Three-dimensional echocardiography has become an important component of the evaluation of the aortic annulus and aorta for transcatheter procedures.89 Studies suggest that 3D TEE can accurately measure the area or perimeter of aortic annulus90–93 and can also be used to measure the distance between the annulus and leaflet tips to the coronary ostia89 in the setting of severe, calcific aortic stenosis. For transcatheter valve procedures, this annular measurement is performed in midsystole.94
With TEE, a 2D image of the AV at either the ME AV SAX view or the ME AV LAX view should be obtained (Table 11). After the 2D image is optimized, narrow-angle acquisition mode can be used to optimize the 3D image and to examine AV and root anatomy. After acquisition, when displayed en face, the AV should be oriented with the right coronary cusp located at the bottom of the sector regardless of whether the aortic or the LV outflow tract perspective is presented (Figure 5).
Once a wide-angle acquisition 3D data set of the aortic root is obtained, the cropping plane can be aligned parallel to the AV orifice, as identified from the LAX view. This results in a SAX 3D image of the AV orifice, which can be used for planimetry. As well, the cutting plane can be moved to the LV outflow tract, the sinus of Valsalva, or the sinotubular junction to obtain these respective cross-sectional areas. Last, the cropping planes can be placed perpendicular as well as parallel to the aortic annulus to assess supravalvular and subvalvular anatomy for serial stenoses.
Color Doppler 3D TEE should also be performed to detect the appearance of flow in both systole and diastole. Additional color 3D data sets allowing cut planes to be oriented perpendicular and parallel to the regurgitant or antegrade flow orifice may be of value for understanding the morphologic and hemodynamic importance of abnormal flow.
The PV, similar to the AV, is a semilunar valve with three cusps. Unlike the AV, the PV cusps are thinner, and there is no fibrous continuity with the muscular septum or the right atrioventricular (tricuspid) valve.95 The three PV cusps are named by their relative position to the AV. Thus, the right and left cusps, corresponding to the right and left cusps of the AV. The third cusp is named the anterior or “opposite” cusp given its position opposite the AV.49 The plane of the PV is oblique to the plane of the AV. Awareness of this spatial relationship is useful when the operator is attempting to define the optimal imaging window for the PV. Because the PV is an anterior and thus far-field structure for TEE, views are more challenging to obtain, either because of interference from other structures (bronchus) or from patient intolerance of the high esophageal or TG transducer position. Therefore, these additional views may be of particular clinical utility in the critical care unit or operating room where patients are receiving heavy sedation or general anesthesia.96,97
The PV can be imaged from several windows, not all of which can be consistently obtained or necessary in every study. Similar to other valves, 2D, color Doppler, spectral Doppler, and 3D imaging modalities are useful.
During the comprehensive imaging examination, the first view of the PV can be obtained by turning the probe to the left (counterclockwise) from the ME ascending aorta LAX view (view #7) as well as the ME ascending aortic SAX view (view #8). Imaging the PV from these ME views typically requires slight withdrawal of the probe into a higher esophageal position. From the ME ascending aorta LAX turning left (counterclockwise) yields a LAX view of the main PA with the PV in the far field. Maintaining the position of the main PA in the center of the imaging sector, rotating backward (toward 0°) allows visualization of the main PA and PA bifurcation. Because the Doppler beam will be parallel to transvalvular flow, pulsed-wave and continuous-wave Doppler as well as color flow Doppler can be performed from either of these views. In addition, turning to the right (clockwise) allows imaging of the right lobar PA (in the LAX view) and the main pulmonary artery bifurcation, as well as the superior vena cava (in the SAX view).
The ME RV inflow-outflow view (view #11) allows visualization of two of the leaflets (typically the left or right and anterior) and is a useful screen for leaflet mobility, thickness, and regurgitation with 2D and color Doppler imaging. This view is frequently limited by acoustic noise from the AV or aortic prosthesis, which is immediately posterior to the PV. Advancing the probe and placing the RVOT perpendicular to the insonation beam enhances imaging for measurement of RVOT diameter (Figure 11A).
When imaging the PV in three dimensions, the transesophageal echocardiographic probe can be positioned at either the UE aortic arch SAX view (view #28) position at 70° to 90° or by obtaining a three-chamber LV–aortic root view at ~120° and then turning the probe to the left (counterclockwise) to bring the PV into view (Table 11). Typically, acquisition is difficult because there is signal dropout from the thin leaflets.
Once the valve is optimally visualized, the PV can be acquired using single-beat, narrow-angle acquisition mode for rapid assessment. The narrow-angle, multiple-beat mode allows visualization of the PV leaflets. The image set can be cropped and rotated to display the valve in an en face view from either the PA or the right ventricle. When displayed in this en face view, the anterior leaflet should be located superiorly in the 12 o’clock position irrespective of perspective.
The wide-angle acquisition mode of the PV also permits examination of the main PA and the RVOT. Once the pyramidal volume is captured, cropped and rotated, the en face view of the valve can be displayed. As well, the cropping plane can be used to assess the dimensions of the main PA and the RVOT.98 Last, the cropping plane can be used to show the RVOT, PV, and main PA in a single image.
In patients with pulmonary regurgitation or stenosis, color flow Doppler should be added to the narrow-angle, multiple-beat acquisition. The size of the region of interest should be limited to the PV and the color flow Doppler jet to optimize frame rate. As mentioned previously, the largest number of individually gated component slabs should always be attempted when electrocardiographic gating and brief acquisition times are possible. Once acquired, the pyramidal volume can first be viewed as originally obtained and then rotated to view the PV from the PA and right ventricle to identify the site of jet origin. Further cropping and the use of the black-and-white suppress can be used to identify effective orifice area, regurgitant orifice area, 3D proximal isovelocity surface areas, and vena contracta.
The TV is the largest and most apically positioned valve. The TV complex is composed of three leaflets (anterior, posterior, and septal), attached chordae tendineae, three papillary muscles (anterior, posterior, and a third variable papillary muscle), and the fibrous TV annulus.108 Tricuspid leaflets are significantly different in circumferential (annular) and radial size. The relative circumferential or annular ratio of the anterior to septal to posterior leaflets in normal patients is 1:1:0.75.101,109 The anterior leaflet is the longest radial leaflet, and the septal leaflet is the shortest. This short septal leaflet is attached to the tricuspid annulus directly above the interventricular septum, with a number of third-order chordae attached directly to the septum. The tricuspid annulus is complex and dynamic. Three-dimensional echocardiography has been integral in our understanding of TV anatomy.110,111 A normal annulus is triangular with nonplanar high and low points, superiorly displaced in the anterior/posterior portion and inferiorly (apically) displaced in the posteroseptal portion.100
Typically the first image of the TV is obtained from the ME four-chamber view (view #2). From this view, the septal and anterior leaflets are typically imaged. Turning the probe to the right (clockwise) to bring the TV annulus to the center of the sector allows imaging of multiple planes of the TV during axial rotation. The TV plane is frequently not coaxial with the transesophageal echocardiographic imaging plane, however, making an assessment of all the leaflets difficult; 3D imaging may be helpful (see below). Because the septal leaflet has the shorter radial length and is most often fixed by the rigid tricuspid annulus, regurgitant jets frequently are directed toward the interatrial septum. The ME inflow-outflow view (view #11) as well as the ME modified bicaval TV view (view #12) thus may be the most useful for color flow Doppler and spectral Doppler, because the septal leaflet is seen en face, and tricuspid regurgitant jets imaged in this plane may be directed toward the interatrial septum and thus well aligned with the insonation beam.
The TG basal RV view (view #19), TG RV inflow-outflow view (view #20), and TG RV inflow view (view #23) are additional TG views that may be useful when imaging the TV. From these views, the posterior leaflet of the TV is typically seen (in the near field). Color Doppler of the valve in the SAX view (TG basal RV view) may give a better assessment of the shape of the vena contracta for complex TR jets (Figure 12). Nonstandard deep TG views may also be performed to obtain the deep TG LAX views of the TV (0°); maximal anteflexion possibly with some right flexion results in the TV annular plane aligning perpendicular to the insonation beam (with TR jet parallel to the insonation beam).
Three-dimensional TEE of the TV allows visualization of all aspects of the TV from a single full-volume data set or a focused examination on a particular TV aspect using a narrower imaging acquisition mode with higher resolution. Acquisition is from a 0° to a 30° view, with the TV centered in the image (Table 11).
Once the TV image is optimized with 2D echocardiography, a narrow-angle single-beat acquisition can be performed. When displaying the TV en face, the septal leaflet should be located in the 6 o’clock position, irrespective of perspective. These en face views may be especially helpful in localizing leaflet disease such as leaflet prolapse, perforation, or vegetation, as well as localizing the origin of regurgitation jets, or performing planimetry of the tricuspid regurgitant orifice area to assess the severity of tricuspid stenosis. In addition to standard views, the cropping plane can be adjusted to visualize a particular section of the TV.
Wide-angle acquisition mode allows visualization of the tricuspid apparatus from the annulus to the papillary muscle tips. Enlarging the region of interest excessively will result in a further detrimental decrease of temporal resolution. This can be ameliorated using multiple-beat mode, which increases spatial resolution, permitting detailed diagnosis of complex pathologies (Figure 13) with high temporal resolution (>30 Hz), which is desirable when diagnosing mechanisms of abnormal tricuspid leaflet motion.
Color flow Doppler should be added to the multiple-beat acquisition in patients with tricuspid regurgitation and/or stenosis. Similar to the technique for acquiring noncolor Doppler multiple-beat imaging, obtaining a 3D color flow Doppler data set initially requires the identification of a region of interest in the orthogonal planes. The size of the region of interest should be limited to the tricuspid apparatus and color flow Doppler jet to optimize frame rate. In addition, although a high line density may be desirable, a lower line density will permit a larger sector to be displayed. Finally, the largest number of individually gated component subvolumes (4-6 beats) should always be attempted when electrocardiographic gating and reasonable acquisition times can be achieved.
Assessment of ventricular function is most commonly performed by TTE. However, there are some situations in which TEE may be used to assess ventricular function.32,112 Three-dimensional and simultaneous multiplane imaging has enabled the application of a variety of qualitative and quantitative techniques for the assessment of LV and RV function.113 Higher frequency transesophageal echocardiographic transducers, however, have restrictions such as reduced penetration and increased attenuation, resulting in limited far-field image resolution from ME views and a reliance on TG views for accurate wall motion assessment in large hearts. Hemodynamic alterations (i.e., due to anesthetic agents) may affect ventricular function and should be considered when assessing global function.
The normal LV is composed of an inlet portion containing the MV apparatus, an apical portion with characteristic muscle bundles, and an outlet portion proximal to the AV.114 The normal LV is shaped like a prolate ellipse, and thus geometric models are used to estimate the ventricular volume using linear measurements. Studies have suggested that measurements from TTE are nearly identical to those from TEE,98,115,116 but standard imaging planes for measurements have yet to be determined. Studies directly comparing TEE with TTE measurements used the TG mid-LV SAX view (view #17), its orthogonal TG LV two-chamber view (view #22), or the TG LV LAX view (view #24). Diameter measurements should be made perpendicular to the long axis of the left ventricle, so the LAX or two-chamber view is the recommended view for obtaining these measurements. If the SAX view is used, use of simultaneous multiplane imaging helps ensure an on-axis measurement, perpendicular to the long axis of the left ventricle (Figure 14). Normative values for TEE have not been published. The location of measurement differs slightly (closer to the mid left ventricle for TEE and closer to the MV leaflet tips for TTE), and this may account for differences. The use of ME views for linear measurements is feasible but discouraged given lateral gain resolution issues with the endocardial surface, which is parallel to the insonation beam from these views. The ME view can be used for the biplane Simpson’s method of disks for the calculation of LV volume and ejection fraction when the entire length of the left ventricle can be imaged without foreshortening however this method has limited validation.
The normal RV is similarly composed of an inlet portion containing the TV apparatus, an apical portion with characteristic muscle bundles, and an outlet portion proximal to the PV. The shape of the RV, however, differs significantly. The three portions do not lie in one plane, and the apical and outflow portions of the ventricle wrap around the LV. The shape of the RV cannot be distilled into a simple geometric shape, and thus volumes cannot be accurately derived from linear measurements.
Assessment of ventricular function can be performed via the gastric and esophageal views. In the TG views, SAX projections can be obtained at the basal, midpapillary, and apical levels (views #16–18).113 Orthogonal views can be obtained either at the midgastric (view #24) or deep gastric (apical) levels. The ME level (views #1–5) provides views that are analogous to TTE views; the four-chamber (0°–10°), two-chamber (80°–100°), and apical LAX (120°–140°) views113 as well as the five-chamber (0°-10°) and mitral commissural (50°-70°) views. The sum of these views provides excellent and comprehensive coverage of the LV endocardial motion for all segments, as previously described,79 allowing assessment of regional wall motion abnormalities, although the apex is frequently poorly visualized because of foreshortening.
Optimizing 2D images helps improve the accuracy and reliability of ventricular function assessment. This includes adjusting the depth to include the entire ventricle, manipulating the anteflexion and retroflexion of the probe tip to avoid foreshortening the ventricle, optimizing gain to best depict the endocardium, and either placing the focal zone midway between the ventricular base and apex or using dual focal zones to better define the apical region. If necessary, use contrast to better delineate the endocardial border. The entire left ventricle cannot always be imaged from ME view, because of variation in its orientation in relation to the esophagus.
An initial qualitative analysis is followed by a more detailed quantitative assessment if needed. Qualitative assessment of global function is performed by visually estimating the ejection fraction after reviewing multiple orthogonal views. Although quantitative assessment is possible, the limited imaging planes and lack of normative data for TEE limit the use of standard M-mode, B-mode, and Doppler-based methods used in TTE.
The ventricular apex can be foreshortened unless care is taken to avoid this issue. If unnoticed or unaddressed, apical foreshortening can result in underestimation of ventricular volumes. Because Doppler beam alignment can be challenging, particularly of the AV, Doppler-based ventricular function indices may not be as accurate with TEE.
In many patients TEE avoids the physical contributors to poor transthoracic echocardiographic images, such as soft tissue and intervening lung. In addition, the close proximity of the probe to the heart permits use of higher transducer frequencies and thereby higher resolution images but at the cost of far field attenuation. Although overall, endocardial definition should be better with TEE, on occasion image quality may be limited. In such cases, contrast agents can improve border definition. Contrast administration also is able to augment Doppler signals. Last, agitated saline contrast via a peripheral venous access is used to rule out atrial shunts.
Although evaluation of diastolic function is accurately and efficiently performed by TTE, in technically difficult situations or when TEE is being done for other purposes, TEE can be used to evaluate diastolic parameters.117,118 TEE can be used to obtain mitral inflow velocities, pulmonary vein velocities, and tissue Doppler velocity. Among these, access to all four pulmonary veins and an optimal orientation of the Doppler beam is a particular advantage of TEE. Mitral inflow and annular tissue Doppler velocities are equally well assessed by TTE or TEE, unless the former images are poor quality or transducer positions inaccessible. A recent study of patients undergoing coronary artery bypass graft surgery evaluated a simplified TEE algorithm for assessing diastolic dysfunction, using only the lateral mitral annular é velocity (abnormal < 10 cm/s) and transmitral E to é ratio (normal ≤ 8). LV diastolic dysfunction using this algorithm was predictive of long-term major adverse cardiac events.119
Evaluation of the RV is easily performed by TTE, but poor image quality or limited access of the transducer to the chest wall may require TEE. Also, when TEE is being performed for other reasons, it may provide high-resolution and superior quality images of the RV compared with TTE. During the evaluation of a critically ill patient, assessment of RV size and function may offer insights into the presence or physiologic consequences of pathology, such as RV infarction, pulmonary embolus, loculated pericardial effusion, and extracardiac pathology such as masses that may be impinging on the right ventricle. Although RV size on TEE is often assessed visually and considered normal if less than two thirds the diameter of the LV, the guidelines are published with TTE reference values for size and function.117 RV assessment by TEE is usually performed in the ME four-chamber view or in the TG views. LAX (views #20 and #23) and SAX (views #16-19) views of the right ventricle are available from these projections. To date, there are inadequate data to make specific recommendations for values for RV size and function by TEE.
Single-beat and real-time 3D acquisition allow the potential use of 3D imaging in routine clinical practice. At the present time, it is feasible to obtain “full-volume” data sets of the left or right ventricle. Offline analysis of the full 3D volume allows the operator to delineate the endocardial border without making any geometric assumptions. Thus, when the entire ventricle can be imaged in the 3D volume, accurate and reliable measurements of end-diastolic and end-systolic volumes can be made and lend themselves to calculation of volume-based function indices such as stroke volume and ejection fraction (Figure 14C).
LA and LA appendage imaging has become an increasingly important role for TEE. The most common reason for TEE is cardiac source of embolus, and the LA appendage is a primary target for this evaluation.8,120 The sensitivity and specificity of TEE to diagnose thrombus in the LA appendage are 100% and 99%, respectively,121,122 but because of the complex nature of this structure, small (<2 mm) thrombi can be missed.123 AUC support the use of TEE for the evaluation of cardiac source of embolus or to facilitate clinical decision making in patients with atrial fibrillation or atrial flutter.21 Exclusion of the LA appendage has been shown to reduce stroke risk in some patient populations,125,126 and transcatheter LA appendage closure devices have sparked interest in characterizing the highly variable LA appendage anatomy by TEE.123,128–130 The LA appendage orifice is typically oval shaped, and the body of the LA appendage is highly variable length and shape (Figures 1–3).131,132 Because the LA appendage is actively contractile and is trabeculated with pectinate muscles, its size and position vary with the cardiac cycle, making it particularly difficult to image with static imaging planes. Both the shape and function of the LA appendage also vary with a number of factors, including age, hypertension, diabetes, and the duration of atrial fibrillation.132,133 Autopsy studies have shown that the LA appendage can vary from having one to as many as five lobes.134
The left atrium is a boxlike chamber that lies posterior at the base of the heart. On the septal surface, there is a shallow depression that corresponds to the right atrial fossa ovalis. The venous portion of the chamber receives the openings of the four pulmonary veins posteriorly, with the left veins typically more superior than the right veins. The vestibule of the left atrium surrounds the MV.135 The LA appendage or auricle is a blind-ending structure with the orifice or os typically located superiorly and laterally. The normal diameter of the os ranges from 10 to 24 mm.131 The ridge between the os of the LA appendage and the left superior pulmonary vein is a triangular fold of serous pericardium and has been variously referred to as the Q-Tip sign the posterolateral ridge, the warfarin ridge, and the ligament (or fold) of Marshall.
The walls of the left atrium are muscular, but thickness may vary. Autopsy studies have shown areas of deficient myocardium resulting in markedly thinned regions (1 ± 0.5 mm) typically occurring along the anterolateral or lateral LA wall within the vestibule leading to the mitral annulus as well as distal to the LA appendage orifice. In addition, small pits and troughs can be seen around the orifice; each of these is thin walled, which may have implications for percutaneous devices.127 Abnormal increases in thickness may be a result of laminar, mural thrombus or endocarditis. Dystrophic mitral annular calcification may extend onto the wall of the left atrium, also increasing the wall thickness.
MV imaging planes will necessarily image the left atrium. Because the left atrium is a near-field structure during TEE, the entire structure is difficult to see from a single imaging plane, making quantitative measures of LA volume difficult. LA area or volume by TEE underestimates the area and volume by TTE.136 The linear measurement of the left atrium that has best correlated with transthoracic echocardiographic anteroposterior (parasternal LAX) measurements is taken from the ME AV LAX view (view #6) or the ME AV SAX view (view #10), measuring from the apex of the sector (i.e., the posterior wall of the left atrium) to the posterior aortic root,116,136 but normative data are limited. LA width (septolateral) in the ME four-chamber view has the highest correlation with equivalent transthoracic echocardiographic views,136 but normative data for this measurement are not available.
The orifice of the LA appendage, however, is a lateral cardiac structure and is frequently imaged initially in the 0° four-chamber plane. To image 180° of the LA appendage, however, this orifice should be centered in the imaging plane, typically by turning the probe to the left (counterclockwise) and ante flexing to bring the LA appendage to the center of the imaging plane. Not infrequently, the ligament of Marshall causes a reverberation artifact that can be confused with thrombus. In this situation, a better position for imaging the LA appendage requires a deeper probe position in which the ridge is no longer between the cavity of the LA appendage and the probe. Organized thrombus is defined echocardiographically as a well-circumscribed, highly reflective mass with different texture from the atrial wall and uniform consistency.27 Spontaneous echocardiographic contrast, on the other hand, will not be well circumscribed or have uniform consistency. Its location may be dynamic with a “smokelike” appearance due to its slow motion.137 There are some thrombi, however, that do not appear well circumscribed but have spontaneous echocardiographic contrast surrounding an organized portion; in these instances, prolonged observation in a single plane or using simultaneous multiple-plane imaging may be required to differentiate sludge from thrombus.
Doppler of the LA appendage can be performed, particularly in the setting of atrial fibrillation or atrial flutter, to assess the risk for thrombus formation, because flow velocity at the ostium has significant prognostic utility.138 The pulsed Doppler sample volume is typically placed 1 to 2 cm from the orifice within the chamber (Figures 15A and 15B). LA appendage emptying velocities of <20 cm/sec were associated with spontaneous echocardiographic contrast, thrombus formation, and embolic events. LA appendage emptying velocities >40 cm/sec predict a greater likelihood of sustained normal sinus rhythm after cardioversion from atrial fibrillation.139
The left pulmonary veins are imaged from the ME LA appendage and left upper pulmonary vein view (view #16). Right pulmonary veins are imaged from the ME right pulmonary vein view (view #9) at 0° or turning right (clockwise) from the ME bicaval view (view #13) at 90°. Doppler evaluation of the pulmonary vein flow can also be assessed by TEE in select situations (Figures 15C and 15D). Although the presence of pulmonary vein stenosis (either congenital or acquired) is more frequently and accurately diagnosed with computed tomography and magnetic resonance imaging, continuous-wave Doppler of the veins during TEE adds to the assessment of severity.140,141 Reversal of systolic pulmonary vein flow has a high specificity for severe mitral regurgitation when the mitral regurgitant jet is not directed into the vein imaged.69
Understanding right atrial anatomy has become increasingly important for transcatheter interventions as TEE is increasingly used to aid in transseptal punctures and catheter ablation techniques.
The right atrium is the receiving chamber for blood from the superior and inferior vena cavae and the coronary sinus. The right atrial side of the interatrial septum is demarcated by the limbus of the fossa ovalis. This semicircular structure is the edge of the secundum septum. The shallow depression of the thin fossa ovalis (the foramen ovale in the fetus) overlaps this edge. Within weeks of delivery, closure of the foramen ovale eliminates the communication between the left and right atria. However, when this closure is incomplete, a PFO results. Autopsy studies suggest that the incidence of PFO is about 27%, but this is inversely dependent on age.145 Although there may be a separation of the primum septum flap and the secundum septum limbus resulting in left-to-right flow under resting conditions, the in vivo diagnosis often is made by injecting agitated saline contrast (see below), with or without maneuvers that increase the right atrial pressure (i.e., release of the Valsalva maneuver).
A higher prevalence of shunting has long been associated with atrial septal aneurysms.146-149 There is no consensus on the definition of an atrial septal aneurysm, which has variously been defined as diameter of the base of the flimsy portion of interatrial septum ≥ 15 mm and excursion of the aneurysmal membrane ≥11 mm in either the left or right atrium, or if the sum of the total excursion is ≥11 mm147; a protrusion of the aneurysm >10 mm beyond the plane of the atrial septum into either the right or left atrium150; a dilated portion of the interatrial septum protruding ≥15 mm beyond the plane of the interatrial septum or when the atrial septum shows phasic excursions during the cardiorespiratory cycle ≥15 mm with the base of the aneurysm ≥15 mm151; and a thin localized outpouching of the middle portion of the atrial septum, but not the entire septum, protruding >6 mm outside the plane of the atrial septum.148
The Eustachian valve is a fibrous or fibromuscular flap of tissue that guards the entrance of the inferior vena cava. It is typically concave and directed superiorly, extending between the fossa ovalis and the ostium of the coronary sinus along the Eustachian ridge. In utero, this structure directed blood flow from the inferior vena cava across the foramen ovale. In the setting of a PFO, a prominent Eustachian valve may perform the same function. In 1% to 4% of the population, a reticulated network or fibers or thin membrane called a Chiari network may be seen. The Chiari network is a remnant of the right sinus venosus valve.152 Although thought to be benign, studies have shown a much higher prevalence of atrial septal aneurysms as well as PFO.153,154 The PFOs associated with this congenital anomaly are more likely to exhibit pronounced right-to-left shunting.
The crista terminalis is a C-shaped structure that separates the smooth-walled venous inflow of the right atrium from the pectinated right atrial appendage. This structure can vary considerably in thickness and depth.
The coronary sinus opens into the right atrium between the inferior vena cava and the TV. In the majority of patients, the orifice is guarded by the valve of the coronary sinus (or valve of Thebesius), and this valve can be variable in size.
This venous structure runs in the retroperitoneal space, to the right of the vertebral body, and enters directly into the right atrium from the abdominal cavity. The hepatic vein is the last tributary to the inferior vena cava. Both venous structures may be important to image or Doppler for hemodynamic assessment of right atrial pressures, severity of tricuspid regurgitation and abnormal RV filling patterns.
This venous structure resides in the anterior right superior mediastinum and is the confluence of the right and left brachiocephalic (or innominate) veins. Imaging and Doppler of the superior vena cava may also be important for hemodynamic assessment of right atrial pressures, but because it courses through the thoracic cavity, flow and pressures may be influenced by intrathoracic pressures.
Imaging of the TV will result in imaging of the majority of the right atrium, but focused imaging of the interatrial septum is required to assess intracardiac shunts. In addition, focused imaging of the coronary sinus is important intraoperatively when coronary sinus cannulation is required. The ME four-chamber view (view #2) images the midanterior interatrial septum and the primum portion of the interatrial septum. Deeper esophageal views (at 0°) allow imaging of the coronary sinus, which is an inferior and posterior structure (Figure 16A). The coronary sinus can be also be imaged in the SAX view in the ME two-chamber view (view #4) at 90°, but turning the probe to the left (counterclockwise) from this view will frequently allow LAX imaging of the coronary sinus (Figure 16B). Occasionally, the coronary sinus can be imaged from the ME bicaval view (view #13) with slight advancement and clockwise turning of the probe.
The ME bicaval view (view #13) is also obtained at 90° with a clockwise turning of the probe to focus on right heart structures. In this view, the superior vena cava, inferior vena cava, crista terminalis, and right atrial appendage are well defined (Figure 17A). From this view, the fossa ovalis is well imaged as well as the “flap” of a PFO.154 Withdrawing the probe will allow more complete imaging of the superior vena cava and the caval-septal wall. The right superior pulmonary vein is adjacent to the superior vena cava, and clockwise turning will allow imaging of this structure as well as the right inferior pulmonary vein. Anomalous right pulmonary venous return into the superior vena cava is typically imaged from these views.
Inserting the probe to a deeper bicaval view (still at 90°) is helpful to assess the inferior vena cava, Eustachian valve, and the inferior caval-septal wall. Further insertion may allow imaging of the inferior vena cava within the liver as well as imaging of the hepatic veins (Figures 17B and 17C).
Provocative maneuvers to increase both filling and pressure within the right atrium have been shown to increase the sensitivity of this test. Coughing or releasing a sustained Valsalva maneuver is most effective, but abdominal compression has been used in the setting of conscious sedation during TEE.157 Failure of the interatrial septum to move toward the left atrium even when the right atrium is well opacified with agitated saline should be considered an indeterminate bubble study. Repeat attempts at the end of the examination when the patient may be awakening and capable of performing a cough or a Valsalva maneuver can be considered.
In adults with known or suspected ACHD, TEE is performed for diagnosis, indications, guidance of cardiac intervention, and to assess the results of interventions. Because of the limited flexibility in imaging and Doppler windows, TEE in ACHD is most useful in clinical circumstances in which comprehensive TTE was not definitive or could not be performed. TTE should be the initial test for evaluating suspected or known ACHD. TEE should be performed and interpreted by physicians with experience and/or training in ACHD to maximize the clinical utility of results obtained.
Equally important is the process of care of patients with ACHD undergoing TEE. Younger patients with ACHD and/or those with extensive cardiac interventions may have higher sedation requirements than those with acquired heart disease. If high sedation requirement is anticipated or there is a history of difficulty achieving adequate sedation during prior procedures, it would be prudent to ask for support from anesthesia and perform TEE in a setting with more intensive monitoring (such as a postanesthetic recovery room or critical care unit). The importance of achieving satisfactory sedation cannot be overstated in the ACHD population, as evaluation of primary and associated congenital abnormalities will often prolong the study.
The diagnostic utility of TEE is most apparent in circumstances in which the results of TTE are nondiagnostic or equivocal and the site of suspected pathology is better visualized by TEE than by TTE, including interatrial shunts, pulmonary venous drainage, aortic dissection, abscesses or vegetations, intracardiac thrombus, intracardiac baffles, and prosthetic valves. Although 3D TEE is now available and has been shown to be feasible,162 the evidence for superior diagnostic utility of TEE was compiled from studies examining the use of monoplane, biplane, or multiplane transesophageal transducers.163-168 In the catheterization laboratory and in the operating room, TEE has become standard of care because it can guide the intervention and/or provide assessment of its results in real time (Figure 19).169,170 The environment and time constraints associated with performing TEE in the catheterization or operating room often preclude a detailed comprehensive study. Ideally intraprocedural TEE should be preceded by comprehensive preoperative TTE or TEE.
When state-of-the-art cardiac magnetic resonance scanners and physicians with expertise in cardiac magnetic resonance are available, CMR is a complementary or alternative imaging modality to TEE in patients with ACHD. Although TEE is more feasible in the operating room, catheterization laboratory, or emergency department, in the ambulatory or non–critical care setting, cardiac magnetic resonance may be used in place of or complementary to TEE in patients with intracardiac or extracardiac baffles or conduits (such as the Fontan, Senning/Mustard, or Rastelli operation).167,171 TEE is more useful than TTE to assess these complex surgically created pathways but may not be able to visualize the entire length of the pathway.167,168 If the clinical indication includes quantitation of RV volumes, regurgitant fraction, shunt flow (i.e., repaired tetralogy of Fallot), collateral flow (coarctation or pulmonary atresia), aortic size (coarctation or ascending aorta in bicuspid AV), cardiac magnetic resonance is likely the best choice for the next test after TTE. In the catheterization laboratory, intracardiac echocardiography is used at some centers as an alternative to TEE.172 Because the parameters required to guide intraprocedural interventions can be variable and beyond the scope of this article, operators should work with their interventional and/or surgical colleagues to ensure that the requisite information has been collected during TEE. Table 12 presents the recommended imaging views in selected ACHD diagnostic scenarios.
This document presents the 28 views in a comprehensive TEE examination. A suggested protocol of image acquisition is provided, with the caveat that anatomic variability may require unconventional imaging planes be used. Although the performance of a comprehensive TEE examination is recommended whenever possible, individual patient characteristics, anatomic variations, pathologic features, or time constraints imposed may limit the ability to perform all aspects of the examination described in this document. The “Specific Structural Imaging” section of this document includes additional views that can be obtained. The document is not intended to review specific indications for TEE or cover extensively abnormalities seen with this modality.
This report contains recommendations only and should not be used as the sole basis to make medical practice decisions or for disciplinary action against any employee. The statements and recommendations contained in this report are based primarily on the opinions of experts rather than on scientifically verified data. The ASE makes no express or implied warranties regarding the completeness or accuracy of the information in these reports, including the warranty of merchantability or fitness for a particular purpose. In no event shall the ASE be liable to you, your patients, or any other third parties for any decision made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of medical advice by the ASE or create any physician-patient relationship between the ASE and your patients or anyone else.
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