PRINTER-FRIENDLY VERSION AT ANESTHESIOLOGYNEWS.

COM

Echocardiography
For the Anesthesiologist
D. WESLEY HUDSON, MD
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Fellow in Cardiothoracic Anesthesiology

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Medical University of South Carolina

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Charleston, South Carolina

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J. ROSS SIMRIL, MD
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Fellow in Cardiothoracic Anesthesiology

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Medical University of South Carolina

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Charleston, South Carolina

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JAMES H. ABERNATHY III, MD, MPH

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Associate Professor of Anesthesiology

and Perioperative Medicine
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Medical University of South Carolina

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Charleston, South Carolina

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The authors have no relevant disclosures to report.

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Basic Examination

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ransesophageal echocardiography
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Transesophageal echocardiography provides

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(TEE) plays an important role in

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an excellent diagnostic and monitoring tool for

anesthesiologists in the operating room. The TEE
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patient management during the examination can be broken down into complete/
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comprehensive and abbreviated forms; the user

perioperative period. It is routinely used
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may select either depending on the urgency of

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during cardiac surgery but also has great the situation and other clinical responsibilities.
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As with any invasive procedure, the potential

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value for the unstable patient undergoing

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risks and benefits of TEE should be discussed

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with the patient and preoperative informed

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noncardiac surgery. This article presents consent obtained. A study by researchers at

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Brigham and Women’s Hospital, in Boston,

the anesthesiologist with a practical review
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reviewed more than 7,000 TEE examinations

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of the basic TEE examination, ultrasound and found rates of procedure-related morbid-
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ity and mortality of 0.2% and 0%, respectively.

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physics and fundamental principles, Although rare, the most common TEE-related
injuries were odynophagia, dental trauma, mal-
indications for TEE, the TEE certification positioning of the endotracheal tube, upper
process, perioperative use of transthoracic gastrointestinal hemorrhage, and esophageal
perforation. Few contraindications exist to inser-
echocardiography (TTE), and the increasing tion of the TEE probe; these include dysphagia,
odynophagia, significant reflux, hematemesis,
use of 3-dimensional (3-D) echocardiography. history of gastric and/or esophageal pathology
(a hiatal hernia is not a contraindication but may

I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N • O C TO B E R 2 0 1 1 95
complicate imaging), and significant resistance dur-
ing insertion or advancement of the probe (Table 1). By
carefully selecting candidates using these guidelines, as
well as minimizing probe manipulation, clinicians can
make intraoperative TEE relatively safe and beneficial
for assessing cardiovascular function and anatomy.1
In 1999, the American Society of Echocardiography
and the Society of Cardiovascular Anesthesiologists
(SCA) developed recommendations on what should be
included in a comprehensive TEE examination. Shane-
wise and colleagues applied these recommendations to
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Image acquisition depends on controllable and
uncontrollable factors. Uncontrollable factors, such as
the patient’s anatomy, “acoustic windows,” and shad-
ows from an implanted cardiac device, will affect the
quality of the ultrasound images. However, an experi-
enced and skilled user can manipulate both the prop-
erties and the position of the probe to obtain adequate
images.
The probe is controlled by advancing and with-
drawing the instrument to view more distal and proxi-
mal structures and by rotating it counterclockwise and

the 20 standard imaging views that allow for a com- clockwise to image left- and right-sided structures. In
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plete examination of the ventricular, valvular, and major combination with using the large control dial to anteflex
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vascular functions and anatomy.2 Miller and colleagues or retroflex the probe tip, using the smaller dial to flex
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subsequently condensed the comprehensive examina- the probe tip right to left, and using the scan angula-
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tion into 12 necessary views that would enable basic tion control from 0 to 180 degrees, the practitioner can
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TEE practitioners to quickly examine and interpret car- obtain and optimize the required TEE images in order
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diovascular function and anatomy.3 to acquire accurate data for analysis.4

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The following section describes how to complete the The basic examination begins with insertion of the
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basic TEE examination. The order can vary according TEE probe. After securing the patient’s airway and evac-
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to practitioner preference. In any case, the sequence uating the stomach, the clinician should carefully insert
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should minimize probe movement. a bite guard with lubricating jelly into the patient’s
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mouth. The probe is then passed (with the control lock

in the off position) into the upper esophagus using a
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Table 1. Contraindications sustained jaw lift, constant gentle pressure, and a slight
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To Intraoperative TEE twisting motion. Beyond the cricopharyngeus muscle, a

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distinct loss of resistance will be noted. Particular care

Dysphagia
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must be taken at this point because numerous possibil-

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Odynophagia ities exist for trauma and morbidity to both the patient
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and the probe.1

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Hematemesis
When positioned in the esophagus, the probe should
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History of gastric and/or esophageal pathology

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be gently advanced until a recognizable structure is

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Significant reflux reached—usually the mid-esophageal 4-chamber (ME-

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Significant resistance during insertion or 4C) view . This view is obtained by advancing the probe
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at 0 degrees of scan angulation and slight retroflexion

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advancement of the probe

of the tip. All 4 cardiac chambers, the tricuspid valve
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For meanings of abbreviations, see key on page 103.

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(TV), and the mitral valve (MV), should be visible with

the left-sided structures on the right of the TEE screen
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and right-sided structures on the left of the screen (as

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with a chest x-ray). These structures should be eval-

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uated regarding size, shape, structure, and function.4

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This view is easy to obtain and commonly is used as a

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landmark if the practitioner loses orientation during the

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examination.
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The next images that are relatively easy to obtain are

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the ME-4C view with colorflow Doppler (CFD) of the MV

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and the TV (Figure 1). To adjust the viewing box over

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the MV or TV in the ME-4C view, depress the CFD but-

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ton on the echocardiography machine and use the track

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ball. These views will allow the practitioner to assess

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directional flow and any turbulence through the MV and

the TV. They are useful in the assessment of any signif-
icant pathology in valvular flow, including tricuspid or
Figure 1. Mid-esophageal 4-chamber mitral regurgitation or stenosis.
view with colorflow Doppler over The mid-esophageal 2-chamber (ME-2C) view is
the mitral valve. obtained by advancing the scan angulation to 90
This image allows assessment of atrioventricular degrees to reveal a long-axis view of the left side of
valve function and flow patterns. the heart. The anterior wall of the left ventricle (LV) will
appear on the right of the screen and the LV inferior

96 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
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Figure 2. Mid-esophageal 2-chamber
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view.
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This image allows assessment of the anterior and
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inferior walls of the left ventricle and assessment
of the left atrial appendage.
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wall on the left of the screen. This view may provide the
best imaging of the LV apex, LV anterior, and inferior
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wall function, and the left atrial appendage4 (Figure 2).
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The mid-esophageal bicaval (ME-BC) view is
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obtained by rotating the scan angulation from 100 to
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120 degrees and turning the probe clockwise (Figure 3).
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The image will reveal the right atrium (RA) with the
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superior vena cava on the right of the screen and the
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inferior vena cava on the left of the screen. This view is
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helpful for identifying RA pathology, masses, thrombi,
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and atrial septal defects, especially patent foramen ova-
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les when using CFD.4
From the ME-BC view, the mid-esophageal aortic
valve short-axis (ME-AoSx) view is obtained by reduc-
ing the probe scan angulation to 30 to 50 degrees and
slightly withdrawing the probe (Figure 4). The left, right,
and noncoronary cusps emerge in clockwise order. The
anatomy of the aortic valve (AV) can be assessed to
identify bicuspid or unicuspid structures.4
The next view to be obtained is the mid-esophageal
aortic valve long axis (ME-AoLx). This is visualized by
simply increasing the scan angulation to 120 degrees
while keeping the AV in the center of the screen. This
view allows evaluation of the AV, the sinus of Valsalva,
the sinotubular junction, and the ascending aorta.4
By pressing the CFD button on the echocardiography
machine and positioning the Doppler window over the
AV, the practitioner can evaluate the flow and turbu-
lence across the valve in order to evaluate if regurgita-
tion or stenosis is occurring (Figure 5).
The mid-esophageal RV inflow–outflow (ME-RV IO)
view is achieved by reducing the scan angulation to
40 to 60 degrees from the ME-AoLx view and slightly
adjusting to include the AV, RV, and RV outflow tract. As
a result, the RV, TV, and pulmonic valve (PV) appear in
the same frame. With the use of CFD, the practitioner
can better evaluate flows in the TV and PV and detect
A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N • O C TO B E R 2 0 1 1
Figure 3. Mid-esophageal bicaval
view.
This image allows evaluation of right-sided cardiac
structures, including evaluation of the atrial septum
for patent foramen ovales.
any significant regurgitation or stenosis (Figure 6).
The last 2 views of the basic examination require
the probe to be in neutral position and at a 0-degree
scan angle. The practitioner gently advances the probe
into the stomach and anteflexes the tip to see the LV
with both papillary muscles to obtain the transgastric
mid short-axis (TG-MSx) view. The configuration of the
screen changes as the posterior medial papillary muscle
appears at the top of the screen and the anterior lateral
papillary muscle appears near the bottom (Figure 7). In
this view, clinicians can evaluate LV wall motion and all
3 coronary artery territories.6 To obtain the transgas-
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tric 2-chamber (TG-2C) view from this point, adjust the
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scan angle from 80 to 90 degrees. This view allows a
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more complete evaluation of the LV anterior and infe-
rior walls as well as the MV subvalvular apparatus. For
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reference, Table 2 lists the expanded, standardized TEE
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examination performed at the Medical University of
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South Carolina.
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On completion of the examination, the probe is
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returned to the neutral position and gently removed
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from the patient.
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Ultrasound and Echocardiography
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RESOLUTION, IMPEDANCE, AND ATTENUATION
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The images generated by 2-D echocardiography
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result from the transmission of ultrasound waves from
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a probe through tissues in their path. Because ultra-
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sound travels at a constant speed in biological tissues
(1,540 m/sec), the time required for the sound waves
to be reflected back determines the exact location of a
structure. Echocardiography uses sound waves with fre-
quencies of 2 to 10 mHz, which are higher than the audi-
ble range for humans. The shorter the wavelength and
the higher the frequency, the better the ultrasound can
differentiate 2 distinct objects lying within the plane of
the beam. This phenomenon is called axial resolution.5
97
 Table 2. MUSC Standardized TEE
Exam
Ventricular Assessment
ME-4 chamber view
ME-2 chamber view
ME long axis
Decrease depth to focus on the valve being
examined.
Examine with and without CFD.
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MV in ME 4-chamber view
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ME mitral commissural
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Figure 4. Mid-esophageal aortic

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MV in ME 2-chamber
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valve short-axis view.

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MV in ME long axis
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AV long axis This image allows evaluation of the aortic valve leaf-
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let structure and function.

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Ascending aorta long axis for diameter

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AV short axis
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ME ascending short axis

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RV inflow–outflow
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TV and PV with CFD in RV inflow–outflow

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Bicaval
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Assess for PFO

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ME 4-chamber for RV
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TV with CFD in ME 4-chamber

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Gastric Views
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Transgastric basal short axis

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Transgastric midpapillary
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Transgastric 2-chamber
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AV long axis Figure 5. Mid-espohageal aortic

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Deep transgastric AV valve long-axis with colorflow

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Doppler.
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Continuous wave through AV

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Transgastric RV inflow This image allows evaluation of the aortic valvular

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Aorta function and flow velocities, including interrogation

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for aortic stenosis or insufficiency.

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Descending aorta short and long axis

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Upper esophageal arch short and long axis

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Diastology
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encounters tissues with different acoustic impedances,

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ME 4-chamber
part of that energy is reflected. Large differences in
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Pulse wave through MV

acoustic impedance, such as between tissue and bone,
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TVI cause a high percentage of energy to be reflected back

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Pulse wave in pulmonary veins to the transducer, resulting in echo-dense or bright

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signals on the screen. Smaller differences in acoustic

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impedance, such as when tissue interacts with blood,

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cause less reflection and more transmission.4,5 An echo-

Each type of tissue has a different capacity for sound
transmission, or acoustic impedance. Bone, fluid, and
other relatively dense tissues have high acoustic imped-
ance and are excellent transmitters of ultrasound. Air
and lung tissue are less dense and thus do not transmit
ultrasound well. When an ultrasound wave encounters
an interface of 2 tissues with similar acoustic imped-
ance, it continues in its path. When an ultrasound wave
lucent, or dark, picture is the result.
As ultrasound travels away from the transducer, the
signal changes and loses energy. This loss of inten-
sity is referred to as attenuation. Returning signals
can be amplified by increasing the gain. Lower ultra-
sound frequencies have less attenuation compared with
higher frequencies. Therefore, for structures that are far
from the ultrasound probe, it is helpful to use a lower

98 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
frequency. However, lower frequencies have poorer res-
olution, so the ultrasonographer must always balance
resolution with attenuation. Keeping the structure of
interest close to the ultrasound probe will allow use of
higher frequencies.5

ECHOCARDIOGRAPHY MODES
Basic 2-D imaging is based on brightness mode
(B-mode). The brightness of the displayed image is pro-
portional to the strength of the returning signal. Motion
mode (M-mode) offers a 1-dimensional slice through
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the heart that is displayed over time and is optimal for

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timing of cardiac events. M-mode presents the best

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display of cardiac motion but is limited in its ability to

Figure 6. Mid-esophageal right
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show a detailed picture of cardiac anatomy. B-mode–

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ventricular inflow–outflow with

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based echocardiography is able to show shape and lat-

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eral motion of structures, whereas M-mode displays colorflow Doppler.

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only axial motion.5

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This image allows for assessment of blood flow

Doppler ultrasonography is an important adjunct for across the tricuspid and pulmonic vales.
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use with 2-D echocardiography to assess speed and

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direction of blood flow. The Doppler principle states

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that the velocity and direction an object is traveling

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affect the change in frequency that the object pro-

duces. For example, a red blood cell traveling toward
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the transducer creates a positive Doppler shift, whereas

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the same cell traveling away creates a negative Doppler

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shift. Pulsed-wave and continuous wave Doppler are 2

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types of Doppler ultrasonography that permit the echo-

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cardiographer to make quantitative measurements of

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blood flow and to grade the severity of disease.

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Pulsed-wave Doppler uses a single crystal to emit

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and receive sound waves. It is limited by a maximum

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frequency and blood velocity that can be measured,

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and is therefore used to gauge slower-moving objects

(transmitral blood velocity).5 Continuous wave Doppler
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uses 2 crystals, one to continuously transmit sound and

Figure 7. Transgastric mid-short axis
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view.
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the other to continuously receive it. Because this mode

has one crystal that is constantly receiving ultrasound
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This view allows assessment of overall left ventric-

signals, it can measure the velocity of blood as it tra- ular function, specifically evaluation of coronary
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verses a stenotic aortic valve.5 artery perfusion distribution. This view also allows
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CFD can simultaneously image structures and blood for assessment of overall left ventricular filling or
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flow. Many sample volumes are recorded and displayed volume status.
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on top of the 2-D echocardiographic image. Tradition-

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ally, red indicates blood flow toward the probe and blue
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indicates flow away from the probe. CFD is susceptible

TEE FOR CARDIAC SURGERY
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to aliasing artifacts but is an excellent tool for assess- The recommendations state that TEE should be used
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ing valve function, aortic dissection, and congenital car- for all open heart (valvular) and thoracic aortic surgical
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diac anomalies.5 procedures in adult patients without contraindications.

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Achieving the best echocardiography image occurs TEE should be considered in coronary artery bypass
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when one understands the principles of ultrasound and graft surgeries to confirm and refine the preoperative
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the techniques available, and focuses on the structure
under investigation.
Indications for TEE
Transesophageal echocardiography is an important
diagnostic and monitoring tool, yet it is not without
risks. In May 2010, the American Society of Anesthesi-
ologists and the SCA published practice guidelines for
the perioperative use of TEE6 (Table 3).
diagnosis, to detect new or unsuspected pathology, to
adjust anesthetic and surgical plans based on these
findings, and to assess the results of the surgical inter-
vention. TEE should be considered on a case-by-case
basis in small children undergoing cardiac surgery.6
Transesophageal echocardiography may be used dur-
ing transcatheter intracardiac procedures, particularly if
the patient is under general anesthesia and intracardiac
ultrasound is not used. Specifically, TEE should be used

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N • O C TO B E R 2 0 1 1 99
 for septal defect closure, atrial appendage obliteration,
Table 3. ASA/SCA Indications and catheter-based valve replacement and repair.
For TEE
TEE FOR NONCARDIAC SURGERY
Cardiac surgery
The recommendations for use of TEE in noncardiac
Case-by-case basis in small children surgery include cases when the nature of the proce-
Coronary artery bypass graft surgeries dure or the patient’s known or suspected cardiovascular
Open heart (valvular) and thoracic aortic surgical pathology may result in severe hemodynamic, pulmo-
procedures in adults without contraindications nary, or neurologic compromise. Such cases include but
Transcatheter intracardiac procedures (particularly are not limited to lung transplantation; major abdom-
in patients under general anesthesia and inal or thoracic trauma; pathology such as persistent
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intracardiac ultrasound is not used) including: unexplained hypoxemia or hypotension; and suspected
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abnormalities such as atrial septal defect, myocar-

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• Septal defect closure

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dial ischemia, hypovolemia, pericardial tamponade,

• Atrial appendage obliteration
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and thromboembolic events. In addition, TEE should

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• Catheter-based valve replacement/repair

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be used when equipment and expertise are available

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Noncardiac surgery and a patient experiences unexplained life-threaten-

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ing circulatory instability that persists despite correc-

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Atrial septal defect

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Hypovolemia tive therapy.6

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Lung transplantation
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Miniaturized TEE
Major abdominal or thoracic trauma
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When diagnostic information that is expected to

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Myocardial ischemia change the management of critical care patients cannot

be obtained by TTE or other diagnostic modalities in
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Patients at risk for severe hemodynamic,

a timely manner, TEE should be considered. Diagnosis
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pulmonary, or neurologic compromise

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Pericardial tamponade of valvular abnormalities, aortic dissection, intracardiac

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mass, tamponade, ventricular failure, and hypovolemia

Persistent, unexplained hypoxemia or hypotension
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with TEE has been reported in this patient population.6

Thromboembolic events
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Miniaturized TEE is another device for patient man-

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Unexplained, life-threatening circulatory instability agement in the intensive care unit (ICU). Clari-TEE (Ima-
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that persists despite corrective therapy Cor) is a disposable, miniaturized TEE system that uses
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a disposable, monoplane probe with a 5-mm diame-

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ter. The device is capable of providing images of endo-

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cardial borders and ventricular thickening, and is best

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used for monitoring. To date, Doppler modalities are

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not available. The probe is FDA-approved to remain in

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a patient for up to 72 hours. After 72 hours the probe

is disposed.7
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Current indications for use of the miniaturized TEE

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are in the ICU setting. These indications include hemo-

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dynamic instability due to low cardiac output, excessive

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vasodilatation, increasing requirement of hemodynamic

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support, and unexplained hypotension. Other indica-

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tions include suspected RV dysfunction, postoperative

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bleeding with suspected tamponade, and severe acute

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lung injury or unexplained hypoxemia. The miniaturized

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TEE device also may be beneficial in the management of

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known cardiac conditions such as diastolic dysfunction,

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systolic anterior motion, or mitral regurgitation, as well

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as contributing to medical decision making when wean-

Figure 8. Transthoracic echocardio-
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ing patients from hemodynamic support.

graphic image of all 4 cardiac
chambers. Certification
The Basic Perioperative Transesophageal Echocar-
Note that this image is inverted, compared to an
image of the heart obtained by transesophageal diography (Basic PTE) certification is offered through
echocardiography. the National Board of Echocardiography (NBE). The
NBE requires practitioners to pass the Basic PTE exam-
ination, but to sit for the test, one must meet several
prerequisites. The applicant must have both a current

100 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
medical license and board certification in anesthesiol-
ogy. The applicant also must have specific training or
experience in perioperative TEE—including the study of
150 TEE examinations and at least 50 basic examina-
tions performed by the applicant. (The applicant also
may qualify if he or she has performed 150 basic intra-
operative TEE examinations within 4 years, with no
less than 25 examinations per year, and have at least
40 hours of American Medical Association Category
1 CME credits for perioperative TEE). Applicants who
are advanced TEE-certified may sit for the basic exam-
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ination.9 (For more information about obtaining certi-

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fication, visit http://www.echoboards.org/sites/default/

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files/BasicPTEeXAM.pdf.)
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Figure 9. A 3-dimensional TEE

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Transthoracic Echocardiography image of the left ventricle.

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Transthoracic echocardiography is another use-

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These images are used to create a 3-dimensional

ful tool for assessment of cardiac function in the peri-
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quantification model.
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operative period. Unlike TEE, TTE is noninvasive but

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offers limited images in patients with a large body hab-

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itus, positive pressure ventilation, obstructive lung dis-

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ease, and occlusive surgical dressings. Nevertheless, way to visualize the structures of the heart. Although
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TTE offers rapid, bedside evaluation of hemodynamics, this technology has been used primarily by advanced
which is particularly valuable in the unstable patient in cardiac examiners to guide interventions such as MV
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the ICU or in the recovery room. The modality also may repair, some elements of the 3-D evaluation will assist
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be considered if a patient has contraindications to TEE. in the basic exam of cardiac function. For example, 3-D
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A focused TTE examination that evaluates a specific Quantification software is a semi-automated process for
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clinical concern can be performed in approximately 10 modeling of wall motion across all 17 segments of the
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minutes.10,11 New technologies such as portable hand- LV. After a 3-D image of the LV is obtained (Figure 9),
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held echocardiography devices, harmonic imaging, the software package identifies the endocardial bor-
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digital image acquisition, and contrast echocardiogra- ders. Tracking these borders through systole and dias-
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phy have increased the availability and quality of TTE tole allows for precise calculations of end-systolic and
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imaging.12 end-diastolic volumes. Estimating LV volumes or ejec-

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tion fraction by 2-D necessitates the use of geometric

INDICATIONS
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assumptions.
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The most common indication for bedside TTE in the Using a 3-D–generated analysis of the true endo-
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ICU is assessment of LV function (Figure 8). Examina- cardial borders of the LV reduces the error inherent in
tion of the LV in the parasternal long axis view allows assumptions of LV shape based on 2-D evaluation and
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measurement of the valve’s dimensions and subse- is more accurate and reproducible.13 This analysis will
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quent calculations of ejection fraction and fractional evaluate the contribution of individual wall segments
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shortening. A new ischemic event can be diagnosed by to LV volume, ejection fraction, and stroke volume.
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observing the valve for abnormalities in the motion of This information can generate an image displaying the
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the regional wall. Right-sided cardiac dysfunction, peri- motion of each segment of myocardium and its con-
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cardial effusions or tamponade, valvular dysfunction, tribution to LV function (Figure 10). Evaluation of this
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endocarditis, and intracardiac shunts are other causes type is beneficial for both the diagnosis of preexisting
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of hemodynamic instability that TTE can help to diag- LV wall motion abnormalities and for the development
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nose. This noninvasive tool will continue to be useful of these abnormalities during an operative procedure.
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in guiding perioperative patient management and is 3-D evaluation has been shown superior to 2-D eval-
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becoming increasingly available to the anesthesiologist. uation for assessment of the cardiac valves, especially
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the mitral. The asymmetrical, hyperbolic parabolic

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3-D Echocardiography shape of the MV creates difficulty when viewing the

As TEE has developed as a diagnostic tool and guide
for surgical intervention, much research and develop-
ment has been invested into improving the capabilities
of the instrument. Probes are smaller and more respon-
sive, machines have become faster with better resolu-
tion, and different modalities have been developed to
supplement the evaluation of cardiac function. Most
recently, 3-D TEE evaluation has created an entirely new
valve in 2-D.4,14,15 Live 3-D evaluation of the MV allows
the surgeon to visualize the anatomy and pathology of
the valve. Improved surgical planning is possible due
to this modality’s ability to provide an en face view of
the valve highlighting the surgical anatomy and pathol-
ogy (Figure 11). MV models also can be created, provid-
ing detailed visualization and multiple measurements
of the valve. However, they require offline processing

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Figure 10. A 3-dimensional

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Figure 12. A 3-dimensional model of

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the mitral valve.

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AO, aortic valve

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as a few contraindications are kept in mind and a gen-

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tle approach is taken, TEE is a very safe and efficient

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tool for diagnosing causes of hemodynamic instability.

Knowledge of the basic TEE examination and principles
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of Doppler and ultrasound allow the general anesthesi-

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ologist to correctly use this technology. Newer equip-

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ment, such as high-quality handheld ultrasound and

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3-D echocardiography will be commonplace in the near

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future. Developing proficiency with these resources

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will allow the anesthesiologist to optimally care for the

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unstable patient before, during, and after surgery.

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References
in

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pa

1. Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK. The
safety of intraoperative transesophageal echocardiography:
un ou
rt

a case series of 7,200 cardiac surgical patients. Anesth Analg.

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2001;92(5):1126-1130.
ith

ss

Figure 11. A 3-dimensional en face 2. Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guide-
ot

lines for performing a comprehensive intraoperative multiplane

view of the mitral valve.
he

transesophageal echocardiography examination: recommen-

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dations of the American Society of Echocardiography Council

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for Intraoperative Echocardiography and the Society of Car-

er

diovascular Anesthesiologists Task Force for Certification in

is
m

Perioperative Transesophageal Echocardiography. Anesth Analg.

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is

and may be too cumbersome for intraoperative use 1999;89:870-884.

no
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(Figure 12). Progressive improvement in the design of 3. Miller JP, Lambert AS, Shapiro WA, Russell IA, Schiller NB, Cahalan
te

3-D TEE probes, the computers to analyze data, and MK. Adequacy of basic intraoperative transesophageal echocar-
d.
is

diography performed by experienced anesthesiologists. Anesth

software will continue to augment the ability to diag- Analg. 2001;92(5):1103-1110.
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nose pathology and guide intervention in patients with

oh

4. Reves JG, Reeves S, Abernathy J, eds. Atlas of Cardiothoracic

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ib

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ite

5. Perrino AC, Reeves ST, eds. A Practical Approach to Transesoph-

progress, 3-D echo will prove important for visualiza- ageal Echocardiography. 2nd ed. Philadelphia, PA: Lippincott
d.

tion both pre- and post-repair as in these views during
a percutaneous mitral clip for repair of mitral regurgita-
tion (Figures 13 and 14).
Conclusion
Transesophageal and transthoracic echocardiog-
raphy are excellent diagnostic and monitoring tools
that are becoming increasingly prevalent in the care
of patients during the perioperative period. As long
Williams & Wilkins; 2008.
6. American Society of Anesthesiologists and Society of Car-
diovascular Anesthesiologists Task Force on Transesophageal
Echocardiography. Practice guidelines for perioperative trans-
esophageal echocardiography. An updated report by the American
Society of Anesthesiologists and the Society of Cardiovascular
Anesthesiologists Task Force on Transesophageal Echocardiogra-
phy. Anesthesiology. 2010;112(5):1084-1096.
7. Wagner CE, Bick JS, Webster BH, Selby JH, Byrne JG. Use of
a miniaturized transesophageal echocardiographic probe in

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 the intensive care unit for diagnosis and treatment of a hemo-
dynamically unstable patient after aortic valve replacement. J
Cardiothorac Vasc Anesth. 2011 March 25. [Epub ahead of print]

8. Imacor probe [online image] www.imacormonitoring.com/solu-

tions/products/miniaturization-technology.html, Accessed
September 20, 2011.

9. Basic perioperative transesophageal echocardiography certifi-

cation. http://www.echoboards.org/sites/default/files/BasicPTEe
XAM.pdf. Accessed July 2, 2010.

10. Cowie B. Focused cardiovascular ultrasound performed by anes-

thesiologists in the perioperative period: feasible and alters patient
management. J Cardiothorac Vasc Anesth. 2009;23(4):450-456.
A
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11. Manasia AR, Nagaraj HM, Kodali RB, et al. Feasibility and poten-
tial clinical utility of goal-directed transthoracic echocardiography
rig

Figure 13. A 3-dimensional image of

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performed by noncardiologist intensivists using a small hand-car-

a catheter traversing the interatrial
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ried device (Sonoheart) in critically ill patients. J Cardiothorac

Vasc Anesth. 2005;19(2):155-159.
s

septum.
rig ed.
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12. Showkathali R, Hausenloy D. Echocardiography and the critically ill

ht
se

patient. Curr Anaesth Crit Care. 2006;17(3-4):237-244. TEE is important to localize the optimal position for
rv

the trans-septal punch

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13. Jenkins C, Bricknell K, Hanekom L, Marwick TH. Reproducibil-

20

ity and accuracy of echocardiographic measurements of left

ventricular parameters using real-time three-dimensional echocar-
11
Re

diography. J Am Coll Cardiol. 2004;44(4): 878–886.

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14. Abraham TP, Warner JG Jr, Kon ND, et al. Feasibility, accuracy and
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incremental value of intraoperative three-dimensional transesoph-

ageal echocardiography in valve surgery. Am J Cardiol. 1997;
uc

ah in w

80(12):1577-1582.
tio

on

15. Macnab A, Jenkins NP, Bridgewater BJ, et al. Three-dimensional

n

echocardiography is superior to multiplane transesophageal echo

Pu

in the assessment of regurgitant mitral valve morphology. Eur J

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Echocardiogr. 2004;5(3):212-222.
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Figure 14. A 3-dimensional image

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of a mitral clip in place.

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3-dimensional TEE confirms the proper placement of

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the mitral clip over the diseased mitral valve.

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Key LLVW, lateral left ventricular wall PPM, posterior medial papillary muscle
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LCC, left coronary cusp PV, pulmonary valve

A, anterior
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LV, left ventricle RA, right atrium

AL, anterior-lateral
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LVOT, left ventricular outflow tract RCC, right coronary cusp

ALVW, anterior left ventricular wall
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ME, mid-esophageal
AMVL, anterior mitral valve leaflet RV, right ventricle
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MUSC, Medical University of South Carolina

APM, anterior lateral papillary muscle SCA, Society of Cardiovascular
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MV, mitral valve Anesthesiologists

ASA, American Society of Anesthesiologists
MV w/CFD, mitral valve with colorflow
d.

SLVW, septal left ventricular wall

Asc Ao, ascending aorta Doppler
SOV, sinus of valsalva
AV, aortic valve NCC, noncoronary cusp
AV w/CFD, valve with colorflow Doppler STJ, sinotubular junction
P, posterior
CFD, colorflow Doppler SVC, superior vena cava
PA, pulmonary artery
ILVW, inferior left ventricular wall PAC, pulmonary artery catheter TEE, transesophageal echocardiography
IVC, inferior vena cava PFO, patent foramen ovale TV, tricuspid valve
LA, left atrium PM, posterior-medial TVI, tissue velocity imaging
LAA, left atrial appendage PMVL, posterior mitral valve leaflet VOT, left ventricular outflow tract

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