Tee Echocarigraphy

Transesophageal Echocardiography

Multiplane Examination Primer

Bernard E. Bulwer, MD, mSc and Stanton K Shernan, MD

Contents

Transesophageal Echocardiography (Figs. 1 and 2) Anatomical and Spatial Relationships (Figs. 3-7) Order of Examination: Summary Order of Examination: Detailed Stages Suggested Reading

This primer is an atlas illustrating basic nomenclature and standard views adopted by the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) in the performance of a comprehensive intra-operative multiplane transesophageal echocardiography examination.

Echocardiography Images

Fig. 1. Instrumentation of transesophageal echocardiography. Two models of transesophageal echocardiography (TEE) probes (A). Miniature multiplanar transducer and housing located at tip of TEE probe (B). Profile of TEE probe controls. Multiplane (Omni) control button is indicated by arrow (C). View from top showing TEE probe control positions as indicated—neutral (N), right (R) and left (L) flexion, anteflex (A), and retroflex (P) (D).

Fig. 1. Instrumentation of transesophageal echocardiography. Two models of transesophageal echocardiography (TEE) probes (A). Miniature multiplanar transducer and housing located at tip of TEE probe (B). Profile of TEE probe controls. Multiplane (Omni) control button is indicated by arrow (C). View from top showing TEE probe control positions as indicated—neutral (N), right (R) and left (L) flexion, anteflex (A), and retroflex (P) (D).

From: Contemporary Cardiology: Essential Echocardiography: A Practical Handbook With DVD Edited by: S. D. Solomon © Humana Press, Totowa, NJ

Echocardiography Hand Book
Multiplanes

Fig. 2. TEE probe and multiplanar transducer: position basics. Transesophageal echocardiography probe and multiplanar transducer manipulation. Mechnanical movements of the trans-esophageal probe include anterior and posterior flexion and flexion to the right or left. The entire probe can also be manually rotated to the right or to the left. The first TEE probes permitted only a single, and later two planes of examination. Arrays of crystals in modern miniaturized ultrasound transducers permit visualization along multiple planes—hence, the multiplanar examination.

Oropharynx Visualization
Fig. 3. TEE probe: anatomical relationships. Illustration showing the descent of the probe through the mouth, oropharynx, and pharynx. These are all sites of potential injury during the introduction and manipulation of the probe. Note the use of a bite block to protect the probe.
Posterior Oropharynx Tee

Fig. 4. Anatomic reference scheme and nomenclature adopted by the Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. The fundamental parts of the TEE multi-planar examination are represented by a set of 20 cross-sectional imaging planes represented by letters of the alphabet.

Fig. 4. Anatomic reference scheme and nomenclature adopted by the Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. The fundamental parts of the TEE multi-planar examination are represented by a set of 20 cross-sectional imaging planes represented by letters of the alphabet.

Medical Imaging Planes

Fig. 5. Anatomical relationships transesophageal echocardiography. Illustration showing the transverse relationships of the major mediastinal structures at the level of the eighth thoracic vertebra. Note the close relationship of the esophagus to the left atrium (LA). As the transducer is confined to the esophagus at this level, this constant relationship orients the operator during the many permutations of images acquired during TEE.

Fig. 5. Anatomical relationships transesophageal echocardiography. Illustration showing the transverse relationships of the major mediastinal structures at the level of the eighth thoracic vertebra. Note the close relationship of the esophagus to the left atrium (LA). As the transducer is confined to the esophagus at this level, this constant relationship orients the operator during the many permutations of images acquired during TEE.

Echocardiography Images

Fig. 6. Spatial relationships of transesophageal echocardiography. Understanding anatomical relationships between the transducer and the major mediastinal structures provide the basis for acquisition and interpretation of TEE images. Spatial relationships at the ME level (approximately at the eighth thoracic vertebra) are shown (see also Figs. 5-6). Note the relationship of the transducer within the esophagus to the LA and the descending thoracic aorta. At higher levels, the air filled trachea and bronchi may cause suboptimal visualization of the distal ascending aorta and proximal aortic arch (blind spots).

Fig. 6. Spatial relationships of transesophageal echocardiography. Understanding anatomical relationships between the transducer and the major mediastinal structures provide the basis for acquisition and interpretation of TEE images. Spatial relationships at the ME level (approximately at the eighth thoracic vertebra) are shown (see also Figs. 5-6). Note the relationship of the transducer within the esophagus to the LA and the descending thoracic aorta. At higher levels, the air filled trachea and bronchi may cause suboptimal visualization of the distal ascending aorta and proximal aortic arch (blind spots).

ORDER OF EXAMINATION: SUMMARY

Stage 1. ME Level: Multiplane from 0 to approx 120°.

• ME four-chamber 15° (A): Figs. 8-10 (please see companion DVD for corresponding video for Figs. 8 and 10).

• ME mitral commissural 80° (G): Figs. 11 and 12 (please see companion DVD for corresponding video for Fig. 12).

• ME two-chamber 90° (B): Figs. 13 and 14 (please see companion DVD for corresponding video for Fig 14).

• ME long axis 120° (C): Figs. 15 and 16 (please see companion DVD for corresponding video for Fig. 16).

Stage 2. ME level: with angle approx 90°, sweep R to L.

• ME right ventricular inflow-outflow 80° (M): Figs. 17 and 18 (please see companion DVD for corresponding video for Fig. 18).

• ME bicaval 110° (L): Figs. 19 and 20 (please see companion DVD for corresponding video for Fig. 20).

• Withdraw: ME ascending aortic long axis 100° (P): Figs. 21 and 22 (please see companion DVD for corresponding video for Fig. 22).

• Advance: ME aortic valve long axis 130° (I): Figs. 23 and 24 (please see companion DVD for corresponding video for Fig. 24).

• ME ascending aortic short axis 20° (O): Figs. 25 and 26 (please see companion DVD for corresponding video for Fig. 26).

• Withdraw: ME aortic valve (AV) short axis 60° (H): Figs. 27 and 28 (please see companion DVD for corresponding video for Fig. 28).

• UE aortic arch long axis 0° (S): Figs. 29 and 30 (please see companion DVD for corresponding video for Fig. 30).

• UE aortic arch short axis 90° (T): Fig. 31 (please see companion DVD for corresponding video).

• Turn left, advance: descending aortic long axis 90° (R): Figs. 32 and 33 (please see companion DVD for corresponding video for Fig. 33).

• Descending aortic short axis 0° (Q): Figs. 34 and 35 (please see companion DVD for corresponding video for Fig. 35).

Stage 4. Advance to stomach, anteflex.

• Transgastric mid-short axis 0° (D): Figs. 36 and 37 (please see companion DVD for corresponding video for Fig. 37).

• Withdraw slightly: transgastric basal short axis 0° (F): Figs. 38 and 39 (please see companion DVD for corresponding video for Fig. 39).

• Transgastric two-chamber 90° (E): Figs. 40 and 41 (please see companion DVD for corresponding video for Fig. 41).

• 90-120°: transgastric long axis 120° (J): Figs. 42 and 43.

• Turn right: transgastric right ventricular inflow 120° (N): Figs. 44 and 45 (please see companion DVD for corresponding video for Fig. 45).

• Advance, anteflex: deep transgastric long axis 0° (K): Figs. 46 and 47 (please see companion DVD for corresponding video for Fig. 46).

Echocardiography Images

Fig. 7. Anatomic reference scheme and nomenclature adopted by the Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Variability exists in the precise anatomic relationship between the heart and the esophagus, and the depths at which optimal images are optimally acquired in individual patients, but identifiable anatomic landmarks aid in the reproducibility of images acquired. The terminologies used provide good correlation with images acquired by transthoracic echocardiography, upper esophageal views (20-25 cm), mid-esophageal (ME) views (30-40 cm), transgastric views (40-45 cm), deep transgastric views (45-50 cm).

Fig. 7. Anatomic reference scheme and nomenclature adopted by the Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Variability exists in the precise anatomic relationship between the heart and the esophagus, and the depths at which optimal images are optimally acquired in individual patients, but identifiable anatomic landmarks aid in the reproducibility of images acquired. The terminologies used provide good correlation with images acquired by transthoracic echocardiography, upper esophageal views (20-25 cm), mid-esophageal (ME) views (30-40 cm), transgastric views (40-45 cm), deep transgastric views (45-50 cm).

Echocardiography Images
Fig. 8. Midesophageal four-chamber (A). (Please see companion DVD for corresponding video.)

Mid esophageal four-chamber

MITRAL Posterior leaflet

Tricuspjd valve;

Midesophageal Two Chamber View

Mid esophageal four-chamber

(LVOT view) LA

Midesophageal Two Chamber View

Fig. 10. Midesophageal four-chamber (A). (Please see companion DVD for corresponding video.)

Midesophageal Two Chamber View

Mid esophageal

Mitral Valve Commissural View

Diastole mitral commissural

Midesophageal Two Chamber View
Systole

Fig. 12. Midesophageal mitral commissural (G). (Please see companion DVD for corresponding video.)

Mid esophageal Multiplane two chamber an9|e

Midesophageal Two Chamber ViewEchocardiography ImagesMidesophageal Two Chamber View

Mid esophageal two chamber

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