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Structural Evaluation of the Heart by Transesophageal Echocardiography

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Transesophageal Echocardiography for Congenital Heart Disease

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Abstract

It is well-known that the echocardiographic evaluation of congenital heart disease (CHD) can present challenges due to a number of factors: the multiplicity of the different forms of CHD, the variations in anatomy and physiology associated with each class of cardiac lesion, and the complex (and unique) three-dimensional anatomy seen with many of the individual cardiac defects. These challenges have been well documented with transthoracic and fetal echocardiography, and they are equally daunting, if not more so, with transesophageal echocardiography (TEE) due to the limited availability of echocardiographic windows afforded by the esophageal/gastric location of the probe. Nonetheless, in most patients with CHD, an excellent and comprehensive TEE study can be performed using a variety of probe manipulations and views as well as a systematic approach to evaluation. The goal of this chapter is to discuss the general aspects of structural evaluation of CHD by TEE. The standard American Society of Echocardiography/Society of Cardiovascular Anesthesiologists (ASE/SCA) TEE views and probe manipulations will be detailed, along with their specific application (and modifications) for CHD evaluation. Throughout this textbook, these guidelines will be used for the assessment of the various cardiac defects. This chapter also presents a methodology for a comprehensive, systematic, and segmental approach to the TEE evaluation of a patient with CHD.

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Notes

  1. 1.

    There are two major schools of thought regarding segmental evaluation of the heart, one led by Richard Van Praagh, MD, and the other by Robert Anderson, MD While a number of elements are common to both schools, there also exist important differences that have engendered some controversy among CHD specialists, particularly in regard to nomenclature, shorthand notation, and taxonomy. One important difference is that the Van Praagh school utilizes a shorthand method to record the three main cardiac segments of any given heart as a set, enclosed in braces. Individual letters are used to represent the different possibilities for each segment, listed in venoarterial sequence or blood flow order, as follows: {atria, ventricles, great arteries}. For example, a normal heart (situs solitus) would comprise the segmental set {S,D,S}, situs inversus/mirror image dextrocardia{I,L,I}, complete transposition {S,D,D}, etc. This shorthand method is rather elaborate, and while well known and widely used, it has not been universally adopted. A detailed exposition of this system, along with other similarities and differences between the two schools, is beyond the scope of this chapter. Instead, a simpler and more unified segmental approach is presented that, in the author’s opinion, represents an integration of the best, most easily understandable elements from both schools. For further details, readers are referred to the references at the end of this chapter.

  2. 2.

    At the time of this textbook’s final pre-publication editing, a revised set of ASE/SCA guidelines was released. While still primarily adult-based, these revised guidelines are much more extensive in scope compared to the previous document; they present a good deal of new information including TEE training recommendations, additional TEE views, and suggested 3D TEE evaluation protocols. Also, a brief section has been added that addresses adult CHD evaluation. While this textbook centers upon an approach to structural TEE evaluation based upon the previous ASE/SCA guidelines and additional modified views, the editors want to acknowledge the updated 2013 document and provide it as an important additional reference. The updated guidelines can be found in: Hahn RT, Abraham T, Adams MS, et al. 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;26:921–964.

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Author information

Authors and Affiliations

  1. Division of Cardiology, Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Mailstop #34, Los Angeles, CA, 90027, USA

    Pierre C. Wong MD

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  1. Pierre C. Wong MD
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Correspondence to Pierre C. Wong MD .

Editor information

Editors and Affiliations

  1. Childrens Hospital Los Angeles Department of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA

    Pierre C. Wong

  2. Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, Houston, USA

    Wanda C. Miller-Hance

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Sweep demonstrating slow withdrawal of the TEE probe in the lower esophageal position depicting hepatic veins entering into the inferior vena cava, as seen from the lower esophageal situs short axis view (multiplane angle 0°), and later in the clip, from the lower esophageal IVC long axis view (multiplane angle 79°) (AVI 39771 kb)

Mid esophageal bicaval view, obtained with a multiplane angle of about 90°. The entrance of the superior vena cava (SVC) into the right atrium is seen. With further probe advancement into the esophagus the entrance of the inferior vena cava (IVC) into the right atrium would be demonstrated. LA left atrium, RA right atrium, RAA right atrial appendage(MPG 6374 kb)

Sweep demonstrating a left superior vena cava (LSVC) returning to the coronary sinus. In this patient there is an absent right SVC, with the innominate vein (Inn V) returning to the LSVC, which then drains through a dilated coronary sinus (CS) to the right atrium. The probe is turned to the left, multiplane angle about 90°, and first displays an upper esophageal aortic arch short axis view. The probe is then advanced to visualize the LSVC returning to the CS. The LSVC courses anterior to the left pulmonary artery (LPA). A catheter is seen in the Inn V and LSVC. Ao transverse aortic arch, LA left atrium, LV left ventricle, PA main pulmonary artery (MPG 15266 kb)

Right and left pulmonary veins returning to the left atrium, multiplane angle approximately 0°. The probe is first rotated to the right, then to the left. For both sides, the lower veins take a more horizontal course (on the display) than the upper veins. LLPV left lower pulmonary vein, LUPV left upper pulmonary vein, RLPV right lower pulmonary vein, RUPV right upper pulmonary vein (AVI 46945 kb)

Atrial septum as visualized from the mid esophageal view, using imaging and color flow Doppler. The first part of the video is from a mid esophageal four chamber view, multiplane angle 0°, with probe rotation toward the right. Slowly withdrawing and then advancing the probe performs a superior to inferior sweep of the septum. A catheter is seen in the superior vena cava. The second part shows a multiplane angle sweep as the multiplane angle is turned to about 85–95°, producing the mid esophageal bicaval view. The right coronary artery can also be seen traversing the atrioventricular groove. IVC inferior vena cava, LA left atrium, LV left ventricle, RA right atrium, RAA right atrial appendage, RV right ventricle, SVC superior vena cava (MPG 19418 kb)

Atrial septum visualized from the mid-esophagus, with multiplane angle 0°. The probe is rotated to the right, showing both right atrium (RA) and left atrium (LA) and the thin atrial septum primum (arrow) located to the left of septum secundum. The right atrial appendage (RAA) is also visible. Withdrawal of the probe demonstrates the superior limbic band of septum secundum, along with the entrance of the superior vena cava (SVC) into the RA, just anterior to the entrance of the right upper pulmonary vein (RUPV) to the LA. Ao aorta, RV right ventricle (MPG 5290 kb)

Left atrial appendage (LAA) and left upper pulmonary vein (LUPV) as seen from a mid esophageal view with probe rotation toward the left, and multiplane angle of 20–30°. LA left atrium (MPG 5846 kb)

Mid esophageal bicaval view with leftward probe rotation demonstrating a small patent foramen ovale with left to right shunting. LA left atrium, RA right atrium, RV right ventricle (MPG 3628 kb)

Contrast injection into a central venous catheter to evaluate for occult atrial right to left shunting. Video shows no right to left shunt at the atrial level (MPG 3444 kb)

Contrast injection into a central venous catheter to evaluate for occult atrial right to left shunting. Video shows an occult right to left shunt (AVI 8272 kb)

Mid esophageal four chamber view (multiplane angle 0°) showing the atrioventricular valves both by two-dimensional imaging and color flow Doppler (AVI 29155 kb)

Mid esophageal mitral commissural view (multiplane angle 60–70°), showing the mitral valve and two papillary muscles. The P1 and P3 scallops of the posterior leaflet, as well as the A2 segment of anterior leaflet, are shown. The papillary muscles (marked by an *) are faintly seen as well. LA left atrium, LV left ventricle (MPG 6162 kb)

Mid esophageal two chamber view (multiplane angle 94°) showing the mitral valve, left atrium, left ventricle, and left atrial appendage. The papillary muscles are also briefly visualized. At the end of the video, the circumflex coronary artery is also seen coursing along the atrioventricular grove (AVI 14583 kb)

Mid esophageal long axis view (multiplane angle 100–130°) showing the anterior leaflet (A2) and posterior leaflet (P2) of the mitral valve, as well as the left ventricular outflow tract and aortic valve. In this view, mitral to aortic fibrous continuity is readily seen. Ao aorta, LA left atrium, LV left ventricle, RV right ventricle (MPG 8056 kb)

Transgastric basal short axis view of the left ventricle in cross section with the mitral valve en face. The anterior leaflet (Ant leaflet) and posterior leaflets (Post leaflet) of the mitral valve are shown. This view is obtained with the TEE probe in the anteflexed position, using a multiplane angle between 0° and 20° (MPG 4212 kb)

Transgastric mid short axis view of the left ventricle (LV) and right ventricle (RV) in cross section. From the position in Video 4.14, the probe has been advanced further in the stomach (while maintaining anteflexion) to visualize the anterolateral (AL) and posteromedial (PM) papillary muscles as well as the more inferior portion of the left ventricle (MPG 3426 kb)

Transgastric two-chamber view of the left atrium (LA) and left ventricle (LV). The probe has been advanced into the stomach to the level of the transgastric window, and anteflexed. Using a multiplane angle between 80 and 100°, the LA, LV, and mitral valve leaflets are visualized. The probe is then rotated slightly counterclockwise (to the left) and the multiplane angle changed to 100 and 110° to visualize the mitral valve chordae and LV papillary muscles (MPG 7842 kb)

Transgastric long axis view (multiplane angle 90 and 120°). The left atrium (LA), left ventricle (LV), mitral valve (MV), aortic valve (AoV), and ascending aorta (Ao) can all be seen. This view provides an excellent view of LV outflow tract, enabling good color flow Doppler evaluation and providing a favorable angle for spectral Doppler assessment (MPG 5702 kb)

Visualization of tricuspid valve inflow and right ventricular outflow using a mid esophageal probe position. This mid esophageal right ventricular inflow-outflow view can be obtained using a multiplane angle of 60–90°. AO aorta, LA left atrium, MPA main pulmonary artery, RA right atrium, RV right ventricle (MPG 9336 kb)

Modified transgastric mid/basal short axis view, with the probe anteflexed and turned toward the right (clockwise). By adjusting the multiplane angle between 0 and 50°, the tricuspid valve can be seen en face. All three tricuspid valve leaflets are visualized: anterior (A), posterior (P), and septal (S). LV left ventricle, RV right ventricle (MPG 4728 kb)

Development of the transgastric right ventricular inflow view. This video first starts with a modified transgastric basal/mid short axis, in which the probe is rotated to the right (clockwise) to visualize the right ventricle (RV) and tricuspid valve. The multiplane angle is then rotated from 0° to about 100°, producing the transgastric right ventricular inflow view. The tricuspid valve leaflets, as well as chordae and papillary muscles, are well seen. Slight leftward (counterclockwise) probe rotation then visualizes the apical RV and RV outflow tract (RVOT). With further leftward probe rotation, the left ventricular outflow tract (LVOT) is shown. If the probe were rotated even further, a transgastric long axis view would be obtained. LV left ventricle, RA right atrium (MPG 11922 kb)

Modified transgastric right ventricular inflow view. The probe is rotated slightly more rightward to visualize the inflow of superior vena cava (SVC) into the right atrium. Note the excellent angle for spectral interrogation of SVC inflow. RA right atrium, RV right ventricle (MPG 4936 kb)

Evaluation of the ventricular septum in multiple planes in the mid esophagus to display the inlet, membranous and muscular portions. This assessment requires the use of multiple angles of interrogation from several transducer positions (see text for details). The views shown are obtained by rotating the imaging plane as well as flexing the probe anteriorly and posteriorly (AVI 87684 kb)

Left ventricular outflow tract as viewed from mid esophageal 4 chamber view (multiplane angle of 0°) as the probe is anteflexed, and mid esophageal aortic valve long axis view (multiplane angle about 120°). Both two dimensional imaging and color flow Doppler are used. LA left atrium, LV left ventricle, LVOT left ventricular outflow tract, RA right atrium, RV right ventricle (MPG 15336 kb)

Mid esophageal ascending aortic long axis view provides excellent visualization of the ascending aorta (Asc Ao) in a long axis as it courses anterior to the right pulmonary artery (RPA). This view is very useful for evaluation of supravalvar aortic stenosis, and also for quantitative measurements of the Asc Ao (MPG 3242 kb)

Mid esophageal ascending aortic long axis view. With slight leftward (counterclockwise) probe rotation, the main pulmonary artery (MPA) can be seen; this view is helpful for assessment of pathology in the supravalvar pulmonary area (MPG 6528 kb)

Mid esophageal ascending aortic short axis displays the ascending aorta (Ao) in cross-section. This view is also useful for visualizing the main pulmonary artery (MPA) and right pulmonary artery (RPA), and sometimes the pulmonary valve (arrow) can also be seen in this view. SVC superior vena cava (MPG 5694 kb)

Deep transgastric long axis view with multiplane angle of 0–20°. The left ventricular outflow tract is very well seen and there is an excellent angle for spectral Doppler evaluation. This particular image also shows a perimembranous ventricular septal defect. Ao aorta, LA left atrium, LV left ventricle, RA right atrium, RV right ventricle (MPG 2948 kb)

Deep transgastric sagittal view evaluating both right and left ventricular outflow tracts. Multiplane angle of about 90° simulates a transthoracic subcostal sagittal view. Note the favorable angles for spectral Doppler interrogation of flow across both outflow tracts (AVI 34480 kb)

Deep transgastric sagittal view that simulates a transthoracic subcostal sagittal view. The superior vena cava (SVC) is seen to enter the right atrium (RA), and the left atrium (LA) is also seen, as well as a small atrial septal defect (arrow). A catheter tip is present in the RA. Color flow Doppler shows SVC return and left to right flow across the atrial defect (MPG 4648 kb)

Aortic valve as viewed en face in the mid esophageal aortic valve short axis view, multiplane angle about 35°. Both coronary origins can be well-seen(AVI 14584 kb)

Aortic valve as viewed en face in the mid esophageal aortic valve short axis view. In this video, there has been leftward (counterclockwise) rotation of the TEE probe along with rotation of the image plane to a more sagittal view that visualizes the right ventricular outflow tract, multiplane angle about 100°. As the probe is rotated to the left (counterclockwise) to a mid esophageal two chamber view, the bifurcation of the left main coronary artery into the left anterior descending and circumflex coronary arteries is seen (MPG 6210 kb)

Mid and upper esophageal views of great arteries, using a multiplane angle of 0°. Starting first at mid esophageal ascending aorta short axis view, the main pulmonary artery (MPA) and pulmonary valve (PV) are seen along with the ascending aorta (Asc Ao) in cross-section. Turning the probe to the right, the MPA is seen continuing to the right pulmonary artery (RPA), with the superior vena cava (SVC) anterior to the RPA. The probe tip is rotated back to midline and slightly leftward, and when the probe is gradually withdrawn, an upper esophageal aortic arch long axis view is obtained, showing Asc Ao and transverse aortic arch (ARCH). When the probe is advanced slightly and turned to the left, the upper esophageal pulmonary artery long axis view can often be obtained, showing the left pulmonary artery (LPA) just anterior to the aortic arch/descending aorta (Ao). If the probe were then turned back to midline, the MPA and RPA will be seen again, and sometimes the bifurcation of the branch pulmonary arteries (MPG 32064 kb)

Upper esophageal aortic arch short axis view (multiplane angle 90–100°). The probe is slowly turned from right to left, showing the innominate vein (Inn V), ascending aorta (Asc Ao), aortic arch (Ao), and main pulmonary artery (MPA). Note the position of the Inn V anterior and superior to the transverse aortic arch. Further leftward probe rotation and slight probe advancement displays the descending aorta (Desc Ao) and mid left pulmonary artery (LPA) (MPG 26802 kb)

Upper esophageal aortic arch short axis sweep (multiplane angle about 90°) used to display the aortic arch vessels, in a patient with a left aortic arch. The transducer is first turned to the right to visualize the ascending aorta (Asc Ao); in this view the innominate artery (Inn Artery) is first seen. As the transducer is rotated toward to the left (counterclockwise), the aortic arch (Ao) gives rise to the left common carotid artery (LCCA) and left subclavian artery. Note the innominate vein (Inn Vein) seen in cross section (short axis), anterior and superior to the aortic arch. MPA main pulmonary artery (MPG 33304 kb)

Upper esophageal aortic arch long axis view in the patient from Video 4.3 with an absent right superior vena cava (SVC). The innominate vein (Inn V) is seen crossing anterior to the aortic arch (Ao) to connect with a left SVC (LSVC), which then drains via a dilated coronary sinus into the right atrium (not shown). A catheter is seen in the Inn V and LSVC (MPG 3434 kb)

Descending thoracic aorta views. In the mid esophageal window the probe is rotated to the left (counterclockwise) to visualize the aorta. A multiplane angle of 0° displays the descending thoracic aorta in cross section; changing the multiplane angle to 90–110° produces a long axis display of the vessel (MPG 7784 kb)

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Wong, P.C. (2014). Structural Evaluation of the Heart by Transesophageal Echocardiography. In: Wong, P., Miller-Hance, W. (eds) Transesophageal Echocardiography for Congenital Heart Disease. Springer, London. https://doi.org/10.1007/978-1-84800-064-3_4

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