Transoesophageal Echocardiography in Anaesthesia and Intensive Care Medicine, Second Edition

359 Pages·2004·21.12 MB·English

Transoesophageal Echocardiography in
Anaesthesia and Intensive Care Medicine
Second edition
Edited by
Tan Poelaert
Clinical Director, Cardiac Anaesthesia and Postoperative Cardiac Surgical Intensive Care Unit,
Gent University Hospital, Gent, Belgium
Karl Skarvan
Professor of Anaesthesiologx University of Basel, Kantonsspital Basel,
Basel, Switzerland
0 BMJ Publishing Group 2004
BMJ Books is an imprint of the BMJ Publishing Group
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording and/or
otherwise, without the prior written permission of the publishers.
First published in 2000
by BMJ Books, BMA House, Tavistock Square,
London WClH 9JR
First edition 2000
Second edition 2004
www.bmjbooks.com
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the
British Library
ISBN 0 7279 1796 X
Typeset by SIVA Math Setters, Chennai, India
Printed and bound in Malaysia by Times Offset
Contents
Contributors vii
Preface ix
Abbreviations xi
1. Physical principles of ultrasound 1
Pierre-Guy Chassot
2. Perioperative transoesophageal echocardiography 23
Karl Skarvan, Jan Poelaert
3. Global left ventricular systolic function 47
Christoph Schmidt, Frank Hinder, Hugo Van Aken, Jan Poelaert
4. Left ventricular diastolic function 80
Stefan G De Hert
5. Mitral valve disease 103
Heinz M Loick, Thomas Wichter, Christoph Schmidt
6. Aortic valve 121
Jack S Shanewise
7. Prosthetic valves 134
Herman FJ Mannaerts, Cees A Visser
8. Right ventricle 145
Isabelle Michaux, Miodrag Filipovic, Karl Skarvan
9. Thoracic aorta 161
Raimund Erbel, Steven N Konstadt
10. Haemodynamics 176
Jan Poelaert, Karl Skarvan
11. Myocardial ischaemia 196
Manfred D Seeberger, Karl Skarvan, Michael K Cahalan
12. Congenital heart disease 221
Pierre-Guy Chassot, Dominique Bettex
13. Cardiac masses, air, and foreign bodies 248
Kazumasa Orihashi, Yasu Oka
14. Minimally invasive and minimal access cardiac surgery 265
Fiona Clements
15. Circulatory assist devices, artificial heart, and heart and lung transplantation 281
Joachim M Erb
Contents
16. Artifacts and pitfalls 305
Bijoy K Khandheria
17. Training and certification in the United States 315
Daniel M Thys
18. Training and certification in Europe 332
Karl Skarvan, Clemens-Alexander Greim, Norbert Roewer,
John D Kneeshaw, Tan Poelaert
Index 338
Contributors
Ruggero Ama
Research Fellow, Cardiac Anaesthesia and Postoperative Surgical ICU, Department of Intensive Care,
University Hospital, Gent, Belgium
Dominique Bettex
Assistant Professor of Anaesthesiology, Division of Cardiac Anaesthesia, Institute of Anaesthesiology,
University Hospital (USZ) Zurich, Switzerland
Michael K Cahalan
Professor of Anesthesiology and Chairman, Department of Anesthesiology, University of Utah, Salt Lake
City, USA
Pierre-Guy Chassot
Associated Professor of Anaesthesia, Head of Cardiac Anaesthesia Division, Department of
Anaesthesiology, CHUV, Lausanne, Switzerland
Fiona Clements
Professor of Anesthesiology, Heart Center, Duke University, Durham, USA
Stefan G De Hert
Professor of Anaesthesiology, Director of the Division of Cardiothoracic and Vascular Anaesthesia,
University Hospital, Antwerp, Belgium
JoachimM Erb
Staff Anaesthesiologist, Head Intraoperative Echocardiography, Deutsches Herzzentrum Berlin,
Anaesthesiology Clinic, Berlin, Germany
Raimund Erbel
Professor of Cardiology, Director of Division of Cardiology, Zentrum Fur Innere Medizin, Medizinische
Klinik und Poliklinik, Universitatsklinikum Essen, Hufelandstrasse, Germany
Miodrag FiLipovic
Assistant Professor of Anaesthesiology, Department of Anaesthesia, University of Basel, Kantonsspital
Basel, Basel, Switzerland
Clemens-AlexanderG reim
Professor of Anaesthesiology, Clinic of Anaesthesiology, University of Wurzburg, Wurzburg, Germany
Frank Hinder
Associate Professor of Anaesthesiology, Department of Anaesthesiology and Surgical Intensive Care
Medicine, University Hospital UKM, Munster, Germany
Bijoy K Khandheria
Professor of Medicine, Mayo Medical School Consultant, Cardiovascular Diseases and Internal
Medicine, Mayo Clinic and Chair, Information Management and Technology Committee, Mayo Clinic,
Rochester, Minnesota, USA
John D Kneeshaw
Consultant Anaesthetist, Department of Anaesthesia and Critical Care, Papworth Hospital, Papworth
Everard, UK
Steven N Konstadt
Professor of Anesthesiology, Department of Anesthesiology, CO-director, Division of Cardiothoracic
Anesthesia, Mount Sinai School of Medicine, New York, USA
Contributors
Heinz M Loick
Professor of Anesthesiology, Director, Clinic of Anaesthesiology and Operative Intensive Care Medicine,
Marien Hospital, Euskirchen, Germany
Herman FJ Mannaerts
Associate Professor of Cardiology, Department of Cardiology, VU Medical Center, Amsterdam, the
Netherlands
Isabelle Michaux
Associate Professor, Department of Intensive Care Medicine, Mont-Godinne University Hospital,
Universit6 Catholique de Louvain, Yvoir, Belgium
Yasu Oka
Professorial Lecturer, Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Mount
Sinai Medical Center, New York, USA
Kazumasa Orihashi
Associate Professor, First Department of Surgery, Hiroshima University School of Medicine, Hiroshima,
Japan
Jan Poelaert
Professor and Clinical Director, Cardiac Anaesthesia and Postoperative Cardiac Surgical Intensive Care
Unit, University Hospital, Gent, Belgium
Norbert Roewer
Professor of Anaesthesiology, Director, Clinic of Anaesthesiology, University of Wurzburg, Wurzburg,
Germany
Christoph Schmidt
Associate Professor of Anaesthesiology, Department of Anaesthesiology and Surgical Intensive Care
Medicine, University Hospital UKM, Munster, Germany
Manfred D Seeberger
Associate Professor of Anaesthesiology, Head of Cardiac Anaesthesia Division, University of Basel,
Kantonsspital Basel, Based, Switzerland.
Jack S Shanewise
Professor of Anesthesiology, Division of Cardiothoracic Anesthesiology, Emory .University School of
Medicine, Atlanta, Georgia, USA
Karl Skarvan
Professor of Anaesthesiology, Department of Anaesthesia, University of Basel, Kantonsspital Basel, Basel,
Switzerland
Daniel M Thys
Professor of Anesthesiology, Chairman, Department of Anesthesiology, St Luke’s-Roosevelt Hospital
Center and Department of Anesthesiology, College of Physicians and Surgeons, Columbia University,
New York. USA
Hugo Van Aken
Professor of Anaesthesiology, Chairman, Department of Anaesthesiology and Surgical Intensive Care
Medicine, University Hospital UKM, Munster, Germany
Cees A Visser
Professor of Cardiology, Chairman, Department of Cardiology, University Hospital, Free University of
Amsterdam, Amsterdam, the Netherlands
Thomas Wichter
Associate Professor of Internal Medicine, Department of Cardiology, University Hospital UKM, Munster,
Germany
Preface
The four years that have passed since the first edition of this textbook represent only a short period of
the twenty-year history of perioperative transoesophageal echocardiography (TOE). Nevertheless, the
new information obtained through research and educational activity in this field during the last four
years justifies an updated second edition of this textbook. The new title of our textbook, TOE in
Anaesthesia and Intensive Care Medicine, reflects the present wide deployment of TOE in cardiac and
non-cardiac surgical patients as well as in non-surgical critically ill patients. The chapters from the first
edition have been revised, updated or completely rewritten to incorporate the numerous new publications
generated in the field of perioperative TOE.
Important developments in the field of ultrasound technology, such as three-dimensional echocardiogra-
phy, contrast echocardiography, and tissue doppler imaging, have entered the practice of echocardiography
during these last four years. We considered including new chapters that would comprehensively cover
these techniques; however, we believe that the present impact of these methods on the practice of peri-
operative TOE does not yet justify extensive coverage in the present textbook. Nonetheless, we do feel that
contrast echocardiography, tissue doppler imaging, and three-dimensional echocardiography are promising
additions to perioperative TOE and their principles as well as clinical applications are covered in
Chapters 1, 7, and 11. We have also added a new chapter covering the use of TOE during mechanical
ventricular assistance, implantation of an artificial heart, and heart transplantation (Chapter 15) in
response to the suggestions of our readers.
Our goal is to provide the present and future practitioners of TOE with a comprehensive and updated
review of perioperative TOE. We believe that it would have been wrong to restrict the material to only
the technical and sonographic aspects of TOE. Therefore, the TOE findings are not presented in isolation,
but are accompanied by relevant physiological and clinical data. We hope that this additional informa-
tion helps the readers to better understand the findings and that it will help them integrate TOE into the
diagnostic process in both the operating theatre and in the intensive care unit.
The method of TOE in its existing form satisfies the needs of both anaesthetists and intensivists.
Therefore, the main emphasis can now be shifted from the acquisition of new and highly sophisticated
techniques to training and certification of physicians who care for cardiac, critically ill, or traumatized
patients in operating theatres, intensive care units, and emergency wards. Today a critical and timely
diagnosis need never again be missed because of the unavailability of a physician who is certified in
TOE. Important guidelines for training and certification of physicians in perioperative TOE were
recently published and are included in Chapters 17 and 18. Whereas in the first edition only the
certification process in the USA was described, in this edition, we have added a review of the present
educational situation of perioperative TOE in Europe and its future prospects are presented.
A prerequisite for proper documentation of perioperative findings is the use of universally accepted
terminology for TOE imaging. Chapter 2 describes the practice of perioperative TOE and the whole
potential of multiplane TOE imaging in the traditional way. Nevertheless, the twenty TOE images that
were recommended in the guidelines for comprehensive intraoperative TOE examination by the
American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force are
also presented and the corresponding terminology is used throughout this edition. Some structures can-
not be interrogated or correctly imaged in the selected views because of anatomic or pathologic causes.
Therefore, the knowledge of alternative views that can be made possible by multiplane TOE imaging
remains important.
The findings obtained by perioperative TOE must be stored and readily available to the physicians
who might subsequently need them. Comprehensive TOE documentation, including stored images and
written reports based on the recommendation mentioned above, may not be feasible in every institution
or in every situation. Therefore, we also provide an example of a more realistic TOE report based on a
minimum set of TOE images.
Preface
Our textbook is the result of a collective effort, and therefore some overlaps are inevitable. Examples
are the assessment of intracardiac pressures or of ventricular filling patterns. These techniques and findings
are discussed in several chapters in accordance with the respective context. We accepted such minor
overlaps when the information appeared useful for the structure of these chapters.
We greatly appreciate the contribution of all the authors to this revised edition and thank them for
their willing cooperation. We also extend our thanks to Joan Etlinger of the Department of Anaesthesia
in Base1 for her invaluable support, to Christina Karaviotis at BMJ Books for her outstanding editorial
work and Mary Banks for her ongoing encouragement.
Jan Poelaert
Karl Skarvan
Abbreviations
2D two-dimensional LUFJV left upper pulmonary vein
3D three-dimensional LV left ventricle/left ventricular
ABD automated border detection LVAD left ventricular assist device
AR aortic regurgitation LVOT left ventricular outflow tract
ARDS acute respiratory distress syndrome MOE mid-oesophageal
AS aortic stenosis MPI myocardial performance index
ASD atrial septal defect m mitral regurgitation
AV aortic valve MRI magnetic resonance imaging
AVA aortic valve area MYG myocardial velocity gradient
BVAD bivenh-icular assist device PA pulmonary artery
CABG coronary artery bypass graft@ PCWP pulmonary capillary wedge pressure
CAD coronary artery disease PFO patent foramen ovale
CF colour flow PISA proximal isovelocity surface area
CI cardiac index PM papillary muscle
CPB cardiopulmonaryb ypass PRF pulse repetition frequency
cs coronary sinus PW pulsed wave
CT computed tomography PwRInax maximal venh-icular power
cw continuous wave RAP right atrial pressure
CVP central venous pressure RCA right coronary artery
EAC endoaortic clamp RLPV right lower pulmonary vein
ECG electrocardiogramlelectrocardiography RUPV right upper pulmonary vein
EDA end-diastolic area RV right ventriclehight ventricular
EDD end-diastolic diameter RVAD right ventricular assist device
EDV end-diastolic volume RVIT right ventricular inflow tract
ESA end-systolic area RVOT right ventricular outflow tract
ESD end-systolic diameter SAX short axis
ESV end-systolic volume SR strain rate
sv
FAC fractional area change stroke volume
svc
FVR flow velocity ratio superior vena cava
LABP intraaortic balloon pump SWMA systolic wall motion abnormality
LAS interatrial septum TAH total artificial heart
ICU intensive care unit TAPSE tricuspid annular plane systolic excursion
IVC inferior vena cava TDI tissue Doppler imaging
IVCT isovolumic contraction time TG transgastric
IVRT isovolumic relaxation time TOE transoesophageal echocardiography
IVS interventricular septum TOF tetralogy of Fallot
LA left atrium/left atrial TR tricuspid regurgitation
LAA left atrial appendage TTE transthoracic echocardiography
LAD left anterior descending coronary artery UOE upper oesophageal
LAP left atrial pressure VAD ventricular assist device
LAX long axis VSD ventricular septal defect
LCX left circumflex coronary artery VTI velocity time integral
LLPV left lower pulmonary vein
I Physical principles of ultrasound
Pierre-Guy Chassot
Defi n i t ions (1). They are linked together by a simple
relationship:
Ultrasound represents a mechanical pressure
disturbance propagating as waves through
materials that are dense enough to transmit the
fast oscillations imparted on molecules (Figure 1.1). In human soft tissues the speed of ultrasound (c)
Their frequencies are much higher than those is assumed to be fairly constant; its mean value is
perceptible to the human ear; for medical 1540 m/sSz The equation above implies that
purposes they range from 2 to 12 MHz (1 frequency and wavelength vary in an opposite
MHz = 106H z).' Ultrasound waves have certain manner; the lower the frequency, the longer the
properties: wavelength. The spatial resolution, which is the
minimum distance between two objects at which
they can be orientated like beams they can be differentiated, is increased when the
they follow the physical laws of reflection and frequency is higher; this is because the wavelength
refraction must be shorter than this distance if the two objects
they are reflected by dense materials are to be distinguished from each other. The
they propagate freely in liquids but very poorly resolution is higher along the travelling axis (axial
through air. resolution) than it is perpendicularly because it
depends only on the physical properties of the
A wave is defined by three physical terms: its ultrasound wave; this resolution is in the
velocity (c), its frequency (fl, and its wavelength 0.5-1 mm range.3I n the lateral direction images are
Figure 1. I Ultrasound wave.The
wave amplitude defines its intensity (in
decibels [dB]). One cycle consists of one
compression and one rarefaction.The
wavelength is the distance between two
maximal pressure values. Frequency is
the number of cycles per second
(I cycle/s= I Hz).