11-11-20 Echo Heart Anatomy- Dr. Pantin

11-11-20 Echo Heart Anatomy- Dr. Pantin

Transcript

1. Echocardiographic Heart Anatomy Enrique Pantin, MD Professor of Anesthesiology Robert Wood Johnson University Hospital – Rutgers RWJMS http://blogs.discovermagazine.com/crux/files/2015/06/shutterstock_198620987.jpg
6. Equipment / resources available  Echocardiography laboratory with Phillips machines  Operation room Philips machines – 5 EPIQ machines » Adult and pediatric TEE and TTE probes » L12-4 probes » L15-7 “hockey stick” probe – 6 Sparq machines » Vascular, CVICU, peds OR, and PACU -C  Echocardiography library  Digital echo lab  YouTube
8. Ultrasound  Concepts  Clinical applications  The routine exam and Imaging planes  Image nomenclature
9. Ultrasound-basics  Ultrasound: sound with a frequency greater than 20,000Hz  Advantages of US as a diagnostic tool: It can be directed as a beam Obeys the laws of reflection and refraction Is reflected by small size objects
10.  Frequency number of cycles in a given time velocity = frequency x wavelength velocity of sound in human soft tissue 1,540m/sec  Penetration decreases as frequency increases Ultrasound-basics
11.  Depth  Resolution  Attenuation depends on the “half-value layer” Water= 380cm; blood =15; soft tissue=1-5; muscle= 0.6-1. Ultrasound-basics
12. Advantages of TEE over TTE  TTE does not provide complete or adequately detailed information in the evaluation of: – posterior cardiac structures (e.g. left atrium, left atrial appendage, interatrial septum, the aorta distal to the root) – assessment of prosthetic cardiac valves – delineation of cardiac structures less than 3 mm in size (e.g. small vegetations or thrombi) Pavlides et al., 1990
13. Advantages of TEE over TTE  Image quality with TTE is significantly limited by ultrasound interference by chest wall and lung especially in obese and elderly patients and in patients with COPD  TEE is conclusive in many cardiac diseases so that it can diagnose 95% of cases versus 48% using TTE Pavlides et al., 1990
14. Doppler
15.  Evaluate heart anatomy, function and ischemia susceptibility  Evaluate native or mechanical heart valves, great vessels and de-airing.  Heart transplantation  Mechanical assist device placement (IABP, VAD, ECMO, etc.)  Post-operative assessment  Hypotension: differential diagnosis  Hemodynamics  Guide for procedures (cannulation, structural heart cases, etc)  Suspected massive PE  Unexplained hypoxemia  Trauma  Suspected endocarditis  Source of embolus  Follow up tool  Electrophysiology lab, pacemaker optimization TTE/TEE Clinical Applications
16. TEE: is it useful ? Alters the planned cardiac surgical procedure: 5.6% 1.4% valvular 4.2% PFO Anesthesia & Analgesia 2002 95(4):824-7 TEE altered the management in five ways in the OR or ICU: 1) changing medical therapy 2) changing surgical therapy 3) confirmation of a diagnosis 4) positioning of an intravascular device 5) substitute to a pulmonary artery catheter Can J of Anaesthesia 2002 49(3):287-93
17. TEE: is it useful ? TEE for elective valve replacement in 300 patients: clinical impact 1.3% 0.7% had an additional valve repair /replaced 0.7% diagnosed valvular malfunction / complication J Am Soc of Echocardiography 2001 14(7):659-67 TEE is a beneficial and cost-effective intervention in children requiring complex cardiac repair Surgical therapy was altered in 3% of patients. Am Heart Journal 1999 138:771-6
18. The incidence of new information ranges from 12.8% to 38.6%, whereas the impact on treatment ranged from 9.7% to 14.6%. http://www.acc.org/clinical/guidelines/echo/index.pdf TEE: is it useful ?
19. TEE contraindications Relative Esophageal pathology ( Zenker’s diverticulum, esophagitis, esophageal varices, dysphagia, etc) Severe respiratory insufficiency (non-intubated patient) Large ascending thoracic aortic aneurysm Absolute Esophageal or gastric perforation / recent surgery No cardiopulmonary resuscitation equipment available
20. TEE contraindications Anesth Analg 2001 92 1126
21. TEE Safety • General population – Complications rate less than 0.5% – Out of 10,000 one death »hemorrhage from esophageal cancer. –Swallowing dysfunction (7.8 times greater odds) –Gastro-esophageal injury estimated in one in 10,000 • ICU –Complications rate 1.7% –Serious Cx 0.2% (respiratory failure, seizures) • 7200 intraoperative TEE performed in cardiac surgical patients, • no mortality and a morbidity of only 0.2% were observed Anesth Analg. 2001;92:1126-30
22. TEE complications Anesth Analg 2001 92 1126
23. TEE complication. Patient # 1, POD # 2 Anesth Analg 2004 99 41
24. TEE complication. Patient # 2 Anesth Analg 2004 99 41
25. TEE complication. Patient # 2, POD # 6 Anesth Analg 2004 99 41
27. Una sala del hospital durante la visita del médico en jefe 1889, Óleo sobre lienzo, 290 x 445 cm. Luis Jimenez Aranda (1845-1928) Museo del Prado, Madrid. https://www.museodelprado.es/coleccion/obra-de-arte/una-sala-del-hospital-durante-la-visita- del/318cc81b-77d6-4688-ad98-ffbe3dd7a4a5
28. https://www.museodelprado.es/coleccion/obra-de-arte/una-sala-del-hospital-durante-la-visita- del/318cc81b-77d6-4688-ad98-ffbe3dd7a4a5
29. https://franciscojaviertostado.com/2013/05/27/la-medicina-en-el-arte-pintura-la- visita-al-hospital/
32. Fumagalli
38. Fumagalli
39. Fumagalli T T T E E PA LA T
42. TTE TEE TEE
43. TTE
44. TEE
49. TTE
51. Beaulieu - Crit Care Med 2007;35:S235 T T E
52. T T E
54. Parasternal Long http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
62. Parasternal Long RV Inflow View http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
65. Parasternal Short Axis AV and RV Outflow Tract Level http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
70. Parasternal Short Axis LV at MV Level http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
71. Parasternal Short Axis LV at Mid Level http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
76. Parasternal Short Axis LV at Apex Level http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
77. Apical Four Chamber http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
84. Apical Five Chamber http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
86. Apical Two Chamber http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
87. Apical Long Axis (Three Chamber View) http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
88. Subcostal Four Chamber http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
92. Subcostal LV at MV http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
93. Subcostal LV at Mid http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
94. Subcostal LV at Apex http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
95. Subcostal IVC http://www.pie.med.utoronto.ca/TTE/TTE_content/standardviews.html
97. BARIUM SWALLOW ANATOMY
98. probe motion TEE Anesth Analg 1999 89:870-84
99. Movimientos del Transductor Anesth Analg 1999 89:870-84
108. Multiplane TEE made imaging of the entire LV possible
109. Feigenbaum
111. Summary: LV Segmentation Circulation 2002;105:539 TEE View
113. Normal LV Motion DIASTOLE SISTOLE R T R’ T’
114. TEE
115. TEE
117. Standardized Myocardial Segmentation and Nomenclature for Tomographic Imaging of the Heart TTE Circulation 2002; 105(4): 539-542
118. Mid Esophageal Four Chamber http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
120. Mid Esophageal Two Chamber http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
122. Mid Esophageal Mitral Commissural http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
123. Mid Esophageal Long Axis http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
126. Mid Esophageal AV SAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
131. Mid Esophageal AV LAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
133. Mid Esophageal RV Inflow-Outflow http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
134. Mid Esophageal Bicaval http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
135. Mid Esophageal Ascending Aorta LAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/standardVi ews/index.htm
137. Mid Esophageal Ascending Aorta SAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/standardVi ews/index.htm
139. Upper Esophageal Aortic Arch LAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
140. Mid Esophageal Descending Aortic SAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/standardVi ews/index.htm
142. Mid Esophageal Descending Aortic LAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/standardViews/index. htm
143. Transgastric Mid SAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
145. Transgastric Two Chamber http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
146. Transgastric Basal SAX http://www.pie.med.utoronto.ca/TEE/TEE_content/assets/applications/sta ndardViews/index.htm
147. CWD http://www.pie.med.utoronto.ca/TEE/TEE_content/TEE_spectral_intro.html
148. PWD http://www.pie.med.utoronto.ca/TEE/TEE_content/TEE_spectral_intro.html
149.  Disadvantages of Ultrasound: – Operator dependent – Interpretation requires experience – Limited view of aortic arch (TEE) – Invasive (TEE) – Ultrasound machine can serve as a fomite Conclusions
150.  Preoperative Evaluation – Aortic Stenosis – Ventricular Function – Pericardial / Pleural Effusion  Intraoperative Monitoring – Preload – Myocardial Ischemia – RV / LV Function  Intraoperative Evaluation – Non Responsive Hypotension – Preload – Ventricular Function  Trauma  Cardiac Arrest Conclusions
151.  Big mentality change – To adopt it and exploit the potential of bedside ultrasonography  Requires acquisition of an ultrasound machine and training of physicians Conclusions
152.  “Ultrasound will result in loss of the ability to perform landmark-based techniques when an ultrasound is not available”  Largest barrier appears to be the lack of a clear path for training and credentialing physicians in bedside ultrasound techniques. Conclusions
153.  Very useful  Very low risk of complications  Easy to learn the basic examination  Part of the training of the anesthesiologist, intensivist, trauma surgeon, and emergency physician (should be) Conclusions
154.  Rapid diagnosis  Portable  No instrumentation of aorta  No need for contrast  Aids resuscitation  Diagnosis of cardiac injuries Conclusions
155.  Increases the quality of care and speed of diagnosis in hemodynamically unstable patients  Should be part of the “routine” examination on any patient admitted to an ICU! Conclusions
156. MI, myocardial stunning, myocarditis, motion artifacts and BBB can cause RWMA but a sudden, severe decrease or cessation of segmental contraction is almost due to myocardial ischemia. Conclusions
157. Use EKG (ST, rhythm, BBB, pacer, TIME EVENTS) Evaluate the heart regionally and globally Clinical correlation Conclusions
158. Refresh the anatomy Every patient is different (no need to memorize angle). Record baseline exam Conclusions
159. Eyeball LV systolic function (Calibrate yourself using cardiologist, videos, CATH and ECHO REPORTS) Test yourself against experts (QA) Talk to surgeons Conclusions