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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5189_Библиотеки_им_академика_М_И_Перельмана.pdf
96
Pro-tip
M. Hamlin and A. Bensimhon
Small probe movements may yield larger
than expected image alterations.
Furthermore, while patients are similar,
they are not the same. As such, the described
omniplane angles are relative and may
need adjustment for each patient.
ab
Fig. 9.1 Schematic displaying probe manipulations and positions utilized in image acquisition [1]
9 Transesophageal Windows andViews
97
Fig. 9.2 Pictorial representation of probe movements used to shift between TEE views [4]
98
Image/video 1. ME 4C view.
Image/video 2. ME 5C view.
Mid-esophageal four
chamber (ME 4C) 0–20°
The probe is positioned in
the mid esophagus with an
omniplane angle of 0–20°,
behind the left atrium (LA)
and utilizing the LA as the
acoustic window. In a left
ventricular (LV) centered
view, the LA and LV are
aligned in the center of the
imaging plane.
Optimization will include
retroexion and omniplane
angle adjustment to
visualize the LV from base
to apex, attempting to
eliminate foreshortening.
Rightward probe rotation
will better align the right
atrium (RA) and right
ventricle (RV) with
imaging plane center for a
right heart centric view.
Visible structures include
the LA, LV (anterolateral
and inferoseptal walls),
MV (mitral valve—A3,
A2, P2, P1 scallops), RA,
RV, TV (tricuspid valve),
interatrial septum (IAS),
and interventricular septum
(IVS) (Image/Video 9.1)
[1, 3]
Mid-esophageal ve
chamber (ME 5C) 0–20°
From the ME 4C, slight
probe withdrawal will
bring the aortic valve (AV)
and left ventricular outow
tract (LVOT) into view.
Visible structures include
the LA, LV (anterolateral
and inferoseptal walls), AV,
MV (mitral valve—A2,
A1, P1 scallops), RA, RV,
TV, IAS, IVS (Image/
Video 9.2) [1, 3]
M. Hamlin and A. Bensimhon
Image/Video 9.1 ME 4C view
Image/Video 9.2 ME 5C view
(continued)
Image/video 3. ME MC view.
Image/video 4. ME 2C view.
9 Transesophageal Windows andViews
Mid-esophageal mitral
commissural (ME MC)
50–70°
From an appropriate
LV-centered ME 4C view,
increase the omniplane to
60°, visualizing the LA,
LV, and MV (P1, A2, P3
scallops from right to left).
Additionally, the
anterolateral and
posteromedial papillary
muscles and associated
chordae, as well as the
coronary sinus, may be
seen. Color ow Doppler
can assist with localization
of MV regurgitation
(Image/Video 9.3) [1, 3]
Image/Video 9.3 ME MC view
Mid-esophageal two
chamber (ME 2C)
80–100°
Increasing the omniplane
to 90° from either the ME
4C or ME MC views will
yield the ME 2C view.
This is an orthogonal view
to ME 4C and seen when
placing biplane imaging
through a LV-centered ME
4C image. In the ME 2C
plane, visible structures
include the LA, LA
appendage (LAA), LV
(anterior and inferior
walls), MV, and coronary
sinus. With regard to the
MV, the amount of
withdrawal/insertion and
probe rotation will
determine which scallops
are visualized. A more
anterior position may
capture A2, A3, and P3
while a more posterior
position may visualize P1,
P2, and P3, both from
screen right to left (Image/
Video 9.4) [1, 3]
Image/Video 9.4 ME 2C view
99
(continued)
100
Image/video 5. ME LAX view.
Image/video 6. ME LAA view.
Mid-esophageal long Axis
(ME LAX) 120–150°
From the ME 4C, ME MC,
or ME 2C views, increase
the omniplane to
120–150°, until the LVOT
and AV are seen in a long
axis orientation at screen
right, ensuring capture of
the full LV.The ME LAX
displays the LA, LV
(anteroseptal and
inferolateral walls), MV
(A2 and P2 scallops),
LVOT, AV, aortic root and
proximal ascending aorta,
IVS, and RV.See Fig.9.3
for further delineation of
mitral valve segments
(Image/Video 9.5) [1, 3]
Mid-esophageal left
atrial appendage (ME
LAA) 80–110°
Returning to the ME 2C
view at 90° and adding
slight probe withdrawal,
anteexion, and/or
rightward rotation, will
bring the LAA into view,
adjacent to the MV.The left
superior pulmonary vein
(LSPV) may be seen to the
right of the
LAA.Alternatively, from
the ME RV inow–outow
view, decrease the
omniplane to 50–70° and
rotate leftward with slight
withdrawal to image the
LAA to the right of the AV.
multiplane imaging, color
ow Doppler, and pulse
wave Doppler are used to
interrogate the
LAA.Alterations in the
omniplane angle may be
necessary to fully visualize
all LAA lobes (Image/Video
9.6) [1, 3]
M. Hamlin and A. Bensimhon
Image/Video 9.5 ME LAX view
Image/Video 9.6 ME LAA view
(continued)
Image/video 7. ME bicaval view.
Image/video 8. ME Modified bicaval view.
9 Transesophageal Windows andViews
Mid-esophageal Bicaval
80–100°
Centering on the IAS at 0°
and increasing the
omniplane to 80–100°, then
rotating the probe to the
right, will visualize the LA,
RA, right atrial appendage
(RAA), IAS, superior vena
cava (SVC), and inferior
vena cava (IVC). Depending
on probe alignment, the
coronary sinus (CS) may be
seen between the IVC and
IAS.Alternatively, the ME
bicaval view is obtained
when rotating the probe
rightward from the ME 2C
view. The IAS can be
evaluated for aneurysm and
perforation. A Eustachian
valve, crista terminalis, and/
or device wires/cannulas
may be seen. A further
increase in rightward probe
rotation or omniplane will
allow for imaging of the
right pulmonary veins
adjacent to the SVC (Image/
Video 9.7) [1, 3]
Mid-esophageal modied
Bicaval
Continuing to increase the
omniplane from the ME
Bicaval view to 110–140°
will align the TV inow
with the Doppler beam
(Image/Video 9.8) [3]
Image/Video 9.7 ME bicaval view
101
Image/Video 9.8 ME modied bicaval view
(continued)
102
Image/video 9. ME Left pulmonary vein view.
Image/video 10. ME Right pumonary vein view.
Mid-esophageal left
pulmonary veins 80–100°
From the ME LAA view,
slight probe withdrawal
and/or leftward rotation
will position the left
pulmonary vein (either the
LSPV or the left superior
and inferior pulmonary
vein conuence) to the
right of the
LAA.Alternatively,
rotating leftward from the
ME bicaval view will bring
the LAA and left
pulmonary veins into view
(Image/Video 9.9) [1, 3]
Mid-esophageal right
pulmonary veins 0° or
80–100°
From the ME 4C view,
slight probe withdrawal
and rightward rotation will
position the right
pulmonary veins in the left
upper portion of the
screen. Alternatively, from
the ME bicaval view,
rightward rotation and/or
an increase in omniplane
angle will place the right
superior pulmonary vein
on screen right, owing
into the LA (Image/Video
9.10) [1, 3]
M. Hamlin and A. Bensimhon
Image/Video 9.9 ME left pulmonary vein view
Image/Video 9.10 ME right pulmonary vein view
(continued)
Image/video 11. ME AV SAX view.
Image/video 12. ME AV LAX view.
9 Transesophageal Windows andViews
Mid-esophageal aortic
valve short-Axis (ME AV
SAX) 30–50°
Beginning at the ME 4C
view, withdraw the probe
slightly to bring the AV
into view. Then increase
the omniplane to about
40°, utilizing slight probe
rightward rotation and/or
anteexion may improve
the short axis alignment.
The right coronary cusp of
a trileaet valve will be
seen in the far eld. The
non-coronary cusp will be
adjacent to the IAS and the
left coronary cusp will be
on screen right.
Visualization of the left
main and right coronary
arteries is possible with
slight probe withdrawal
(Image/Video 9.11) [1, 3]
Mid-esophageal aortic
valve long-Axis (ME AV
LAX) 120–150°
This is the orthogonal view
to the ME AV SAX and is
obtained by increasing the
omniplane to 120–150°
from the ME AV SAX
view. Alternatively, from
the ME LAX, decreasing
the imaging depth and
slightly withdrawing the
probe and/or adding
rightward rotation centers
the aortic valve. Structures
imaged include: LVOT,
aortic valve annulus, right
(anterior) and either left
and/or non-coronary aortic
valve leaets, sinuses of
Valsalva, sinotubular
junction, and ascending
aorta. (Image/Video 9.12)
[1, 3]
Image/Video 9.11 ME AV SAX view
Image/Video 9.12 ME AV LAX view
103
(continued)
104
Image/video 13. ME RV inflow outflow view.
Image/video 14. DTG 5C view.
Mid-esophageal right
ventricular inow
outow 50–70°
Begin with a ME 4C view
and rotate rightward to
obtain an RV centric
image. Then, increase the
omniplane angle to 60°
thereby visualizing the LA,
RA, IAS, TV, RVOT, and
PV.On the left side of the
TV will be the posterior
leaet, while on the right
side of the TV will be
either the anterior or septal
leaet (Image/Video 9.13)
[1, 3]
Deep Transgastric ve
chamber/long Axis (DTG
5C) 0°
Advance the probe from
the ME 4C view, following
the LV, into the stomach
and to the DTG position.
Always yield to resistance
in order to avoid patient
injury. Once in the DTG
position, anteex, left ex,
rotate rightward, and
withdraw the probe to
center the aortic valve in
the screen while keeping
the LV apex at the top of
the imaging sector.
Alternatively, advance the
probe into the stomach,
rotate leftward, then
anteex and withdraw the
probe. Parallel alignment
between the LVOT/AV and
spectral Doppler allows for
less inaccurate calculations
than less parallel
measurements (Image/
Video 9.14) [1, 3]
M. Hamlin and A. Bensimhon
Image/Video 9.13 ME RV inow outow view
Image/Video 9.14 DTG 5C view
(continued)
Image/video 15. TG mid papillary SAX view.
Image/video 16. TG basilar SAX view.
9 Transesophageal Windows andViews
Transgastric midpapillary short Axis (TG
mid SAX) 0°
Insert the probe from the
ME 4C view or withdraw
the probe from the DTG
5C, both at 0–20° until the
imaging sector is at the
mid- papillary level. Slight
anteexion may enhance
contact with the LV and
improve image quality.
Biplane imaging assists in
recognizing a
foreshortened image. This
view enables simultaneous
visualization of LV wall
segments perfused by the
left anterior descending,
circumex, and right
coronary arteries (Image/
Video 9.15) [1, 3]
Image/Video 9.15 TG mid-papillary SAX view
Transgastric basilar
short Axis (TG basal
SAX) 0°
Slight probe withdrawal,
and/or anteexion, from
the TG mid SAX allows
for evaluation of the
basilar LV segments. Also
visualized is a short axis
view of the MV with the
anterior leaet on the left
and posterior leaet on the
right (Image/Video 9.16)
[1, 3]
105
Image/Video 9.16 TG basilar SAX view
(continued)