Transesophageal echocardiography (TEE): Difference between revisions
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<ref name="pmid9636915">{{cite journal| author=Chow MS, Taylor MA, Hanson CW| title=Splenic laceration associated with transesophageal echocardiography. | journal=J Cardiothorac Vasc Anesth | year= 1998 | volume= 12 | issue= 3 | pages= 314-6 | pmid=9636915 | doi=10.1016/s1053-0770(98)90013-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9636915 }} </ref> | <ref name="pmid9636915">{{cite journal| author=Chow MS, Taylor MA, Hanson CW| title=Splenic laceration associated with transesophageal echocardiography. | journal=J Cardiothorac Vasc Anesth | year= 1998 | volume= 12 | issue= 3 | pages= 314-6 | pmid=9636915 | doi=10.1016/s1053-0770(98)90013-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9636915 }} </ref> | ||
<ref name=" | <ref name="pmid20418689">{{cite journal| author=American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography| title=Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. | journal=Anesthesiology | year= 2010 | volume= 112 | issue= 5 | pages= 1084-96 | pmid=20418689 | doi=10.1097/ALN.0b013e3181c51e90 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20418689 }} </ref> | ||
==Advantages== | ==Advantages== | ||
Revision as of 07:58, 31 May 2020
Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Eli V. Gelfand, M.D.; Anne B. Riley, M.D.
Overview
A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. This is known as a transesophageal echocardiogram, or TEE (TOE in the United Kingdom). The advantage of TEE over TTE is usually clearer images, especially of structures that are difficult to view transthoracicly (through the chest wall). The explanation for this is the heart rests directly upon the esophagus leaving only millimeters in distance that the ultrasound beam has to travel. This reduces the attenuation (weakening) of the ultrasound signal, generating a stronger return signal, ultimately enhancing image and Doppler quality. Comparatively, transthoracic ultrasound must first traverse skin, fat, ribs and lungs before reflecting off the heart and back to the probe before an image can be created. All these structures, and the distance the beam must travel, attenuate the ultrasound signal, degrading image and Doppler quality.
In adults, several structures can be evaluated and imaged better with the TEE, including the aorta, pulmonary artery, valves of the heart, both atria, atrial septum, left atrial appendage, and coronary arteries. While TTE can be performed quickly, easily and without pain to the patient, TEE requires a fasting patient, a team of medical personel, takes longer to perform, is uncomfortable for the patient and has some risks associated with the procedure (esophageal perforation--1 in 10,000, and adverse reactions to the medication).
Before inserting the probe, conscious sedation is induced with the patient to ease the discomfort of the individual and to decrease the gag reflex, thus making the ultrasound probe easier to pass into the esophagus. Conscious sedation is a light sedation usually using the medications midazolam (a benzodiazepine with sedating, amnesiac qualities) and fentanyl. Sometimes a local anesthetic spray is used for the back of the throat, such a xylocaine and/or a jelly/lubricant anesthetic for the esophagus. Children are anesthetized. Unlike the TTE, the TEE is considered an invasive procedure and is thus performed by physicians in the U.S., not sonographers.
To insert the TEE probe, the probe is placed in the patient’s mouth through a bite block (to protect the $30,000 TEE probe), and then passed down the patient's throat when they swallow, preventing inadvertent placement into the trachea. Although the placement of the pinky-wide transducer is uncomfortable, there are very few complications with gagging from the patient once the transducer is in the correct location.
Historical Aspect
- 1971(2)
- 1976
- 1977
- 1980(1)
- 1982
- 1990(1)
- 2007(1)
- Recently
Procedure
Prophylaxis
Clinical Applications
- inoperative procedures ( Cardiac and aorta) (5, other))
- Trnasplant surgery (lung and liver) (5,other)
- intensive care unit/ critically ill/ ER(5other)
- interventional laboratory/transcatheter procedures
- outpatient
aortic pathology, (5,otehr)cardiac valve dysfunction,percutaneous noncoronary cardiac interventions,infective endocarditis,atrial fibrillation or flutter,embolic events.
Contraindications
Relative contraindications:(3)
- Esophageal varices
- Gastric varices,
- Tumors
- Strictures
- Mallory-Weiss tears
- Medication use, such as steroids and bisphosphonates
Complications
- The majority of the complications are caused by injury or trauma and may result in:[1]
- Lip
bruising/laceration ASA - Dental injury (eg. loosened tooth) [1]ASA
- Oroharyngeal,hypopharyngeal, esohageal or gastric abrasion[1] or perforation [2] [3][1][4][5]
Pharyngeal hematoma- Hemorrhage (eg, upper GI bleeding, hemoptysis, blood-tinged sputum) [1][3][6][7]
Splenic laceration- Sore throat[7], odynophagia[1] [5]and dysphagia[1] ASA
Compression of mediastinal structuresAirway compromise- Laryngospasm[6][7], bronchospasm[3][4]
Thermal injury/ burnTongue necrosisRecurrent laryngeal nerve injuryVocal cord paralysis- Hoarsness[7]
- Lip
Asiration- Accidental tracheal intubation[4] or endotracheal tube malposition[1]
- Profound gag[7]
- Bradycardia[7]
- Congestive heart failure[6][7]
Endocarditis- Dysrhythmias(PVC, AF, sutained VT, SVT, NSVT, AV block)[4][3][6] [7]4<gabiel
- Transient hyotention or hypertension[6][7]
- Hypoxia[3][6][7]
Methemoglobinemia- Fatality is rare. [5] [3] [6] [7]
loose/chipped tooth,displaced dentures
Advantages
Combined with Transthoracic echocardiography (TTE), a TEE before cardiac surgery can[15]:
- Confirm or exclude previous TTE findings
- Assess the immediate preoperative hemodynamics
- Assess ventricular function of the patient
- Facilitate placement of central venous catheters
- Assist with selection of anesthetic agents
- Be used as an inotropic support in identifying ventricular systolic size and function
After surgery but before closure, a TEE can[15]:
- Improve overall outcome
- Assist in determining whether the level of repair is acceptable
- Detect and diagnose significant disease remaining to be treated
- Assess cardiac function
- Assess the presence of intracardiac air
- Diagnosis abnormal cardiac rhythms
- Monitor ventricular function and loading
- Provides a better imaging view for determination of appropriate timing and the hemodynamic effect of sternal closure
- Assist in monitoring inotropic drugs
In noncardiac procedures, TEE can:
- Enhance monitoring of myocardial function
- Enhance monitoring of volume status
Disadvantages
Constraints for testing include:
- Limited potential for optimal Doppler alignment
- Limited time to perform a complete study
- Suboptimal ambient lighting
Standard views of Transesophageal echocardiography (TEE)
1. Esophageal Position
Four-Chamber Plane
- Location: high trans-esophageal position, probe posterior to the left atrium at 0 degrees rotation, angle transducer toward the left ventricular apex
- View
- Lateral wall and inferior segments of left ventricle. Apparent apex may be a more proximal segment of anterior wall
- Anterior and posterior mitral valve leaflets
- Assess the size, shape, systolic function of the RV by turning the probe towards the patient's right
Two-Chamber Plane
- Location: with LV apex in center of image in four chamber view, rotate probe 60 degrees
- View
- Inferior and anterior LV walls
- Rotation to 90 degrees shows LA appendage
Long-Axis Left Ventricular Plane
- Location: with high trans-esophageal positioning, posterior to left atrium, rotate image plane 120 degrees
- View
- Proximal ascending aorta, sinuses of Valsalva, right and non coronary leaflets of the aortic valve, anterior and posterior mitral valve leaflets
- Good view for evaluating ascending aortic dissection, subaortic membrane, supracristal VSD, sinus of Valsalva aneurysm, aortic valve vegetations and abscess formation
Short-Axis Plane
- Location: withdraw the probe to the level of the aortic valve and rotate the image plane to between 30 and 45 degrees
- View
- Visualization of detailed aortic anatomy including 3 leaflets and sinuses of valsalva and the origin of the L main coronary artery
- Interatrial septum and fossa ovalis are well seen
2. Gastric Position
Short-Axis Plane
- Location: with probe in tip of the stomach, flex the scope superiorly
- View
- Global LV systolic function and global LV function can be evaluated
- May obtain a view of the mitral valve by withdrawing the transducer towards the esophagus
Two-Chamber Plane
- Location: in the transgastric position, rotate the image plane to the 90 degree position, then turn the probe towards the patient's right
- View
- Right atrium, tricuspid valve, right ventricle
- Can occasionally see RVOT and pulmonic valve
3. Transgastric Apical Position
Four-Chamber Plane
- Location: from transgastric short axis view, transducer is advanced further into the fungus
- View: apical four chamber, allows for doppler interrogation of LV outflow tract and valve
Long-Axis Plane
- Location: from transgastric apical four chamber plane, rotate the image to 120 degrees
- View: LVOT, allows doppler of the LVOT and aortic velocities
Descending Thoracic Aorta
- By rotating proble from the transesophageal or transgastric position until the image is directed just left of the patients spine, can visualize a short axis view of the thorasic aorta
- Useful for evaluation of aortic dissection, aneurysms and atheromas
Examples
Resources
- SeeMyHeart Patient Information on Echocardiograms (Heart Ultrasounds)
- American Society of Echocardiography
- Stress Test with Echocardiography
- Echocardiography information
- Coronary heart disease and echocardiography
- Echocardiography Resources & Simple echocardiography tutorials
- Atlas of Echocardiography
- E-chocardiography: Internet Journal of Cardiac Ultrasound
- Basic introduction to echocardiography
- Basic information about echocardiography
- 3D Echocardiography
- Perioperative Interactive Education VIRTUAL TEE
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK (2001). "The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients". Anesth Analg. 92 (5): 1126–30. doi:10.1097/00000539-200105000-00009. PMID 11323333.
- ↑ Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC, Yusoff IF (2005). "Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients". J Cardiothorac Vasc Anesth. 19 (2): 141–5. doi:10.1053/j.jvca.2005.01.020. PMID 15868517.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Daniel WG, Erbel R, Kasper W, Visser CA, Engberding R, Sutherland GR; et al. (1991). "Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations". Circulation. 83 (3): 817–21. doi:10.1161/01.cir.83.3.817. PMID 1999032.
- ↑ 4.0 4.1 4.2 4.3 Chan KL, Cohen GI, Sochowski RA, Baird MG (1991). "Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations". J Am Soc Echocardiogr. 4 (6): 577–82. doi:10.1016/s0894-7317(14)80216-2. PMID 1760179.
- ↑ 5.0 5.1 5.2 Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP; et al. (2005). "Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations". J Am Soc Echocardiogr. 18 (9): 925–9. doi:10.1016/j.echo.2005.01.034. PMID 16153515.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Seward JB, Khandheria BK, Oh JK, Freeman WK, Tajik AJ (1992). "Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications". J Am Soc Echocardiogr. 5 (3): 288–305. doi:10.1016/s0894-7317(14)80352-0. PMID 1622623.
- ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 Khandheria BK, Seward JB, Tajik AJ (1994). "Transesophageal echocardiography". Mayo Clin Proc. 69 (9): 856–63. doi:10.1016/s0025-6196(12)61788-1. PMID 8065188.
- ↑ Urbanowicz JH, Kernoff RS, Oppenheim G, Parnagian E, Billingham ME, Popp RL (1990). "Transesophageal echocardiography and its potential for esophageal damage". Anesthesiology. 72 (1): 40–3. doi:10.1097/00000542-199001000-00008. PMID 2297132.
- ↑ Kharasch ED, Sivarajan M (1996). "Gastroesophageal perforation after intraoperative transesophageal echocardiography". Anesthesiology. 85 (2): 426–8. doi:10.1097/00000542-199608000-00027. PMID 8712461.
- ↑ Sriram K, Khorasani A, Mbekeani KE, Patel S (2006). "Tongue necrosis and cleft after prolonged transesophageal echocardiography probe placement". Anesthesiology. 105 (3): 635. doi:10.1097/00000542-200609000-00043. PMID 16932012.
- ↑ Kim CM, Yu SC, Hong SJ (1997). "Cardiac tamponade during transesophageal echocardiography in the patient of circumferential aortic dissection". J Korean Med Sci. 12 (3): 266–8. doi:10.3346/jkms.1997.12.3.266. PMC 3054279. PMID 9250927.
- ↑ Dalby Kristensen S, Ramlov Ivarsen H, Egeblad H (1996). "Rupture of Aortic Dissection During Attempted Transesophageal Echocardiography". Echocardiography. 13 (4): 405–406. doi:10.1111/j.1540-8175.1996.tb00912.x. PMID 11442947.
- ↑ Chow MS, Taylor MA, Hanson CW (1998). "Splenic laceration associated with transesophageal echocardiography". J Cardiothorac Vasc Anesth. 12 (3): 314–6. doi:10.1016/s1053-0770(98)90013-1. PMID 9636915.
- ↑ American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography (2010). "Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography". Anesthesiology. 112 (5): 1084–96. doi:10.1097/ALN.0b013e3181c51e90. PMID 20418689.
- ↑ 15.0 15.1 Ayres NA, Miller-Hance W, Fyfe DA, Stevenson JG, Sahn DJ, Young LT; et al. (2005). "Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease: report from the task force of the Pediatric Council of the American Society of Echocardiography". J Am Soc Echocardiogr. 18 (1): 91–8. doi:10.1016/j.echo.2004.11.004. PMID 15637497.