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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.
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.
This chapter deals with mitral valve (MV) disease. Mitral stenosis is obstruction of left ventricular inflow at the level of the MV, as a result of structural abnormalities of the MV apparatus that limit proper opening during diastole. Mitral annular calcification is a degenerative process, and is a common incidental finding in the elderly. Rheumatic carditis is the commonest cause of mitral stenosis in both developed and developing countries. Mitral regurgitation (MR) is the most commonly encountered valvular lesion in modern clinical practice. Primary MV prolapse syndrome (MVPS) refers to a disease spectrum with frank myxomatous degeneration at one extreme. The transesophageal echocardiography (TEE) variables used in the assessment of MR severity can be classified as semi-quantitative or quantitative. The vena contracta (VC) refers to the narrowest portion or neck of the regurgitant jet, which occurs at or just beyond the regurgitant orifice.
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.
This chapter deals with transesophageal echocardiography (TEE) reporting. An echocardiography report leaves a permanent time-related record from the imaging episode that will allow future studies to follow the progression of patient's disease, or the effect of therapy. TEE reports can and should contain numerical data which may be useful in both randomized controlled trials and large-scale observational studies and case series. Verbal reporting is essential in perioperative and emergency echo. Perhaps the easiest approach to a written TEE report is the blank sheet of paper. A standardized written reporting system is relatively easy to adapt to computerized storage and recall. Data recorded are: patient demographics; date, time and location of the study; name and grade of the operator; name of the referring physician; equipment employed; indications for performing the study; quality of the study, difficulties, and complications; hemodynamic conditions; specific findings; conclusions and therapeutic suggestions.
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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