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Chapter 30: TEE in the ICU

This chapter describes TEE as a tool for hemodynamic monitoring in critical care. Images, and video recordings will demonstrate practical ICU applications.

1

Figures

Cardiac tamponade. This is a hemodynamically unstable 68-year-old woman after cardiac surgery. (A, B) ME 4C view shows a clot compressing the RA and RV. (C, D) The right heart chambers expand after clot evacuation.<em> Abbreviations</em>: 4C, four-chamber; LA, left atrium; LV, left ventricle; ME, mid-esophageal; RA, right atrium; RV, right ventricle. Adapted from Durand et al.<sup>210</sup> <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 30.5

Cardiac tamponade. This is a hemodynamically unstable 68-year-old woman after cardiac surgery. (A, B) ME 4C view shows a clot compressing the RA and RV. (C, D) The right heart chambers expand after clot evacuation. Abbreviations: 4C, four-chamber; LA, left atrium; LV, left ventricle; ME, mid-esophageal; RA, right atrium; RV, right ventricle. Adapted from Durand et al.210

Dynamic LVOTO. This is a 47-year-old man following cardiac arrest from RCA occlusion. (A, B) ME 5C view with CFI shows flow acceleration in the LVOT consistent with SAM. (C) CWD of the LVOT gives a late-peaking systolic gradient of 20 mmHg after treatment. The cause of the LVOTO was perhaps both inotrope usage and RV dysfunction from the RCA occlusion.<em> Abbreviations</em>: 5C, five-chamber; CFI, color flow imaging; CWD, continuous wave Doppler; DA, dopamine; ETCO2, end-tidal CO2; LA, left atrium, LV, left ventricle; LVOT, left ventricular outflow tract; LVOTO, left ventricular outflow tract; ME, mid-esophageal; Pabd, abdominal pressure; Pfa, femoral arterial pressure; PG, pressure gradient; Ppa, pulmonary artery pressure; Pra, right atrial pressure; RA, right atrium; RCA, right coronary artery; RV, right ventricle; SAM, systolic anterior motion.

eFigure 30.6

Dynamic LVOTO. This is a 47-year-old man following cardiac arrest from RCA occlusion. (A, B) ME 5C view with CFI shows flow acceleration in the LVOT consistent with SAM. (C) CWD of the LVOT gives a late-peaking systolic gradient of 20 mmHg after treatment. The cause of the LVOTO was perhaps both inotrope usage and RV dysfunction from the RCA occlusion. Abbreviations: 5C, five-chamber; CFI, color flow imaging; CWD, continuous wave Doppler; DA, dopamine; ETCO2, end-tidal CO2; LA, left atrium, LV, left ventricle; LVOT, left ventricular outflow tract; LVOTO, left ventricular outflow tract; ME, mid-esophageal; Pabd, abdominal pressure; Pfa, femoral arterial pressure; PG, pressure gradient; Ppa, pulmonary artery pressure; Pra, right atrial pressure; RA, right atrium; RCA, right coronary artery; RV, right ventricle; SAM, systolic anterior motion.

LV apical thrombus. (A, B) This is a 35-year-old man with cardiomyopathy evaluated for LVAD. The TG 2C view shows an unexpected mobile apical LV thrombus (arrow). (C, D) This is a 79-year-old man with a prior anterior myocardial infarction. (C) The ME 2C view shows a calcified apical thrombus which (D) intraoperatively was under the calcified scar. (E) The lateral chest X-ray shows the calcified aneurysm.<em> Abbreviations</em>: 2C, two-chamber; LA, left atrium; LV, left ventricle; LVAD, left ventricular assist device; ME, mid-esophageal; TG, transgastric. Source: Photo A and E courtesy of Dr. JK Shim and Dr. Raymond Cartier. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 30.7

LV apical thrombus. (A, B) This is a 35-year-old man with cardiomyopathy evaluated for LVAD. The TG 2C view shows an unexpected mobile apical LV thrombus (arrow). (C, D) This is a 79-year-old man with a prior anterior myocardial infarction. (C) The ME 2C view shows a calcified apical thrombus which (D) intraoperatively was under the calcified scar. (E) The lateral chest X-ray shows the calcified aneurysm. Abbreviations: 2C, two-chamber; LA, left atrium; LV, left ventricle; LVAD, left ventricular assist device; ME, mid-esophageal; TG, transgastric. Source: Photo A and E courtesy of Dr. JK Shim and Dr. Raymond Cartier.

Acute aortic dissection. This is a hemodynamically stable patient with known AR who is presented to the emergency room with acute chest pain radiating to the back. (A, B) ME AoV LAX view with CFI shows eccentric moderate AR directed toward the AMVL from a prolapsed right coronary cusp. (C, D) These are the intraoperative photos (C) before and (D) after Asc Ao opening just above a visible IMH. (E, F) CT shows the hematoma and an intimal flap 2 cm above the origin of the right coronary artery.<em> Abbreviations</em>: AMVL, anterior mitral valve leaflet; Ao, aorta; AoV, aortic valve; AR, aortic regurgitation; Asc Ao, ascending aorta; CFI, color flow imaging; CT, computed tomography; FL, false lumen; IF, intimal flap; IMH, intramural hematoma; LA, left atrium; LAX, long<strong>-</strong>axis; LV, left ventricle; ME, mid-esophageal; RV, right ventricle; TL, true lumen. Source: Courtesy of Drs. Michel Carrier and Carl Chartrand-Lefebvre. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 30.10

Acute aortic dissection. This is a hemodynamically stable patient with known AR who is presented to the emergency room with acute chest pain radiating to the back. (A, B) ME AoV LAX view with CFI shows eccentric moderate AR directed toward the AMVL from a prolapsed right coronary cusp. (C, D) These are the intraoperative photos (C) before and (D) after Asc Ao opening just above a visible IMH. (E, F) CT shows the hematoma and an intimal flap 2 cm above the origin of the right coronary artery. Abbreviations: AMVL, anterior mitral valve leaflet; Ao, aorta; AoV, aortic valve; AR, aortic regurgitation; Asc Ao, ascending aorta; CFI, color flow imaging; CT, computed tomography; FL, false lumen; IF, intimal flap; IMH, intramural hematoma; LA, left atrium; LAX, long-axis; LV, left ventricle; ME, mid-esophageal; RV, right ventricle; TL, true lumen. Source: Courtesy of Drs. Michel Carrier and Carl Chartrand-Lefebvre.

RA strain, portal pulsatility and fluid responsiveness. (A) RA strain before coronary revascularization surgery was 36%. After CPB, there was (B) monophasic portal vein velocity by PWD, (C) normal RV pressure waveform and (D) reduced RA strain at 7.8%. Transfusion of 200 ml blood resulted in (E) significant portal pulsatility and (F) increased Ppa and Prv pressure with a square root sign and reduction in rSO<sub>2</sub> suggesting liver and brain venous congestion.<em> Abbreviations</em>: CPB, cardiopulmonary bypass; ED, end-diastole; L, left; Ppa, pulmonary artery pressure; Prv, right ventricular pressure; PVV, portal vein velocity; R, right; RA, right atrial; RAScd, right atrial conduit strain; RASct, right atrial contraction strain; RASr, right atrial strain reservoir; rSO<sub>2</sub>, regional oxygen cerebral saturation; RV, right ventricular.<i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 30.14

RA strain, portal pulsatility and fluid responsiveness. (A) RA strain before coronary revascularization surgery was 36%. After CPB, there was (B) monophasic portal vein velocity by PWD, (C) normal RV pressure waveform and (D) reduced RA strain at 7.8%. Transfusion of 200 ml blood resulted in (E) significant portal pulsatility and (F) increased Ppa and Prv pressure with a square root sign and reduction in rSO2 suggesting liver and brain venous congestion. Abbreviations: CPB, cardiopulmonary bypass; ED, end-diastole; L, left; Ppa, pulmonary artery pressure; Prv, right ventricular pressure; PVV, portal vein velocity; R, right; RA, right atrial; RAScd, right atrial conduit strain; RASct, right atrial contraction strain; RASr, right atrial strain reservoir; rSO2, regional oxygen cerebral saturation; RV, right ventricular.

Lung recruitment. This is a 75-year-old woman with acute hypoxic respiratory failure. (A–F) ME 4C views show changes in RA and RV size as PEEP increases from 12 to 30 cmH<sub>2</sub>O, escalating Pra from 17 to 25 mmHg and ETCO<sub>2</sub> to a maximum of 23 mmHg at 25 cmH<sub>2</sub>O of PEEP.<em> Abbreviations</em>: 4C, four-chamber; ETCO<sub>2</sub>, end-tidal carbon dioxide; ME, mid-esophageal; PEEP, positive end-expiratory pressure; Pra, right atrial pressure; RA, right atrium; RV, right ventricle. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 30.20

Lung recruitment. This is a 75-year-old woman with acute hypoxic respiratory failure. (A–F) ME 4C views show changes in RA and RV size as PEEP increases from 12 to 30 cmH2O, escalating Pra from 17 to 25 mmHg and ETCO2 to a maximum of 23 mmHg at 25 cmH2O of PEEP. Abbreviations: 4C, four-chamber; ETCO2, end-tidal carbon dioxide; ME, mid-esophageal; PEEP, positive end-expiratory pressure; Pra, right atrial pressure; RA, right atrium; RV, right ventricle.

Takotsubo syndrome. This patient receiving intravenous adrenaline developed (A-F) apical akinesia associated with mild MR in the ME LAX view with CFI that resolved after stopping the adrenaline.<em> Abbreviations</em>: Ao, aorta; CFI, color flow imaging; LA, left atrium; LAX, long-axis view; LV, left ventricle; ME, mid-esophageal; MR, mitral regurgitation; RVOT, right ventricular outflow tract. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 30.22

Takotsubo syndrome. This patient receiving intravenous adrenaline developed (A-F) apical akinesia associated with mild MR in the ME LAX view with CFI that resolved after stopping the adrenaline. Abbreviations: Ao, aorta; CFI, color flow imaging; LA, left atrium; LAX, long-axis view; LV, left ventricle; ME, mid-esophageal; MR, mitral regurgitation; RVOT, right ventricular outflow tract.

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Videos

Chapter 30 Fig03A

Chapter 30 Fig03C

Chapter 30 Fig05A

Chapter 30 Fig05C

Chapter 30 Fig07A

Chapter 30 Fig07C

Chapter 30 Fig07E

Chapter 30 Fig08A

Chapter 30 Fig09A

Chapter 30 Fig09D

Chapter 30 Fig10A

Chapter 30 Fig10C

Chapter 30 Fig10D

Chapter 30 Fig11A

Chapter 30 Fig14AC

Chapter 30 Fig14D

Chapter 30 Fig14F

Chapter 30 Fig15A

Chapter 30 Fig15B

Chapter 30 Fig15C

Chapter 30 Fig15D

Chapter 30 Fig16B

Chapter 30 Fig16E

Chapter 30 Fig17B

Chapter 30 Fig18B

Chapter 30 Fig18D

Chapter 30 Fig20A

Chapter 30 Fig20F

Chapter 30 Fig21A

Chapter 30 Fig21B

Chapter 30 Fig21C

Chapter 30 Fig21D

Chapter 30 Fig21E

Chapter 30 Fig21F

Chapter 30 Fig21G

Chapter 30 Fig21H

Chapter 30 Fig22A

Chapter 30 Fig22B

3

Tables

eTable 30.2 Diagnostic criteria for stress cardiomyopathy*

  1. Transient RWMAs of LV or RV myocardium which are frequently, but not always, preceded by a stressful trigger (emotional or physical).
  2. The RWMAs usually extend beyond a single epicardial vascular distribution and often result in circumferential dysfunction of the ventricular segments involved.a
  3. The absence of culprit atherosclerotic coronary artery disease, including acute plaque rupture, thrombus formation, and coronary dissection or other pathological conditions to explain the pattern of temporary LV dysfunction observed (e.g., hypertrophic cardiomyopathy, viral myocarditis).
  4. New and reversible ECG abnormalities (ST-segment elevation, ST depression, LBBBb, T-wave inversion, and/or QTc prolongation) during the acute phase (3 months). 
  5. Significantly elevated serum natriuretic peptide (BNP or NT-proBNP) during the acute phase.
  6. Positive but relatively small elevation in cardiac troponin measured with a conventional assay (i.e., disparity between the troponin level and the amount of dysfunctional myocardium present). c
  7. Recovery of ventricular systolic function on cardiac imaging at follow-up (3–6 months). d

* according to the Heart Failure Association of the European Society of Cardiology diagnostic criteria for Takotsubo Syndrome

a Acute, reversible dysfunction of a single coronary territory has been reported
b LBBB may be permanent after Takotsubo syndrome but should also alert clinicians to exclude other cardiomyopathies. T-wave changes and QTc prolongation may take many weeks to months to normalize after the recovery of LV function
c Troponin-negative cases have been reported but are atypical.
d Small apical infarcts have been reported. Bystander subendocardial infarcts have been reported, involving a small proportion of the acutely dysfunctional myocardium. These infarcts are insufficient to explain the acute RWMA observed.

Abbreviations: BNP, b-type natriuretic peptide; ECG, electrocardiography; LBBB, left bundle branch block; LV, left ventricular; NT-proBNP, N-terminal pro b-type natriuretic peptide; RV, right ventricular; RWMA, regional wall motion abnormality. Adapted from Lyon et al. 178