Trans-esophageal & Intra-cardiac Echocardiography
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Transcript of Trans-esophageal & Intra-cardiac Echocardiography
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TRANS-ESOPHAGEAL & INTRA-CARDIAC ECHOCARDIOGRAPHY
HIMAL RAJ
SR CARDIOLOGY
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HISTORY
Side and Gosling (1971) - TEE for CwD of cardiac
flow
Frazin et al (1976) - TEE M mode echo
Hisanaga et al (1977) - illustrated use of cross
sectional real time imaging
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INTRODUCTION
TEE uses sound waves to create high-quality moving
pictures of heart and its blood vessels
involves a flexible tube or probe with a transducer at its
tip
probe is guided down throat and esophagus
more detailed pictures of heart as esophagus is directly
behind heart
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TEE: TYPES
• Types of TEE :
1. 2-Dimensional (2D)
2. 3-Dimensional (3D)
• Standard TEE pictures
are 2D
• 3D pictures provide more
details about
• Structure and function of
heart and Its blood vessels
• 3D TEE helps to diagnose
heart problems like:
• Congenital heart disease
• Heart valve disease and
• To assist with heart surgery
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TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)
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TEE
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TEE: ADVANTAGES
Transducer - 2- 3 mm from heart
Closer to posterior structures - Better visualization
of LA, LAA, PV, MV, LV, Aorta
Far from surgical area - Intra-operative monitoring
High resolution images : [Absence of intervening lung
or bone tissue - Better signal to noise ratio and
decreased image depth – allows use of higher freq (5
and 7 MHz) transducers – enhances image quality]7
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TEE: DISADVANTAGES
• semi invasive procedure: chances of injury ;
• needs special setup, technique, preparation,
instrumentation
• needs orientation and expertise
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INDICATIONS -COMMON• Assessment of prosthetic valves; infective endocarditis ;
native valve disease
• Assessment of a suspected cardioembolic event
• Assessment of cardiac tumors
• Assessment of atrial septal abnormalities
• Assessment of aortic dissection, intramural hematomas
• Evaluation of CHD; CAD ;pericardial disease
• Evaluation of critically ill patients
• Intraoperative monitoring
• Monitoring during interventional procedures
• Stress echocardiography
• Nondiagnostic TTE
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CONTRAINDICATIONS
ABSOLUTE
Oesophageal stricture or obstruction
Suspected or known perforated viscus
Instability of cervical vertebrae
GI bleeding not evaluated
RELATIVE
Esophageal varices or diverticula
Cervical arthritis
Oropharyngeal distortion
Bleeding diathesis or over-anticoagulation 10
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PROCEDURE
4- 6 hours fasting
Written consent
Intravenous line ; oxygen ; suction equipment ;
Remove denture or devices ; 2% lidocaine spray
ECG must be monitored throughout
Left lateral position
Introduce the probe with some anteflexion through
a bite block11
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PROCEDURE
Routine antibiotic prophylaxis before TEE is not
advocated [ risk of IE is extremely
low].Recommended in high risk patients - prosthetic
valves, multivalvular involvement or those with a
past h/o IE]
Persistent resistance to advancing the instrument
mandates termination of TEE and endoscopy
should be performed before re-examination.
After each TEE - Disnfect ; Check for any damage -
ensure electrical safety12
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COMPLICATIONS
Majority are minor.
Major complications [death, laryngospasm,
sustained VT & CHF occur in ≈ 0.3% of patients]
Cardiac complications include SVT or AF, VT,
bradycardia, transient hypotension or hypertension,
angina ,CHF and pulmonary edema.
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COMPLICATIONS
MAJOR
Death
Esophageal rupture
Laryngospasm or bronchospasm
Congestive heart failure or pulmonary edema
Sustained ventricular tachycardia
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COMPLICATIONS
MINOR
Excessive retching or
vomiting
Sore throat
Hoarseness
Minor pharyngeal bleeding
Blood tinged sputum
Non sustained or sustained
supraventricular tachycardia
Atrial fibrillation
Nonsustained ventricular
tachycardia
Bradycardia or heart block
Transient hypotension
Transient hypertension
Angina
Transient hypoxia
Parotid swelling
Tracheal intubation15
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TEE PROBE
Modification of standard gastroscope, with
transducers in place of fibreoptics
Conventional rotary controls with inner and outer
dials
Inner dial guides anteflexion and retroflexion
Outer dial controls medial and lateral movement
Multiplane probe has a lever control to guide
rotation16
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TEE PROBE
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TEE TRANSDUCER
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TEE Transducer Relation of TEE transducer with heart
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TEE PROBE
Monoplane TEE - provides images in horizontal
plane only
Biplane TEE - orthogonal longitudinal plane also
Multiplane TEE transducer : single array of crystals [phased array transducers with 64
-256 piezoelectric elements]
that can be electronically and mechanically rotated in an
arc of 180 °
to produce a continuum of transverse and longitudinal
images from a single probe position 19
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STANDARD IMAGING PLANE LEVELS (FROM THE INCISORS)
upper or high esophageal (25–28 cm)
mid-esophageal (29–33 cm)
transgastric (38–42 cm)
deep-transgastric (>42 cm)
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PROCEDURE
Proceed systematically - from mid esophagus [≈35
cms from the incisors] to gradually more distal
esophagus, fundus of the stomach after gentle
advancement across the cardia [≈40-50 cms from
incisors] and finally slow withdrawal of the probe for
complete scan of the thoracic aorta [from high
esophageal views].
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PROCEDURE
A complete TEE exam usually takes 15–20 min.
An abbreviated or problem-focused TEE study may
be appropriate in unstable or uncooperative
patients
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TRANSDUCER MANIPULATION OPTIONS
[1] Advancement/withdrawal (for inferior or superior
structures respectively)
[2] Rotation (clockwise to view rightward structures and
counter- clockwise for leftward structures)
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TRANSDUCER MANIPULATION OPTIONS[3] Anteflexion and retroflexion of the probe shaft (to
view structures towards the heart base or towards the apex)
[4] Leftward and rightward flexion of the probe shaft (used infrequently with the advent of multiplane probes)
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TRANSDUCER MANIPULATION OPTIONS
[5] Electronic image plane rotation (0–1800)
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TEE PROBE ORIENTATION
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• By convention, in TEE, tip of 2D sector is displayed
on top of screen and left-sided cardiac structures
appear on right side of display.
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BASIC VIEWS
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• Prior guidelines developed by the ASE and the SCA have
described the technical skills for acquiring 20 views in the
performance of a comprehensive intraoperative multiplane
transesophageal echocardiographic examination
• But current guidelines recommend that a basic PTE
examination should focus on encompassing the 11 most
relevant views.
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CROSS-SECTIONAL VIEWS OF THE 11 VIEWS OF THE ASE AND SCA BASIC PTE EXAMINATION.
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ASE & SCA RECOMMEND 20 VIEWS FOR A COMPREHENSIVE TEE.
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MID ESOPHAGUS 4C ( 0°)Position probe in mid-esophagus behind LA. depth 14cm,angle 0-10°. Image all 4 heart chambers. Optimize LV apex by slight retroflexion of probe tip. Ensure no part of AV or LVOT is seen. Aim to maximize TV diameter, and adjust depth to view entire LV. Assess :chamber size; ventricular function; mitral valve disease; tricuspid valve disease; ASD; pericardial effusion
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ME 4 CHAMBER VIEW
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ME 2C ( 90° ) From ME 4C : keep probe tip still and MV in the center; rotate omniplane angle forward to 80-100°; RA + RV disappear, LAA appears.Retroflex probe tip for true LV apex; adjust depth to see entire LV apex.Assess : LAA mass/thrombus; LV size and function; MV disease (A1, A2 & P3 scallops); MV annulus measurement
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ME TWO-CHAMBER VIEW
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ME LAX (120°) Rotate omniplane angle forward to 120-130°Imaging plane is directed thru the LA to image the aortic root in LAX and entire LV. The more cephalad structures are lined up on the display right. The LV anteroseptal + inferolateral walls & MV segments, A2 and P2 are seen.Assess : LV function, MV disease, AV and aortic root disease, IVS pathology.
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ME LAX VIEW
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ME ASC A LAX ( 90°) Find the ME AV LAX (120°). Withdraw the probe to bring the
right pulmonary artery in view Decrease omniplane angle
slightly by 10-20° to make the aortic wall symmetric
Imaging plane is directed thru the right pulmonary artery to
image the proximal ascending aorta in LAX.
For: aortic pathology, pericardial effusion, pulmonary embolus
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ME ASC A LAX ( 90°)
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ME ASC A SAX (0°)From ME AV LAX (120°) OR from ME AV SAX (30°)…. Withdraw probe (asc aorta ), Rotate the omniplane angle back to 0°Imaging plane is directed slightly above the aortic valve thru the RPA(seen in LAX), ascending aorta (seen in SAX) and SVC (SAX).For : PA pathology, pulmonary embolus, ascending aorta pathology ,PDA, swan-ganz in SVC
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ME ASC A SAX (0°)
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ME AV SAX (30-45°) From ME 4C (0°) withdraw cephalad to obtain the ME 5C(0°)
[imaging plane is directed thru the LA and aligned parallel to the AV annulus] rotate to 30-45°; center aortic valve and aim to make 3 aortic valve cusps symmetric. Withdraw probe for coronary ostia.Advance probe for LVOT.
Assess : AV disease, OS ASD, LA size, coronary artery pathology
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ME AV SAX (30-45°)
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ME RVIO VIEW (60-75°)From ME AV SAX (30-60°) rotate omniplane angle to 60-75°
Optimize TV leaflets, open up RVOT,
Bring PV + main PA into view
For : P valve / PA / RVOT /TV pathology /VSD
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ME RVIO VIEW (60-75°)
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ME BCV ( 90°) From ME 2 C (90°), Turn entire probe right
Change angle or rotate probe slightly to image both IVC (left)
and SVC (right) simultaneously
For : ASD (secundum, sinus venosus), atrial pathology,
lines/wires,VENOUS CANNULA (SVC, IVC)
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ME BCV ( 90°)
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TG MID SAX (0°) Advance probe until you see stomach (rugae) or liver. anteflex to contact stomach wall and inferior wall of heart . center LV by turning probe R or L . image both papillary muscles .imaging plane transversely thru the mid inferior wall of the LV with all 6 mid LV segments viewed at once from the stomach.For: Left ventricle size, function, IVS motion, VSD, pericardial effusion
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TG MID SAX (0°)
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ME DA SAX (0°) Insert the probe to the ME, sector depth 10-12cm, angle 0°; Turn probe to left to find the aorta; put aorta in middle of
display Decrease depth to 5cm; advance + withdraw probeNear field image of the circular aorta represents the right anterior wall of the aortaFor :Aortic pathology , Color flow reversal: AI severity, IABP position
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ME DA SAX (0°)
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ME DA LAX (90°)From ME DA SAX…. Rotate to 900 … aortic walls appear in
parallel
Distal aorta is to the display left and the proximal aorta to the
display right
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ME DA LAX (90°)
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ME MITRAL COMMISSURAL VIEW (60°)Find the ME 4C : keep the probe tip still and MV in the center; rotate omniplane angle forward to 45-60°;RA,RV disappear, retroflex slightly for LV apex; Imaging plane is directed thru the LA to image LA, MV and LV apex.
Assess : MV disease, LV function, LA pathology.
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ME AV LAX (120°) From ME AV SAX (30-60°), rotate to 120 -150°LVOT, AV, proximal ascending aorta line up.Optimize aortic annulus and make sinuses of valsalva symmetricAssess : MV disease, AV disease, aortic root dimensions & pathology, LVOT pathology, VSD
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TG 2C (90° )
From mid TG SAX (0°) .. rotate omniplane angle to 90°.. Anteflex until LV is horizontal
Imaging plane ….Transversely thru the inferior wall of the LV and subvalvular structures of the mitral valve from the stomach.
For : LV function , mitral valve subvalvular pathology
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TG BASAL SAX(0°)
From TG mid SAX view … withdraw the probe until MV is seen in SAX … aim to see symmetric MV commissures
Views MV (with A3 & P3) that is parallel to the annulus
For : LV size, function ; VSD ; MV planimeter orifice area
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TG LAX (110-120°)
From TG 2 chamber (90°) … rotate omniplane angle to 110-120°
Imaging plane is directed longitudinally thru the LV to image the aortic root in LAX.
For : MV pathology ,VSD, LV systolic function, Aortic valve: spectral and color doppler, LVOT: spectral and color doppler
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DEEP TG LAX (0°)
From mid or apical TG SAX view, anteflex and gently advance probe, hugging the stomach mucosa until the LV apex is seen at the top of the display
For: paravalvular leak prosthetic aortic valve ; AV gradient
spectral doppler ; LVOT gradient spectral doppler
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TG RV INFLOW (90°)
From mid TG SAX (0°) turn probe right to put RV in center …
Rotate omniplane angle to 90°… anteflex until RV is horizontal
Imaging plane is directed longitudinally thru the posterior RV wall to reveal a long axis view of the RV, with the apex of the RV to the display left and the anterior free wall in the far field.
For : RV function; tricuspid subvalvular /TV pathology
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UE AORTIC ARCH LAX (0°)
From ME(0°)… ME descending aorta SAX (0°) view… Withdraw probe until aorta changes into oval
shape…
Turn probe slightly to the right
Imaging plane is directed thru the longitudinal axis of the transverse aortic arch. The circular shape of the DA changes to an oblong shape of the transverse aortic arch (0°)
For : aortic pathology
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UE AORTIC ARCH SAX (60-90°)
From UE aortic arch LAX (0°) view…. Rotate the omniplane angle
to 60-90°…. Bring the pulmonic valve and pulmonary artery in view
Imaging plane is directed thru the transverse aortic arch in SAX and the pulmonary artery in LAX.
For : Aortic arch pathology, Pulmonic valve disease, PDA
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3 DIMENSIONAL TEE
Main advantages of Real-time three-dimensional (RT3D) TEE
during catheter-based interventions: Ability to visualize the entire lengths of
Intracardiac catheters, including the tips of all catheters and the balloons
Devices they carry, along with a clear depiction of the positions in
relation to other cardiac structures
To demonstrate certain structures in an ‘‘en face’’ view
RT3D TEE is a powerful new imaging tool
May become the technique of choice and the standard of care
for guidance of selected percutaneous catheter-based
proceduresGila Perk, et al. J Am Soc Echocardiogr 2009;22:865-82
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INTRACARDIAC ECHOCARDIOGRAPHY
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INTRACARDIAC ECHOCARDIOGRAPHY
An imaging technique that helps to guide
percutaneous interventional procedures
Probe can be inserted under local anaesthesia
Principally used during closure of atrial septal
abnormalities
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INTR
AC
AR
DIA
C
EC
HO
CA
RD
IOG
RA
PH
Y
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INTRACARDIAC ECHOCARDIOGRAPHY
• The 1st generation ICEs were introduced in 1980s
• They provided high resolution imaging
• Tissue penetration limited due to high frequency of the
transducers (20–40 MHz)
• Anatomic intracardiac overviews not properly obtained
• Recently the development of steerable phased array
ultrasound catheter systems with low frequency and
Doppler qualities has expanded the clinical use of
ICE
M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981–990.
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ICE: ADVANTAGESNo radiation is needed
Patient discomfort is less
General anaesthesia not
needed
Communication with the
patient during the
procedure possible as
compared to TEE
Not necessary to position a
transducer in a sterile field
as compared to TTE
Availability of direct online
information on the position
of catheters and devices
The possibility of direct
monitoring of acute
procedure related
complications such as: Thrombus formation
Pericardial effusion etc
M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981–990.
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ICE: LIMITATIONS Considerable shaft size (10 French)
Lack of additional catheter features, such as Ports for guidewires
Therapeutic devices and pressure
The phased array catheters are expensive and for single
use only
Phased array ICE provides only monoplane image sections
Difficult for operators to obtain the same views
No standard views for ICE are currently defined as
compared to standard views for for TTE and TOE.M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981–990.
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ICE: CLINICAL IMPLICATIONS Applications of intracardiac echocardiography (ICE) in
interventional procedures
Evaluation of intracardiac thrombus
Transseptal puncture
Atrial septal defect/patent foramen ovale closure Interventional
electrophysiological
procedures Pulmonary vein ablation in
patients with atrial fibrillation
Atrial flutter ablation
Ventricular tachycardia
ablation74
Other applications Diagnosis/biopsy of
intracardiac masses
Balloon mitral valvuloplasty
Atrial appendage occlusion
Visualisation of coronary
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CLOSURE OF AN ASD UNDER ICE GUIDANCE
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ICE: TECHNICAL REQUIREMENTS
Mechanical ultrasound tipped catheter: Can be used for both
Intravascular
Intracardiac imaging
For intracardiac use 9 MHz single element transducer is incorporated in an 8 French
catheter
A Piezoelectric crystal is rotated at 1800 rpm in the radial
dimension perpendicular to the catheter shaft
Provides cross sectional images in a 360˚ radial plane
The ICE catheter needs to be filled with 3–5 ml sterile water
before it is connected to the ultrasound machine
M R M Jongbloed, et al. Heart 2005;91:981–990.
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ICE: TECHNICAL REQUIREMENTS
Phased array ultrasound tipped catheter system
uses A 10 French ultrasound catheter
Positioned in the right atrium (RA) or right ventricle (RV)
via a femoral approach
Through a 10 French introducer
Measurements of haemodynamic and physiologic
variables can be made using Doppler imaging
Catheter is connected to an ultrasound system
M R M Jongbloed, et al. Heart 2005;91:981–990.
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ICE FUTURE ADVANCES
Higher resolution Are more reproducible
and more flexible than
piezoelectric ceramic
They are extremely
reproducible and can be
made from masks like
integrated circuits
Electrophysiology-
Enabled Devices for
Imaging and Therapy Integration of ultrasound
imaging with mapping
technologies, fusion,
and overlay images
Ziyad M. Hijazi, et al. Circulation. 2009;119:587-596
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REFERENCES
OTTO – The practice of clinical echocardiography – 4th edition
FEIGENBAUM’S Echocardiography – 7th edition
Basic perioperative TEE – A consensus statement of ASE and
SCA – S.T Reeves – J Am Soc Echo 2013
Recommendations for TEE: update 2010 – Flachskampf -
European Journal of Echocardiography 2010
TEE Multimedia Manual - André Y. Denault, Pierre Couture
TEE Study Guide and Practice Questions-Dr Andrew Roscoe
Virtual TEE Website – University of Toronto
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MCQS
1)The number of most relevant views for a basic
perioperative TEE examination according to current
guidelines by ASE and SCA –
a) 20 views
b) 15 views
c) 12 views
d) 11 views
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2) In ME 2 chamber view , the omniplane angle is
a) 135˚
b) 120˚
c) 90˚
d) 60˚
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3) In ME LAX view, the omniplane angle is
a) 45˚
b) 60˚
c) 90˚
d) 120˚
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4) In desc aortic LAX view, the omniplane angle is
a) 0˚
b) 60˚
c) 90˚
d) 120˚
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5)Principal use of ICE is in
a) Evaluation of intracardiac thrombus
b) Balloon mitral valvuloplasty
c) ASD closure
d) Pulmonary vein ablation
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