transesophageal pulsed wave Doppler recordings from
the mitral annulus and right upper pulmonary vein.
HOW MUCH FLUID ?
HOW MUCH IS TOO MUCH ?
WHEN TO STOP?
1.Based on mitral valve study
2.Using E/A wave ratio
3. Tissue Doppler e/a ratio
WHAT HAPPENES IN MYOCARDIAL
ISCHEMIA?
5. Detection of myocardial ischemia:
• Acute myocardial ischaemia produce abnormal inward
motion and thickening of affected myocardium.
• Short axis view of LV at level of papillary muscle : best view
• Wall thickening more specific marker than wall motion.
CLASS OF MOTION
CHANGE IN RADIUS
NORMAL
>30% decreased
MILD HYPOKINESIS
10 – 30% decreased
SEVERE HYPOKINESIS
0 – 10 % decreased
AKINESIS
None
DYSKINESIS
Increased
SVC COLLAPSIBILITY AND FLUID
RESPONSIVENESS
20% TO 30 % COLLAPSIBILTY
ME bicaval
IAS
LA
IVC
SVC
Eustachian valve
Left Atrium (LA)
Right Atrium (RA)
Inferior Vena Cava (IVC)
Superior Vena Cava (SVC)
Intra atrial septum (IAS)
Right Atrial
Appendage
Fossa Ovalis
RA
CAN WE SEE PULMONARY EMBOLISIM (
BLOOD CLOT/GAS/AMNIOTIC FLUID)
 RV bigger than LV
 D shaped LV
 McConnel sign
 You can really see the clot
ME asc aortic SAX
Rt PA
SVC
PA
Asc
Pulmonary Artery (PA)
Right Pulmonary Artery (Rt PA)
Superior Vena Cava (SVC)
Ascending Aorta (Asc)
ME asc aortic LAX
Orientation:
Ascending Aorta (Asc)
Right Pulmonary Artery
(Rt PA)
Rt PA
Asc
Proximal
Distal
IMAGING TECHNIQUES
• M MODE
• One-dimensional views of cardiac structures
produced by single-crystal transducers .
• Density and position of all tissues in the path of a
narrow ultrasound beam displayed as a scroll .
• It is a timed motion display.
• Principally used to view rapidly moving structures eg.
valve leaflets.
• Disadvantages: orientation and interpretation of
spatial relationships difficult.
M-mode transesophageal echocardiogram of a normal aortic valve
IMAGING TECHNIQUES
• 2D MODE
• Rapid, repetitive scanning along many different
radii within an area in the shape of a fan (sector).
• A live (real time image) of heart is produced.
• Advantage: the image obtained resembles an
anatomic section and can be easily interpreted.
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two-dimensional cross section of a normal aortic valve (AV)..
IMAGING TECHNIQUES
• DOPPLER TECHNIQUE:•
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Based on doppler principle.
With doppler, blood flow velocity can be measured.
Different types of Doppler techniques:
1. Pulsed wave doppler
2. Continuous wave doppler
3. Colour flow doppler
BART
 BLUE AWAY
 RED TOWARDS
Different types of doppler technique
TISSUE DOPPLER
• A new use of PWD technology
• To measure myocardial velocity.
• It measures the velocity of the descent of the mitral
annulus (Sm) towards the apex of the heart during
normal LV contraction.
• It decreases in presence of myocardial ischemia.
LA PRESSURE ESTIMATION
 PCWP not needed for LA pressure estimation
 Pulse wave doppler / Tissue doppler
 Can diagnose impending Pulmonary Edema
ADVANTAGES OF TEE
Transducer 2-3 mm from heart
: high resolution image: better
image quality
Closer to posterior structures
: better visualization of LA,MV,
LV, PV, Aorta etc.
Far from surgical field
: intraoperative monitoring
DISADVANTAGES OF TEE
 Semi invasive procedure : chances of injury
 Needs special set up, technique, preparation,
instrumentation
 Needs orientation and expertise
CONTRAINDICATIONS OF TEE
 ABSOLUTE:
• Previous esophagectomy
• Severe esophageal obstruction
• Esophageal perforation
• Ongoing esophageal haemorrhage
 RELATIVE:
• Esophageal diseases-diverticulum, varices, fistula
• Previous esophageal surgery
• Previous mediastinal irradiation
• Unexplained swallowing difficulty
COMPLICATIONS OF TEE
 Oral and pharyngeal injuries (0.1 – 0.3%)
 Transient hoarseness (0.1 – 12%)
 Esophageal injuries
 Splenic injuries – 2 case reports
 Endocarditis in outpatients
THANK YOU