Mark S. Adams

Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Scott T. Reeves, MD, FASE, Kathryn E. Glas, MD, FASE, Holger Eltzschig, MD, Joseph P. Mathew, MD, FASE, David S. Rubenson, MD, FASE, Gregg S. Hartman, MD, and Stanton K. Shernan, MD, FASE, for the Council for Intraoperative Echocardiography of the American Society of Echocardiography, Charleston, South Carolina; Atlanta, Georgia; Tubingen, Germany; Durham, North Carolina; La Jolla, California; and Lebanon, New Hampshire

Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: A report from the american society of echocardiography

General Considerations 40 Scope of Work 41 I. Echocardiographic Hemodynamic Monitoring Tools 41 Two-Dimensional Echocardiographic Monitoring Parameters 42 LV Chamber Dimensions 42 Inferior Vena Cava (IVC) Size and Collapsibility 43 Doppler Monitoring Parameters 43 Mitral Inflow 43 TDI 43 Calculated Monitoring Parameters 44 SV, Cardiac Output (CO), and SVR Calculations 44 RV Systolic Function 44 PA Systolic Pressure 45 II. Advantages, Disadvantages, and Recommendations of Echocardiography as a Monitoring Tool 45 III. Clinical Scenarios 45 Acute CHF Monitoring 45 Critical Care Monitoring 47 Pericardial Tamponade Monitoring 48 Pulmonary Embolism Therapy Monitoring 48 Prosthetic Valve Thrombosis Monitoring 48 Echocardiographic Monitoring in Trauma 48 IV. Perioperative Medicine 49 Echocardiographic Monitoring During Liver, Kidney, and Lung Transplantation 49

Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Scott T. Reeves, MD, FASE, Alan C. Finley, MD, Nikolaos J. Skubas, MD, FASE, Madhav Swaminathan, MD, FASE, William S. Whitley, MD, Kathryn E. Glas, MD, FASE, Rebecca T. Hahn, MD, FASE, Jack S. Shanewise, MD, FASE, Mark S. Adams, BS, RDCS, FASE, and Stanton K. Shernan, MD, FASE, for the Council on Perioperative Echocardiography of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists, Charleston, South Carolina; New York, New York; Durham, North Carolina; Atlanta, Georgia; Boston, Massachusetts

Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.

TABLE OF CONTENTSIntroduction 921General Guidelines 922Training and Certification 922Indications for TEE 923Management of Patient Sedation 927Sedation and Anesthesia 929Probe Insertion Techniques 930Instrument Controls 930Instrument Manipulation 931Comprehensive Imaging Examination 932ME Views 932TG

Doppler color flow mapping of epicardial coronary arteries: Initial observations☆

OBJECTIVES We addressed the hypothesis that blood flow could be imaged by Doppler color flow mapping of the coronary arteries and characteristic patterns described in normal and diseased vessels. BACKGROUND Echocardiographic imaging of the epicardial coronary arteries has been suggested as a useful adjunct to their intraoperative evaluation. Addition of Doppler color flow mapping could potentially enhance this evaluation by displaying the flow disturbance produced by anatomic lesions whose physiologic significance may otherwise be uncertain. In experimental models, such displays could also potentially provide insights into the pathophysiology of coronary blood flow and stenosis. METHODS Epicardial coronary arteries were examined with a high resolution 7-MHz linear phased-array transducer both in vivo and in vitro. 1) The coronary arteries were studied in the beating hearts of 10 open chest dogs in which experimental stenoses were also created; the maximal extent of the arterial tree in which flow could be seen in the most ideal setting was also examined in four additional excised perfused canine hearts. 2) Six excised human coronary arteries were perfused in a pulsatile manner to determine whether abnormal flow patterns could be prospectively identified and subsequently correlated with pathologic evidence of stenosis. RESULTS All normal coronary artery segments studied showed homogeneous flow without evidence of flow disturbance. In the excised heart, flow could be visualized to the distal extent of the epicardial vessels; in the open chest model, visualization of the proximal 5 to 6 cm was comparable, although surrounding structures limited access to the terminal portions of the vessels. The stenotic lesions created in the canine hearts (n = 9) showed recognizable alterations in the flow pattern: localized aliasing, proximal blood flow acceleration, distal flow disturbance and recirculatory flow. In the excised human arteries, these features identified 12 lesions, all of which corresponded to areas of > or = 50% lumen narrowing by pathologic examination. CONCLUSION Blood flow in the epicardial coronary arteries can be imaged by Doppler color flow mapping and characteristic flow patterns described in normal and diseased vessels.

The Cardiac Sonographer in the Operating Room: Who's Left Holding the Probe?

Among the many opportunities available to the cardiac sonographer, the operating room is possibly the most elusive and challenging environment of all. This setting currently accounts for only a small percentage of employment opportunities for sonographers, and their appropriate role in the operating room has been slow to evolve. The invasive nature of obtaining transesophageal echocardiography (TEE) clinical data and the somewhat restrictive current guidelines for TEE training and reporting are the primary reasons for the small numbers of registered sonographers working within the perioperative environment. While many sonographers see the operating room as an opportunity to advance their roles in the diagnostic process, the current boundaries are clear. ASE and the Society of Cardiovascular Anesthesiologists (SCA) recently published a joint document entitled ‘‘ASE/ SCA Recommendations and Guidelines for Continuous Quality Improvement in Perioperative Echocardiography.’’ This document supports the position paper, ‘‘Guidelines for Cardiac Sonographer Education: Recommendations of the American Society of Echocardiography Sonographer Training and Education Committee,’’ stating that ‘‘the role of the sonographer in the performance TEE is limited to maximizing image quality by the manipulation of the controls on the ultrasonography system.’’ Outside of the perioperative environment, the boundaries for sonographers’ responsibilities may be relaxing. ‘‘Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography: Recommendations of the American Society of Echocardiography Council on Cardiac Sonography’’ and recent sonographers’ communications within this journal highlight the developing role of the sonographer in contrast administration. After recognizing a clinical need, the ASE highly recommends that cardiac sonographers take the appropriate steps to become trained in the administration of contrast agents. These communications identified an area where guidelines for patient care could be usefully and safely expanded. An initiative to define educational requirements and competencies that would allow this newly expanded area of contrast cardiac sonography to develop has been productive. There may also be room for expanding the role of the sonographer within the demanding and dynamic domain of perioperative echocardiography. The growing clinical importance of TEE in the operating room brings with it changes and new opportunities. Recognizing the need to be proactive in embracing these opportunities, the Massachusetts General Hospital created an intraoperative sonographer position. The Division of Cardiothoracic Anesthesia and the Noninvasive Echocardiographic Laboratory considered utilizing the unique skills of a credentialed cardiac sonographer within the operating room for performing intraoperative echocardiographic studies. This interest emerged around the need to reevaluate the role of the anesthesiolo-

Unusual Position of a Prosthetic Mitral Valve

Extensive calcification of the mitral annulus in patients who require mitral valvereplacement presents a significant challenge to the surgeon. Several techniques, includingdebridement of the calcium, reconstruction of the annulus, and insertion of the prosthesis in a locationother than the annulus, have been used in such patients. We report the echocardiographictechniques used to evaluate the case of a woman with an unusually positioned prosthetic mitralvalve.

743-1 Quantitative Transthoracic Three-dimensional Voxel Imaging of the Left Ventricle: Clinical Validation

Recent computational advances have permitted 3-dimensional (3D) reconstruction of echo intensities over the cardiac volume from rotated 2D echo views gated to ECG and respiration. Unlike approaches using selected 2D views, such automated voxel acquisitions conveniently provide rapid spatial appreciation in animated views from multiple perspectives. However, only limited data are available regarding the accuracy of such reconstructions in patients, particularly using the transthoracic approach without the need for TEE. We therefore reconstructed the left ventricles of 10 consecutive patients referred for cardiac gated blood pool scan (GBPS) by transthoracic apical rotation, 5 with abnormal wall motion. LV volume was calculated by summing endocardial areas in parallel cross-sections derived from the voxel data, and compared to GBPS values by validated techniques to normalize counts for attenuation and countstvolume of blood sample. Results Reconstructed volumes (vol) agreed well with those from GBPS: y = r SEE Mean Error End-diastolic vol 0.85x + 17.2 098 8.66 cc 1.4% End-systolic vol 0.89x + 9.42 099 5.29 cc 4.6% Stroke vol 0.93x + 0.64 095 6.01 cc 2.4% Ejection fraction 0.94x - 0.23 0.99 2.59% 5.5% Conclusion 3D volumetric reconstruction of the LV not only provides convenient gated acquisition and ready spatial appreciation from multiple perspectives, but is also quantitatively accurate for LV size and function in patients by the transthoracic approach. This study supports the use of this technique to address clinical and research questions.