NTRAOPERATIVE transesophageal echocardiography (TEE)provides both qualitative and quantitative information about valvular anatomy and function that can facilitate clinical and surgical management.It is important, however, to understand the limitations of TEE, and to always perform a comprehensive examination.In this report, the pitfalls of both the direct short-axis and the Doppler methods of assessing severity of aortic stenosis by TEE are presented. CASE REPORTA 33-year-old female presented for cesarean delivery.Past medical history included the presence of a bicuspid aortic valve diagnosed at 2 years of age.A recent transthoracic echocardiogram (TTE) had revealed left ventricular (LV) hypertrophy, normal LV ejection fraction, and a stenotic, noncalcific bicuspid aortic valve with a Doppler-estimated peak flow velocity of 4.1 m/s (Fig 1).The derived peak and mean pressure gradients were 67 mmHg and 47 mmHg, respectively.Moderate aortic insufficiency and a dilated ascending aorta (diameter, 4.5 cm) were also noted.The cesarean section was performed under general anesthesia.Intraoperative TEE was used as an adjunct to routine monitoring by the anesthesia care team.After induction of anesthesia, a multiplane 5.0-MHz TEE probe (Sonos OR System, Hewlett Packard, Andover, MA) was placed without difficulty.A comprehensive TEE examination was performed to include a systematic evaluation of the aortic valve, which had a bicuspid morphology without calcific changes.1,2 In contrast to the ambulatory TEE findings, aortic valve area obtained by direct short-axis planimetry appeared to be within normal limits (Fig 2).Doppler-estimated flow velocities from a transgastric approach also appeared to be within normal limits.Additional TEE findings included ascending aortic dilatation q diameter, 4.3 cm) and moderate aortic valvular insufficiency. DISCUSSIONCongenital aortic stenosis accounts for approximately 6.1% of all congenital heart disease, and is the leading cause of
Transesophageal color flow Doppler findings were studied in 30 patients with aortic insufficiency who had cardiac operations. Measurements were expressed as ratios of corresponding left ventricular outflow tract dimensions. Regurgitant jet proximal width ratio was significantly related to jet area ratio (r = 0.92) and correlated poorly with the degree of jet penetration into the left ventricular cavity (r = 0.32). The vectors of the regurgitant jets were variable. Nine patients had undergone aortography. Regurgitant jet proximal width and area ratios were significantly related to angiographic grade (r = 0.88 and 0.87, respectively) in these patients. We concluded that the esophagus offers a satisfactory transducer orientation for color flow Doppler assessment of aortic insufficiency.
The authors describe a quality-assurance-oriented database program designed for an intraoperative transesophageal echocardiography monitoring service. Entry data include patient and operation demographics and two-dimensional echocardiographic, saline-contrast, and color flow/pulsed Doppler assessments of the heart and great vessels. A statistical analysis component allows for comparison of intraoperative interpretations with those of an external reviewer 'gold standard' on a field-by-field basis. This provides an objective means for quantifying expertise in each individual aspect of the patient examination sequence. Such self-appraisal data are essential for delineating the status and tracking the progress of service being provided.< >
I. Basic Considerations: Indications, Complications, And Equipment Mishaps Ii. Patient Examination Sequence: Transverse Plane Two-Dimensional Echocardiography Patient Examination Sequence. Transverse Plane Color Flow Doppler Patient Examination Sequence. Color Flow Doppler Quantification of Aortic, Mitral, And Tricuspid Valvular Regurgitation. Biplane and Multiplane Two-Dimensional Echocardiographic Patient Examination Sequences Iii. Techniques and Procedures: Spectral Display Pulsed-Wave Doppler Evaluation of Pulmonary Vein Flow. Transverse Plane Evaluation of Left and Right Ventricular Systolic Function. Rationale for Use of Left Ventricular Regional Wall Motion Abnormalities as Indicators of Myocardial Ischemia Iv. Related Issues: Echocardiographic Contrast Media and Techniques. Selected Topics. Quality Assurance in Transesophageal Echocardiography
