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Aortic valve (AV) disease is very common in Western populations. Aortic sclerosis is diagnosed when there is an ejection systolic murmur present in the AV region due to calcification in the ascending aorta, with associated turbulent flow. Aortic stenosis (AS) is differentiated from sclerosis when significant restriction of cusp movement and a raised transaortic peak velocity is seen on echocardiography. Transesophageal echocardiography (TEE) evaluation of AS starts with a 2D examination of the mid-esophageal short-axis (ME SAX) and long-axis (LAX) views of the valve. Continuous-wave Doppler (CWD) is applied to measure flow velocity across the valve and then calculate a pressure gradient using the Bernoulli equation. Aortic regurgitation (AR) results from a primary valve lesion, an abnormal aortic root and/or ascending aorta, or a combination of both. TEE is valuable in revealing important aspects of AV disease.
Intraoperative transesophageal echocardiography (TEE) is increasingly being used to assess ventricular function in patients about to undergo coronary revascularization, and it should always be used to assess the result of surgery and cardiac function both following bypass and/or at the time of chest closure. The development of standard chocardiographic views, coupled with agreed terminology for describing manipulation of the TEE probe, has been essential for the development of TEE into an effective imaging modality. Th e 20 standard views described in 1999 form the basis of the TEE study. Echocardiographic examination of left ventricular function can reveal useful information when the heart is at rest or under stress with a pharmacological agent such as dobutamine. In order to evaluate each part accurately, the left ventricle has been divided into a number of segments. TEE is particularly useful for examining the mitral valve.
This chapter deals with safety and complications, and probe maintenance in transesophageal echocardiography (TEE). TEE is frequently undertaken outside the operating room. The usual sedation offered includes topical anesthesia to the mouth and oropharynx, and one or more intravenous sedatives. Intravenous benzodiazepines have been the mainstay of intravenous sedative techniques over the years, particularly for non-anesthetists, and they are still frequently used. TEE has been described as a semi-invasive procedure, presumably to identify it as less invasive than intravascular monitoring and diagnostic procedures. TEE is a relatively safe procedure that can be undertaken on a wide range of patients and with minimal complications. Close attention to probe care, maintenance, and disinfection also plays an important role in maintaining the effectiveness of each study and of the TEE service, whether in the echo lab or in the operating room.
Core Topics in Transesophageal Echocardiography is a highly illustrated, full color, comprehensive clinical text reviewing all aspects of TEE. The text has been written particularly for those who are seeking accreditation in TEE. Section 1 includes chapters on first principles including cardiovascular anatomy, safety issues, indications and contraindications for use, US technology and physics and the details of image acquisition and interpretation in a variety of routine pathologies. Section 2 chapters discuss the use of TEE in a variety of more demanding clinical conditions including valve disease, complex ischaemic heart disease, the use of TEE in critical care and emergency settings, new echocardiography technologies, and TEE reporting. An outstanding free companion website (www.cambridge.org/feneck) contains numerous TEE video clips showing both normal and pathological states. Written by leading TEE experts from EACTA and EAE, this is an invaluable practical resource for all clinicians involved in the care of cardiac patients.
Ejection fraction (EF) is a well accepted and useful index of quantitative left ventricular (LV) function, but it is influenced by changes in preload, afterload, and contractility. Stroke volume (SV) can be obtained with 2D transesophageal echocardiography (TEE) by measuring LV end-systolic and end-diastolic volumes for measuring EF. TEE evaluation of LV systolic function, both global and regional, provides insight into hemodynamic impairment in a variety of situations. Doppler echocardiography is the principal diagnostic tool to assess LV diastolic function non-invasively. TEE facilitates a complete evaluation of diastolic LV function by assessing diastolic phases and elucidating structural causes of altered diastole. The use of this tool has relevant implications in the management of hemodynamic derangement due to impaired diastolic function, in vasoactive drugs titration, in the detection of myocardial ischemia, and in performing prognostic stratification.
Transesophageal echocardiography (TEE) is a valuable means of assessing diseases of the thoracic aorta. The portion of descending aorta between the left subclavian artery proximally and the ligamentum arteriosum distally is known as the aortic isthmus. A number of the branches of the aorta can be imaged using TEE. Coarctation of the aorta may present as a partial narrowing, or rarely a complete occlusion, of the aorta. The ductus arteriosus connects the pulmonary artery to the aorta in the fetal circulation. Supravalvular aortic stenosis is a narrowing of the aorta usually at the level of the border of the sinus of Valsalva. The etiology of a true aortic aneurysm has much in common with aortic dissection. True tumors of the aorta, including leiomyosarcoma, fibroelastoma, and epithelioma, are fortunately extremely rare. Traumatic injury to the aorta usually occurs as a result of rapid deceleration injury or blunt chest trauma.
The long- and short-axis views of the right ventricle (RV) are defined by the corresponding views of the left ventricle (LV), but these two standard echocardiographic imaging planes often transect the RV in an oblique way. Discrete probe manipulations and the proper use of the multiplane capacity of transesophageal echocardiography (TEE) are often necessary to fully visualize the RV. Continuous-wave Doppler plays an important role in the study of pathological conditions of the RV and pulmonary circulation. Abnormalities in the shape and motion of the interventricular septum (IVS) reflect the altered pressure differences between the LV and RV. Tricuspid annular plane systolic excursion (TAPSE) corresponds to wall shortening of the RV free wall along its long axis. The total ejection isovolume (TEI) index or myocardial performance index is a Doppler derived measurement combining systolic and diastolic time intervals as a parameter of global ventricular function.
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