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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5189_Библиотеки_им_академика_М_И_Перельмана.pdf
106
Image/video 17. TG apical SAX view.
Image/video 18. TG 2C view.
Transgastric apical short
Axis (TG apical SAX) 0°
Slight probe insertion, or
retroexion, from the TG
mid SAX allows for
assessment of the LV
apical segments (Image/
Video 9.17) [1, 3]
Transgastric two
chamber (TG 2C)
80–100°
From the TG mid SAX,
increase the omniplane to
90°. This places the
anterior LV wall at image
bottom (far eld) and the
LV inferior wall at image
top (near eld). The MV
apparatus is also visualized
(Image/Video 9.18) [1, 3]
M. Hamlin and A. Bensimhon
Image/Video 9.17 TG apical SAX view
Image/Video 9.18 TG 2C view
(continued)
Image/video 19. TG LAX view.
Image/video 20. Descending aorta SAX view.
9 Transesophageal Windows andViews
Transgastric long Axis
(TG LAX) 120–140°
From the TG 2C,
increasing the omniplane
angle to 120–140°, with or
without slight rightward
rotation, will obtain the TG
LAX view. For patients
with a difcult to obtain
DTG 5C, the TG LAX
may align the AV and
LVOT appropriately for
Doppler interrogation
(Image/Video 9.19) [1, 3]
Image/Video 9.19 TG LAX view
Descending aortic short
Axis 0°
With the probe in the TG
position at 0°, rotate
leftward until the
descending aorta appears
in short axis at the imaging
vector apex. Decrease the
image depth and utilize
biplane imaging to best
interrogate the descending
aorta. The descending
aorta can be followed
retrograde in a cephalad
movement, from TG to ME
and UE probe positions, to
the distal portion of the
aortic arch (Image/Video
9.20) [1, 3]
107
Image/Video 9.20 Descending aorta SAX view
(continued)
108
Image/video 21. Descending Aorta LAX view.
Image/video 22. UE aortic arch LAX view.
Descending aortic long
Axis 90°
After localizing the
descending aorta in short
axis, rotate the omniplane
to 90° to view the aorta in
long axis. Proximal aorta
will be on screen right and
distal aorta will be on
screen left. Alternatively,
utilize biplane imaging to
simultaneously view the
descending aorta in both
short and long axes
(Image/Video 9.21) [1, 3]
Upper esophageal aortic
arch long Axis 0°
As the descending aorta is
viewed in short axis from
the TG to UE probe
positions, the aorta will
change from a circular
descending aorta to an
elliptical aortic arch. The
left subclavian, left
common carotid, and
innominate arteries may be
visualized with rightward
probe rotation and
increased omniplane
toward 90°. Part of the
aortic arch will likely be
obscured by the left main
bronchus as it passes
between the esophagus and
aorta (Image/Video 9.22)
[1, 3]
M. Hamlin and A. Bensimhon
Image/Video 9.21 Descending aorta LAX view
Image/Video 9.22 UE aortic arch LAX view
(continued)
Image/video 23. UE aortic arch SAX view.
Image/video 24. ME ascending aorta SAX view.
9 Transesophageal Windows andViews
Upper esophageal aortic
arch short Axis 90°
From the upper esophageal
aortic arch short axis view,
increase the omniplane
angle to 90° to view the
aortic arch in short axis.
Alterations of probe depth
and omniplane angle will
bring the main pulmonary
artery and pulmonic valve
into view (Image/Video
9.23) [1, 3]
Image/Video 9.23 UE aortic arch SAX view
Mid-esophageal
ascending aorta short
Axis 0–20°
Beginning with the ME 5C
or ME AV SAX view,
adjust the omniplane angle
to 0–20° and withdraw the
probe slightly, visualizing
the ascending aorta and
SVC in short axis and
main pulmonary artery
(PA) in long axis. The right
PA is seen interposed
between the probe and
aorta. The left PA is
obscured by the left main
bronchus. This view can be
used to identify the
position of a PA catheter
tip during catheter
placement or identify a
proximal “saddle”
pulmonary embolism
(Image/Video 9.24) [1, 3]
Image/Video 9.24 ME ascending aorta SAX view
109
(continued)
110
Image/video 25. ME ascending aorta LAX view.
Image/video 26. 3D full volume.
Mid-esophageal
ascending aorta long axis
90–110°
This view is orthogonal to
the mid-esophageal
ascending aorta short axis
view and can be obtained
by increasing the
omniplane from that
position. Alternatively,
from the ME AV LAX
view, slight omniplane
decrease and probe
withdrawal will display the
PA in short axis again
interposed between the
probe and the ascending
aorta in long axis (Image/
Video 9.25) [1, 3]
3D transesophageal
imaging
While 2D imaging
acquires individual sector
scans to produce a planar
image, three- dimensional
(3D) imaging utilizes
pyramidal volume data sets
to display an image
capable of being
manipulated in the X, Y,
and Z axes. Usable 3D
images begin with a
quality 2D image as any
limitation within the 2D
sector will be present in
the 3D image.
M. Hamlin and A. Bensimhon
Image/Video 9.25 ME ascending aorta LAX view
Image/Video 9.26 3D full volume
(continued)
Image/video 27. 3D AV LAX.
Image/video 28. 3D MV surgeon’s view.
9 Transesophageal Windows andViews
3D image displays range
from multiplane to full
volume modes, with the
acquired volume size
altered based on the
structure(s) to be imaged.
Image acquisition can be
in real time or over
multiple beats, the latter of
which will allow for a
higher temporal resolution,
but also the introduction of
stitching artifact.
Image/Video 9.27 3D AV LAX
Quality 3D images can be
used for examining
chamber morphology and
calculating ventricular
volumes and ejection
fractions, assessing valve
structure and abnormal
ow patterns, and
visualizing structural heart
interventions including
transcatheter valve
therapies and left atrial
appendage occlusion
devices (Images/Videos
9.26, 9.27, and 9.28) [5, 6]
111
Image/Video 9.28 3D MV surgeon’s view
112
M. Hamlin and A. Bensimhon
Fig. 9.3 Diagram of MV segments potentially visualized within standard ME views. The actual segments viewed,
however, will vary with probe position and movements [1]
Summary Points
• The TEE exam consists of images obtained in
the UE, ME, TG, and DTG esophageal
positions
• Imaging sequence will be determined by clinical situation and institutional protocols
• Cardiac structure and function can be evaluated with 2D and 3D images, in combination
with color ow and spectral Doppler, enabling
diagnosis of pathology and guidance of cardiac interventions
Questions
1. Transesophageal echocardiography utilizes
which structure as the acoustic window for
mid-esophageal views?
A. Right atrium
B. Right ventricle
C. Left atrium
D. Left ventricle
Answer: Transesophageal echocardiography uti-
lizes the left atrium as the acoustic window in
mid-esophageal views.
9 Transesophageal Windows andViews
113
2. Which image contains myocardium perfused
by the left anterior descending, circumex,
and right coronary arteries?
A. Mid-esophageal four chamber
B. Deep transgastric
C. Transgastric long axis
D. Transgastric mid-papillary short axis
Answer: The transgastric mid-papillary short
axis view allows simultaneous imaging of left
ventricular myocardium perfused by the left
anterior descending, circumex, and right
coronary arteries.
3. At 120° which mitral valve scallops are most
likely visualized?
A. P1, P2, P3
B. A2, P2
C. P1, A2, P3
D. A2, A1, P1
Answer: The mitral valve scallops most likely
visualized around 120° are A2, P2, selection
b. P1, P2, and P3 scallops may be visualized
in a posteriorly directed mid-esophageal two
chamber view. P1, A2, and P3 are seen in the
mid-esophageal mitral commissural view. A2/
A1, P1 are imaged in a mid-esophageal ve/
four chamber view.
References
1. Hahn RT, Abraham T, Adams MS, etal. Guidelines
for performing a comprehensive transesophageal
echocardiographic examination: recommendations
from the American Society of Echocardiography and
the Society of Cardiovascular Anesthesiologists. J Am
Soc Echocardiogr. 2013;26:921–64.
2. Puchalski MD, Lui GK, Miller-Hance WC, et al.
Guidelines for performing a comprehensive transesophageal echocardiographic: examination in
children and all patients with congenital heart disease: recommendations from the American Society
of Echocardiography. J Am Soc Echocardiogr.
2019;32:173–215.
3. Vegas A. Perioperative two-dimensional
transesophageal echocardiography: a practical handbook. Springer; 2018. https://doi.
org/10.1007/978- 3- 319- 60902- 7.
4. Virtual TEE: Standard views, transesophageal echocardiography, cardiac, education, interactive guide.
http://pie.med.utoronto.ca/tee/TEE_content/TEE_
guideSheet.html. Accessed 23 Dec 2021.
5. Vegas A, Meineri M, Jerath A. Real-time
three- dimensional transesophageal echocardiography. Springer; 2012. https://doi.
org/10.1007/978- 1- 4614- 0665- 5.
6. Lang RM, Badano LP, Tsang W, et al. EAE/ASE
recommendations for image acquisition and display
using three-dimensional echocardiography. Eur Heart
J Cardiovasc Imaging. 2012;13:1–46.
Artifacts andPitfalls
inTransesophageal
Echocardiography
MarcusBehrens andToniaTimperleyTauh
10
Ultrasound Assumptions
Ultrasound images are created by the return of
emitted ultrasound pulses that have interacted with
targeted structures. These returning signals are
then received by the probe and processed thereby
producing an image. Unfortunately, the machine is
limited by certain assumptions, listed below [1].
1. Ultrasound travels in straight lines
2. Ultrasound pulses are innitely thin
and pulses are extremely small
3. The depth of an object is directly
related to the travel time for an ultrasound pulse to return to the transducer;
speed=1540m/s
4. Echos originate only from objects
located on the main transducer axis
5. Echos return to the transducer after a
single reection
6. Pulses and echos are attenuated uniformly by all tissues
Artifacts, dened as “an ultrasound image that
does not correlate directly with the actual structure being visualized” [2], are produced when
these assumptions are violated. Spatial resolution
is the ability of the ultrasound system to detect
and display structures that are close together in
space. Spatial resolution is a combination of both
lateral and axial resolution. Conceptually, artifacts exist due to violation of the ultrasound
imaging assumptions occurring in either of these
planes [3]. Echocardiographic imaging artifacts
can be grouped into either the violation of ultrasound imaging assumptions, equipment malfunction, and nally interactions within an external
device (Table10.1).
M. Behrens (*)
Department of Anesthesiology and Pain Medicine,
University of Washington, Seattle, WA, USA
e-mail: mab221@uw.edu
T. T. Tauh
Department of Anesthesiology and Pain Medicine,
University of British Columbia,
Vancouver, BC, Canada
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_10
115
116
M. Behrens and T. T. Tauh
Table 10.1
description of why the artifact is created, and a clinical example of each artifact
Assumption Artifact Violations Example
Artifacts in the lateral direction
1. Ultrasound travels in a
straight line
2. Ultrasound pulses are
extremely small and pulses are
extremely thin
3. The depth of an object is
directly related to the travel
time for an ultrasound pulse to
return to the transducer;
speed=1540m/s
4. Echos originate only from the
main transducer axis
Artifacts in the axial direction
5. Echos return to the transducer
after a single reection
6. Pulses and echos are
attenuated uniformly by all
tissues
A list of the ultrasound assumptions, the corresponding artifacts linked to violations of the assumptions, a
Refraction Ultrasound travels in broken
Reection
Beam width Echos originate from objects
Refraction Different mediums conduct
Side lobe,
grating lobe
Reverberation,
mirror image
Shadowing,
enhancement
lines and is redirected in
different angles
located off the transducer axis
sound at various speeds,
echos return from alternative
angles which will result in
refracted images
Echos originate from objects
located off the transducer axis
Echos are reected multiple
times and will take longer
before it returns to echo
probe
Brightness of an object is
related to not only the
reective properties, but also
to the acoustic shadow and
enhancement of nearby
structures
Double aortic valve
Thickened or blurred valves
Pseudoaneurysm of aorta
Dissection ap ascending
aorta
Double barrel aorta
Areas of heavy calcication
and presence of external
device such as guidewire,
valve implant, and catheters
Fig. 10.1 Midesophageal ascending
aortic long axis with an
example of both mirror
image and reverberation
artifact. PA pulmonary
artery
Reverberation Artifact
The reverberation artifact violates the assumption
that the ultrasound beam returns to the transducer
after a single reection. This occurs when an
ultrasound beam encounters two strong parallel
reectors, for example, such as the pulmonary
artery and aorta interface, mimicking an intimal
ap (Fig.10.1).