Atlas of Transesophageal Echocardiography, 2nd Edition (2007)

Chapter 1. Normal Anatomy

The first probes used for transesophageal echocardiography provided imaging in only a single plane. The development of the biplane probe, which had an imaging plane orthogonal to the transverse view obtained with single-plane devices, added considerably to the diagnostic information that could be obtained. The currently available multiplane probes make imaging studies much more flexible by allowing visualization of the in-between planes. In fact, the monoplane probe should now be regarded as obsolete. Smaller probes that enhance patient comfort and increase safety have become available. Images obtained with the smaller probes are usually not as good in quality as those obtained with the larger probes because the smaller probes have a smaller number of elements than do the larger probes.

Although the planes discussed usually refer to the orientation of the transducer relative to the esophagus, the terms also apply to the heart because the esophagus is located directly behind the heart. However, the exact relationship of the esophagus to the heart varies from individual to individual so that it is not always possible to obtain in a given individual all the planes and structures described in this chapter. The position and size of air-filled structures such as the trachea and the left and right main bronchi also determine the ability to image cardiovascular structures optimally in the upper chest. As in transthoracic echocardiography, the anatomic structures imaged by the transesophageal approach are identified by comparing them to known cardiovascular anatomy and, in some instances, by the use of contrast echocardiography. Transverse plane imaging (0° angle on the multiplane probe) generally provides transverse or horizontal sections of the heart, whereas longitudinal plane imaging gives longitudinal or vertical sections. During longitudinal plane examination, clockwise rotation of the probe shifts the vertical plane to the right so that right-sided structures such as the superior vena cava and the right pulmonary veins are brought into view, whereas counterclockwise rotation results in imaging of left-sided structures such as the left atrial appendage and the left pulmonary veins. Therefore, obtaining transverse sections of the heart at various levels requires up-and-down movement of the probe; imaging of vertical sections, however, can be accomplished by mere rotation of the probe. The multiplane probe, like the biplane probe, can be moved up and down within the esophagus and can also be physically rotated in clockwise and counterclockwise directions to give both transverse and vertical sections. In addition, a manual switch on the handle rotates the transducer at the tip of the probe to provide oblique sections through the heart. Therefore, a comprehensive examination of various cardiac structures can be performed using the multiplane probe.

There is no universally agreed upon transesophageal approach for the examination of cardiac structures. In practice, however, one tends to first examine structures of immediate interest on the basis of clinical indications and transthoracic echo findings. In the awake patient, it is best not to begin examination with the probe placed high up in the esophagus or in the stomach because this may result in gagging and increased patient discomfort. We often begin examination with the probe in mid-esophagus and proceed with the examination of structures from a high esophageal or transgastric position only after the patient has relaxed, frequently toward the end of the study. However, for the sake of simplicity and convenience, the anatomic findings in this section of the Atlas are shown as if the examination commenced in the upper esophagus, with the probe advanced gradually down the esophagus into the stomach. Therefore, the great vessels and their branches or tributaries located at the base of the neck are displayed first, followed by the aortic valve and adjacent structures such as the coronary arteries and the pulmonary veins, the cardiac chambers and the atrioventricular valves, the descending thoracic aorta, and lastly, the structures visualized from the transgastric approach.

Transesophageal examination with the probe positioned in the upper esophagus is useful in imaging the mid- and distal portions of the ascending aorta and the aortic arch and its branches. The innominate artery is the easiest branch to visualize, but other branches can also be imaged. Color Doppler–guided pulsed Doppler interrogation is useful in distinguishing an arterial branch from an accompanying vein. Flow signals from an artery are predominantly systolic, whereas the venous flow shows prominent systolic and diastolic components. Comprehensive evaluation of the aortic arch requires meticulous examination with a multiplane probe using transverse, longitudinal, and oblique planes. Because the aortic arch courses not only to the left but also posteriorly, the first, largest, and most anterior branch is the innominate artery; the left common carotid and the left subclavian arteries are identified arising more posteriorly. We have found longitudinal plane examination most useful in the identification of the aortic branches. Clockwise rotation with the probe set at an angle of 90° moves the plane to the right, bringing the origin of the innominate artery into view. Counterclockwise rotation of the probe, on the other hand, moves the vertical plane to the left, which helps in locating and identifying the left common carotid and left subclavian arteries. The innominate artery may also be followed to its bifurcation into the right common carotid and the right subclavian branches. The vein most commonly imaged when examining the aortic arch is the left innominate vein, but other veins such as the right innominate and the subclavian veins may also be visualized. Venous valves may occasionally be imaged as linear, mobile echoes in the tributaries of the major veins and should not be mistaken for a dissection flap. The main pulmonary artery and its branches, especially the left pulmonary artery, are often imaged adjacent to the aortic arch, and the left pulmonary artery can be followed to its branching into lobar arteries. A small portion of the left atrium may also be imaged next to the aortic arch. Contrast echocardiography has proved useful in identifying anatomic structures imaged in this region.

Advancement and rotation of the probe from the position where the aortic arch and its branches are identified brings into view the ascending aorta in short axis during transverse plane (0°) examination. The main pulmonary artery and a long segment of the right pulmonary artery can be seen wrapping around the aorta in this view. The origin and proximal portion of the left pulmonary artery may also be imaged. To the right of the aorta, the superior vena cava is imaged in short axis. The superior branch of the right pulmonary artery and segments of the right pulmonary veins may also be visualized. Longitudinal plane examination images the ascending aorta in long axis and the right pulmonary artery in short axis posterior to it. Further advancement of the probe images the aortic root, with the left atrium located posteriorly and the right ventricular outflow tract and pulmonary valve located anteriorly and to the left. All three aortic leaflets and sinuses can be easily identified using a multiplane probe. This is usually best accomplished at a plane angulation between 30° and 60°. During transverse plane examination, slight adjustment of the probe with rotation to the left brings the left atrial appendage and the left pulmonary veins (usually the left upper) into view; rotation to the right is used to image the right upper pulmonary vein and its junction with the left atrium. Slight advancement of the transducer often images the right lower pulmonary vein and its junction with the left atrium. Minimal withdrawal of the probe from the aortic root position with rotation to the left and right is used to identify the origins and proximal segments of the left and right coronary arteries, respectively. Longitudinal plane (90°) examination is used to view the aortic root and the proximal ascending aorta in long axis. Counterclockwise (leftward) rotation of the probe from this position views the right ventricular outflow tract, the pulmonary valve and the proximal main pulmonary artery in long axis. The anterior and posterior (inferior) leaflets of the tricuspid valve may also be identified in this vertical section. Further counterclockwise rotation displays the two-chamber view, in which the inferior and anterior free walls of the left ventricle are imaged together with the mitral valve, the left atrium, and the left atrial appendage. The left-sided pulmonary veins can also be imaged using this approach. Further counterclockwise rotation points the probe posteriorly and images the descending thoracic aorta in long axis. Clockwise (rightward) rotation of the probe from the aortic root position moves the vertical plane to the right, displaying the superior vena cava in long axis. The atrial septum and the fossa ovalis region are also often well visualized in this plane. Further clockwise rotation images the right upper pulmonary vein in long axis.

Advancement of the probe from the aortic root position during transverse plane (0°) examination usually displays the five-chamber view, in which the left ventricular outflow tract, aortic root, left atrium, mitral valve, right ventricle, and right atrium are imaged. Further advancement gives the four-chamber view, in which both the mitral (anterior and posterior leaflets) and tricuspid (anterior and septal leaflets) valves are imaged, in addition to the atrial septum, ventricular septum, both atria, and both ventricles. From this position, further advancement with some clockwise rotation during transverse plane (0°) imaging brings into view the openings of the inferior vena cava and coronary sinus into the right atrium, together with the eustachian and thebesian valves, the right atrial appendage, and the tricuspid inflow region. Leftward probe rotation may image the mitral valve in short axis. It is important to realize that at this point the transducer is close to the esophageal–gastric junction. Rotation of the probe with the transducer pointing posteriorly permits comprehensive examination of the descending thoracic aorta in the long, short, and oblique axes, and at all levels, by moving the transducer up and down the entire length of the esophagus. Azygos and hemiazygos veins and intercostal arteries and veins can be imaged. Higher up in the esophagus, the intervertebral discs together with the spinal canal and the “pulsating” spinal cord within may also be viewed.

The probe can then be advanced into the stomach to view both the left and right ventricular cavities, the mitral and tricuspid valves, the chordae, and the papillary muscles in the long, short, and oblique axes. The aortic root, proximal ascending aorta, right ventricular outflow tract, and pulmonary valve may also be imaged from the transgastric approach. The abdominal aorta and its branches, for example, the celiac, superior mesenteric, and renal arteries and veins, as well as other abdominal structures, for example, the kidneys, spleen, pancreas, liver, and stomach, have been imaged using the transgastric approach.

Transesophageal Echocardiographic Examination

Indications

Transesophageal echocardiographic examination (TEE) is indicated in the following circumstances: to determine the cardiac source of an embolism; to diagnose or rule out suspected endocarditis; to check suspected prosthetic valve dysfunction; to assess for aortic dissection; to assess the severity of valvular regurgitation; to compensate for a poor acoustic window; and to detect congenital cardiac lesions.

Intraoperative Indications

TEE is used during surgery to assess the adequacy of a valve repair; to assess prosthetic valve or ring regurgitation; to monitor ventricular function; to evaluate removal of air from the heart; and to assess the adequacy of repair of congenital heart lesions.

Contraindications

TEE is contraindicated in the presence of esophageal tumor, stricture, diverticulum, fistulas, and previous esophageal surgery.

Esophageal varices and severe cervical spine problems are relative contraindications.

Complications

Complications are rare, but include esophageal bleeding, esophageal rupture, oropharyngeal injury, supraventricular tachycardia, laryngospasm, methemoglobinemia, and problems related to oversedation.

Performance of Transesophageal Echocardiography

Transesophageal echocardiography is now a well-developed procedure. There is no substitute for adequate training under expert supervision. Our recommended approach to the performance of transesophageal echocardiography is described in the following paragraphs.

Prerequisites

The physicians/cardiologists performing transesophageal echocardiography must have expertise in two-dimensional and conventional and color Doppler echocardiography.

They also must be fully trained in intubating the esophagus.

Procedure Room Setup

When performing TEE, the physician echocardiographer, a technologist echocardiographer or fellow, and a nurse are in attendance.

The procedure room is equipped with an examination table, an ultrasound machine, TEE probes, a bite guard, tongue depressors, gloves, a flashlight, a stethoscope, an intravenous (IV) setup, wall oxygen, suction apparatus, a fingertip oximeter, and a Dinamap (for blood pressure [BP] monitoring). Cardiopulmonary resuscitation (CPR) equipment and medications must be available. Sedatives and other medications must be on hand. Facilities for probe cleaning and sterilization are necessary.

Before Starting the Procedure

Before TEE is begun, discuss the case and the indications for the study with the referring physician. Ascertain that the probe has been sterilized as follows: (a) clean the probe with a mild cleansing agent and water, (b) immerse the probe in 2% glutaraldehyde (Cidex) or metricide for 20 minutes.

Remember

Transesophageal echocardiography is modestly invasive but is safe and feasible in 98% to 99% of patients. This procedure is well tolerated by critically ill patients and also by elderly patients.

Establish rapport with the patient. Explain the procedure fully, including its benefits and risks. Obtain informed consent. Verify that the patient has been fasting for the preceding 4 to 6 hours.

Question the patient closely about any dysphagia; esophageal problems (e.g., diverticula, strictures, rings, carcinoma); operations on the esophagus, throat, or chest, especially in childhood; any thoracic radiation; hematemesis; or allergies. If there is a question of dysphagia or the history is not clear-cut, perform a barium swallow to make sure the esophagus is normal.

Determine whether the patient has severe pulmonary disease, including chronic obstructive pulmonary disease (COPD) or bronchial asthma.

Perform a brief cardiovascular examination, check vital signs, and perform auscultation of the lungs. Check O2 saturation with fingertip oximetry. Check the mouth and throat. Look for loose teeth and remove any dentures. If the patient's BP is too high, nifedipine, 5 to 10 mg sublingually, can help bring it down.

Inspect the CPR equipment. Insert an IV line, or, if one is already in place, check its patency. Give prophylactic antibiotics if the patient has a prosthetic valve or any other internal device such as a defibrillator, if the patient is at increased risk for endocarditis (e.g., bad teeth or gums, previous history of endocarditis), or if the referring physician recommends them. Follow American Heart Association (AHA) guidelines for endoscopy procedures when giving antibiotics.

·         Prophylactic Antibiotics. The gastroenterology and infectious disease literature suggests no serious bacteremia or increased chances of endocarditis for endoscopy procedures without biopsy. No evidence has been adduced that mandates bacterial endocarditis prophylaxis for this procedure, and it is reasonable to use none. Nevertheless, many physicians prefer to employ antibiotics in an attempt to forestall endocarditis, particularly if the patient has a prosthetic valve. In this event, give ampicillin, 2 g intravenously in 50 mL of D5W (5% dextrose in water) or 0.9% NaCl, and then gentamycin 1.5 mg/kg intravenously in the same manner after vigorously flushing the IV system, 30 minutes before the procedure. This may be repeated in 8 hours. If the patient is allergic to penicillin, give gentamycin first, flush the IV system vigorously, and then give vancomycin 1 g intravenously over 60 minutes in 50 mL D5W or 0.9% NaCl. This may be repeated in 8 to 12 hours. For children, follow the same technique but adjust the dosages as follows: ampicillin 50 mg/kg, gentamycin 2.0 mg/kg, vancomycin 20 mg/kg.

·         Anesthesia and Sedation. Check the suction apparatus. Anesthetize the pharynx with 20% benzocaine spray to suppress the gag reflex and retching. Each spray should be 1 second in duration, and the patient should gargle for at least 1 minute before swallowing. Two or three sprays are usually sufficient to suppress the gag reflex, which should be tested using a tongue depressor following each spray. In some patients, the gag reflex is suppressed immediately after using the spray; in others the effect may be delayed for as long as 5 minutes. The duration of gag reflex suppression also varies from individual to individual, from a few minutes to several minutes. It is advisable not to use too much of the spray because potentially fatal methemoglobinemia resulting in oxygen desaturation and cyanosis may occur in susceptible patients. If methemoglobinemia is suspected, do a blood gas analysis to confirm it and immediately give methylene blue intravenously. If necessary, give an anticholinergic agent such as glycopyrrolate, 0.2 mg intravenously, to reduce salivary and gastroenterologic secretions.

Give IV sedation if the patient is very apprehensive. Begin with low doses, and increase if necessary. If the patient has pulmonary disease or is elderly, give no or minimal sedation. No sedation should be given if the patient plans to drive home.

The most commonly used sedative is midazolam (Versed), 0.5 to 5 mg. This causes anterograde amnesia, but respiratory arrest can occur. The effect of midazolam can be reversed by flumazenil (Romazicon), 1.0 mg. Other commonly used sedatives are morphine, 1 to 4 mg; Phenergan, 12.5 to 25 mg; diazepam (Valium), 1 to 5 mg; and meperidine (Demerol), 12.5 to 50 mg. The effect of Demerol can be reversed by naloxone (Narcaine), 0.4 to 0.8 mg. More sedation is desirable to lower the patient's BP if aortic dissection is suspected, because BP often increases following benzocaine spray.

·         Final Preparations. Select the appropriate probe. Check for any breakage, and make sure the probe is sterilized. Check whether the transducers are operational and the echo system is in appropriate working condition. Unlock it if it is locked. Stop IV heparin at least 2 hours before the procedure.

Performance of the Procedure

Flex the patient's neck with the patient in the left lateral decubitus position. Place a bite guard in the patient's mouth. Apply gel liberally to the probe, up to at least 15 to 20 cm, flex it slightly, insert it in the patient's mouth through the bite guard, and ask the patient to swallow when he or she feels it at the back of the throat. If necessary, guide the probe by inserting one finger along the side of the bite guard. This prevents the patient from biting the operator's fingers or damaging the probe. An alternative approach is to ask the patient to open his or her mouth, grasp the probe near the transducer between the index and middle fingers, and direct it at the back of the pharynx, asking the patient to swallow it. A bite-block, previously placed on the probe, is then advanced into the mouth.

Remember that patient cooperation is required for swallowing the probe. If too much of sedation is given, the patient may not be able to cooperate.

Gently advance the probe into the esophagus up to 30 or 35 cm. Then stop to let the patient get used to the probe for 1 to 3 minutes, especially if he or she is retching or gagging. Keeping the probe stationary allows any gagging to pass. It also allows the patient's heart rate and BP to revert toward baseline. Monitor the patient's vital signs and O2 saturation with Dinamap, fingertip oximetry, and one-lead electrocardiography (ECG) on the echo monitor while the probe is being passed and afterward. Suction intermittently and as required. Give oxygen if needed.

Never advance the probe if any resistance is encountered. Warn the patient not to swallow secretions after probe passage and to signal if suctioning is needed. Withdrawing the probe into the esophagus is helpful if nausea or vomiting occurs when it is in the stomach. If a vasovagal episode or hypotension occurs, lower the head end of the table and give atropine, 0.5 to 1.0 mg intravenously, and run IV fluids and IV pressor agents.

Perform a multiplane examination of each chamber and structure using various angulations from 0° to 180°. A good approach is to begin by addressing the problem that precipitated the examination in case the patient is not able to tolerate the probe and the procedure has to be terminated early.

The Intubated Patient

It may be difficult to pass a probe beyond an inflated endotracheal cuff in an intubated patient. In such a case, briefly deflate the cuff as the probe meets resistance from the cuff and then immediately reinflate it when the probe has passed beyond it. Extending the patient's neck often is helpful in passing the probe when the cuff is not deflated. A good rule is to keep the probe parallel and close to the endotracheal tube while advancing it. Some physicians also remove any nasogastric tube to facilitate probe passage. In the very uncooperative intubated patient, temporary pharmacologic paralysis may facilitate performance of the procedure.

After the Procedure

Check the tip of the probe for any evidence of bleeding. Check the patient's mouth and pharynx for any abrasions or other trauma. Monitor vital signs for 20 to 30 minutes. The patient can leave with a caregiver once the sedative effect has worn off.

Postprocedure Precautions for the Patient

The patient should be given the following instructions after the procedure:

·         Do not swallow, eat, or drink for 1 to 2 hours after the procedure.

·         Do not drive or operate machinery for at least 12 hours after the procedure.

·         Have another person drive home if sedation was used.

·         Report to physician if sore throat persists for >2 days.

·         See a physician immediately if bleeding occurs from the mouth, the IV site becomes painful and inflamed, or fever or other symptoms develop.

FIGURE 1.1. Transesophageal probes. A. From left to right: pediatric, biplane, and monoplane probes, all from the same manufacturer, are displayed. At least one manufacturer has marketed an adult probe that is only slightly larger than the pediatric probe. The smaller probes produce less discomfort but sacrifice some image quality. B.The nasogastric tube (right) is only slightly smaller than the pediatric probe shown next to it. (Reproduced with permission from 

Helmcke F, Mahan EF III, Nanda NC, et al. Use of the smaller pediatric transesophageal echocardiographic probe in adults. Echocardiography 1990;7:727–737.

)

FIGURE 1.2. Multiplane probe. A. The multiplane probe shown here has a maximum width of 15.7 mm. A switch on the handle rotates the annular phased-array transducer, permitting multiplanar views. B. Various imaging planes can be obtained at the level of the aortic root with a multiplane probe, which can rotate the imaging plane through all of the angles from 0° to 180°. AV, aortic valve; LA, left atrium; RA, right artium; TD, transducer diameter; Tip D, probe tip diameter. (Reproduced with permission from 

Nanda N, Pinheiro L, Sanyal R, et al. Multiplane transesophageal echocardiographic imaging and three-dimensional reconstruction. Echocardiography 1992;9:667–676.

)

FIGURE 1.3. Transverse and longitudinal imaging planes. Examples of transverse imaging planes that can be obtained by moving the probe up and down the esophagus (A). Bshows both transverse (T) and longitudinal (L) planes. (A reproduced with permission from 

Nanda NC, Mahan EF III. Transesophageal echocardiography. AHA Council on Clinical Cardiology Newsletter 1990; Summer: 3–22

B reproduced with permission from 

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788.

)

FIGURE 1.4. Transverse sections. A and B show sections obtained at the level of the sixth (A) and eighth (B) vertebrae. AZ, azygos; DA, descending thoracic aorta; E, esophagus; HAZ, hemiazygos vein; LA, left atrium; LAA, left atrial appendage; LPA, left pulmonary artery; LUPV, left upper pulmonary vein; LV, left ventricle; PA, main pulmonary artery; RA, right atrium; RAA, right atrial appendage; RUPV, right upper pulmonary vein; RV, right ventricle; SVC, superior vena cava. (Reproduced with permission from 

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788.

)

FIGURE 1.5. Ascending aorta and pulmonary artery. Transverse plane examination with the transducer in the upper esophagus. A–C. Schematics show an imaging plane passing through the ascending aorta and the adjacent pulmonary artery. The corresponding transesophageal images are shown in D and EAO, aorta; PA, pulmonary artery; PV, pulmonary valve; RVOT, right ventricular outflow tract.

FIGURE 1.6. Aortic arch. Transverse plane examination with the transducer in the upper esophagus. A,B. The aortic arch (ACH) and the adjacent left innominate vein (IV) are shown. Note that the blood flow in these vessels is in opposite directions (B). Pulsed Doppler interrogation of the aortic arch (C) shows predominantly systolic (arterial-type) flow signals in contrast to prominent systolic and diastolic (venous-type) flow signals (D) obtained from the innominate vein. Imaging of the left innominate vein next to the aortic arch may mimic aortic dissection. The pulsed Doppler examination rules out dissection by demonstrating venous-type flow in the innominate vein.

FIGURE 1.7. Aortic arch. Longitudinal plane examination with the transducer in the upper esophagus. A. The aortic arch (ACH) and its relation to the adjacent main pulmonary artery (MPA) and the left innominate vein (IV). The innominate artery (IA) can be seen arising from the aortic arch (B,C)

FIGURE 1.8. Ascending aorta and arch. Transducer in the upper esophagus. Transverse plane examination shows flow signals anteriorly, representing an artifact (AF), and not the flow in a vascular structure. Such artifacts are fairly common but are easily recognized because they are not confined by any known anatomic structure. AA, ascending aorta; ACH, aortic arch.

FIGURE 1.9. Identification of individual arch vessels. A. Schematic representation of the technique used for identifying the aortic arch branches during longitudinal plane examination. AA, ascending aorta; IA, innominate artery; LC, left common carotid artery; LPA, left pulmonary artery; LS, left subclavian artery; MPA, main pulmonary artery;RC, right common carotid artery; RPA, right pulmonary artery; RS, right subclavian artery; T, transducer. B–E. All three arch vessels could be delineated in this patient using both transverse (T) and longitudinal (L) planes. ACH, aortic arch; CA, left common carotid artery; SA, left subclavian artery. F–H. Longitudinal plane examination in a different patient shows the innominate artery (IA) clearly arising from the aortic arch (ACH). F. The left common carotid (LCA) and left subclavian arteries (LSA) are located more posteriorly and were best visualized in this patient by counterclockwise rotation of the transducer, which resulted in the innominate artery becoming less prominent and less recognizable (G). In this patient also, all three arteries could be visualized in the transverse plane (H)IV, innominate vein. I. Another patient in whom all three arch vessels could be delineated in longitudinal plane examination. J–M. In another patient, the innominate artery (IA) could be followed to its bifurcation into the right common carotid artery (CCA) and right subclavian artery (SCA). Color Doppler–guided pulsed Doppler interrogation of the innominate artery shows predominantly systolic, arterial-type flow signals (arrowhead, M). (Reproduced with permission from 

Agrawal G, LaMotte LC, Nanda NC. Identification of the aortic arch branches using transesophageal echocardiography. Echocardiography 1997;14:461–466.

)

FIGURE 1.10. Transesophageal echocardiographic examination of the innominate artery and its branches. A. The innominate artery (IA) is shown arising from the aortic arch (AO). B. The bifurcation of IA into the right subclavian artery (RSA) and right common carotid (RCC) branches is shown. The left inset demonstrates high-resistance flow from the RSA, whereas the right inset shows low-resistance flow from the RCC. (Reproduced with permission from 

Nanda NC, Nekkanti R, Melendez A, et al. Transesophageal two-dimensional echocardiographic demonstration of the innominate artery and its branches. Am J Geriatric Cardiology 2001;10:368–370.

)

FIGURE 1.11. Transesophageal echocardiographic detection of left subclavian artery branches. A. Demonstrates the vertebral artery (VA) arising from the superior aspect of the left subclavian artery (LSA). Inset shows low-resistance antegrade systolic and diastolic flow signals (arrowheads) obtained by pulsed Doppler interrogation of the VA. I, inferior; L, lateral; M, medial; S, superior. B. Left internal mammary artery (arrow, LIMA), which arises from the inferior aspect of the LSA. Inset shows high-resistance flow signals with retrograde diastolic flow obtained by pulsed Doppler interrogation of the LIMA. (Reproduced with permission from 

Navin C. Nanda, Abhash C. Thakur, Dineshkumar Thakur, et al. Transesophageal echocardiographic examination of left subclavian artery branches. Echocardiography 1999;16:271–277.

)

FIGURE 1.12. Transesophageal echocardiographic detection of left subclavian artery branches. A. Arrow points to the thyrocervical trunk, which divides into three branches (numbered 1–3). Pulsed Doppler interrogation of the thyrocervical trunk reveals high-resistance flow signals (inset). B. Arrow points to the costocervical trunk, which shows high-resistance flow signals on pulsed Doppler interrogation (inset). The top arrowhead points to the left vertebral artery whereas the bottom arrowhead shows artifactual reverberations from color flow signals. LSA, left subclavian artery. (Reproduced with permission from 

Navin C. Nanda, Abhash C. Thakur, Dineshkumar Thakur, et al. Transesophageal echocardiographic examination of left subclavian artery branches. Echocardiography 1999;16:271–277.

)

FIGURE 1.13. Transesophageal echocardiographic detection of left subclavian artery branches. A. Demonstrates high-resistance flow with prominent retrograde signals in diastole obtained by pulsed Doppler interrogation of left subclavian artery (LSA). LCC, left common carotid artery. B. Arrow shows left internal mammary artery (LIMA). C.Pulsed Doppler interrogation of this vessel shows prominent antegrade diastolic flow signals resulting from grafting of this vessel to the left anterior descending coronary artery in this patient. (Reproduced with permission from 

Nanda NC, Thakur AC, Thakur D, et al. Transesophageal echocardiographic examination of left subclavian artery branches. Echocardiography 1999;16:271–277.

)

FIGURE 1.14. Transesophageal echocardiographic detection of right vertebral artery. A. The right vertebral artery (VA) is seen arising from the right subclavian artery (SA). Color Doppler guided pulse Doppler examination of VA shows antegrade flow signals in systole and diastole typical of a low-resistance vessel (right inset). Left inset shows the typical high-resistance Doppler spectral flow signals from SA. B. Right inset shows continuous venous-type flow signals from the adjoining right subclavian vein (SV). C.Demonstrates the right vertebral vein (VV), and the venous-type Doppler flow signals obtained from it are displayed in the right inset. The left inset in both B and C shows Doppler flow signals from SA. (Reproduced with permission from 

Ahmed S, Nanda NC, Manchikalapudi P, et al. Transesophageal echocardiographic identification of right vertebral artery. Echocardiography 2002;19:527–530.

)

FIGURE 1.15. Transesophageal echocardiographic examination of neck veins. A. Diagrammatic representation of neck veins. AA, ascending aorta; ARCH, aortic arch; AZ, azygos vein; IA, innominate artery; LC, left common carotid artery; LE, left external jugular vein; LIJ, left internal jugular vein; LIV, left innominate vein; LS, left subclavian artery; LSV, left subclavian vein; RC, right common carotid artery; RE, right external jugular vein; RIJ, right internal jugular vein; RS, right subclavian artery; RIV, right innominate vein; RSV, right subclavian vein; SVC, superior vena cava. B. Transesophageal echocardiographic identification of the left innominate vein. The linear echo-free space recorded behind the aortic arch (ACH) mimicking aortic dissection represents the left innominate vein (LIV). C. Injection of normal saline through a peripheral left arm vein almost completely fills the LIV. D. Demonstration of the relationship of the LIV (filled with contrast agent) to the IA. E. Pulsed Doppler interrogation of the LIV in the same patient shows prominent flow signals in both systole and diastole, typical of venous flow. F,G. Longitudinal plane examination shows the LIV and RIV joining to form the SVC.H,I. Transverse plane examination shows a small azygos vein (solid arrows) entering the SVC. AO, aorta; LA, left atrium; RPA, right pulmonary artery; RUPV, right upper pulmonary vein. (Reproduced with permission from 

LaMotte LC, Nanda NC, Thakur AC, et al. Transesophageal echocardiographic identification of neck veins: value of contrast echocardiography. Echocardiography 1998;15;259–267.

)

FIGURE 1.16. Transesophageal echocardiographic examination of left internal jugular and subclavian veins. A,B. Injection of normal saline through a left arm vein demonstrates contrast echoes (arrowhead) initially appearing in the left subclavian vein (LSV) and then moving into the left innominate vein (LIV). No contrast echoes are seen in the left internal jugular vein (LJV). ACH, aortic arch. C–E. Transesophageal echocardiographic examination of left internal jugular, left subclavian, and left innominate veins. The arrows point to a venous valve located in the left internal jugular vein (LIJV) near its junction with the left subclavian vein (LSV). A pacemaker wire (C) is noted coursing through the left subclavian and left innominate (LIV) veins. Color M-mode examination (E) shows the undulating motion of the venous valve (arrowheads) located in the internal jugular vein. The undulating motion of a venous valve can be confused with a dissection flap. F,G. In another patient, the course of the left common carotid artery (LCC) is demonstrated. Initially (F), it courses posteriorly (left upper panel) but is subsequently located more anteriorly (left lower panel). Its relationship to LIV, left internal jugular vein (LIJ) and left subclavian (LSV) vein are also shown. The upper right panel in F demonstrates low-resistance flow signals from LCC whereas the lower right panel shows continuous venous flow signals from LIJ. The arrowhead in G (upper panel) points to a venous valve at the junction of LIJ and LIV. Normal saline injection through a peripheral left arm vein shows contrast signals (arrow) moving from LSV into LIV (lower panel in G). (A–E are reproduced with permission from LaMotte LC, Nanda NC, Thakur AC, et al. Transesophageal echocardiographic identification of neck veins: value of contrast echocardiography. Echocardiography 1998;15;259–267. F and G are reproduced with permission from 

Samal AK, Nanda NC, Biederman RW, et al. Traumatic rupture of atherosclerotic plaque producing aortic isthmus dissection. Echocardiography 1998;(15)7:695–701.

)

FIGURE 1.17. Aortic arch and pulmonary artery. Transducer in the upper esophagus. A. The appearance of contrast signals (black arrow) in the left innominate vein following an intravenous bolus of saline contrast. Contrast signals (arrowheads) are also noted in the main pulmonary artery. The small contrast-free space adjacent to the main pulmonary artery represents the left atrium (LA), which is imaged anterior to the aortic arch (AO). B. The left subclavian artery (SA) and the left common carotid artery (CA) arising from the aortic arch (ACH). The left subclavian vein (SCV) is imaged next to the SA. Also seen are the LA and the main pulmonary artery (MPA). C–G. The LA is imaged anterior to the aortic arch (ARC). Injection of normal saline through a left atrial line resulted in the appearance of contrast (CON) echoes in the LA (E). Color Doppler–guided pulsed Doppler examination (G) demonstrates normal low-velocity phasic signals in the left atrium. Contrast echocardiography is useful in identifying structures adjacent to the aortic arch. AA, ascending aorta; PA, pulmonary artery; PV, pulmonary valve; RVOT, right ventricular outflow tract. H. Linear echo on the pulmonary valve (arrowhead) in another patient, consistent with Lambl's excrescence. This is a normal finding. (D and F reproduced with permission from 

Agrawal GG, Parekh HH, Tirtaman C, et al. Transesophageal echocardiographic imaging of the left atrium behind the ascending aorta mimicking aortic dissection: validation by contrast echocardiography. Echocardiography 1997;14:411–415.

)

FIGURE 1.18. Left pulmonary artery branches. Transducer in the upper esophagus. Numbers 1 and 2 in A and B are branches of the left pulmonary artery (LPA). AO, aorta. C–E. Multiple branches, some of them representing lobar arteries to upper and lower lobes of the left lung (arrowheads, numbers 1–4), in another patient. F. Pulsed Doppler interrogation of one of the branches demonstrates predominantly systolic flow signals (arrowhead).

FIGURE 1.19. Ascending aorta and pulmonary artery. Transducer in the upper esophagus. A–D. Transverse plane examination shows the aorta in short axis with the main and right pulmonary arteries wrapping around it. The echo-free space to the right of the aorta is the superior vena cava (unlabeled in D). D. A catheter (C) is seen in the right pulmonary artery. AO, aorta; LPA, left pulmonary artery; MPA, main pulmonary artery; RPA, right pulmonary artery. E. A greater length of the left pulmonary artery than that in D is seen. LA, left atrium; PV, pulmonary valve; RVOT, right ventricular outflow tract. F. Right panel: The aorta and the superior vena cava (SVC) imaged in short axis using the transverse plane. The echo-free space anterior to the aorta is a pericardial effusion (PE). Left panel: Longitudinal plane examination of the SVC in the same patient. The PE is seen anterior to the right atrium (RA). PA, pulmonary artery. G. The right pulmonary artery turns anteriorly after giving off the superior branch to the upper lobe. H.Longitudinal plane examination shows the AO in long axis and the RPA in short axis. (E reproduced with permission from 

Agrawal GG, Parekh HH, Tirtaman C, et al. Transesophageal echocardiographic imaging of the left atrium behind the ascending aorta mimicking aortic dissection: validation by contrast echocardiography. Echocardiography 1997;14:411–415.

)

FIGURE 1.20. Aortic root. Advancement of the probe from the ascending aorta and arch position brings the aortic root into view. A–E. All three leaflets of the aortic valve (AV, AoV) are shown, open in systole and closed in diastole. LA, left atrium; N, noncoronary cusp; L, left coronary cusp; PA, pulmonary artery; PV, pulmonary valve; R; right coronary cusp; RA, right atrium; RVO, RVOT, right ventricular outflow tract; TD, transducer diameter; Tip D, probe tip diameter. F. Aortic cusp (arrow) imaged in an oblique plane; this should not be mistaken for prolapse. In the true short-axis view (usually imaged at a plane angulation between 30° and 60° from the transverse plane, 0°) there was no cusp redundancy. LV, left ventricle. (A reproduced with permission from 

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788.

)

FIGURE 1.21. A–G. Left atrial appendage. The left atrial appendage (LAA) should be imaged at various angulations with the multiplane probe to visualize all its lobes. LA, left atrium; AV, aortic valve. B. Bilobed appendage (arrowheads). MV, mitral valve; LV, left ventricle. C. Pulsed Doppler interrogation of the LAA shows a prominent velocity waveform above the baseline following the P wave of the electrocardiogram, representing the flow out of the LAA during atrial systole. This is followed immediately by a waveform recorded below the baseline, representing flow into the LAA in atrial diastole. With LAA dysfunction, the velocities and waveform slopes are reduced. D,E. The pectinate muscles (arrows), which usually are transversely oriented and should not be mistaken for clot. The echo-free space lateral to the appendage most commonly indicates fat; however, the same picture is produced by a pericardial effusion. AO, aorta; RV, right ventricle. F. The echo density separating the appendage from the left upper pulmonary vein (LUPV) is a normal variant caused by nonspecific thickening. The arrow points to the left main coronary artery. G. Pectinate muscles in the LAA (arrowheads) in a patient with aortic dissection. The echo-free space lateral to the LAA is pericardial effusion. F, dissection flap; FL, false lumen; TL, true lumen.

FIGURE 1.22. A–C. Pulmonary valve. All three leaflets of the pulmonary valve (left, anterior, and posterior cusps) are imaged in the closed position in diastole (B) and in the open position in systole (C). Most commonly, only two cusps are seen (A). D–N. Coronary arteriesD. The left main coronary artery (arrow) is seen originating from the aortic root and coursing laterally. The more distal anteriorly directed flow signals represent the left anterior descending branch. E. The left atrial branch (BLA) is well seen. LM, left main coronary artery. F–I. The left circumflex coronary artery (arrowheads) in the left atrioventricular groove in another patient. J–L. The first marginal branch of the left circumflex artery (Cx; arrowheads). M. Pulsed Doppler interrogation of the first marginal branch demonstrates predominantly diastolic flow signals (arrowheads). N. The right coronary artery is seen arising anteriorly from the aortic root between right atrium (RA) and right ventricular outflow tract (RVO) and coursing to the right toward the atrioventricular groove. (F and K reproduced with permission from 

Samdarshi T, Nanda NC, Gatewood RP Jr, et al. Usefulness and limitations of transesophageal echocardiography in the assessment of proximal coronary artery stenosis. J Am Coll Cardiol 1992;19:572–580.

)

FIGURE 1.23. Coronary arteries. A. Slight withdrawal of the probe from the aortic root brings the sinuses of Valsalva into view. The left main (LM) coronary artery is seen arising from the left coronary sinus and the right coronary artery (RCA) from the right sinus. B–F. The entire course of the left main coronary artery (LM, LMCA) and its bifurcation into the left circumflex (CX, LCX) and left anterior descending (LAD) coronary arteries are shown. G. Pulsed Doppler examination of the LAD shows both systolic and diastolic flow signals. The diastolic flow signals have much higher velocity than the systolic signals. H,I. A long segment of the circumflex (CX) branch is seen coursing laterally.J. A long segment of the LAD courses anteriorly. K. The anterior (ANT) interventricular (I.V.) vein imaged next to the LAD. The flow in the vein is directed opposite to the LAD. This image was taken during rapid cardioplegia infusion, which reduced cardiac motion, thereby enhancing visualization of the vein. L. A ramus branch is shown. M. The left main (LM), left circumflex (LCX), LAD, and a long segment of the first diagonal branch are all well seen. N. The left circumflex coronary artery (LCX CA) is shown in short axis next to the coronary sinus (CS) and the mitral valve. O–R. The right coronary artery (RCA, arrow) is seen originating anteriorly from the aorta and coursing to the right toward the right atrioventricular groove. S,T. Pulsed Doppler examination of the RCA demonstrates prominent systolic and diastolic signals. T. The systolic signals are more prominent than the diastolic signals in this patient. U. The posterior descending coronary artery (PDA) is visualized using the transgastric approach. (F and K reproduced with permission from 

Samdarshi T, Nanda NC, Gatewood RP Jr, et al. Usefulness and limitations of transesophageal echocardiography in the assessment of coronary artery stenosis. J Am Coll Cardiol 1992;19:572–580.

)

FIGURE 1.24. A–G. Aortic root and ascending aorta. Longitudinal plane examination shows the aortic root and the ascending aorta (AO) in long axis. B. The sinuses of Valsalva are well seen. Two other patients are shown, one in E and one in F and G. The linear echo (arrowheads in F and G) attached to the aortic valve on the side of the aorta is a Lambl's excrescence, which is a normal finding. (A and B reproduced with permission from 

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788.

)

FIGURE 1.25. Pulmonary veins. A–O. A. Diagrammatic representation of the pulmonary veins. Left: Posterior view of the heart. The relationship of the pulmonary veins to the adjacent structures is shown. The arrows depict the spatial orientation of the pulmonary vein trunks. Right: Superior view of the heart. During longitudinal plane examination, imaging of the right and left pulmonary veins is accomplished by posterior displacement of the ultrasonic plane by rotation of the probe (T1) from the position used for viewing the right and left upper pulmonary veins. When the lower veins enter the left atrium in a posteroanterior direction rather than the frontal plane (as shown with the right lower pulmonary vein [RLPV]), successful imaging of their proximal portions is accomplished by first advancing the probe (from T1 to T2) and then rotating it. B. Diagrammatic representation of transverse (T) and longitudinal (L) plane examination of the upper and lower pulmonary veins (right-sided veins are used in this example). The RLPV is visualized by slight advancement (straight arrow) and clockwise rotation (curved arrows) of the probe. C. Composite image obtained by combining three consecutive transverse views shows the angle of entrance of the left upper pulmonary vein (LUPV) into the LA and its close relationship with the LAA and the descending thoracic aorta (DA). D–G.Sequence of frames from one patient demonstrates all four pulmonary veins using transverse and longitudinal plane examination. D. Transverse plane imaging of the left lower pulmonary vein (LLPV; left panel) and LUPV (right panel). E. Longitudinal plane imaging of the LLPV (left panel) and LUPV (right panel). The left pulmonary artery (LPA) is located superior to the LUPV. F. Transverse plane imaging of the RLPV (left panel) and right upper pulmonary vein (RUPV; right panel). Unlike the RUPV, the entrance of the RLPV is located at a considerable distance from the interatrial septum. The RUPV enters LA just posterior to the SVC. G. Longitudinal plane imaging of the RLPV (left panel) and RUPV (right panel). The right pulmonary artery (RPA) is seen in short axis just superior to RUPV. The insets show pulsed Doppler spectral traces from the respective pulmonary veins. H. Longitudinal plane imaging of the distal portion of the LUPV. Several tributaries (T) are seen joining the main trunk of LUPV (left panel). Slight counterclockwise rotation of the probe with further leftward displacement of the ultrasonic plane demonstrates branching of the left pulmonary artery (LPA) (arrows, right panel). I. Transverse plane examination of the LUPV and LLPV in another patient. Note that, unlike the LUPV, the lower vein is not related to the LAA. In this example, the lower vein is seen together with the posterior atrioventricular groove and the LV. Withdrawing the probe from this position to the level of the main pulmonary artery (PA) brought the LUPV into view in this patient. J. In the longitudinal plane examination (left) in this patient, the LUPV was imaged first. The transducer was then tilted to the left to include the lower vein. The probe was not rotated or advanced. In the transverse plane examination (right), the lower vein was delineated first, and the transducer was then tilted upward to image the upper vein. The two pulmonary veins are separated by a wide angle, but they converge to open into the left atrium (LA) not far from each other. K. In the transverse plane examination (left) in a different patient, the right upper and lower pulmonary veins are visualized simultaneously. The dotted line represents the level at which the longitudinal plane is taken (right panel). Although the RUPV is visualized in both examination modes, the transverse plane sections the lateral walls of the vein whereas the longitudinal plane cuts through the superior and inferior walls. C, catheter in right pulmonary artery. L. Composite image resulting from the combination of three consecutive transverse views, obtained by rotation of the probe. The presence of pleural effusion (PLE) in this patient permits delineation of the entire course of the RLPV from the hilum of the lung to its entrance into the left atrium (LA). M. Examination of the right pulmonary veins in an adult patient with sinus venosus atrial septal defect. The RUPV overrides the defect (arrowheads), and its flow is seen to enter both the RA and the LA (left panel). The RLPV enters LA normally (right panel). N–O. Separate (N) and simultaneous (O)examination of the RLPV and RUPV in another patient. As with the left-sided veins, the right-sided veins are separated from each other by a wide angle. This is more apparent when the veins are imaged separately rather than simultaneously. In this patient, the RUPV was imaged first and then the transducer was tilted to the right to view the RLPV simultaneously. LAA, left atrial appendage; LV, left ventricle. Left pulmonary veinsP–S. The left upper pulmonary vein (LUPV, LPV) is imaged adjacent to the left atrial appendage. T. The left lower pulmonary vein is imaged at a plane angulation of 41°. When two left-sided veins are imaged, the one adjacent to the left atrial appendage is usually the left upper pulmonary vein, and the one not adjacent to the appendage is the left lower pulmonary vein. Right pulmonary veinsU–Y. Transverse plane examination(U) shows the RUPV imaged next to the SVC viewed in short axis. Pulsed Doppler examination shows a large systolic (S) wave, a smaller diastolic (D) wave, and a small atrial systolic A wave in the opposite direction representing flow from the LA into the vein. Longitudinal plane examination (V–X) shows the RUPV imaged adjacent to the right pulmonary artery (RPA). Y. The RUPV and RLPV are simultaneously visualized. The RLPV is imaged lateral and posterior to the RUPV (small vertical arrow). (A–O reproduced with permission from 

Pinheiro L, Nanda NC, Jain H, et al. Transesophageal echocardiographic imaging of the pulmonary veins. Echocardiography 1991;8:741–748.

)

FIGURE 1.26. A–K. Right ventricle and pulmonary valve. The longitudinal plane examination demonstrates the right ventricular outflow tract (RVOT), the pulmonary vein (PV), and the proximal pulmonary artery in A through G, I, and K. Abnormalities of the RVOT and PV are often well seen in this plane. The TV leaflets are demonstrated in B and in Fthrough J. H. The inferior posterior (P) and the anterior (A) leaflets of the TV are shown. I,J. All three leaflets of the tricuspid valve (AAL, anterior; PPL, posterior or inferior; SSL, septal) can sometimes be imaged. The anterior and septal leaflets are separated by the anteroseptal commissure, the anterior and posterior leaflets by the anteroposterior commissure, and the posterior and septal leaflets by the posteroseptal commissure. AZ, azygos vein; E, esophagus; LCC, left coronary cusp; NCC, aortic noncoronary cusp; RCC, aortic right coronary cusp; TC, tricuspid valve cusps. L–NAscending aorta. Clockwise rotation of the probe from the position where one sees the RVOT and pulmonary artery brings the aortic root and ascending aorta (A) into view. The inferior vena cava (IVC) and eustachian valve (EV) are also visualized in N. (A through D, G,and K reproduced with permission from Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788. H through J reproduced with permission from 

Maxted W, Nanda NC, Kim KS, et al. Transesophageal echocardiographic identification and validation of individual tricuspid valve leaflets. Echocardiography 1994;11:585–596.

)

FIGURE 1.27. A–N. Superior vena cava and right atrium. Longitudinal (L) plane examination shows the superior vena cava (SVC) and its entry into the right atrium (RA), viewed in long axis. D. The crista terminalis (arrow). E. A right pulmonary artery (RPA) bifurcation is seen. F. Normal trabeculation in the RA (arrowheads). I–K. Intravenous injection of normal saline results in the appearance of contrast echoes in the SVC, with subsequent filling of the RA. L. Intravenous normal saline injection results in the appearance of contrast echoes in the SVC (left panel), with subsequent filling of the right pulmonary artery (RPA; middle and right panels). The arrow in the left panel points to a catheter in the RPA). M,N. The azygos vein (closed arrow) is seen entering the right superior vena cava (RSVC). The open arrow represents the superior branch of the right pulmonary artery. Intravenous injection of normal saline results in the appearance of contrast echoes in the RSVC and RA. A few contrast signals are noted entering the azygos vein. A large thrombus (TH) with adjacent spontaneous contrast echoes is noted in the LA in this patient with mitral stenosis. (A through D, G, and L reproduced with permission from 

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788.

 M and Nreproduced with permission from 

Nanda NC, Pinheiro L, Sanyal R, et al. Transesophageal echocardiographic examination of left-sided superior vena cava and azygos and hemiazygos veins. Echocardiography 1991;8:731–739.

)

FIGURE 1.28. A–I. Five-chamber view. This view is obtained by further advancement of the probe from the aortic root position. In addition to imaging both atria and ventricles, this view shows the aortic root (AO in E). H. A plane angulation of 5° shows the noncoronary (N) and the right coronary (R) cusps of the aortic valve; plane angulation at 111° shows the left (L) and right (R) leaflets. I. Intravenous injection of normal saline results in the appearance of contrast echoes in the RA and the RVOT, but the left-sided structures are not opacified. (C reproduced with permission from 

Nanda NC, Mahan EF III. Transesophageal echocardiography. AHA Council on Clinical Cardiology Newsletter 1990; Summer: 3–22.

)

FIGURE 1.29. A–I. Four-chamber view. The four-chamber view is obtained by slight advancement of the probe from the five-chamber view. Both the atria and ventricles as well as the mitral (anterior [AML] and posterior [PML] leaflets) and tricuspid (anterior [A] and septal [S] leaflets) valves are seen. The VS and the LV posterolateral walls are seen in this view. In C, the linear echo on the ventricular aspect of the MV represents a Lambl's excrescence. G. The valve of the foramen ovale (VFO) is shown. H,I. The atrial septum (arrowheads) bulging into the right atrium (RA) (H) and into the left atrium (LA) (I) during different phases of the cardiac cycle reflecting changing hemodynamics. The atrial septum bulges into the atrium with the lower pressure. (B reproduced with permission by Nanda NC, Pinheiro L, Sanyal RS, Storey O. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788. F reproduced with permission from 

Maxted W, Nanda NC, Kim KS, et al. Transesophageal echocardiographic identification and validation of individual tricuspid valve leaflets. Echocardiography 1994;11:585–596.

)

FIGURE 1.30. Two-chamber view. Angulation of the beam 90° from the four-chamber view demonstrates the orthogonal two-chamber view. In this view, the inferior and anterior free walls of the left ventricle (LV) are seen. The left atrial appendage (LAA) is noted on the same side as the anterior free wall. C, chordae tendinae. (A and Ereproduced with permission from Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788. B reproduced with permission from Nanda NC, Mahan EF III. Transesophageal echocardiography. AHA Council on Clinical Cardiology Newsletter 1990; Summer: 3–22. C reproduced with permission from 

Mahan EF III, Nanda NC. Transesophageal echocardiography. In: Rackley CE, ed. Challenges in Cardiology I. Mount Kisco, NY: Futura, 1992:85–101.

)

FIGURE 1.31. A–J. Superior vena cava and inferior vena cava. The superior vena cava (SVC) and inferior vena cava (IVC) are shown simultaneously in A through E and Hthrough J. The eustachian valve (EV) is noted at the IVC–RA junction in E through G. The region of the foramen ovale and the tricuspid valve may also be visualized.

FIGURE 1.32. A–M. Right atrial appendage and tricuspid valve. Advancing the probe down the esophagus from the four-chamber view with slight rotation often brings the right atrial appendage (RAA) into view. The coronary sinus (CS), inferior vena cava (IVC), and the anterior (A) and septal (S) leaflets of the tricuspid valve may also be well visualized.D. A pericardial effusion (PE) is present behind the RAA. G. A catheter (arrow) in the right ventricle (RV). The eustachian valve (EV), a normal vestigial structure, often is seen at the RA–IVC junction. I,J. A large, patulous eustachian valve with a fishnet appearance is often referred to as a Chiari network (C). It generally produces no obstruction or embolism but has been confused with RA tumor. K. The thebesian valve, another vestigial structure, is often seen at the coronary sinus–RA junction. L. SVC, IVC, and CS are imaged simultaneously. This corresponds to the schematic shown in C. M. Pulsed Doppler interrogation of the coronary sinus shows prominent systolic and diastolic flow signals. (E reproduced with permission from 

Maxted W, Nanda NC, Kim KS, et al. Transesophageal echocardiographic identification and validation of individual tricuspid valve leaflets. Echocardiography 1994;11:585–596.

)

FIGURE 1.33. Mitral valve. The short-axis view of the mitral valve may be obtained with the transducer positioned close to the esophageal–gastric junction. AMVL, anterior mitral leaflet; PMVL, posterior mitral leaflet.

FIGURE 1.34. A–S. Descending thoracic aorta and azygos and hemiazygos veins. The entire extent of the descending thoracic aorta (AO) can be viewed in multiple planes by rotating the transducer posteriorly and moving it up and down the esophagus. A. Schematic. B,C. Echo-free spaces seen behind the aorta represent an artifact caused by the close proximity of the aorta to the transducer. The vertical echoes within this space are reverberation artifacts. E. An intercostal artery is well seen and should not be confused with aortic dissection. F. Pulsed Doppler interrogation of the intercostal artery shows both systolic and diastolic flow signals, typical of a low-resistance vessel. G. A large pleural effusion (PLE) is present behind the aorta. H. A large color artifact is present next to the descending aorta and should not be mistaken for a vascular structure. I. Flow signals are more prominent in the reverberation artifact (R) than in the descending aorta (AO) itself. J–L. The hemiazygos vein (HAZ) is noted joining the azygos vein (AZ) in the transverse plane examination (J,K). Both HAZ and AZ are located posterior to the descending thoracic aorta (DA). Pulsed Doppler interrogation of HAZ and AZ demonstrates low-velocity, continuous signals throughout the cardiac cycle, typical of venous flow (K). L. Both AZ and DA are imaged in long axis using the longitudinal plane examination. When AZ is prominently imaged, as in this patient, an erroneous diagnosis of aortic dissection may be made because the two vessels are in close contact with each other and their contiguous walls may be misinterpreted as a dissection flap separating the true and false lumens of a dissected aorta. Therefore, it is important to perform a pulsed Doppler examination, which will show continuous venous flow pattern throughout the cardiac cycle in AZ. M. An intercostal vein (ICV) is seen draining into the HAZ, which connects with the AZ. N. Anatomic illustration shows the relation of the AZ to the RSVC, the right pulmonary artery (RPA), and the superior branch of RPA. O–R. Pulsed Doppler interrogation also helps to differentiate the veins of the azygos system from other vessels in the vicinity, e.g., intercostal and bronchial arteries. O. The right (RIC) and left (LIC) posterior intercostal arteries are noted adjacent to HAZ. Pulsed Doppler interrogation of RIC in this patient (P) shows arterial-type flow signals confined mainly to systole. Q. ICVs viewed adjacent to the DA imaged in long axis in the longitudinal plane examination. The inset shows venous-type flow signals obtained by color Doppler–guided pulsed Doppler interrogation of one of these veins. R. The relationship of a bronchial artery (BA) to the DA, the LPA, and its branches (arrows). The inset shows arterial-type flow signals obtained by color Doppler–guided pulsed Doppler interrogation of this vessel. The prominent flow signals in diastole reflect the flow resistance of the pulmonary vascular bed.SP, spine. S. An intervertebral disk (VB), as well as a “pulsating” spinal cord, may be visualized posteriorly from the upper esophagus. (A and G reproduced with permission from

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788.

 Dreproduced with permission from 

Nanda N. Innovations in echocardiography. Cardiology Trends 1990;10:1,22–23.

 J–R reproduced with permission from 

Nanda NC, Pinheiro L, Sanyal R, et al. Transesophageal echocardiographic examination of left-sided superior vena cava and azygos and hemiazygos veins. Echocardiography 1991;8:731–739.

)

FIGURE 1.35. Transgastric views. The transducer is advanced into the stomach and is flexed when it abuts the gastric wall. In these views, the liver (L) is always in the near field. A. Schematic. B–D. The anterior (AML) and posterior (PML) leaflets of the mitral valve, together with chordae tendinae (C), are seen in short axis in the open and closed positions (transverse plane examination). The mitral valve commissures are well seen. E. left ventricle (LV) endocardium (closed arrow) and trabeculated right ventricle (RV) wall (open arrow). F–L. Minimal advancement from the mitral leaflets brings the papillary muscles into view. These can be imaged in both long and short axis. SVS, ventricular septum; AAL, ALPM, anterolateral papillary muscle; PPM, PMPM, posteromedial papillary muscle; ANT, anterior LV wall; INF, inferior LV wall; LAD, lateral wall. M,N. A heavily trabeculated LV (arrowheads) imaged in the apical region. O,P. A hypertrophied LV imaged in long axis in diastole (O) and systole (P). Q. Both papillary muscles (PM) and the chordae tendinae (CH) are well shown. R,S. Long-axis views from another patient showing the left ventricle in diastole (R) and systole (S). Note the marked thickening of the LV walls in systole. T–V. LAA and left upper pulmonary vein (PV) imaged from the transgastric view. W. An intramyocardial coronary vessel (arrow) imaged using a high-resolution color Doppler system. (F–H and U reproduced with permission from 

Nanda NC, Pinheiro L, Sanyal RS, et al. Transesophageal biplane echocardiographic imaging: technique, planes, and clinical usefulness. Echocardiography 1990;7:771–788.

)

FIGURE 1.36. A–F. Transgastric views. Anterior angulation of the transducer often brings into view the aortic root (AO) surrounded by the RA, TV, RV, RVOT, PV, and PA. E. The SVC and RV apex are also visualized. F. Pulsed Doppler interrogation shows normal systolic flow signals from the main pulmonary artery (PA). RA, right atrium; TV, Tricuspid valve; RVOT, right ventricular outflow tract; PV, pulmonary vein.

FIGURE 1.37. A–G. Transgastric views. The aortic root (AO) and the ascending aorta are viewed in long axis. Both left ventricle (LV) and right ventricle (RV) are well imaged. G.All three leaflets of the TV (A, anterior; P, posterior or inferior; S, septal) are imaged in systole adjacent to the aorta (AO). The normal tricuspid valve (TV) in systole has a star-shaped appearance rather than the “smile” of a closed normal mitral valve (MV). (G reproduced with permission from 

Maxted W, Nanda NC, Kim KS, et al. Transesophageal echocardiographic identification and validation of individual tricuspid valve leaflets. Echocardiography 1994;11:585–596.

)

FIGURE 1.38. Transgastric views. A–J. Examination of superior mesenteric and renal vessels. A–C. Transverse plane imaging. A. Both the superior mesenteric (SMA) and the left renal (LRA) arteries are visualized arising from the abdominal aorta (AO). Inset: Pulsed Doppler spectral tracing obtained from the SMA. B. The left renal vein (LRV) is seen crossing anterior to the abdominal aorta (AO) to drain into the IVC. C. Color Doppler–guided pulsed Doppler interrogation of the LRV demonstrates low-velocity flow signals practically throughout the cardiac cycle. D. Schematic representation. E–J. Examination of the abdominal structures and vessels in another patient. E. Longitudinal and transverse plane imaging of the left kidney (LK). C, cortex; M, medulla. F. Visualization of the pancreas (PN) using transverse plane imaging. G. Transverse and longitudinal plane imaging of the splenic artery (SA) and vein (SV). H. Pulsed Doppler interrogation shows relatively high velocity pulsatile flow in the SA and lower-velocity continuous flow in the SV. I. Pulsed Doppler interrogation of the proximal LRA reveals a peak systolic velocity of 0.52 m/sec (not angled correct). The fairly prominent antegrade diastolic flow denotes a low-resistance vessel. J. Visualization of the intrarenal artery (RA) and vein (RV). Pulsed Doppler interrogation of the artery in this patient demonstrates pulsatile signals with prominent antegrade diastolic flow. SMV, superior mesenteric vein; SP, spleen. K. Multiple hepatic veins (HV) are seen entering the IVC. (A through J reproduced with permission from 

Chouinard MD, Pinheiro L, Nanda NC, et al. Transgastric ultrasonography: a new approach for imaging the abdominal structures and vessels. Echocardiography 1991;8:397–403.

)

FIGURE 1.39. A–D. Transgastric views. The stomach is well seen. B. Rugae (arrowheads). C,D. Slow-moving contrast echoes (arrowheads) caused by the stomach contents.

 

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