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Chapter 6: Goal-Oriented TTE, Epicardial and Epiaortic Echocardiography

This chapter presents goal-directed echocardiography for acute care, including transthoracic, epicardial, and epiaortic approaches. Key imaging views and protocols are discussed. Procedural videos and annotated images will illustrate each technique in clinical use.

1

Figures

Focused cardiac ultrasound study (FOCUS). The FOCUS exam includes the most important echocardiographic views with scanning in a systematic, clockwise fashion, from three main areas: the parasternal (1), apical (2), and subcostal (3) areas. Adapted from the <em>FOCUS pocket guide</em>, with permission from ICCU Imaging Inc.

eFigure 6.1

Focused cardiac ultrasound study (FOCUS). The FOCUS exam includes the most important echocardiographic views with scanning in a systematic, clockwise fashion, from three main areas: the parasternal (1), apical (2), and subcostal (3) areas. Adapted from the FOCUS pocket guide, with permission from ICCU Imaging Inc.

Takotsubo syndrome. Acute hemodynamic instability occurs in a 73-year-old woman after duodenal perforation. (A, B) A focused cardiac ultrasound study (FOCUS) exam from a subcostal view revealed severe left ventricular (LV) dysfunction with basal sparing typical of Takotsubo syndrome. (C, D) A parasternal SAX view confirms the abnormal LV function.<em> Abbreviations</em>: LA, left atrium; RA, right atrium; RV, right ventricle; SAX, short-axis. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 6.5

Takotsubo syndrome. Acute hemodynamic instability occurs in a 73-year-old woman after duodenal perforation. (A, B) A focused cardiac ultrasound study (FOCUS) exam from a subcostal view revealed severe left ventricular (LV) dysfunction with basal sparing typical of Takotsubo syndrome. (C, D) A parasternal SAX view confirms the abnormal LV function. Abbreviations: LA, left atrium; RA, right atrium; RV, right ventricle; SAX, short-axis.

Methods used for epicardial echocardiography. (A, B) A trained cardiac surgeon can manipulate high-frequency transthoracic and linear probes in sterile sheaths on the epicardium to identify the key structures. (C, D) In certain cases, an experienced echocardiographer can use a TEE probe in a sterile sheath that the surgeon positions on the epicardium to enable epicardial echocardiography. <em>Abbreviation</em>: TEE, transesophageal echocardiography. <em>Source</em>: Courtesy of Dr. Michel Pellerin. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 6.10

Methods used for epicardial echocardiography. (A, B) A trained cardiac surgeon can manipulate high-frequency transthoracic and linear probes in sterile sheaths on the epicardium to identify the key structures. (C, D) In certain cases, an experienced echocardiographer can use a TEE probe in a sterile sheath that the surgeon positions on the epicardium to enable epicardial echocardiography. Abbreviation: TEE, transesophageal echocardiography. Source: Courtesy of Dr. Michel Pellerin.

Epicardial LV LAX view#5. (A, B) This view is equivalent to the transthoracic parasternal LV LAX view. Probe placement is on the anterior RV with a marker towards the right shoulder. From the epicardial LV mid-SAX view, angling the ultrasound beam superiorly and rotating the probe toward the patient’s right shoulder generates the epicardial LV LAX view. This view evaluates the inferolateral and anteroseptal walls of the LV and the RV, LA, LVOT, aortic valve, and mitral valve. Color flow Doppler can assess for aortic regurgitation, mitral regurgitation, ventricular septal defects, LVOT obstruction, or systolic anterior motion of the mitral valve using this view. (C, D) An epicardial LV LAX view before myxoma removal localizes fixation of the tumor on the interatrial septum. (E) Pathological specimen is shown.<em> Abbreviations</em>: Ao, aorta; LA, left atrium; LAX, long-axis; LV, left ventricle; LVOT, left ventricular outflow tract; RVOT, right ventricular outflow tract. Photo E courtesy of Dr. Michel Pellerin. Adapted from Reeves et al. <strong><sup>73</sup></strong>. <i class='fa fa-video-camera' aria-hidden='true'></i>

Figure 6.25

Epicardial LV LAX view#5. (A, B) This view is equivalent to the transthoracic parasternal LV LAX view. Probe placement is on the anterior RV with a marker towards the right shoulder. From the epicardial LV mid-SAX view, angling the ultrasound beam superiorly and rotating the probe toward the patient’s right shoulder generates the epicardial LV LAX view. This view evaluates the inferolateral and anteroseptal walls of the LV and the RV, LA, LVOT, aortic valve, and mitral valve. Color flow Doppler can assess for aortic regurgitation, mitral regurgitation, ventricular septal defects, LVOT obstruction, or systolic anterior motion of the mitral valve using this view. (C, D) An epicardial LV LAX view before myxoma removal localizes fixation of the tumor on the interatrial septum. (E) Pathological specimen is shown. Abbreviations: Ao, aorta; LA, left atrium; LAX, long-axis; LV, left ventricle; LVOT, left ventricular outflow tract; RVOT, right ventricular outflow tract. Photo E courtesy of Dr. Michel Pellerin. Adapted from Reeves et al. 73.

Broken stent in LMCA (A, B) Epicardial view of a broken stent in the LMCA and the epiaortic view shows a small linear hyper-echoic artefact close to the LMCA orifice.<em> Abbreviations</em>: LMCA, left main coronary artery. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 6.29

Broken stent in LMCA (A, B) Epicardial view of a broken stent in the LMCA and the epiaortic view shows a small linear hyper-echoic artefact close to the LMCA orifice. Abbreviations: LMCA, left main coronary artery.

Mobile atheroma, (A, B) Epiaortic images of the aortic arch in zone 2 reveal a mobile atheroma (Grade 5) in a 74-year-old woman before cardiopulmonary bypass. (C) To avoid aortic clamping during off-pump coronary artery bypass grafting, the surgeon anastomosed the saphenous vein graft between the RCA and the LIMA graft rather than onto the aorta, as is usually the case. (D,E) Unexpected floating plaque or thrombus in the ascending aorta.<em> Abbreviations</em>: Ao, aorta; LAD, left anterior descending coronary artery; LIMA, left internal mammary artery; RCA, right coronary artery. <em>Source</em>: Photo C courtesy of Dr. Louis P. Perrault. <i class='fa fa-video-camera' aria-hidden='true'></i>

Figure 6.39

Mobile atheroma, (A, B) Epiaortic images of the aortic arch in zone 2 reveal a mobile atheroma (Grade 5) in a 74-year-old woman before cardiopulmonary bypass. (C) To avoid aortic clamping during off-pump coronary artery bypass grafting, the surgeon anastomosed the saphenous vein graft between the RCA and the LIMA graft rather than onto the aorta, as is usually the case. (D,E) Unexpected floating plaque or thrombus in the ascending aorta. Abbreviations: Ao, aorta; LAD, left anterior descending coronary artery; LIMA, left internal mammary artery; RCA, right coronary artery. Source: Photo C courtesy of Dr. Louis P. Perrault.

2

Videos

Chapter 06 Fig02A

Chapter 06 Fig02B

Chapter 06 Fig02C

Chapter 06 Fig02D

Chapter 06 Fig02E

Chapter 06 Fig02F

Chapter 06 Fig02G

Chapter 06 Fig02H

Chapter 06 Fig03B

Chapter 06 Fig03C

Chapter 06 Fig03D

Chapter 06 Fig04A

Chapter 06 Fig04D

Chapter 06 Fig05A

Chapter 06 Fig05C

Chapter 06 Fig06A

Chapter 06 Fig07A

Chapter 06 Fig08A

Chapter 06 Fig08B

Chapter 06 Fig09A

Chapter 06 Fig09B

Chapter 06 Fig10D

Chapter 06 Fig11A

Chapter 06 Fig12A

Chapter 06 Fig12C

Chapter 06 Fig13A

Chapter 06 Fig13B

Chapter 06 Fig13DE

Chapter 06 Fig14A

Chapter 06 Fig15A

Chapter 06 Fig16A

Chapter 06 Fig17A

Chapter 06 Fig18A

Chapter 06 Fig19A

Chapter 06 Fig20A

Chapter 06 Fig21A

Chapter 06 Fig22A

Chapter 06 Fig22B

Chapter 06 Fig23A

Chapter 06 Fig23C

Chapter 06 Fig24A

Chapter 06 Fig24C

Chapter 06 Fig25A

Chapter 06 Fig25C

Chapter 06 Fig25C1

Chapter 06 Fig26A

Chapter 06 Fig27A

Chapter 06 Fig28A

Chapter 06 Fig28C

Chapter 06 Fig28D

Chapter 06 Fig29A

Chapter 06 Fig31B

Chapter 06 Fig31C

Chapter 06 Fig31D

Chapter 06 Fig31E

Chapter 06 Fig32B

Chapter 06 Fig33A

Chapter 06 Fig34BC

Chapter 06 Fig35B

Chapter 06 Fig36B

Chapter 06 Fig37BC

Chapter 06 Fig38BC

Chapter 06 Fig39A

Chapter 06 Fig39C

Chapter 06 Fig39D

3

Tables

x Epicardial and epiaortic views

Epicardial Views View-Technique Utility/Disadvantages

 

1

Epicardial AoV SAX
Orientation marker points left
  • Assess AoV cusps
  • Perpendicular alignment precludes PWD or CWD AoV gradient interrogation

 

2

Epicardial AoV LAX
Orientation marker points posterior
  • Good alignment to measure AoV gradients
  • Assess proximal aortic root

 

3

Epicardial LV basal SAX
Orientation marker points left
  • Evaluate IVS motion for RV pressure or volume overload
  • MV assessment, PMC is on the left and the ALC on the right portion of the screen

 

4

Epicardial LV mid SAX
Orientation marker points left

  • Assess wall motion abnormalities
  • LV AL papillary muscle on right and PM papillary muscle on left

 

5

Epicardial LV LAX
Orientation marker points toward right shoulder

  • Favourable alignment to detect LVOTO and SAM
  • Perpendicular alignment precludes PWD or CWD AoV and MV gradient interrogation

 

6

Epicardial LV 2C
Orientation marker points opposite to LV apex
  • Evaluate anterior and inferior wall
  • To completely exclude the RV, place transducer directly on LV, which is possible only in patients with severe LV dilation

 

7

Epicardial RVOT
Orientation marker points left
  • Favourable alignment to detect RVOTO 46, PV and TV stenosis or regurgitation
  • Perpendicular alignment precludes PWD or CWD of AoV

 

Alternative epicardial views

 

Alt#1

Epicardial alternative RV inflow
Orientation marker points cephalad
  • Evaluates RA, anterior and inferior RV walls

 

Alt#2

Epicardial alternative RA and bicaval views Orientation marker points cephalad
  • Assess caval canulation

 

Alt#3

Epicardial alternative TV SAX
Orientation marker points left
  • Evaluate TV
  • Perpendicular alignment precludes PWD or CWD RV assessment

 

Alt#4

Epicardial alternative PV SAX
Orientation marker points left
  • Evaluate PV
  • Perpendicular alignment precludes PWD or CWD PV assessment

 

Alt#5

Epicardial alternative PV LAX 
Orientation marker points left
  • Evaluate PV anatomy
  • Perpendicular alignment precludes PWD or CWD PV assessment

 

Alt#6

Epicardial alternative RVOT
Orientation marker points left
  • Measure PV gradients 
  • Evaluate distal RVOT and MPA

 

Alt#7

Epicardial alternative Ao SAX
Orientation marker points left
  • Evaluate ascending aorta

 

Epiaortic views

#1

Epiaortic SAX
Zone #1 
Orientation marker points left
  • Evaluate proximal ascending aorta

#2

Epiaortic SAX
Zone #2
Orientation marker points  left
  • Evaluate mid ascending aorta

#3

Epiaortic SAX
Zone #3
Orientation marker points left
  • Evaluate distal ascending aorta

#4

Epiaortic LAX 
Zone #1-3
Orientation marker points cephalad
  • Evaluate longitudinal ascending aorta and RPA

#5

Epiaortic arch SAX Zone 4-5
Orientation marker points  left
  • Evaluate aortic branches

#6

Epiaortic arch SAX Zone #3-6
Orientation marker points cephalad
  • Evaluate aortic arch

Abbreviations: 2C, two-chamber; AL, antero-lateral; ALC, anterolateral commissure; Alt, alternative; Ao, aorta; AoV, aortic valve; CWD, continuous-wave Doppler; IVS, interventricular septum; LAX, long-axis; LCCA, left common carotid artery; LSCA, left subclavian artery; LV, left ventricular; LVOTO, left ventricular outflow tract; MV, mitral valve; MPA, main pulmonary artery;  PM, postero-medial; PMC, postero-medial commissure; PV, pulmonic valve; PWD, pulsed-wave Doppler; RA, right atrium; RBCA, right brachiocephalic artery; RPA, right pulmonary artery; RV, right ventricle; RVOT, right ventricular outflow tract; RVOTO, right ventricular outflow tract; SAM, systolic anterior motion; SAX, short-axis; SVC, superior vena cava; TV, tricuspid valve. Adapted from Rousou 48, Eltzschig 40, Reeves 73, Kumbarathi 45, Stern 74 and Royse et al. 70

eTable 6.6 Suitable epicardial views for congenital lesions

Pathology View

Atrial septal defect

LAX, 4C

Total anomalous pulmonary venous connection

confluence in relation to LA LAX, 4C

Cor triatriatum

SAX

Mitral valve anomalies

LAX, 4C, SAX

Subvalvular apparatus of mitral valve

SAX

Left ventricle function

SAX

Subvalvular and valvular aortic stenosis

LAX

Subvalvular and valvular pulmonary stenosis

RVOT

Branch pulmonary artery stenosis

Trans-aortic SAX

Coarctation

Trans-aortic LAX

Glenn shunt

Trans-aortic LAX

Abbreviations: 4C, four-chamber; LA, left atrium, LAX, long-axis; RVOT, right ventricular outflow tract; SAX, short-axis; Adapted from 53