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Chapter 32: Extra-Cardiac TEE

This chapter introduces lung and abdominal ultrasonography via TEE. Case images and procedural videos will illustrate applications in thoracic and GI pathology.

1

Figures

TELUS TEE probe orientation. The US beam remains at 90°. The TEE knob represents a clock hand starting at 12 o’clock, then rotating counterclockwise from the left to 9, 6, 3 o’clock back to 12 o’clock. This allows the TEE knob position to identify the precise location of the US beam in the chest.<em> Abbreviations</em>: TEE, transesophageal echocardiography; TELUS, transesophageal lung ultrasound; US, ultrasound.

eFigure 32.4

TELUS TEE probe orientation. The US beam remains at 90°. The TEE knob represents a clock hand starting at 12 o’clock, then rotating counterclockwise from the left to 9, 6, 3 o’clock back to 12 o’clock. This allows the TEE knob position to identify the precise location of the US beam in the chest. Abbreviations: TEE, transesophageal echocardiography; TELUS, transesophageal lung ultrasound; US, ultrasound.

TELUS examination. These diagrams represent TELUS examination of the left lung in the anterior region (A-C), lateral (D-F) and posterior (G-I) regions, as indicated by the yellow star.<em> Abbreviations</em>: TELUS, transesophageal lung ultrasound.<i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 32.5

TELUS examination. These diagrams represent TELUS examination of the left lung in the anterior region (A-C), lateral (D-F) and posterior (G-I) regions, as indicated by the yellow star. Abbreviations: TELUS, transesophageal lung ultrasound.

TELUS examination. These diagrams represent TELUS examination of the right lung anterior region (A-C), lateral (D-F) and posterior (G-I) regions, as indicated by the yellow star.<em> Abbreviations</em>: TELUS, transesophageal lung ultrasound. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 32.6

TELUS examination. These diagrams represent TELUS examination of the right lung anterior region (A-C), lateral (D-F) and posterior (G-I) regions, as indicated by the yellow star. Abbreviations: TELUS, transesophageal lung ultrasound.

Mediastinum anatomy. (A) This diagram shows the regions of the mediastinum as superior, anterior, middle, and posterior. The superior mediastinum is from the first rib to T4, the anterior mediastinum is from the sternum to the pericardium, the middle mediastinum is from T4 to T9, and the posterior mediastinum lies between the posterior pericardium to the spine. (B) More recent guidelines by the International Thymic Malignancy Interest Group divide the mediastinum in 3 regions.

eFigure 32.13

Mediastinum anatomy. (A) This diagram shows the regions of the mediastinum as superior, anterior, middle, and posterior. The superior mediastinum is from the first rib to T4, the anterior mediastinum is from the sternum to the pericardium, the middle mediastinum is from T4 to T9, and the posterior mediastinum lies between the posterior pericardium to the spine. (B) More recent guidelines by the International Thymic Malignancy Interest Group divide the mediastinum in 3 regions.

Mediastinal lymph nodes. This is a diagram of the mediastinal lymph node stations for lung cancer staging.<em> Abbreviations</em>: a, artery; A, anterior; Ao aorta; inf, inferior; L, left; ligt, ligament; n, nerve; P, posterior; PA, pulmonary artery; pulm, pulmonary; v, vein. Source: With permission of Mountain CF et al.<strong><sup>32</sup></strong>

eFigure 32.14

Mediastinal lymph nodes. This is a diagram of the mediastinal lymph node stations for lung cancer staging. Abbreviations: a, artery; A, anterior; Ao aorta; inf, inferior; L, left; ligt, ligament; n, nerve; P, posterior; PA, pulmonary artery; pulm, pulmonary; v, vein. Source: With permission of Mountain CF et al.32

Middle mediastinal pathology. (A,B) UE TEE view from endosonography of a malignant 4 X 2 cm sub-carinal lymph node (Station 7) in a patient with small-cell lung carcinoma.<em> Abbreviations</em>: Ao, aorta; LA, right atrium; PA, pulmonary artery; TEE, transesophageal echocardiography; UE, upper esophageal.<i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 32.15

Middle mediastinal pathology. (A,B) UE TEE view from endosonography of a malignant 4 X 2 cm sub-carinal lymph node (Station 7) in a patient with small-cell lung carcinoma. Abbreviations: Ao, aorta; LA, right atrium; PA, pulmonary artery; TEE, transesophageal echocardiography; UE, upper esophageal.

Abdominal aortic aneurysm. This is a patient with an AAA compressing the IVC as seen by on (A) CT scan. Note the tortuous abdominal Ao. (B,C) Corresponding subcostal LAX view with IVC compression (plane #3 on CT scan) (D-G) TGAUS views. A cephalad view (plane #1 on CT scan) shows the AAA. A more caudal plane (plane #2 on CT scan) shows the AAA and the abdominal aorta on the same plane, giving the impression of 2 separate vessels.<em> Abbreviations</em>: AAA, abdominal aortic aneurysm; Ao, aorta; CT, computed tomography; IVC, inferior vena cava; LAX, long-axis; TGAUS, transgastric abdominal ultrasound.<i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 32.24

Abdominal aortic aneurysm. This is a patient with an AAA compressing the IVC as seen by on (A) CT scan. Note the tortuous abdominal Ao. (B,C) Corresponding subcostal LAX view with IVC compression (plane #3 on CT scan) (D-G) TGAUS views. A cephalad view (plane #1 on CT scan) shows the AAA. A more caudal plane (plane #2 on CT scan) shows the AAA and the abdominal aorta on the same plane, giving the impression of 2 separate vessels. Abbreviations: AAA, abdominal aortic aneurysm; Ao, aorta; CT, computed tomography; IVC, inferior vena cava; LAX, long-axis; TGAUS, transgastric abdominal ultrasound.

Visceral artery perfusion. This schematic discloses the four perfusion patterns of visceral arteries. In Type A, there is no dissection in the branch artery with detectable blood flow. In Type B, the dissection extends into the branch artery with patent and dominant true lumen (TL) associated with small non-perfused (type B1) or perfused false lumen (FL) (type B2). Type C involves dissection extending into the branch artery with the narrowed TL compressed by FL without detectable blood flow. Type D has no dissection in the branch artery but the orifice obstructed by the intimal flap in the aorta. Clinically apparent intestinal ischemia was present in three cases: one case with Type C and two cases with Type D. Adapted from Orihashi et al.<strong><sup>48</sup></strong>

eFigure 32.26

Visceral artery perfusion. This schematic discloses the four perfusion patterns of visceral arteries. In Type A, there is no dissection in the branch artery with detectable blood flow. In Type B, the dissection extends into the branch artery with patent and dominant true lumen (TL) associated with small non-perfused (type B1) or perfused false lumen (FL) (type B2). Type C involves dissection extending into the branch artery with the narrowed TL compressed by FL without detectable blood flow. Type D has no dissection in the branch artery but the orifice obstructed by the intimal flap in the aorta. Clinically apparent intestinal ischemia was present in three cases: one case with Type C and two cases with Type D. Adapted from Orihashi et al.48

TGAUS IVC and liver view. (A,B) TGAUS IVC view after RVAD implantation shows an IVC thrombus (white arrow) and free abdominal fluid anterior to the liver (yellow arrow). (C,D) TGAUS view with CFI in a patient with multiple irregular liver cysts<em> Abbreviations</em>: CFI, color flow imaging; IVC, inferior vena cava; RVAD, right ventricular assist device; TGAUS, transgastric abdominal ultrasound. Adapted from Denault et al.<strong><sup>4</sup></strong><i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 32.34

TGAUS IVC and liver view. (A,B) TGAUS IVC view after RVAD implantation shows an IVC thrombus (white arrow) and free abdominal fluid anterior to the liver (yellow arrow). (C,D) TGAUS view with CFI in a patient with multiple irregular liver cysts Abbreviations: CFI, color flow imaging; IVC, inferior vena cava; RVAD, right ventricular assist device; TGAUS, transgastric abdominal ultrasound. Adapted from Denault et al.4

Splanchnic consequence of RV dysfunction. This is a 76-year-old man with cardiomyopathy admitted for lead-extraction. (A-C) ME 4C RV-focused views without and with CFI show RV dilatation without significant tricuspid regurgitation. (D,E) However, using TGAUS, there was significant portal and splenic vein pulsatility. The significant reduction in RA compliance will lead to pressure transmission during the cardiac cycle in the splanchnic and peripheral venous system without any significant tricuspid regurgitation.<em> Abbreviations</em>: 4C, four-chamber; CFI, color flow imaging; LA, left atrium; LV, left ventricle; ME, mid-esophageal; PoVV, portal vein velocity; RA, right atrium; RV, right ventricular; SVV, splenic vein velocity; TGAUS, transgastric abdominal ultrasound. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 32.36

Splanchnic consequence of RV dysfunction. This is a 76-year-old man with cardiomyopathy admitted for lead-extraction. (A-C) ME 4C RV-focused views without and with CFI show RV dilatation without significant tricuspid regurgitation. (D,E) However, using TGAUS, there was significant portal and splenic vein pulsatility. The significant reduction in RA compliance will lead to pressure transmission during the cardiac cycle in the splanchnic and peripheral venous system without any significant tricuspid regurgitation. Abbreviations: 4C, four-chamber; CFI, color flow imaging; LA, left atrium; LV, left ventricle; ME, mid-esophageal; PoVV, portal vein velocity; RA, right atrium; RV, right ventricular; SVV, splenic vein velocity; TGAUS, transgastric abdominal ultrasound.

Renal Doppler abnormalities. (A) PWD of a RAV in a patient with aortic stenosis showing pulsus tardus or delayed peak systolic Doppler signal (arrow) and prolonged acceleration time (>70 msec). <sup>86</sup> (B) Abnormal RVV Doppler signal after CPB an uniphasic diastolic waveform and biphasic waveform on the fourth Doppler signal (arrows).<sup>93</sup>(C,D) Renal artery air embolism and simultaneous TCD upon unclamping at the end of CPB. Both monitoring techniques indicate emboli in multiple organs. A total of 3590 HITS occurred during the procedure, which correlates with increased morbidity and mortality.<sup>168</sup><em> Abbreviations</em>: CPB, cardiopulmonary bypass; EDV, end-diastolic velocity; HITS, high-intensity transient signals; MV, mean velocity; PI, pulsatility index; PSV, peak systolic velocity; PWD, pulsed-wave Doppler, RAV, renal artery velocity, RVV, renal vein velocity; TCD, transcranial Doppler. Adapted from Denault et al.<strong><sup>4</sup></strong><i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 32.42

Renal Doppler abnormalities. (A) PWD of a RAV in a patient with aortic stenosis showing pulsus tardus or delayed peak systolic Doppler signal (arrow) and prolonged acceleration time (>70 msec). 86 (B) Abnormal RVV Doppler signal after CPB an uniphasic diastolic waveform and biphasic waveform on the fourth Doppler signal (arrows).93(C,D) Renal artery air embolism and simultaneous TCD upon unclamping at the end of CPB. Both monitoring techniques indicate emboli in multiple organs. A total of 3590 HITS occurred during the procedure, which correlates with increased morbidity and mortality.168 Abbreviations: CPB, cardiopulmonary bypass; EDV, end-diastolic velocity; HITS, high-intensity transient signals; MV, mean velocity; PI, pulsatility index; PSV, peak systolic velocity; PWD, pulsed-wave Doppler, RAV, renal artery velocity, RVV, renal vein velocity; TCD, transcranial Doppler. Adapted from Denault et al.4

Renal CFI and arterial pressure. This is a 53-year-old man with coronary artery disease undergoing an aortic aneurysm repair. These are the TGAUS renal views with CFI at a very low velocity (A) before CA at a MAP 68 mmHg, (B) during CA at MAP 13 mmHg, there are no velocities but upon weaning from CPB, minimal CFI signals appear at (C) 60 mmHg, (D) 70 mmHg until the MAP reaches (E) 90 mmHg. Thereafter (F) a MAP of 60 mmHg had the same CFI signal as the baseline value.<em> Abbreviations</em>: CA, circulatory arrest; CFI, color flow imaging; CPB cardiopulmonary bypass; MAP, mean arterial pressure; TGAUS, transgastric abdominal ultrasound.<i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 32.44

Renal CFI and arterial pressure. This is a 53-year-old man with coronary artery disease undergoing an aortic aneurysm repair. These are the TGAUS renal views with CFI at a very low velocity (A) before CA at a MAP 68 mmHg, (B) during CA at MAP 13 mmHg, there are no velocities but upon weaning from CPB, minimal CFI signals appear at (C) 60 mmHg, (D) 70 mmHg until the MAP reaches (E) 90 mmHg. Thereafter (F) a MAP of 60 mmHg had the same CFI signal as the baseline value. Abbreviations: CA, circulatory arrest; CFI, color flow imaging; CPB cardiopulmonary bypass; MAP, mean arterial pressure; TGAUS, transgastric abdominal ultrasound.

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Videos

Chapter 32 Fig01

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Tables

eTable 32.3 Ultrasound-guided differential diagnosis of acute hypoxemia

Diagnosis

Lungs

Left Heart

Right Heart

Pneumonia
  • Consolidation (unilateral > bilateral)
  • Dynamic air bronchogram
  • Pleural effusion (simple or complex) ipsilateral to consolidation
  • Lung abscess
  • Variable impact
  • Reduced LVEF might be present with septic cardiomyopathy

 
  • Variable impact
  • Reduced RVEF might be present with septic cardiomyopathy

Obstructive atelectasis
  • Consolidation
  • Early whole lung collapse may have absent lung sliding but preserved lung pulse
  • Absence of dynamic air bronchogram
  • Usually normal
  • Change in LAX position (horizontal axis if left and vertical axis if right atelectasis)
  • Variable impact depending on the degree of associated pulmonary hypertension

Massive pleural effusion
  • Massive pleural effusion
  • Ipsilateral consolidation (compressive atelectasis)
  • Usually normal
  • Normal

ARDS
  • Bilateral heterogeneous B-lines ("skip areas")
  • Focal areas of reduced or absent lung sliding
  • Posterior consolidation(s) unilateral or bilateral
  • Normal LV systolic and diastolic function
  • No valvulopathy
  • Increased SPAP
  • RV dilatation and hypokinesis
  • IVC dilatation

Pneumothorax
  • Absence of lung sliding and pulse
  • Absence of B-lines
  • Presence of A-lines
  • Lung point
  • Small left cavities
  • Small right cavities
  • IVC dilatation
  • Inspiratory collapse of RA and/or RVOT

Pulmonary embolism
  • In acute setting, normal lung exam
  • May eventually develop pleural effusion and/or area of consolidation
  • Usually normal but D-shaped interventricular septum if associated with PH
  • Increased SPAP
  • RV dilatation, McConnell
  • IVC dilatation
  • Thrombus in transit

LV failure
  • Bilateral homogenous B-lines
  • Simple bilateral pleural effusions
  • Decreased LVEF
  • Evidence of increased LA filling pressures (E/e’)
  • Variable impact

Left valvular pathology
  • Bilateral homogenous B-lines
  • Localized B-lines with eccentric MR or SAM
  • Significant valvular pathology

 
  • Variable impact

Abbreviations: ARDS, acute respiratory distress syndrome; E/e’, ratio of the early transmitral filling (E) to the early mitral annular velocity (e’); IVC, inferior vena cava; LA, left atrium; LAX, long-axis; LV, left ventricle; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; PH, pulmonary hypertension; RA, right atrium; RV, right ventricle; RVEF, right ventricular ejection fraction; RVOT, right ventricular outflow tract; SAM, systolic anterior motion; SPAP, systolic pulmonary artery pressure. (With permission of Cavayas et al.3)

eTable 32.5 Clinical role of TGAUS views in the operating room and intensive care unit

TGAUS ViewsClinical Role
Celiac trunk view #1 and SMA-renal confluence view #2Vascular monitoring during aortic dissection and vascular stenting;42, 119,37,45,120,121, 48,43,40 [DB1] detection of compromised splanchnic flow with celiac trunk and mesenteric artery monitoring,48 splanchnic vascular stenosis,49 nutcracker syndrome122, intra-aortic balloon pump positioning39
Stomach view #3Full stomach, upper gastrointestinal bleeding, gastric varices, free peritoneal fluid.35,119
Inferior vena cava and hepatic veins views #4Diagnosis of RV systolic and diastolic dysfunction,123-126,83, 71, 127, 66, 128 pulmonary hypertension,129-131 assessment for IVC stenosis in liver transplantation, heart transplantation, ECMO and artificial heart,132, 133, 73, 134, 71, 72, 135, 136, 37, 137, 24 ruling-out abdominal IVC tumor138, 57, 139-142, 61, 105, 108, 143, 65, 144, 145, 104, 146 or thrombus147, 140, 141, 148, 64, 143, 149, 74 as a cause of pulmonary embolism and right-to-left shunting through a PFO in hypoxic patients with right heart dilatation,147, 140, 141, 148, 64, 143, 149 abdominal compartment syndrome;150, 71, 24 intraoperative monitoring during renal cell carcinoma surgery involving the inferior vena cava.57, 151-154, 105, 107, 155, 108, 143, 65, 156, 144, 145, 102, 104, 157, 106, 146, 109
Portal triad view #5Abdominal compartment syndrome,35, 150, 71 mesenteric ischemia with portal venous air,35, 48 hepatic artery and portal vein stenosis in liver transplantation,134, 74 portal venous Doppler monitoring right ventricular dysfunction associated with venous congestion,92, 119, 76, 60 evaluation of response to medical treatment.92, 123
Liver view #6Detection of cirrhosis and ascites,119, 61 liver abscess or cysts,119 transjugular portal systemic shunt,75 liver transplantation and resection.158, 75, 74, 159
Spleen view #7Free abdominal fluid and splenic rupture in trauma,35, 87 splenic venous Doppler monitoring right ventricular dysfunction associated with venous congestion,92, 119, 76, 60 evaluation of response to medical treatment,92, 123
Kidney view #8Oligoanuria: renal arterial hypoperfusion or elevate renal resistance index,98, 160, 88, 51, 90, 161, 162, 46, 89, 91 renal venous congestion92, 89 left hydronephrosis and renal artery air embolization92 and differentiating acute versus chronic renal failure.119
Pancreatic view #9 and
sub-pancreatic splenic vessels view #10		Splenic venous Doppler monitoring right ventricular dysfunction associated with venous congestion 76 92,119,60 and evaluation of response to medical treatment.92, 123
Abbreviations: ECMO, extra-corporeal membrane oxygenation; IVC, inferior vena cava; PFO, patent foramen ovale; RV, right ventricular; SMA, superior mesenteric artery; TGAUS, transgastric abdominal ultrasound.