1. Intraoperative Echocardiography Harold G. Jackson II Tulane University Anesthesiology Elective

2. Indications Chamber Size Valvular Function Septal Thickness Shunts Masses Perfusion Myocardial Ischemia Global Ventricular Function Regional Wall Motion abnormalities Valve Abnormalities Intracardiac contrast Venous Paradoxical Air Embolism ASSESSMENTMONITORING

3. Contraindication s Esophageal Pathology Coagulopathy or Heparinization Left Atrial Myxoma with Embolization ABSOLUTERELATIVE

4. Advantage of TEE vs Pulmonary Catheterization Ventricular Wall motion abnormality detected by TEE is the most sensitive indicator of myocardial ischemia. Most sensitive modality for detecting intracardiac air embolism. Only device for monitoring paradoxical air embolism.

5. American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Recommendations: TEE should be used for all cardiac or thoracic surgery patients. Including cardiac catheterization when general anesthesia is used.

7. Four Chamber View -Air Emboli -Intracardiac Shunts -AV Valve Repair and Function LA - left atrium, MV - mitral valve, LV - left ventricle, RV - right ventricle, RV - tricuspid valve, RA - right atrium.

8. Regional Wall Motion Abnormalities RWMA’s precede a rise in wedge pressure, ST-T changes, and on set of angina.

9. Global Ventricular Function Assessed by systolic wall thickening (afterload) and LVEDV (preload)

10. Functional Mitral Regurgitatio nb Indicator of acute or chronic ischemia. Marked apical tenting of the mitral leaflets along with reduced leaflet coaptation. The anterior mitral leaflet has a "dog's leg" shape in systole due to tethering of chordae which attach to the belly of the leaflet.

11. http://pie.med.utoronto.ca/TEE/TEE_content/assets/applic ations/standardViews/index.htm TAKE A BETTER LOOK...

12. Recap: Intraoperative Diagnosis Early Ischemia and Air Embolism Hypotensive etiology i.e. separation from cardiopulmonary bypass Adequacy of valve repair and myectomy Masses (myxoma, thrombus, embolus, vegetation) Contrast techniques for shunts

13. References 1. Incidental finding of a large pulmonary valve fibroelastoma: A case report 2. Practice Guidelines for Perioperative Transesophageal Echocardiography:An Updated Report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography* 3. Transesophageal Echocardiography: Intraoperative Uses Anesthesiology Review Chapter 85; Cook M.D.,David J. 4. http://echocardiographer.org/TEE.htmlhttp://echocardiographer.org/TEE.html 5. http://pie.med.utoronto.ca/TEE/TEE_content/assets/applications/standardViews/index.htmhttp://pie.med.utoronto.ca/TEE/TEE_content/assets/applications/standardViews/index.htm