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Table of contents :
TEE Pocket Manual......Page 2
Copyright......Page 4
3.pdf (p.4-5)......Page 5
4.pdf (p.6)......Page 7
Glossary of Acronyms......Page 8
Figure of TEE images......Page 12
7.pdf (p.12-23)......Page 13
8.pdf (p.24-33)......Page 25
9.pdf (p.34-49)......Page 35
10.pdf (p.50-53)......Page 51
11.pdf (p.54-61)......Page 55
Aortic regurgitation......Page 63
13.pdf (p.66-67)......Page 67
14.pdf (p.68-75)......Page 69
15.pdf (p.76-87)......Page 77
Pulmonic Valve......Page 89
17.pdf (p.94-105)......Page 95
18.pdf (p.106-109)......Page 107
19.pdf (p.110-121)......Page 111
20.pdf (p.122-127)......Page 123
21.pdf (p.128-135)......Page 129
Aortic Atherosclerosis Aneurysm Dissection......Page 137
23.pdf (p.142-157)......Page 143
24.pdf (p.158-167)......Page 159
25.pdf (p.168-179)......Page 169
26.pdf (p.180-183)......Page 181
27.pdf (p.184-191)......Page 185
A......Page 193
B......Page 195
C......Page 196
D......Page 197
E......Page 198
F......Page 199
I......Page 200
L......Page 201
M......Page 204
P......Page 206
R......Page 209
S......Page 211
T......Page 212
U......Page 214
Z......Page 215
29.pdf (p.215-218)......Page 216

Citation preview

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TEE

Pocket Manual

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SECOND EDITION LEANNE GROBAN, MD, MS Professor Department of Anesthesiology Wake Forest School of Medicine Medical Center Boulevard Winston Salem North Carolina CHANDRIKA RAJAN GARNER, MD, FASE Assistant Professor Department of Anesthesiology Wake Forest School of Medicine Medical Center Boulevard Winston Salem North Carolina

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1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 TEE POCKET MANUAL, SECOND EDITION

ISBN: 978-0-323-52280-9

Copyright © 2018 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www. elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes inresearch methods,professionalpractices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Content Strategist: Dolores Meloni Content Development Specialist: Meghan Andress Project Manager: Srividhya Vidhyashankar Design Direction: Brian Salisbury Printed in China Last digit is the print number: 9

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PREFACE The first edition of the TEE Pocket Manual in 2007 was well received by perioperative care and cardiology communities, having been through a revised reprint in 2011 and a Spanish translation. In the second edition, we have kept the same concise and pocket-sized format so that the pocket manual remains a practical resource for the on-the-go perioperative echocardiographer and the intensive care clinician. Many chapters have been revised to include the latest terminology and TEE views and reflect the latest recommendations from the American Society of Echocardiography (ASE) guidelines. Specifically, we are particularly pleased that our second edition includes all 28 TEE views, updated ASE grading for valvular heart disease, specifically aortic and mitral stenosis and insufficiency, and additional information on the assessment of right ventricular function relating to volume and pressure overloads. Chapter 13 on prosthetic valves has been amended to include only the most commonly used valves, as well as examples of various transcatheter aortic valves. Chapter 18 on intracardiac masses and artifacts has been expanded to incorporate TEE for catheter-based interventions, including left ventricular assist and MitraClip insertion and left atrial appendage occlusion. Chapter 21 on 3D TEE that was added to the 2011 reprint has also been expanded with more in-depth discussion and TEE images on evaluation of mitral valve anatomy and left ventricular function. The book grew out of a practical need for a rapid reference for resident physicians, fellows, and other practitioners of

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echocardiography working in dynamic arenas, such as the operating room and the intensive care unit. To be concise and portable, we limited the potential pages of references by focusing on the ASE guidelines as our primary resource, unless otherwise specified. Each chapter includes echocardiographic findings specific to 2D, color flow, and Doppler imaging modalities, representative schematics, TEE images, and charts. More than 20 new images have been added to this edition. To enhance the ease and speed of topic location, chapters are identified by color tabs. An updated laminated card serves as an additional, easy-to-use and concise resource. An e-version is also included with the hard-copy version. Use of this pocket manual is not intended to replace the need for reading and mastering the extensive texts and guidelines on echocardiography, nor will it substitute for a detailed review for the Perioperative Transesophageal Echocardiography Certification examination. We do hope that it will become a valuable companion to anesthesiology residents, fellows, cardiology fellows, and experienced clinicians who would like to have ready access to the information contained herein. Leanne Groban Chandrika Rajan Garner

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ACKNOWLEDGMENTS Revising a book can be a daunting task, and we have several people to thank who helped make the process seamless. First, thanks to Addie Larimore for her secretarial assistance. Special thanks go the team at Elsevier, Sri Vidhya Shankar, Meghan Andress, Dolores Meloni, and Emily Costantino. We appreciate the work of Dr. Mandisa-Maia Jones for her contributions to the original 3D chapter. Working on a project like this often takes a great deal of time away from family life. We acknowledge this and thank our families for their support, particularly Chris Garner and the Golden Grobans. We thank our anesthesia residents and fellows who push us to keep learning every day. Last, and most important, thanks to our patients, who continue to teach us so much. Leanne Groban Chandrika Rajan Garner

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GLOSSARY OF ACRONYMS 2D 3D a’ AA Afib AI AL Amax AML AR AS ASA ASD ASH AV AVA BSA CFD Ch CHD CI cm/s CM CPB CO CS CSA C-sept c/s CVP CWD D dB DGC DT DTG x

two-dimensional three-dimensional peak late mitral annular velocity aortic arch atrial fibrillation aortic insufficiency anterior leaflet peak atrial transmitral flow velocity anterior mitral leaflet aortic regurgitation aortic stenosis atrial septal aneurysm atrial septal defect asymmetrical septal hypertrophy aortic valve aortic valve area body surface area color flow Doppler chamber congenital heart disease cardiac index centimeters per second cardiomyopathy cardiopulmonary bypass cardiac output coronary sinus cross-sectional area coaptation-septum cycles per second central venous pressure continuous wave Doppler diastole decibels depth-gain compensation deceleration time deep transgastric

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DVT e’ ECG EDA EF Emax EOA ERO ESA FAC FS HCM HK HOCM HR IABP IAS IV IVC IVRT IVS kHz L LA LAA LAP LAX LCC LUPV LV LVEDP LVH LVOT LV SAX m/s ME ME LAX MI

deep vein thrombosis peak early mitral annular velocity electrocardiography end diastolic area ejection fraction peak early transmitral flow velocity effective orifice area effective regurgitant orifice end systolic area fractional area change fractional shortening hypertrophic cardiomyopathy hypokinesis hypertrophic obstructive cardiomyopathy heart rate intraaortic balloon pump interatrial septum interventricular inferior vena cava isovolumic relaxation time intraventricular septum kilohertz left left atrium left atrial appendage left atrial pressure long-axis left coronary cusp left upper pulmonary vein left ventricle left ventricular end diastolic pressure left ventricular hypertrophy left ventricular outflow tract left ventricular short axis meters per second midesophageal midesophageal long axis myocardial infarction

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MPA MR ms MS MV MVA NCC PA PAP PDA PFO PG PGE1 PHT PISA PL PML PR PRF PVar PVd PVs PWD Qp Qs R RA RAA RAE RAP RBC RCC RF RIMP ROA RV RVE xii

main pulmonary artery mitral regurgitation millisecond mitral stenosis mitral valve mitral valve area noncoronary cusp pulmonary artery pulmonary artery pressure patent ductus arteriosus patent foramen ovale pressure gradient prostaglandin E1 pressure half-time proximal isovelocity surface area posterior leaflet posterior mitral leaflet pulmonic regurgitation pulse repetition frequency pulmonary vein retrograde flow velocity pulmonary vein diastolic flow velocity pulmonary vein systolic flow velocity pulsed wave Doppler pulmonary flow systemic flow right right atrium right atrial appendage right atrial enlargement right atrial pressure red blood cell right coronary cusp regurgitation fraction RV myocardial performance index regurgitant orifice area right ventricle right ventricular enlargement

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RVH RVOT RVSP S S/D ratio SAM SAX SVC SVR TAPSE TAVR TDI TEE TG TGA times/s TOF TR TTE TV TVI UE US VC Vp VSD

right ventricular hypertrophy right ventricular outflow tract right ventricular systolic pressure systole systolic/diastolic ratio systolic anterior motion short-axis superior vena cava systemic vascular resistance tricuspid annular plane systolic excursion transcatheter aortic valve replacement tissue Doppler imaging transesophageal echocardiography transgastric transposition of great vessels times per second tetralogy of Fallot tricuspid regurgitation transthoracic echocardiography tricuspid valve time–velocity integral upper esophageal ultrasound vena contracta propagation velocity ventricular septal defect

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FIGURE OF TEE IMAGES

1. ME 5-Chamber view 2. ME 4-Chamber view 3. ME-Commissural view 4. ME 2-Chamber view

6. ME AV-LAX view

7. ME-Ascending Aorta 8. ME-Ascending Aorta SAX view LAX view

9. ME Right Pulmonary 10. ME AV SAX view vein view

11. ME Right inflow- 12. ME modified bicaval outflow view TV view

5. ME-Long axis view

13. ME Bicaval view

14. Upper Right & Left Pulmonary veins view

17. Transgastric 18. Transgastric Apical Midpapillary SAX view SAX view

15. ME Left Atrial Appendage view

16. Transgastric Basal SAX view

19. Transgastric RV Basal view

20. Transgastric RV inflow-outflow view

21. Deep Transgastric 5-Chamber view

22. Transgastric 2-Chamber view

23. TG RV-inflow view

24. TG LAX view

25. Descending Aorta SAX view

26. Descending Aorta LAX view

27. UE Aortic Arch LAX view

28. UE Aortic Arch SAX view

Adapted from J Am Soc Echocardiogr 2013;26:921-64.

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Ultrasound: mechanical vibrations propagated through a medium at a frequency greater than 20,000 cycles per second (c/s) or 20 kilohertz (kHz) (above audible range)

Ultrasound Principles and Characteristics (Figure 1.1) •

• • • • • •

Each element of the signal is depicted as a sine wave. (A sound signal is usually much more complex and is the assembly of multiple sine wave components. The ultrasound [US] machine provides a coherent single signal, unlike most “sounds.”) Peaks and troughs represent areas of compression and rarefaction of sound waves. A cycle is the sum of one compression and one rarefaction. A wavelength, λ, is the distance between two similar points. Frequency, measured in hertz (Hz), is the number of cycles (peaks and troughs) per second. Amplitude is the intensity or strength of the sound (commonly reported as decibels [dB]). Velocity of propagation is the distance traveled by sound in each second. Velocity through a given medium depends on the density and elastic properties of the medium. Ultrasound travels faster through bone (4080 meters per second [m/s]) than through air (330 m/s), soft tissue, or blood (1540 m/s).

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of Ultrasound

PHYSICS •

1 Basic Physics

BASIC PHYSICS OF ULTRASOUND

of Ultrasound

Compression

1 cycle Amplitude

1 Basic Physics

Rarefaction

Wavelength Propagation Figure 1.1

velocity=frequency × λ(wavelength) To find the wavelength of the signal produced by a 5-MHz transducer through soft tissue or blood: λ= 1:54 (mm/μs)/f λ=1:54/5=0:308 mm

Wavelength and Image Quality (Figure 1.2) • • •

Resolution: This is the smallest distance between two points that allows the points to be distinguished as separate. High-frequency (shorter λ) probes have better resolution than low-frequency probes. High-frequency probes penetrate less (this is relevant when imaging pediatric patients or shallow structures in adults). Sonic absorption and scattering determines how well the US beam penetrates. The more the reflection and refraction, the greater is the loss of beam intensity and the less is the penetration.

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Also, the less homogeneous the medium, the harder it is for the US to penetrate. Ultrasound with higher frequencies has greater absorption and scattering and thus poorer penetration. Low-frequency transducers are thus best suited for transthoracic imaging because they are able to penetrate the chest wall to image the heart. Image resolution is no greater than 1–2 wavelengths. The smaller the wavelength, the finer is the image resolution. 1/λ ∝ f ∝ 1/penetrance ∝ resolution 30 .3

.2

Wavelength (resolution)

.44

0.5

20

.62 1.0

1.5

10

Penetration

1.5

Penetration (cm)

Wavelength (mm)

0

0 0 1 2.5 3.5

5

7.5

10

15

20

Transducer frequency (MHz)

Figure 1.2 (Otto C: Textbook of Clinical Echocardiography, ed 3, Philadelphia, 2004, Saunders.)

Transducer Frequencies • • • •

Transthoracic: 2.5–3.5 MHz Transesophageal: 5–7.5 MHz Epicardial and vascular: 7–10 MHz Intravascular: 30–40 MHz

Ultrasound Interaction with Tissue •

Reflection: fundamental principle for imaging. Amount of US return depends on angle of incidence and impedance

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of the tissue ( tissue density). US return is highest when the angle between the beam and the reflecting interface is 90°. u Acoustic coupling gel placed between the transducer and skin (for transthoracic echocardiography [TTE]) decreases the impedance by nearly eliminating the transducer–air and air– skin interfaces resulting in a greater percentage of US energy transmitted into the body rather than reflected. Scattering: targets that are small relative to the transmitted wavelength ( 50% of patients See thickened TV leaflets, TR, > 10 mm difference in apex–annulus distance of TV and MV (normally < 10 mm)

Tetralogy of Fallot •

Most common cyanotic defect in children (10% of all have congenital heart disease

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[CHD]) and thus a common cyanotic CHD defect in adults. Adults present for reoperation after successful repair in childhood, complete repair after palliative procedure in childhood, or primary repair if previously well-balanced TOF. Classic TOF anatomy u Membranous VSD u Overriding aorta u RVOT obstruction (PS) u RVH Surgical indications for the previously repaired patient include residual VSD, recurrent pulmonary blood flow obstruction, and progressive RV dilation and dysfunction, with associated PR. After RV-to-PA conduit placement, some patients may present with conduit calcification and stenosis. Also, long-term volume overload from large shunts may be associated with LV dysfunction and/or AI secondary to aortic dilatation. ME AV LAX and TG LAX for definition of aortic override and obstruction of the RVOT; gradient estimates can be obtained; ME RV inflow–outflow for RVOT evaluation; ME 4-chamber view for position and extension of VSD and additional VSDs After TOF repair: u Evaluate VSD patch for dehiscence. u Look for interference of MV/TV function by VSD. u Evaluate RVOT gradients with Doppler (1.5 cm; associated with the presence of Chiari network, PFO, and an increased incidence of paradoxical emboli “Coumadin ridge”: invagination of tissue between the left upper pulmonary vein and left atrial appendage (LAA). This normal structure may appear fatty with a “Q-tip”like appearance and may be mistaken for thrombus. (Fig. 19.8 also see fig. 18.1) Persistent left SVC: echo-free space seen between the LUPV and the LAA. It can be identified with color flow Doppler as well as a dilated coronary sinus (>1 cm). An agitated saline injection into the left upper extremity vein opacifies the coronary sinus, thus confirming the diagnosis.

Lipomatous interatrial septum LA

RA

Figure 19.7 Schematic image of a lipomatous interatrial septum. (Gallagher: Bored Stiff TEE Manual, 2004, Butterworth-Heinemann.)

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LUPV

“Coumadin Ridge”

Max V = 31 Max PG = 0

LAA

Figure 19.8 “Coumadin ridge” or invagination of tissue between the LUPV and the LAA.



Transverse sinus: triangular space seen between the aorta and the LA in a transverse view (ME AV LAX). It should not have color flow in it. If filled with fat, it may be confused with thrombus.

Right Ventricle • •

Moderator band: prominent muscular ridge near apical third of RV. This is part of the conduction system (Figure 19.9). Trabeculations: muscle bundles on endocardial surface of RV. This is best seen in RV inflow–outflow view (see Figure 19.5).

LV and AV (Figures 19.10 and 19.11) •



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False tendon or LV band: similar to moderator band on right side but more filamentous. These are false chordae tendonae. Segmental wall motion abnormality: The septal wall may appear hypokinetic or dyskinetic with epicardial pacing; this is dyssynchrony from septal wall depolarizing before other walls.

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LA RA LV

RV

Moderator band Figure 19.9 Schematic image of moderator band in RV seen in the ME 4-chamber view. (Gallagher: Bored Stiff TEE Manual, 2004, ButterworthHeinemann.)

ME AV SAX with nodules of Arantti LA RA RV

Figure 19.10 Schematic image of nodules of Arantii seen in ME AV SAX view. (Gallagher: Bored Stiff TEE Manual, 2004, Butterworth-Heinemann.)





Nodulus arantii: knob-like structures at the center of the free edge of each cusp of the aortic valve. These are best seen in the ME AV SAX view (see Figure 19.10). Lambl excrescences: string-like filamentous structures seen on aortic side

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ME AV LAX VIEW* Transverse sinus LA

LVOT

Lambl excrescence

Ao

RVOT *Note transverse sinus between LA and AV. Figure 19.11 Schematic image of Lambl excrescence on aortic side of aortic valve seen from ME AV LAX view. (Gallagher: Bored Stiff TEE Manual, 2004, Butterworth-Heinemann.)



of the AV, associated with advanced age, risk of embolizing is unclear (see Figure 19.11). Innominate vein: usually poorly seen, but with increases in venous pressure, it will be prominent and may appear as an aortic dissection.

Man-Made Objects in Heart •

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Pacing wires, Swan-Ganz catheters: appear elongated, thin, linear echodensities that may create multiple linear reverberations. Usually their presence is anticipated (based on physical examination of the patient) (see Chapter 18).

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EQUATIONS AND CALCULATIONS DOPPLER FLOW CALCULATIONS •

Stroke Volume (SV): Cross-sectional area (CSA) (π r2) of a vessel or valve is multiplied by the distance (stroke distance or velocity time integral (VTI)) that blood travels with each beat (during systole for the aorta, LVOT, PA, AV, or PV, or diastole for the MV or TV) (Figure 20.1).

CSA (LVOT)

Stroke distance (VTILVOT) Figure 20.1 For better understanding of the Doppler SV calculation, conceptually image the LV ejecting a volume of blood into the cylindrical aorta on each beat. The base of this cylinder is the systolic cross-sectional area of the aorta, whereas its height is the distance the average blood cell travels during the ejection for that beat. The cross-sectional area of the vessel or valve is multiplied by the stroke distance.

u CSA circle = π r

2

Area of LVOT = π (rLVOT )2 u VTILVOT: Place the PWD in the

LVOT, and determine the “stroke distance” or VTI.

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Calculations

πr2 = 3:14 × diameter2 / 4 = 0:785 × d2

20 Equations and

[π = 3:14; r = diameter/ 2]

VTI = area under the plot of velocity versus time (outline the Doppler “envelope,” and the ECG machine will calculate the VTI by using a standard numerical analysis technique) (Figure 20.2).

Time PWD Velocity Figure 20.2 The length of the cylinder of blood ejected through this cross-sectional area on a single beat is referred to as the velocity-time integral (VTI) of the Doppler curve, since velocity is the first derivative of distance. SV then is calculated as CSA × VTI.

SV (cc/ min) = area of LVOT (cm2 ) × VTILVOT (cm) •

Cardiac output (CO): CO (cc/ min) = SV (cc) × HR (bpm)

Calculations

20 Equations and



Shunt (Qp/Qs) ratio: Calculate by using Doppler SVs determined at the PA and LVOT. Qp/ Qs = SVright-side / SVleft-side = SVPA / SVLVOT = CSAPA × VTIPA / CSALVOT × VTILVOT

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Regurgitant volume: amount of blood that flows back through a regurgitant lesion per beat. Remember that the total stroke volume flowing through a regurgitant valve during systole is greater than the SV that flows through a “normal” valve. Regurgitant volume = Regurgitant valve SV2Reference (normal) valve SV

• • •

MR: Calculate by using the difference in Doppler SVs at the mitral annulus and LVOT (reference vessel). AR: Calculate by using the difference in SVs through AV and RVOT (reference vessel). In the absence of significant disease in the chosen reference valve or vessel, this equation can be applied to any regurgitant lesion. RVMV (ml) = SVMV 2SVVLOT RVAV (ml) = SVLVOT 2SVRVOT

Regurgitant fraction or regurgitant percentage (%) = RV/ SV through regurgitant value •

Continuity equation and AV stenosis: (refer to Chapter 5.) SVLVOT = SVAV AVA = CSALVOT × (VTILVOT / VTIAV )

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PRESSURE GRADIENTS AND CALCULATED PRESSURE ESTIMATES •

Using the modified Bernoulli equation, combine a Doppler-derived pressure gradient and a known or estimated proximal or distal pressure. Peak and mean calculations of pressure gradients using the modified Bernoulli equations require accurate velocity measurements. Mean pressure gradient is the instantaneous pressure gradient averaged over the entire flow period—the echocardiography machine can calculate both peak and mean pressure gradients. u Modified Bernoulli equation:





ΔP = P1 2P2 = 4V2

Right-sided pressure estimated from TR jet RVSP or PASP = 4(VTR )2 + RAP PADP = 4 (Vlate PR )2 + RAP Left-sided pressure estimated from MR and AR jets LAP = SBP24(VMR )2 LVEDP = DBP24(Vend AR )2

u If a predefined RA estimate (10 mm Hg)

or direct measurement is not used, the RAP can be estimated from the IVC. – If caval diameter is ≤ 1.5 cm and it changes with respiration, RAP is low (5–10 mm Hg). – If IVC diameter > 2 cm and there is no change with respiration, RAP is > 15 mm Hg. 172

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INTRAOPERATIVE 3D TEE Real-time 3D echocardiography is now possible with various 3D-capable transducers. This new technology is valuable for intraoperative assessment of valves; chamber volume and mass; ventricular function, wall motion, and dyssynchrony; and evaluation of regurgitant lesions and shunts and to aid in catheter-based cardiac interventions, such as transcatheter valve placement, occluder placement for septal defects and paravalvular leak, LAA occluder devices, and MV clips.

MODES OF 3D ECHOCARDIOGRAPHY Real-Time 3D Imaging •

Live 3D u Displays pyramidal data set of 60° × 30° u Useful for imaging small cardiac

structures in the near-field (e.g., AV) u Advantages: real-time imaging, good

spatial and temporal resolution u Disadvantages:

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3D TEE



Small pyramidal data set, inability to image larger structures in their entirety – Probe movement will result in movement of image 3D zoom u Displays magnified pyramidal data set of up to 90° × 90° u Wider sector compared with live 3D because of zoom capability u Useful for imaging: – MV – TV

21 Intraoperative



– LAA – IAS u Advantages: real time imaging, good spatial resolution, larger pyramidal data set u Disadvantages: poor temporal resolution

3D TEE

21 Intraoperative

Reconstructed 3D Imaging A reconstructed image composed of 4–14 smaller pyramidal data sets acquired over 4–14 heartbeats. Acquisition of smaller pyramidal data sets requires ECG gating for accurate reconstruction of complete 3D image. • Full volume u Displays pyramidal volume set of up to 100° × 100° u Can have frame rate >30 Hz with greater gating u Allows for manipulation of images either on machine or offline – Cropping – Multiplane reconstruction – Viewing of three orthogonal planes simultaneously u Useful for: – Volumetric quantification of cardiac chambers – Assessment of LV dyssynchrony – Interrogation of valvular pathology u Advantages: larger pyramidal volume, optimal temporal and spatial resolution u Disadvantages: vulnerable to motion and electrocautery interference – ECG gating required – Ventilation must be held during image acquisition

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Must be acquired in the absence of electrocautery – Requires a regular cardiac rhythm for best images – With poor gating, “stitching” artifacts can result Full-volume color u Displays pyramidal volume set of 60° × 60° u Useful for: interrogation of valvular pathology (ex. MR) u Advantages: localize regurgitant jets (e.g., status post failed MV repair) u Disadvantages: vulnerable to motion and electrocautery interference – ECG gating required – Ventilation must be held during image acquisition – Must be acquired in the absence of electrocautery – Requires a regular cardiac rhythm – Small color flow Doppler interrogation box – Even with gated images, low temporal resolution (frame rate often < 20 Hz) can limit diagnostic value

OPTIMIZING IMAGES • • • • •

Optimize images in 2D before switching to 3D. Optimize ECG tracing before acquiring gated images. Hold vent, and wait for pauses in electrocautery before acquiring gated images. Image the smallest volume needed to image the structure of interest. Set gain and compression settings to midrange.

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VALVE IMAGING MV 3D imaging of the MV should supplement a standard 2D MV interrogation because of its ability to increase the diagnostic accuracy of MV pathology. • Standard en face view (surgeon’s view) of MV with full-volume or 3D zoom u Standard acquisition is at 90° and 120° (ME 2-chamber and ME AV LAX), but often 0° and 90° (ME 4-chamber and ME 2-chamber) are the orthogonal views obtained. u Optimize the two orthogonal views. u Include the AV and the LAA for orientation. u After capture, rotate the image so that the AV is at the 12-o-clock position (Figure 21.1).

Aortic Valve

Figure 21.1 3D full-volume MV in diastole.

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• •

Full-volume color interrogation of MV in patients with MR MV morphology information u Using high-resolution LV images, echocardiography traces the MV and annulus in multiple planes. u Information, such as valve height, AP and PM distance, aortomitral angle, and anterior and posterior leaflet areas, is generated.

AV •

Standard en face view

u Acquire with orthogonal views at

60° and 120° (ME AV SAX and ME AV LAX). u Optimize the orthogonal views. u After capture, rotate the image so that the AV is seen from the ascending aorta with the right coronary cusp at the 6-o-clock position.

TV •

Standard en face view

u Standard acquisition is at 0° and

90° (ME 4-chamber and modified bicaval). u Optimize the orthogonal views. u After capture, rotate the image so that the AV is at the 12-o-clock position.

PV •

Standard en face view

u Standard acquisition is at 0°

(UE AA SAX). u Optimize the orthogonal views. u After capture, rotate the image so that

the septal leaflet is at the 12-o-clock position.

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LV IMAGING Full-volume acquisition of the entire LV allows for endocardial tracking for 3D EF estimates and assessment of segmental wall motion. • Image acquisition (Figure 21.2) u 0° and 90° (ME 4-chamber and ME 2-chamber) u Acquire the entire LV, including the apex. • 3D software allows for the echocardiographer to place labels on the annulus and the apex in the ME 4-chamber and ME 2-chamber views. • The software then tracks the endocardium and calculates LV end-systolic and end-diastolic volume and EF, which has been shown to be more accurate than 2D assessments. • LV animation with colored segments is also possible (Figure 21.3).

TEE X7-2t 19Hz 16cm

3D Beats 4Q 0

0

TIS0.1 MI 0.3 M4

180

Full Volume 2D / 3D % 57 / 44 C 50 / 30 Gen

PAT T: 37.0C TEE T: 39.6C

80 bpm

Delay 0ms

Figure 21.2 3D full-volume LV.

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Figure 21.3 3D LV with segments.

IMAGING TO GUIDE CATHETER-BASED PROCEDURE TAVR 3D full volume can be particularly useful to measure the AV annulus for TAVR in patients who are under general anesthesia with the TEE probe in place. 2D and 3D TEE can be useful to assess paravalvular leak, valve position, and valve function after the procedure. Of note, TAVR is a fluoroscopyguided procedure, and the trend in both Europe and the United States is moving away from the use of general anesthesia and TEE for transfemoral TAVR.

Septal Defect or Paravalvular Leak Closure Devices Live 3D and 3D zoom are useful to show the exact position and size of the defect as well as for guidance of wire placement, including transseptal puncture, if needed. Live 3D, 3D

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zoom, and full volume can all be used to assess orifice before and after closure. Color 3D can be used but is often less useful because of low frame rates. 2D CFD images are useful before and after the procedure.

LAA Closure Several LAA closure devices are currently being used. Before the procedure, 3D and 2D images of the appendage are obtained. Live 3D and 3D zoom are useful for transseptal puncture and advancing the wire into the LAA. 3D can then be used to show appropriate positioning of the device in the appendage. 2D CFD images are useful after the procedure to demonstrate lack of flow into the appendage.

Mitra Clip Live 3D and 3D zoom can be used to for transseptal puncture and advancing the device to the MV. Once the clip is in place, 3D full volume can be used to assess LV function and assess MV opening. 2D images of LV function, CFD of residual MR and PWD of mitral inflow gradient are also essential assessments.

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Note: Page numbers followed by f indicate figures, t indicate tables, and b indicate boxes.

2D images. See Twodimensional (2D) images 3D images. See Threedimensional (3D) echocardiography

A Abnormal filling patterns, 25 Abnormal relaxation, unmasking, 28 Abnormal valve morphology, 50b Abscess, 112 Acoustic coupling gel, placement of, 4 Acoustic energy, loss of, 4 Acute valvular regurgitation, 112 Adult congenital heart disease, 131–146 AI. See Aortic insufficiency Aliasing, 8, 160, 161f Amax decrease, 29 velocity, 24

AML. See Anterior mitral leaflet Amplification, degree of, 6 Amplitude, 1, 2f Anatomic pitfalls, 157–168 Anatomic reflector, 160 Annuloaortic ectasia (Marfan syndrome), 51 Annulus definition of, 39 fibrous, nonmobile region of, 55 Anterior leaflets illustration of, 77, 77–78f, 83, 83f mobility, 85 Anterior mitral leaflet (AML), 48, 55 Anterior MV leaflet, flutter of, 51 Anterolateral commissure, 56f Anterolateral papillary muscle, attachment of, 55 Anteroposterior commissure, 83

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Anteroseptal commissure, 83 Aorta coarctation of, 137 diastolic flow reversal see Descending aorta replacement see Ascending aorta Aortic aneurysm, 51 Aortic annuli, size comparison, 54 Aortic atherosclerosis aneurysm dissection, 125–130 Aortic dissection, 51 Aortic forward flow, 54f Aortic insufficiency (AI) CFD, 41–42 CWD, 41–42 Aortic regurgitation, 40, 51–54, 171 CFD, 51–52 CWD, 53, 54f etiology of, 51 severity assessment, 51–54 chart, 53t Aortic root dilatation, 126 illustration of, 48f pathology, 51 Aortic stenosis (AS) degrees of, 48b

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Aortic stenosis (AS) (Continued) severity, 44 underestimation, 44 Aortic valve area (AVA), 39 criteria, 49t "double envelope" for, 47f obtaining, continuity method, 45–48, 46f Aortic valve (AV), 166–168, 167–168f, 177 anatomy of, 39–42 annulus, PWD sample volume at, 45 closure, mitral valve (MV) opening, time between, 25 CWD placement, 25 diameter of, 18 flow velocity, 18 leaflets, midsystolic closure and fluttering of, 49 replacement, measurements for, 49–50 structures and function, views to evaluate, 39–42 values, 39 velocity of flow, 9 profile, 25f Aortic valve stenosis, 43–50, 171

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Aortic valve stenosis (Continued) associated findings, 50b LVOT obstruction differential, 48–49 mosaic appearance, 43 severity, assessment, 43–50 transvalvular gradients, using CWD, 43–44 type and etiology of, 43t valve area, 44–45 visual appearance, 43 Apical thrombus, mimicking, 150 AR. See Aortic regurgitation Area LVOT, 45, 46f Artifacts, 157–162 AS. See Aortic stenosis Ascending aorta diffuse hypoplasia of, 43t dilatation, 126 replacement, 53 ASD. See Atrial septal defect Asymmetrical septal hypertrophy (ASH), 49, 139 Atherosclerosis, 125–126 assessment/postdissection repair, 129–130

Atherosclerosis (Continued) diagnostic information, 127–129 intimal thickening, 125 JASE classification, 125 Atrial fibrillation (Afib), 29 Atrial septal aneurysm, 147 Atrial septal defect (ASD), 13, 131. See also Coronary sinus ASD; Sinus venosus ASD annular displacement, absence see Primum ASD types, 131–133 Atrioventricular pacing, 98 Attenuation, principle of, 4 Autograft, 105 AV. See Aortic valve AVA. See Aortic valve area Axial resolution, 6 illustration of, 6f Azimuthal resolution, 6

B Background noise, 162 Ball-cage mechanical valve, 99 Beam. See Ultrasound (US) beam Beam focal zone, 5 Beam width, 159 Beam-width artifact, 161 from calcific valve, 112

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Bernoulli equation, 92–93, 172 simplified, 43 Bicuspid aortic valve, 137 Bicuspid congenital aortic stenosis, 137–139 Bicuspid valve eccentric opening, 45 "fish-mouth" appearance, 44 suggestion, 39 Bidirectional Glenn anastomosis, 144 Bileaflet mechanical valves, 101–102 Biological valves, 103–107 2D imaging, 103 CFD, 103 dysfunction of, 108 heterografts, 103–104 homografts, 104–105 regurgitation, 108 Bjork Shiley mechanical valves, 100 Blood speed of sound in, 7 Blood flow, velocity, 7 Bovine biological valve, 103–104

C Calcification. See Degenerative calcification impact see Reverberations; Shadowing

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Calcified AV, 87 Calcium deposition, 50b Calculated pressure estimates, 172 Cannuli, during CPB, 152, 152f Carbomedics, 102, 102f Carcinoid syndrome, 112 Cardiac output (CO), 18, 170 decrease, 44 Cardiac structures, singledimensional images of, 7 Cardiac tamponade, 119 Catheter-based procedure, 179–180 Catheters, 151, 151f data, 44 Caveats, 91 Central venous pressure (CVP), measure of, 81 CFD. See Color flow Doppler Chiari network, 163 Chordae dysfunction, 88 involvement, 55 Chordal muscle elongation, 65 Chronic heart failure, 23 Circumferential fibers, 32 Circumflex coronary artery, 21f CO. See Cardiac output

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Coanda effect, 73b Coaptation defect, evaluation, 73–74 Coaptation point, 39 Coarctation, association, 138 Collagen vascular disease, 126 Color aliasing, appearance of, 58 Color Doppler, 10 Color flow Doppler (CFD), 43, 58 chart, 67t usage, 73 Color gain, limitation, 68 Color imaging artifacts, 162 Color M-mode, usage, 35 Comet tail, 157, 158f Commissural views, 68f, 73–74 Commissures, 39 Compliance, decreased LV, 35 Compression, 1 cycle of, 2f Congenital aortic stenosis, 137–139 Congenital cleft valve, 65 Constrictive pericarditis, 36, 120–124, 121f, 122–123t Continuity equation, 45 Continuous wave (CW) late notching, 139, 140f placement, 25

Continuous wave Doppler (CWD), 9 envelope, late peaking of, 48 Contracture, 57 Contrast echo, consideration of, 13 Convergence zone, radius, illustration, 70f Cor triatriatum, 57 Coronary distribution, 21–22, 21f Coronary sinus ostium, 133 unroofing, 133 Coronary sinus ASD, 133 Coumadin ridge, 165 Crista terminalis, 163 Cryopreserved aortic valve, 104 Cusps, simultaneous visualization, 44 CVP. See Central venous pressure CWD. See Continuous wave Doppler CWD-transmitral, 58–59 Cyanotic CHD defect, 141

D Dagger tooth, 48, 139 DeBakey types, 127, 127f Deceleration, time, 25

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Deep TG LAX, 16–20 impact, 144 view, 25, 41, 41f Degenerative calcification, 57 Delayed relaxation, 31f Depth discrimination, absence, 9 Depth-gain compensation (DGC), 11 Descending aorta, diastolic flow reversal, 52, 52f DGC. See Depth-gain compensation Diastasis, 23, 37t Diastole, 113–114f D shape in, 97 phases of, 23 Diastolic dysfunction, 34f assessment of, 36f causes of, 23 caveats, 35–37 identification of, 10 mild, 34f Diastolic flow reversal, examine for, 80 Diastolic function, 23–38 assessment, 32 illustration of, 33f PV patterns of, 31 normal, 30, 30f right ventricular, 38 transesophageal echocardiographic evaluation of, 32f

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Diastolic PAP, 81 Diastolic pressure gradient, decrease, 53 Diastolic volume, increased, 65 Dilated aortic root, replacement, 53 Dilated IVC, 88 Discrete subaortic stenosis, 138 Disk, mechanical valves, 100, 100f Divergence, illustration of, 5f Doppler, types of, 8–10 Doppler beam, 40–41 Doppler correlates, 37t Doppler equation, 7 Doppler flow calculations, 169–171, 169f Doppler imaging artifact, 160–162 Doppler shift, 7 DTG 5 chamber, 58 Dynamic outflow obstruction, 49 Dynamic range, 11

E E/A, 24 E/e’, 33 Early filling, 37t wave, for determination of VTI, 60f Early LV filling, attenuation, 98

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Early rapid filling, 23 Ebstein’s anomaly, 84, 140–141, 141f annular dilatation, 141 Eccentric MR, 58 ECG. See Electrocardiography Echo, appearance of, 104 Echo-free space, 117 Echocardiographic correlates, 37t Echolucent space, 117 EDA. See End diastolic area Edwards Sapien, 106, 106f EF. See Ejection fraction Effective regurgitant orifice area (EROA), equation, 71t, 72–73 Eisenmenger syndrome, 135 Ejection fraction (EF), 13 biplane method, usage, 16 Electrical processing, 10–11 Electrocardiography (ECG) tracing, 12, 29 usage, 14 Electronic interference, 162 Emax increase, 29 velocity, 24, 73b Embolism, causes of, 108 Embolization, risk of, 111

End diastolic area (EDA), 14 End systolic area (ESA), 14 Endocardial border tracing of, 16 visualization of, 13 Endocardial systolic motion, 13, 20–21t Endocardial wall thickening, 13, 20–21t Endocarditis, 111–116 differential diagnosis, 112–116 impact of, 78 Enhancement, 160 Entry tear, location, 128 Epiaortic scanning limitation, 125 Epicardial transducer frequencies, 3 Equations and calculations, 169–172 ESA. See End systolic area Eustachian valve, 163 Extracardiac effects, 13 Extracardiac Fontan procedure, 145

F

FAC. See Fractional area change False tendon/ LV band, 166 Far field, illustration of, 5–6f

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Fibroelastomas, 151 Fibrosis, 23 Fibrous cusps, or leaflets, 39 Filling pressures index of, 33 reduction of, 28 Fish-mouth appearance, 57 Flail leaflet/chord, 73b Flow conservation, principle of, 69 direction, identification of, 43 equation, 45 Focal zone, illustration of, 6f Focusing, principle of, 5 Foreshortening, awareness of, 20 Forward propagation, 4 Fractional area change (FAC), 14–15 Fractional shortening, 15–16 Frequency, definition of, 1 Full volume, 174 Full-volume acquisition, 178–179 Full-volume color, 175 Functional TR, presence of, 80

G Gain, usage of, 10

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Gain-dependent flow area underestimation, 162 Gated segments, 10 Ghosting, 162 Global function, assessment of, 13–22 Gradient, flow-directed measurement, 41 Gray scale range, 11

H Harmonic imaging, 10 consideration of, 13 Heart-lung transplant, 136 Hemodynamics, 68 Hepatic congestion, 57 Hepatic vein flow, 89–90, 89–90f Heterografts, 103–104 High-frequency probes, 2 High-velocity turbulent flow post stenosis, 43 Homografts, 54, 104–105 Human biological valves, 104–105 Hypertension, 126 Hypertensive aortic root dilation, 51 Hypotension, differential diagnosis of, 20t

I

IAS. See Interatrial septum

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"Ice-pick" view, 7 Image acquisition, 178, 178f appearance, controls to modify, 10–11 degradation, 157 quality of, 2–3 resolution, 3 Imaging. See also Harmonic imaging; Tissue Doppler imaging modalities, 7–8 Impaired relaxation, 25, 26f chart, 27f Impedance, decreases, 4 Infective endocarditis, 111 Inferior RV free wall, 85f Inferior vena cava (IVC), contraction of, 81 Inflow obstruction, 93 Innominate vein, 168 Interatrial septum (IAS), 91 lipomatous hypertrophy, 148 Intercostal arteries aneurysmal formations, 137 Internal mammary arteries, 137 Interventricular (IV) septum wall motion, 97–98 Intraaortic balloon pump, 153, 154f Intraatrial septum aneurysm, 165

Intracardiac fistula, 112 Intracardiac masses and objects, 147–156 Intracavitary air, 153, 155f Intraoperative 3D, 173–180 Intravascular transducer frequencies, 3 Intraventricular pressure, rise of, 18 Isovelocity shell, 62 Isovolumic relaxation, 37t Isovolumic relaxation time (IVRT), 23 decrease, 36 measurement, 25f usage, 25 IVC. See Inferior vena cava IVRT. See Isovolumic relaxation time IVS, 48

L LAA closure, 180 LAE. See Left atrial enlargement Lambl excrescences, 167, 168f LAP. See Left atrial pressure Late filling, 37t atrial contraction, result of, 23 Lateral mitral annulus, descent of, 32

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Lateral resolution, 6 artifact, 160 illustration of, 6f Leaflet-tip restriction, 58 Leaflets apparatus, 57 architecture, 39 closure line, 39 displacement of, 65 malformation, impact, 141 midsystolic closure and fluttering, 49 mobility decrease, 50b evaluation, 75 motion, 40–41 excessive, 65, 66f restrictive, 65 overlap, 55 pathology, 51 perforation, 65 raphe, commissure, 44 segments, involvement, 55 size, unequal, 44 structural abnormalities of, 51 structure, disruption, 65 thickening, 43 thickness, 55 from tips, radius measure, 62 Left anterior descending coronary artery, 21f

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Left atrial area (LAA), jet entry, 73b Left atrial enlargement (LAE), 23 Left atrial pressure (LAP) clues, 36 increase, 29, 33, 36 Left atrium (LA), 165–166, 165–166f compliance, 68 dilation, 73b jet direction in, chart, 67t LA-LV pressure gradient, 68 myxoma, 57 pulmonary venous pressure (PVP) Doppler gradient, 29 thrombi, 57, 149, 149f Left leaflet, illustration of, 77, 77–78f Left-to-right shunting, 131 quantification, 135 Left upper pulmonary vein (LUPV), 29, 71 Left ventricle (LV), 166–168, 167–168f animation, 178, 179f anterior wall, 15f dilation of, 27f, 43 early filling of, 35 endocardial border, tracing, 16

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Left ventricle (LV) (Continued) flow, temporal and spatial propagation of, 35 foreshortening, 16 hypertrophy, 23, 50b imaging, 178 posterior wall, 15f pressure, 27f structure, assessment of, 13 systolic function, 2D assessment of, limitations to, 15 thrombi, 150 volume, 27f Left ventricular assist device (LVAD), 153, 154f Left ventricular end diastolic diameter (LVEDD), 15f Left ventricular end diastolic volume (LVEDV), 16 Left ventricular end systolic diameter (LVESD), 15f Left ventricular end systolic volume (LVESV), 16 Left ventricular hypertrophy (LVH), 43

Left ventricular outflow tract (LVOT), 16–17 area, 45, 46f CWD contours, 139 diameter, 45 maximum velocity, 39 obstruction differential, 48–49 velocity of flow, 9 Libman-Sacks endocarditis, 112 Linear resolution, 6 Lipomatous hypertrophy of intraatrial septum, 165 Live 3D, 173 Load dependence, 15 Localized fibromuscular thickening, 43t Long-axis (LAX) beam, obliqueness, 16 truncation of, 15 Longitudinal fibers, 32 Longitudinal resolution, 6 Low-frequency transducers, 2 Lupus-related cardiac involvement, 112 LUPV. See Left upper pulmonary vein LVAD. See Left ventricular assist device LVH. See Left ventricular hypertrophy

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LVOT. See Left ventricular outflow tract

M Machine-derived EF, 17f Magna Ease biological valves, 103, 103f Malignant tumors, 150 Man-made devices, 151–156 Man-made objects, in heart, 168 Marfan syndrome, 126 Masses, 147–156 ME-2 chamber, 13–14, 18 illustration, 68f ME-4 chamber, 18, 58, 84, 84–85f illustration, 67f, 71f, 74f, 95f rotate probe from, 29, 30f view, 13, 35 ME AV LAX illustration, 75f impact, 142 usage, 16–17 view, 40, 40f, 51 ME AV SAX usage, 44 view, 39, 40f ME RV inflow-outflow, 96f view, 133 Mean pressure gradient, 172 criteria, 49t

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Mean pressure gradient (Continued) by using CWD, measure, 59 Mean velocity, mean gradient, 44 Mechanical valves, 99–102 dysfunction, 108 2D, 108 CFD, 108 CWD, 108 normal Doppler values for, 110t Medtronic CoreValve, 107, 107f Medtronic Hall mechanical valves, 100, 100f Mid-esophageal RV inflow-outflow, illustration of, 77f Mid-papillary view, 15f Midesophageal long-axis (ME LAX), 13–14 annulus size, measurement, 73–74 illustration, 68f view, 41, 41f Mirror image artifact, 161, 161f Mitra Clip, 180 Mitral annular/ basal descent, 13 Mitral annular dilatation, 55

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Mitral annular dilation, consideration, 65 Mitral annulus, 13 Mitral E wave velocity, increased, 71 Mitral inflow, 25f Mitral orifice size and shape, 68 Mitral regurgitation (MR), 171 cause of, 65 diagnostic examination for, 73–74 intraoperative examination, 75–76 jet CWD of, 18–20 illustration of, 19f mechanism, evaluation, 65 presence of, 71 regurgitant jet, 70f upstroke of, 18–20 severity, signs of, 73b volume, 72 Mitral segments, Carpentier nomenclature for, 55 Mitral stenosis (MS) 2D views of, 57–58 E wave profile of, 35 quantitate severity of, 59–61 severity of, 63t

Mitral valve area (MVA), 35 by pressure half-time (PHT), measure, 59, 59t Mitral valve (MV), 176–177, 176f affected segment, identification, 67 anatomy of, 55–56 annulus, 84 association, 132 calculation, CWD, 72 continuity equation, 61, 62f CWD placement, 25 early diastolic closure of, 51 leaflet, 132 motion, types and source of, 65–67 morphology information, 177 orifice, LV blood acceleration, 69 propagation velocity, 35, 35f Mitral valve regurgitation, 65–76 qualitative examination, 65 quantitative measurement, 72–73 semiquantitative examination, 68–71

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Mitral valve regurgitation (Continued) severity, evaluation, 68–71 Mitral valve stenosis, 57–64 etiology of, 57 pathologic features of, 57 qualitative evaluation of, 57–59 M-mode, 58 images, usage, 7 limitations to, 16 Moderator band, 166, 167f Modified Bernoulli Equation, 172 Modified deep TG view, 87, 87f Modified Fontan procedure, 144 Modified ME 4-chamber view, probe direction, 132 Mosaic biological valves, 103, 103–104f MS. See Mitral stenosis Muscular VSD, 134, 134f MVA. See Mitral valve area Myocardial motion, 33 Myocardial wall, 32 impact of, 13 Myxomas, 150, 150f Myxomatous mitral valve, 112

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N

NCC. See Noncoronary cusp Near field illustration of, 5–6f imaging, 5 Nodulus Arantii, 39, 167, 167f Nonbacterial thrombotic endocarditis, 112 Noncoronary cusp (NCC), 39 Normal diastolic function, from pseudonormal diastolic function, 28–29, 28f Nyquist limit, 9

O Oblique sinus, 119 On-X bileaflet tilting disk, 102, 102f Optimizing images, 175 Outflow tract, measurement of, inaccuracies in, 18

P Pacing wires, 168 Pannus formation, 101 PAP. See Pulmonary artery pressure Papillary fibroma, 112 Papillary muscles, 83

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Papillary muscles (Continued) attachment of, 55 dysfunction of, 88 elongation, 65 Parachute valve, 57 Paradoxical ventricular septal motion, 119 Paravalvular leak closure devices, 179–180 Passive myocardial distension, caused by atrial contraction, 33 Patent ductus arteriosus, 136–137 isolation, 136 Patent foramen ovale (PFO), 13 association, 148 Peak mitral E velocity, measurement of, 63 Peak velocity criteria, 49t instantaneous gradient, 44 measurement of, 81 usage of, 45 Penetrance, illustration of, 3f Pericardial disease, 23, 117–124 Pericardial effusion, 117–119, 117f, 128 grading of, 118

Pericardial effusion (Continued) versus pleural effusion, 118–119 Pericardial thickening, 23 Pericarditis, purulent, 112 Perimembranous VSD, 134f, 142 Persistence, usage, 11 Persistent left SVC, 165 PFO. See Patent foramen ovale Physics, 12 Piezoelectric crystals, 4 Planimetry, 63–64 using 2D, 44 Pleural effusion, left, 118f PML. See Posterior mitral leaflet Porcine biological valves, 103–104 Positive pressure ventilation, 120 Post-MV repair, 75–76 Post myocardial infarction, 23 Posterior leaflet, 83 Posterior mitral leaflet (PML), 55 illustration, 70f Posteromedial commissure, 56f Posteromedial papillary muscle, attachment of, 55 Postmyomectomy TEE, 139

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Postrepair SAM, evaluation, 73–74 Poststenotic dilatation, 50b Power output, 10 Pressure gradients, 172 obtaining, 75 Pressure-volume relationships, 25, 27f PRF. See Pulsed repetition frequency Primum ASD, 131, 132f Prolapse, illustration, 66f Propagation, 2f Propagation velocity (Vp), 35, 35f Prosthetic AV, 87 Prosthetic valve biological valves, 103–107 effective orifice area, 109t evaluation of, 109 examination of, 109–110 mechanical valves, 99–102 mechanics of, 109 types of, 99–110 Proximal aortic root, 40 Proximal isovelocity surface area, 58, 62–63 convergence zone, 70f flow, 70f

196

Proximal isovelocity surface area (Continued) radius, 70f PS. See Pulmonic stenosis Pseudonormalization, 26f Pulmonary artery diastolic (PAD), equation, 81 Pulmonary artery (PA) hypoplasia, 78 stenosis, 78 Pulmonary artery pressure (PAP), estimation of, 80f, 81b Pulmonary autograft (Ross procedure), 54 Pulmonary hypertension, severity, 135 Pulmonary vein diastolic flow, 29 Pulmonary vein (PV), 177 pulmonary venous pressure (PVP) Doppler gradient, 29 PWD of, 74f systolic flow reversal, 73b, 74 Pulmonary vein systolic flow, 29 Pulmonary venous flow, 28 PWD, 71

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Pulmonary venous return, 133 determination, 136 Pulmonic annuli, size comparison, 54 Pulmonic insufficiency, 105 Pulmonic regurgitation (PR), 78 2D, 80 CFD, 80 CWD, 80–82 etiology of, 79 Pulmonic stenosis (PS), 78–79 2D images of, 78–79 CWD, 79 etiology of, 78 severity of, 79t Pulmonic valve, 77–82 structure of, 77 Pulsatile IVC, 88 Pulse repetition frequency, limitation, 68 Pulse wave Doppler (PWD) maximum velocity for, 9 placement of, 16–17 of pulmonary vein, 74f sample volume, 45 transmitral, 23–27 usage of, 8, 73 Pulsed repetition frequency (PRF), 8 array of, 10 increase, 9

Pulsed repetition frequency (PRF) (Continued) signals/ depths, comparison of, 11 PWD. See Pulse wave Doppler

Q QRS, usage, 29 Qualitative evaluation, 13 Quantitate TR/TS, PWD with, 85 Quantitative evaluation, 14–20

R

RAA. See Right atrial appendage Radius measurement, errors of, 63 Range ambiguity, 11, 160 Range resolution, 8 Rarefaction, 1 cycle, 2f Real-time 3D imaging, 173–174 Reconstructed 3D imaging, 174–175 Reentry tear, location, 128 Reflection, principle of, 3 Refraction, 158 principle of, 4 Regional LV function, assessment of, 20 Regurgitant fraction (RF), 72

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Regurgitant jet, area, 51 Regurgitant volume, 171 Relaxation primary index of, 36 rate, clues to, 36 Resolution, definition of, 2 Respiratory variation, in E velocity, 121 Restrictive cardiomyopathy, 121–124, 121f, 122–123t Restrictive filling, 26f Restrictive VSD, 135 Retrograde flow (Ar), 29 Return signals, false, 8 Reverberations, 157 calcification, impact, 45 RF. See Regurgitant fraction Rheumatic heart disease, 57 Right atrial appendage (RAA), 83 Right atrial pressure (RAP), measure of, 81 Right atrium (RA), 163–164, 163–164f collapse, 119 probe movement to, 13 thrombi, 148–150 Right coronary artery, 21f Right mainstem bronchus, interposition, 125

198

Right ventricle (RV), 95–98, 166 anatomy, 96 dilation, 96 impact of, 79 dyskinesis, 97 failure, 98 infarction, 98 pressure overload, 98 probe movement to, 13 TEE views, 95–98 thrombi, 149 volume overload, 98 Right ventricular diastolic function, 38 Right ventricular hypertrophy (RVH), 96 Right ventricular outflow tract (RVOT), 41f RIMP. See RV myocardial performance index Ross procedure, 105 RV myocardial performance index (RIMP), 97 RVH. See Right ventricular hypertrophy RVOT. See Right ventricular outflow tract R wave, usage, 14

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S

SAM. See Systolic anterior motion Scattering, principle of, 4 Scoring aortic atheroma, 125 Secondary tears, location, 128 Secundum ASD, 131, 132f Segmental wall motion abnormalities, 128, 166 Semicircular disks, 101 Septal annular wall, 32 Septal bowing, 58 Septal defect, 179–180 Septal distortion, appearance of, 98 Septal hypertrophy, 41 Severe MS DT, 61 mean gradient, 59 PHT, 60 Shadowing, 157, 162 calcification, impact, 45 Short-axis (SAX), beam, obliqueness, 16 Shunt ratio, 170 Side-by-side double image, 158, 159f Signal, frequency, 7 Simple anomalies, 131–140

"Simpson’s Method", 16 Single-tilting mechanical valves, 100 Single ventricle, 144–146 Sinotubular junction, 39, 49 illustration of, 48f Sinus, transverse, 118 Sinus of Valsalva, 39 adjoinment, 39 anatomy, 40 aneurysm, 112 Sinus venosus ASD, 132, 133f Spatial resolution, 32 Spontaneous echo contrast/echo, 149, 149f St. Jude mechanical valves, 101, 101f CFD, 101 Standard en face view, 176 Stanford types, 127, 127f Starr-Edwards mechanical valves, 99, 99f Stented biological valves, 103 normal Doppler values for, 110t Stented xenograft, 54 Stentless aortic valves, 104, 105f Stroke volume, 16–17 assessment, 136

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Subaortic obstruction, 138 Suboptimal image quality, 157 Subpulmonary VSD, 134f, 135 Subvalvular apparatus, 57 Subvalvular membrane, 43t Supravalvular ring, 57 Supraventricular arrhythmias, 140 Swan-Ganz catheters, 168 Systole, 113–114f D shaped in, 96 dP/dt, 97 dynamic outflow obstruction, 48 orifice, tracing, 44 Systolic anterior motion (SAM), 49 examination, 75 Systolic function, 18–20 Systolic leaflet, doming inward, 43 Systolic left ventricular (LV) structure/ function, 13–22

T Tachycardia, 29 Tamponade, 128 2D, 119–120 cardiac, 119 Doppler, 120 echocardiographic findings in, 119–120

200

TAPSE. See Tricuspid annular plane systolic excursion TAVR. See Transcatheter aortic valve replacement TDI. See Tissue Doppler imaging TEE. See Transesophageal echocardiography Tei index, 97 Tetralogy of Fallot (TOF), 78, 141–142 association, 139 TG basal SAX, 86 TG mid SAX, 95f views, 117, 117f TG RV inflow illustration, 79, 95f view of, 86–87, 86–87f TG SAX. See Transgastric short-axis Thebesian valve, 164, 164f Thoracic aortic dissection, 126 Three-dimensional (3D) echocardiography, 173–175 Three-dimensional (3D) imaging, 11–12 3D zoom, 173 Thrombus (thrombi), 112, 148–150 vs. tumor, 13

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Time velocity integral (TVI), 16–17 Tissue, ultrasound interaction with, 3–4 Tissue Doppler imaging (TDI), 28, 32–33, 121 usage of, 10 TOF. See Tetralogy of Fallot TR jet CWD, 92–93 grading, 92t PAP evaluation by, 92–93, 92f Trabeculations, 163f, 166 Trachea, interposition, 125 Transaortic gradient, increased, 48 Transcatheter aortic valve replacement (TAVR), 179 valve-in-valve, 54 Transcatheter AVS, 106–107 Transducer, 4–7 distance, 6 frequencies, 3, 5 graph, 3f Transesophageal echocardiography (TEE), 32 2D, 111–112 findings/complications of, 112–114

Transesophageal echocardiography (TEE) (Continued) goals of, 111–112 M-mode, 111 prognosis and predicting complication risk with, 115–116 Transesophageal transducer frequencies, 3 Transgastric long-axis (TG LAX), 13–14, 15f rotation, 42, 42f usage, 45 Transgastric short-axis (TG SAX), 13–14, 14f, 84 mitral annulus view, illustration, 67f Transmit focus, usage, 11 Transmitral Doppler, limitations to, 29 Transmitral E wave, deceleration slope of, 59 Transmitral flow beam parallel to, 23 PWD of, 24f usage, 24f Transthoracic echocardiography (TTE), 4, 32 Transthoracic transducer frequencies, 3

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Transverse sinus, 118, 166 Tricuspid annular plane systolic excursion (TAPSE), 97 Tricuspid inflow velocity, 94 VTI, 94 Tricuspid regurgitation (TR), 88–93 annular displacement, 88 caveats, 91 CFD, 91 CWD, 91 etiology of, 88 evaluation of, 88 functional abnormality, 88 iatrogenic, 88 inflow, 90 leaflet abnormality, 88 limitations of, 91 PWD, 89–90 severe, 94 VC, 91 Tricuspid transvalvular flows, 18 Tricuspid valve (TV), 177 anatomy of, 83–94 annulus, apical, displacement, 84 stenosis, 93–94 structure/function of, 84–87 thickening of, 112 views of, 84–87

202

True aneurysm, pseudoaneurysm vs., 13 True lumen, false lumen, 128 TS evaluation, 93–94, 94f TTE. See Transthoracic echocardiography Tubular aorta, adjoinment, 39 Tumors, 150–151 Turbulence, color indication, 10 TV. See Tricuspid valve (TV) TVI. See Time velocity integral TVILVOT, 169, 170f T wave, usage, 14 Two-dimensional (2D) echocardiography, 117 Two-dimensional (2D) images, 13 2D left ventricular short axis (LV-SAX) view, combination of, 7 imaging artifacts, 157–160 usage of, 7, 16–17

U Ultrasound (US) absorption of, 2 energy, delivered, 10 physics of, 1–12

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Ultrasound (US) (Continued) principles and characteristics of, 1–2 received burst of, 8 return, amount of, 3 waves, struck, 4 Ultrasound (US) beam axis, 6 defined frequency, 8 gain settings, 5 intensity, loss of, 2 Unicuspid congenital aortic stenosis, 138 Unrestrictive VSD, 135 Upper body collateral circulation, 137 Upper esophageal aortic arch (UEAA) SAX, 77f view of, 79

V Valsalva maneuver, performing, 28, 28f Valve coaptation, preservation, 65 cross-sectional area, measurement of, 16–17 imaging, 176–177 Valvular lesions, 111 Vascular transducer frequencies, 3

Velocity aliasing, 69–71 envelope, 48 equation of, 2 Velocity time integral (VTI), 44 calculation, 72 Vena contracta, 69 Ventricular inversion, association, 139 Ventricular pacing, 98 Ventricular septal defect (VSD), 13, 133–136 closure, 136 types, 133–136 Vents, during CPB, 152, 152f Vertical axis, mirror image on, 160 Vessel, cross-sectional area, measurement of, 16–17 VSD. See Ventricular septal defect VTI. See Velocity time integral

W Wavelength, 2–3 definition of, 1 WPW, 140 "Wrap-around" signal, 8

Z Zoom, usage, 11

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1. ME 5-Chamber view

2. ME 4-Chamber view

3. ME-Commissural view

4. ME 2-Chamber view

5. ME-Long axis view

6. ME AV-LAX view

7. ME-Ascending Aorta LAX view

8. ME-Ascending Aorta SAX view

9. ME Right Pulmonary vein view

10. ME AV SAX view

11. ME Right inflowoutflow view

12. ME modified bicaval TV view

13. ME Bicaval view

14. Upper Right & Left Pulmonary veins view

15. ME Left Atrial Appendage view

16. Transgastric Basal SAX view

17. Transgastric Midpapillary SAX view

18. Transgastric Apical SAX view

19. Transgastric RV Basal view

20. Transgastric RV inflow-outflow view

21. Deep Transgastric 5-Chamber view

22. Transgastric 2-Chamber view

23. TG RV-inflow view

24. TG LAX view

25. Descending Aorta SAX view

26. Descending Aorta LAX view

27. UE Aortic Arch LAX view

28. UE Aortic Arch SAX view

MITRAL STENOSIS (JASE 2009)

MITRAL REGURGITATION (AHA/ASE) MILD

MODERATE

SEVERE

Jet Area/LA area

40%

Pulm vein flow

S NL

S Blunted

S Reversal