this presentation is over trans-esophageal echocardiography imaging specifically it's over the basic and advanced te ultrasound windows as used for basic and advanced te i'm john shiels i'm a nurse anesthetist specializing in cardiac anesthesia objectives for this presentation we're going to describe the use of perioperative tee or pte as an advanced cardiac monitor using 11 relevant windows of the 28 used for hemodynamic monitoring and cardiopulmonary instability as well we're going to discuss advanced perioperative te and some of the uses including doppler aortic valve area gradients and perivalver leaks and in doing so we're going to identify additional ultrasound windows that are required for this use so the physics of ultrasound are pretty much the same with transesophageal echo as they are and some of the other modalities that you use such as gastric uh line insertion etc basically the probe is going to pass a sound wave through a medium or tissue by emitting brief pulses of sound by converting electrical energy into sound and then these returning sound waves are converted into energy which generates an image and then the best image is generated when the beam is perpendicular to the structure we all know that from from placing lines etc and instead of manipulating the probe like tilting rocking sliding and rotating the beam with t is manipulated by advancing the probe like a fiber optic bronchoscope lateral tilt which is the lateral tilt knob the anaflex and retroflex knob as well is going to anaflex and retroflex the probe very similar to the bronchoscope and then omniplane is used instead of rotating the old sound beam physically it actually is able to manipulate the beam by rotating the beam on the piezoelectric crystal similar to the focused assessed transthoracic exam or the tte positioning you're using four pretty distinct positions and uh the probe is placed in the esophagus in one of these four positions and the ultrasound beam is generated these four positions are the upper esophageal such as near the aortic arch the mid-esophageal such as those for mid-esophageal four chamber trans-gastric as you might use for different views of different ventricular structures and valves and finally the deep trans gastric view which is used to pretty much line up your doppler beam such that you can measure gradients across the aortic valve and then the reflected signals are collated to produce an image either 2d or 3d often you also use other modes such as m mode and what you can see here in this lower panel is you pretty much have a near field which is instead of measuring or transducing from outside in you're transducing from inside out such that in the near field here you pretty much are seeing the left atrium and this this is a mid-esophageal view and this is pretty common as we'll look at in a moment pretty much all the mid-esophageal views have the left atrium as a structure in the near field so in this video we're going to show or demonstrate how the probe is advanced it's rotated it's turned its anaflex and is tilted to get perpendicular to the area of structure or structures of interest here's the aortic arch and as you advance down you run across the aorta and you run across the pulmonary artery which is perpendicular to the aorta going a little bit deeper you see the aortic valve the nice mercedes sun and as you continue to advance you see the mid-esophageal four chamber and notice how the beam will start to tilt upward or almost anaflex as you advance just because the esophagus kind of wraps around the the heart so here is the mitral valve and here is the papillary view of the transgastric view and as you get down you can also notice that the beam is is pointed up and you're not really getting the heart this is where you antiflex the probe such that you get a image retrograde more like an apical four chamber such that you can actually look at gradients and do doppler across the aortic valve and then as you withdraw the probe again we don't have a a vertical elementary canal like the sharks do but we have an esophagus that wraps around then in the four chamber you can actually omni so instead of rotating a probe you hit an omni button here you go 130 degrees and you're getting the mid-esophageal long axis view such that you've got advancing you've got tilting you've got anaflexing and you've got rotating information available from even a basic exam using the relevant 11 views include things such as left and right ventricular function biventricular function and it's more of a yes or no and basic echo is it good or bad do you give half the big syringe or all the big syringe do you avoid counter clocking the gas and giving too much fluid do you use ephedrine instead of phenylephrine etc heart wall motion is another very good piece of information available from basic echo along with chamber volume so you've got filling you've got contractility and you've got monitoring for ischemia although that's typically requires about 17 views you can also look at vessel integrity um valve function and integrity rescue functions things like that when you have cardiopulmonary instability as well you can find heart tumors and pericardial effusion which is something that is not uncommon in certain practices echocardiography has found utility throughout the entire perioperative pathway whether it's preoperatively for assessing ejection fraction or a murmur as well you can also use a pre-op to validate a previous echo especially in folks that have a heart failure that's kind of very fluid sensitive intraoperatively of course as we talked about for cardiopulmonary instability as well as post-op for effusion volume status or some other type of cardiopulmonary misadventure subspecialties already utilizing tea liver transplant vascular neural anesthesia obstetrics as well as the intensivists in the intensive care unit are doing a lot of service echo but te has found its role there as well in the emergency room they've been doing echo for probably about 30 years since about 1992 and all sorts of different pokes and as far as cardiac anesthesia goes as well it's pretty much something that you're just going to have to pick up at some point if you're doing cardiac the mortality associated with trans esophageal echo is less than one percent and the morbidity is is between two to five and ten thousand which is typically involves esophageal perforation but there are absolute and relative contraindications to tea you don't really wanna stick it in if you've got a perforated viscous if you have a really nasty esophageal stricture or tumor especially esophageal perforation diverticulum active gi bleed pretty much is uh going to keep you from sticking to probing and a lot of other little things depending on what your your cultural paradigm is and personal paradigm is relative contraindications where you may want to really rethink it uh things like gi surgery in the past radiation to the neck and mediastinum uh just phage uh neck immobility esophageal varices and even coagulopathy although we do a lot of te with patients that are getting atrial fibrillation with acts over 300. so there are a lot of probe and equipment considerations as you might imagine with something this robust along with whether or not you can find the machine depending on your practice but probe insertion you should use a bite block for a few things we'll talk about in a moment you can really damage some probes usually they get damaged with cleaning actually but the dye block is something that you're using to protect your sixty thousand dollar probe generous lubrication um of course a little lubrication is going to allow better contact with the with the esophagus just like it does with uh with surface echo but i'm not sure you need to use 10 packs of lube like i've seen used in the past jaw thrust is also something that's utilized to advance the probe um i know one person that's had one esophageal perforation of all the people that i know uh you typically insert the 30 to 35 centimeters if you think about how far it is from the teeth to the karana it's about 26 centimeters such that you know you're going to go a little bit deeper even for the upper esophageal fuse contraindications again we've talked about but involves esophageal gastric pathology some of the complications that are common and uncommon again esophageal perforation is very rare typically it's just because you've forced it but it's usually very dramatic uh gi and pharyngeal hemorrhage i've seen that a good bit it's up to one in every 100 patients you end up having something that you've got to manage in the icu or pacu dental damage i've never seen that but it's reported oral and lip damage is by far the most common uh typically it's a lot higher and people that aren't used to instrumenting the airway no no no blame being applied here airway compromise um if you think the the your endotracheal tubes been pulled out has been pulled out especially in pediatrics distraction from the patient is one of the more common things that um that i see along with uh misinterpretation although not typically in my practice but it is probably the number one complication of any ultrasound is misinterpreting and making a change in your management plan which is inappropriate so there's basic t and there's comprehensive t basic it's basically using te as an advanced hemodynamic monitor using the 11 most relevant views and you're diagnosing general ideology of cardiopulmonary instability whether it's gross valve pathology filling uh function simple congenital defects like an asd obstructive pathology such as pulmonary embolus and tamponade and typically what you're doing with basic echo if this is is your role you're typically making a judgment that's going to affect your management of cardiopulmonary instability and if you find any other pathology you're going to typically bump it up to a more advanced echocardiographer comprehensive is a little bit different its use of tea is an advanced hemodynamic monitor but you're using a lot more views you're diagnosing specific pathology and sources of cardiopulmonary instability as well you're using doppler to assess for the degree of valve stenosis also not just native valve but also repaired valve sometimes some type of prosthetic valve also regurgitation across the prosthetic valve or mantra clip as well as area not just the area of the valve but also annular area doppler is also used as we talked about before to assess surgical intervention uh you're also looking at natural appendage occlusion devices as well as microclip and tavrs and it also requires a user knowledge of three-dimensional imaging which is um something that um is is interesting i like 3d a lot for micro valve but typically it's it's more of a toy than the tool in my hands the first view is the midsoft dual 4 chamber view in this view you're going to get a lot of information in a very short period of time and what you can see at the top in the near field always is the left atrium in the mid esophagus very easy to figure out what chamber is which the right atrium is is next to it and then you've got the intra-atrial septum you've got the anterior and posterior mitral valve leaflets a 3a2p2p one so one of the things that you look for if you're looking for appropriate valve coaptation you may want to put a little bit of color across this valve to make sure there's no mr and often you can pick up some mitral stenosis as well because of the the change in color is very bright because the velocity is high across the synaptic valve as well you can look at the right ventricle free wall the interactional interventricular septum the intralateral wall the lv and the rv free wall and how far the tricuspid leaflets descend towards the apex is called tapsy other things you can do is is grossly just look at the size ratio of the lv to the rv the lv should be about one and a half times the rv and if it's two and a half or three times or if it's the same size things are bad there's something to miss if you have some type of different dimensions it could be rv dysfunction it could be lv dysfunction you can also take a look at the pericardium which is a very nice bright structure here and you can tell if there's some type of effusion and as well you can look at left atrial size and right atrial size and you can even put a little color across the tricuspid valve to look to see if there's any tricuspid insufficiency the mid-esophageal four chamber view is probably the highest utility and easiest for you to find of all um typically you're going to advance the probe to about 30 to 35 centimeters and you're going to find some basic cardiac structures such as the left atrium which is always in the near field and of course the right atrium next to it and then the lv and the rv things that you can find from this view along with anatomical variants such as a large left atrium you know a large lv such as chamber size but also ventricular function how how well the ventricles squeezing and this is a lot of eyeball ef stuff at least in basic and you can do some more advanced manipulations which we'll talk about in the subsequent uh module uh also anterolateral and infraseptal wall motion abnormalities the uh anterolateral is to the right of the lv there and infraoceptile of course is in the middle mitral valve disease are the leaflets co-acting nicely uh you can even put a little bit of color on there which we'll talk about later on to see what direction the blood flow's going in backwards is bad obviously tricuspid valve disease as well this is a very pretty view if you're looking at vegetations which is is always a highlight of the week atrial septal defect you can look for some type of simple congenital defect with this view which is very nice this is very nice quick down and dirty way of finding a pericardial diffusion you you just grab the probe and you shove it in and take a look it's a lot easier actually use a surface echo but this is a lot more definitive way of declaring pericardial effusion the mid-esophageal two chambers up next you've got the left atrium which is you can also kind of tell what the the size of that is to look for pathology the mitral valve you have all the anterior leaflets in just p3 but you see a very nice view the antra wall the inferior wall the diaphragm pericardium around here you're looking for any type of effusion things like that as well as chamber size you can often see the coronary sinuses little hole over here but it's a very nice high utility view and easy to get and obtain so taking the probe and rotating between 80 and 100 degrees usually about 90 degrees or so you get the mid-esophageal two chamber view which is basically a view of the left atrium which is the closest structure to the near field and the left ventricle but also the mitral valve the posterior leaflets on the left and the anterior leaflets on the right an easy way to remember this is that the anterior leaflet is going to be closest to the aortic valve or a equals a you can also find the left atrial appendage in this view if you rotate the probe a little bit to the left you also can look at left ventricular size and function along with wall motion anterior and inferior wall motion abnormalities and your inferior wall is over here on the right and inferior is on the left mitral valve disease mitral valve annular assessment as well as well along with pericardial effusion as with the other view the mid-esophageal long axis view you typically go to 130 degrees from the cell middle esophageal four and you're going to get a nice view again of the pericardium this time it's the antro septal wall the infra lateral wall the left ventricle you see the left ventricular outflow tract the intra atrials the intraventricular septum so you're looking for some type of hokum uh pathology there just p2 and a2 up here the aortic valve the valve leaflets uh as well as ascending aorta in the left ventricular output effect this is a very high utility view and you can get a lot of information especially using doppler the mid esophageal four chamber which we looked at first is one of three rescue echo views where if you're really in a jam and you're wanting to take a quick look you look at the mitocephgial four chamber the second view is the middle substitute a long axis view which you basically just go 130 degrees from the me long act any four chamber of you to get the long axis view and what you see here is you can see left ventricular function including the anthrocepta wall and infra lateral wall but also you can see some mitral valve disease although you typically just see a couple of snippets of the a2 and p2 portions of the anterior and posterior mitral leaflet but also you can see aortic valve aortic root disease intraventricular symptom pathology like hokum things like that and this is a my favorite view for looking for cardiac air although you should probably be using some of the other views as well but this is a very nice view as well to look at the gross view of the aortic valve you can put some color on here and look for color flow across the aortic valve and you can also zoom in which we'll talk about the middle soft dual aortic valve view a little bit later on uh and and get a good idea about any type of aortic valve pathology mid-esophageal bicable is typically getting the right atrium in the middle of the screen and omni to 90. you've got a nice view of the left atrium closest to the near field intra-atrial septum where you look for pfos things like that asds you see the right atrium here the crystal terminalis and the eustachian valve the ivc and the spc very nice place to find wires but it's it's a very nice little structure and you can get a lot of nice views and pathology and information from it the mine esophageal bicable view is next for me i typically get the right atrium in the middle of my screen and then my omni to between 80 and 100 degrees and i can look at a nice view of the left atrium again at the top closest structure to the near field and the interactional septum and the right atrium the spc is at three o'clock and the ivc is at nine o'clock so obviously this is a very good view for atrial septal defect any type of atrial septal pathology such as as as bulging etc pfo as well if you're looking for your central line wire this is a good place to start as well if you're doing venus cannula you can see the ecmo line come up from below or percutaneous cannulation cannula coming into the ivc from this view as well it's a very nice neat little view but it's also just happens to be the most difficult one to get until you get a little experience with it the short axis view the aortic valve again the near field the left atrium the right atrium you get a very nice interracial septum here you see the non-coronary cusp of the aortic valve the left coronary cusp and the right coronary custom sometimes you're surprised with either a functional bicuspid valve or a true anatomical bicuspid valve you see the pulmonic valve here and a good view of the rv as well the mid-esophageal aortic valve short axis view is attained by pulling the probe back you're going to typically have to go to about 10 degrees or so because the aortic valve doesn't really sit in a very just flat view so you're going to look and see the left atrium again the closest view to the closest structure to the near field you're going to see the right atrium you're going to see the right ventricle and you're going to see the non-coronary cusp the left coronary cusp and the right coronary cusp of the aortic valve the right ventricular inflow outflow view you've got the left atrium here you've got the anteratrol septum right atrium tricuspid valve the anterior and the posterior tricuspid valve leaflets as well this is a good place to put a little doppler on to look for for tr you get a good view from the side of the rv and the pulmonic valve and the pa the right ventricular inflow outflow view still in the mid esophagus again such that you have the left atrium at the top of the screen or the closest to the near field you're going to be able to assess for pulmonic vowel disease the pulmonic valves at four o'clock the tricuspid valve which is at eight o'clock you're going to also see right ventricular outflow track pathology but uh more importantly this is a great view for finding your pulmonary artery catheter and looking for a nice veggie but also you can line up your uh your doppler beam here if you're trying to get the the tricuspid valve velocity to calculate such things as pulmonary artery systolic pressure the mid esophageal acn aorta short axis view you're going to see the ascending aorta in the middle the svc here the right pulmonary artery left pulmonary artery the pulmonary artery main pa pulmonic valve as well it's very nice for you to look for dissection etc so from the um midosophile aortic valve you're going to pull back slightly and you're going to see the ascending aorta in the short axis view and you see the ascending aorta in the middle of the screen you see the the svc just to the left of it and you're going to see the pulmonic or the pulmonary artery to the right here of the acne aorta it's uh typically perpendicular to the aorta such that you see a long axis of the pa when you see a short axis of the ascending aorta here you look for pulmonary artery pathology also you you might be able to see a some scratchy stuff some pulmonary embolus or some clot but typically you don't see it by the time you get to this point with the t e you see some x in aortic pathology dissection things like that uh also you can this is where you find the pda as well as looking for your swan if you feel like playing around but by the time if you if you got the swan passive pulmonic valve you would have seen it in the rv inflow view if you go 90 degrees from the uh acne or a short axis you get the long axis view it's kind of hard to visualize that's why the 3d image is so useful you got the aortic valve here down here you can't really see it because of the angle but you see the take off of the ascending aorta uh right here and you get a very nice view of the ascending order its dimensions etc so from the ascending aorta short axis view you typically just omni to 90 degrees and counter clock the probe a little bit and you get a nice view in long axis of the ac and aorta which you'll see the right pulmonary artery right above the the long axis view of the acne aorta this is a very nice view for aortic pathology dissection things like that but also pericardial effusion and pulmonary embolus you can often see the the clot in the right pa which is typically where it goes sometimes you can see the the balloon of your your swinegas catheter as well but again that's toy not tool the decent aorta is a very easy to get view actually you just kind of rotate to the left the descending aorta may be seen in short axis by rotating your probe to the patient's left and typically you're going to have to zoom in a little bit because it's kind of small on your screen it's actually kind of easy to find it's also a very nice place to look for plural effusion as well this is where you can find your interior balloon pump if you're looking for that sometimes you have a percutaneous bypass wire that's coming up from below color flow reversal is is seen here if you have a really bad aortic insufficiency again though you're going to rotate the probe a little bit to the left and you're going to have to zoom some and the long axis variant you're just basically going to go 90 degrees and you're going to omni and turn your beam vertical from horizontal if you take the descending aorta short axis and you go 90 degrees typically i go to about 100 or 105 actually you can get a nice view they order in long axes this is a great view of course you have to zoom a little bit as well great view to look for a dissection a good view to look for your anterior balloon pump etc it's very important to get the transgastric short axis and have the peppery muscles in view if you don't have the mid papillary view you're not in the middle of the heart you're in the basal or or a more superior or your apical or a little bit inferior to the center of the ventricle but you can see here inferior wall anterior wall lateral and anteroceptal it's a very nice view for filling but also wall motion the only view that is not mid-esophageal in basic echo is the transgastric view you're going to advance the probe into the stomach and you usually have to anaflex a little bit to get this view but it's a very high utility view it's the third of the rescue echo views mid-esophageal long axis mid-esophageal four-chamber and trans-gastric short axis are the three that give you the most information in a quick period of time but you can see left ventricular size and function you can look for an intraventricular septal motion to see if you've got some type of rv failure ventricular septal defect pericardial effusion volume and contractility quick down and dirty um it's all right there for you so you can see the inferior wall here which is the closest to the esophagus remember if you're looking outside in this is going to be the anterior and the parasternal short axis and if you're looking inside out this is the inferior wall because it's the closest to the esophagus so along with the qualitative views and qualitative assessment that you can make with with the previous 11 views you can also use color doppler and color flow mapping doppler is very interesting it provides direction and velocity of flow so you need to know directional flow obviously for regurgitation valves but also you need to have velocity of flow to look at stenotic valves and you can kind of see in this atrial septal defect over here to your right you've got a left or right shunt blew away red towards and typically if you have a very higher velocity if you're changing the necklace limit you can have different as you see here i change the nyquist limit to 50 which is the color scale and you end up getting a very high bright color which is different from blue but it's just because either the velocity or the nocus limit has been adjusted some of the uh higher utility aspects of t is the ability to make a quick call about ejection fraction and you can say good or bad and it's obvious that the one on the left is good and the one on the right is bad or you can say you can actually calculate the exact bf using m mode using planimetry you can also if you have the access you can do a simpson's biplane and some more precise measurements there's also some some different modalities at least in the philips to line up your axis of your your mitral analysis and the apex and give you a pretty close ejection fraction but again there's not much difference between 45 and 50 or between 15 and 20 but you manage both completely differently along with contractility you can also get a very good idea about lb filling you have you bulimia on the left pretty normal volume and on the right you kind of see hypovolemia you kind of see some kissing papillary muscles as they say and this tells you that instead of managing with phenylephrine maybe you need to be giving some volume and believe it or not about 30 of the time when you do rescue echo it's a filling or a volume status issue instead of contractility or pe or some more exotic uh of thing that has caused your hypotension along with contractility and filling you can also look at wall motion abnormalities the the scan on the left shows that all the walls are thickening and moving towards the center but as you can see the scan on the right the anterior portion of the lv in this mid papillary shot is not really moving towards the center this is an anterior wall wall motion abnormality which is representative of myocardial ischemia so how nice that must seem myocardial ischemia directly by looking with the echo well unfortunately it's not quite that easy there are 17 different views and despite the fact that t is probably the best way of ruling in or out ischemia ekg continues to be much more sensitive especially with individual variants as far as the ability to spot the wall motion changes but there are 17 segments required for full assessment typically involving about six views so now comes the so what part of the presentation so what if you've got all these pretty views is uh is it a tool or a toy to be looking directly at the heart itself and the chamber dimensions to figure out whether or not you need to give volume or tone or contractility well it's a lot like basing your uh your ventilator manipulation based on what your peak inspiratory pressures are you don't really know the full picture but with echo you can look at and pump the tank the pipes whether or not you have some type of even rv dysfunction rv dysfunction is very hard to figure out unless there's some pre-existing issue along with with valve issues and some type of obstructive pathology like tamponade or pe so this is the deep transgastric long axis which is kind of difficult to get if you've never done it before you're going to go into the stomach turn to the left and then you're going to antiflex the probe pretty hard and what you're going to get is you're going to see the right ventricle with the left ventricle but more importantly the aortic valve is in a nice position to this near field beam where you can get some continuous wave doppler on here and actually assess the grain across the valve and calculate the aortic valve area using the continuity equation it's a very robust view sometimes it's not quite as pristine as this in fact you can say it usually isn't so along with uh measuring aortic valve gradient with spectral doppler or continuous wave doppler you can also detect perivalver leak from a prosthetic aortic valve and and gradients not just across a native aortic valve but across a prosthetic valve such that like a tavr or something like that because you don't really want to have much much of a gradient especially one much higher than 20 millimeters of mercury and also you can calculate or you can measure left ventricular alpha tract gradients as you might see in hokum pre and post mymectomy so in obtaining this view you're starting out from the arch you're obviously going to descend down past the midsoft joule 4 past the trans-gastric view and you're going to get your probe down past the apex and then you're going to and flex up to get this measurement along with rotating a little bit to the left it's kind of tricky but once you've done it a couple of times it's it's actually not too bad so the mid-esophageal five chamber is different from the four chamber in that you can actually see the aortic valve um and the left ventricular outflow tract as well and you may say to yourself well why not use the five chamber five is greater than four it's because you actually force shorten the left ventricle a little bit you don't get a very good view of the lv apex and the rv and right atrium are a little bit off axis such that the right atrium is a little bit small but it's still regardless a very nice view for getting this quick view of the lvot and the aortic valve although it's not as efficient or doesn't have the utility of the deep trans gastric long axis view but still it's very quick easy to get as well so the utility of the five chamber um a lot of it's the same as the four chamber view uh but you can also look at the septum a little better you can see some ai if you've got aortic insufficiency you obviously put some color flow doppler across the lvot and the aortic valve you're going to see some ai and as well you can see turbulent flow across the lvot because as we talked about previously different velocities are going to have a little bit more aliasing it's going to have more of a color change sort of like the frame rate is unable to keep up with the wagon wheel speed in old westerns well the same thing here the frame rate can't keep up with the velocity such that you have aliasing or color changes so instead of of it being red across there it's actually a bright hue of yellow so kind of a a variation of the mid-esophageal two chamber is a mid-esophageal commissural view where you're only going to about 60 degrees and the advantage of this is you can get a little bit of more of the anterior leaflet here in display you see p1p3 but also you see all three anterior segments and you see a little bit of the left atrium as well but in general this is the true value of the commercial view so such that you can see a little bit better of the microvowel disease you can see the lv function as before but also seeing lethal pathology sometimes you see a little bit better view of the left atrial appendage in this view as well so along with the anatomic rendering on this slot you can kind of see the utility of the mid-esophageal aortic valve long axis you see the left atrium but also you see the the lvot that you can actually measure so if you're calculating uh the continuity equation and the aortic valve variants right here and we'll do that in in the next module uh we also measure the sound of tubular junction where where you're looking uh at where the coronaries come off along with the aortic anulus and looking at the aorta in general but it's a very nice up close view of this segment so to that end in this view you can look at mitral valve disease uh aortic valve disease and sometimes it's very convenient to put your doppler window your your color flow mapping right over this segment right here and you can see you can see everything you can see ai you can see mr you can see as you can see ms all this in in one nice pretty little view especially if you're in a hurry imagine that you've got a lot to do taking care of the patient as well aortic root dimensions pathology lvot pathology this is a great view to look at that that septal bulging from some type of hokum pathology along with the vsd which you might see right in here the transgastric basal short axis view is a lot like the transgastric mid papillary view except it's higher up it's more basal such that you get more of the top of the left ventricle you know the left ventricle really is just a tube as as my neural anesthesia colleagues say the heart's just a stupid pump well actually what they really mean to say is that the left ventricle is just a stupid pump the right ventricle is more like a very uh it's like a third atrium more than anything else but in this view you can see the inferior wall again inside out uh esophagus is here so the inferior walls here anterior walls here rvs here uh anterior mitral valve leaflet posture mitral valve leaflet it's very nice especially if you've got mitral stenosis it's a really pretty view from there and to that end you've got the trans gastric basal short axis you've got the fish mouth so to speak you look at the lv sizing function you can look for a pair pericardial effusion as well mitral valve planimetry area can be accomplished in this view as well there's a lot of very fancy doppler measurements that are affected by blood pressure and contractility such that sometimes it's good just to kind of freeze this when it's open and measure the mitral valve and that's one of the higher utility aspects of this view so in looking at um we'll talk about the utilities a few later but to help look at the anatomy you have to understand it to look at the mitral valve you have to look at it in several different aspects and this is is going into the the the same transgastry view that you just saw uh for the the basal view but you're going to omni 90 degrees and you're going to look at it from the side so you can see the posterior mitral valve leaflet the anterior micro valve leaflet papillary muscles the lv and a little sliver of the mitral valve also this is the anterior wall this is the inferior wall of the lv to that end you can see a this is a great view to look for lv function along with mitral valve subvalvular pathology you have a torn cord something like that this is a very pretty little view this is the transgastric rv inflow view you can see the posterior tricuspid valve leaflet here and the anterior tricuspid valve leaflet here it's very similar to looking from the side from the midosoft jewel 4 if you're looking at the tricuspid valve so again this is just a 90 degree or actually 114 degree view uh 90 degrees gonna give you the mitral valve so you got to really go about 110 114 but it's a very pretty little view you can look at the tricuspid valve pathology really nice with vegetations it's nice to snap pictures and and send them in christmas cards to that end the uh truck trans-gastric rv inflow view you can take a look at rv function you can look at tricuspid sub-valvular apparatus pathology along with tricuspid valve pathology in another view it's always good to look in several different views not just because you're validating your initial impression but also because sometimes the other view is just absolutely miserable for whatever reason a lot like surface echo trans-jurassic echo things like that you should be able to have several different views in your tool bag the trans-gastric long axis you're basically going to go down and you're going to 114 110 something like that you're going a little bit deeper than the basil you're actually going uh just past the mid papillary almost to the apex and you're going to get a nice view of the lvot aorta right ventricle it's almost like the mid-esophageal long axis just kind of slightly inverted because it's deeper and again the esophagus takes a little turn as with the mid-esophageal long axis view the transgastric long axis also offers you the opportunity to look at mitral valve pathology ventricular septal defect lv systolic function and the aortic valve just at a slightly different perspective along with the left ventricular outflow track which you can actually you can put some doppler across there across the lvot because you can use pulse wave doppler you don't have to line it up with the with the near field for the doppler so there's a couple of views of finding the coronary sinus for the surgeon to put the retrograde uh cardioplegia cannula in there and this is one of the views this is the most popular this is the modified midosophjia four chambers so you get the four chamber and you're going to advance the probe slightly and retroflex a little bit and you're going to see the right atrium here the right ventricle and the coronary sinus should be coming off right here which is very nice and convenient because then the surgeon can kind of find the coronary sinus and and probably in my practice at least 50 of the time you're getting this view for the surgeon so uh the the utility of it is extremely high and it's something probably of all the different views that you learned is one that you absolutely have to know along with the bike cable so you can you can turn your back on echo you can avoid echo you can pretend that it doesn't exist or you can just wait until the surgeon talks down to you because you can't find a simple modified me4 chamber which actually is a pretty tough little view to find if you've never done it before but you're going to go and find the four chamber you're going to advance the probe slightly and you're going to retroflex a little bit and you're going to find the coronary sinus right here so he can or she can put their candle in and this is the upper esophageal view so there's again there's four views are upper esophageal mid-esophageal trans gastric and deep trans gastric this is the upper esophageal you pull the probe back pretty far and you're finding the arch and i think probably 50 of the time you can find an ice arch like this and the other half the time you have to end up having to tilt a little bit you have to to tease the probe a little bit to get a decent view of this but this is very nice especially if you're looking for a dissection or something like that so to that end uh you find aortic pathology here uh if you've got some type of ai and you're trying to kind of gauge how bad the ai is and you can't really decide based on some of the other measurements such as pressure half time or how much of the lvot the regurgitate jet takes up this is a very nice view to look for color flow reversal so this is the upper esophageal aortic arch in short axis so you usually think of long axis being at zero degrees but really since the arch is kind of turning um and and is perpendicular to what you're used to you're actually at 90 degrees to get this short axis view such that here's the acing and aorta and this is actually to take off the left subclavian so this is a very high utility view actually as we'll talk about in just a moment and what you're looking for is you're you're typically looking for the tip of the balloon here making sure the tip hasn't come up here and occluded the left subclavian and giving them a cold hand but also it's a very good look for aortic arch pathology which to be honest usually it's kind of a sketchy view and you can't really kind of hang your hand on it pda i've never really looked for a pda in this view i hate to admit but um the view again is you can see the typically probably eighty percent of the time you can see the left subclavian come off here which makes it a high utility view especially if you've got a lot of patients with really low ejection fractions so this is another view um if you can't get a good view with the other view where you found the the four chamber and you're going to advance the probe and retroflex a little bit you can actually go into the bi-cable view and go 120 or 115 instead of 90 degrees and you'll actually have the left atrium up here as always the right air trim but now instead of the svc and the ivc you're going to have a little bit of the take off of the coronary sinus here and sometimes you've got a nice big coronary sinus and and you can actually see and direct the surgeon to go in and here it is in moving time and typically this may be all that you get sometimes just a little bit of a stub uh it's also a very nice view if you're getting the the regurgitate jet from some tr here and you're wanting to transduce it and get a velocity because it comes pretty much as a straight shot right down here off the near field and this is the transgastric april short axis you notice that the chamber size is a little bit smaller as well as the muscle dimensions so you have to be careful not to look at this instead of the trans gastric mid papillary because you can be misled on several fronts including a chamber size muscle size and contractility and filling so in this uh trans gastric apical short axis you can kind of see uh it's pretty obvious what the lv chamber is but what can be misleading is you see this instead of the mid-pappler and you think oh my goodness we're empty we need to get volume uh or oh my goodness the ejection fraction is 50 it's not really 15 well really you have to be looking at the middle of the heart to make volume or contractility assessments so but this is very good if you're looking for intraventricular septal motion or aneurysmal apex as you might see from some type of lad blockage with apical aneurysm so this is a view that is not highly unusual in a practice using a lot of ecmo extracorporeal membrane oxygenation heart transplant surgery percutaneous bypass with mini mitral surgery this is something that especially if you've got some gifted practitioners like i'm some of the physicians that i work with in crnas this is something that you've got to kind of bring your game up a little bit you're basically going to find the deep ivc view and you're going to find the liver and you're going to find the ivc and you're going to find the wire coming up from below for the percutaneous cannula for the ecmo or whatever so this end pretty much you're going to find the right atrium and you're just going to follow the ivc you're going to have to army as you go as you advance the probe you're going to go from from 90 degrees you're going to on me down to 90 to 80 60 then 50. and find this ivc find the hepatic vein make sure the wire doesn't go in that paddock vein and do bad things and cause bleeding then you're doing your surface probe to look to see where if you've got some abdominal bleeding things like this uh you can see some you can see some tr if you got really bad tr uh but in general it's mostly used for uh for interventional purposes the left atrial appendage view is typically you're finding the aortic valve short axis view and then you're going to pull back slightly and go to about 40 50 on your omni whatever gives you the left atrial appendage so if you're especially doing a watchman procedure things like that big left atrium and typically you're also looking for the uh interatrial septum if you're crossing the septum from the right side uh like for a fib ablation something like that or or a watchman or any other atrial ceptostomy procedure maybe asd something like that for for amplets device and plants including device very high utility view pretty easy to find once you've found it but until you find it it's just another one of those things that makes you feel inadequate so in this view you get electrical appendage pathology you actually can measure the uh the left actual appendage as well as see whether it's unilobed or multi-lobed cauliflower you know the usual different characteristics if you're putting a watchman in that tetra appendage flow you can see um if you can if you suspect clot you can put some doppler across there to see if there's flow you can put some color on there to see if there's any type of flow find an aortic aneurysm here as well as a severity of ai from color flow reversal but in general this is usually used in interventional ep or interventional cardiology so what do you use all this stuff for what do you use all these views for it's great to be used as a monitor and um to be honest uh that's the highest utility for me because i'm not guessing at what the filling is by looking at the the pulmonary artery pressure of the cvp or trying to figure it out based on the arterial waveform the pulse pressure variability of the stroke volume variation or whatever type of voodoo rubrics cube eight ball that i would ordinarily use additional views for diagnostic and interventional uses are what we're talking about with advanced te though we're talking about measuring valve area using the continuity equation maybe using some plant imagery if you're looking at advanced valve function assessments such as pressure half time you know there's ai and then there's ai and then you can also guide device deployment whether it's a watchman microclip tavr along with advanced doppler and quantitative assessment you know do you need to replace the aortic valve or you need to catch them on the re-up as i've heard them say and finally it's an assessment of cardiac surgical interventions whether or not your your mantra clip is has got a grain across the mitral valve or whether you continue to have wide open mr uh it's it's really coming of age and a lot of this is because of the the better uh technology the better probes but also because now this is this is a generation of ep and cardiac physicians that have an expectation of having this their work facilitated with echo so let's talk just a little bit about the role of te and tt tte can give you just almost anything that te can give you but it's you're in the way of the surgeon but also you can't really get a good view of the mitral valve you can't get really good 3d images you can't really look at pfos and small asds and and you certainly can't do diagnostic and interventional stuff for the macro valve with tte you can do it with the tap for the tapper though and a lot of people are such that you know you can actually make a case that you shouldn't be doing advanced te unless you can do tt because tte can be done across the entire perioperative cycle pre-op post-op and even intro as far as advanced te goes these additional views offer the surgeon and the interventionalist 2d and 3d imaging that they need to have to do their job very well and finally the full perioperative use of echoes is no longer limited to te but but it's going to be including transthoracic echo as well in the future and you're going to see a lot more uh transferasic echo being done now that the advent of the handhelds and portable imaging is available so in summary a basic perioperative echo offers full assessment of the etiology of cardiopulmonary instability using only 11 windows i mean how many words do you need to have to be able to be functional in a conversation and there are 11 really relevant windows that you've got to have down pat but at the same time advanced te you're using up to 28 windows and even 3d to offer more precise diagnostic information and uh this is something that is especially when the uh with uh with some of the advent of the newer 3d technology that is going to probably change a lot of the way we do things and finally use of basic tte extends the use of echo throughout the entire perioperative period it's it's it's much more difficult than te to do transthoracic echo the the images are much more difficult to obtain it's much more difficult to interpret especially on your phone but it's a basic essential ingredient in advanced echo thank you very much