These slides illustrates the basics of transthoracic and transoesophageal echocardiography in the cardiac operating room. Competent surgical results in shunt lesions, valve repairs, surgery for heart failure, establishment of peripheral bypass are derivatives of good knowledge in assessing gross and finer details of the heart intro-operatively. Assessment of myocardial viability, contractility and patency of repair are few aspects that are covered under this subject. They illustrate some of the basic must-knows for cardiothoracic surgeons from the perspective of a cardiac anaesthetist. This is courtesy of Dr. Parimala Prasanna Simha, Professor of Cardiac Anaesthesiology and Critical Care at Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru. This presetation is part of a video which belongs to the lecture series of IACTS SCORE 2020 held at the Sri Sathya Sai Institute of Higher Medical Sciences Whitefield, Bengaluru between 7th and 8th March, 2020.

1. Echocardiography for cardiac
surgeons
Dr. Parimala Prasanna Simha
Professor
Sri Jayadeva Institute of Cardiovascular
Sciences and Research

2. Contents
• Physics of ultrasound
• Epicardial echo
• Standard 2-D views
• 3-D ECHO
• LV function assessment (Stress test0
• Mitral & aortic valves
• Congenital lesions

3. Physics
• Human hearing 20-
20,000Hz
• Ultrasound: 1-20MHz
• Scanning errors
1. Reflection – missing
structures
2. Refraction – mirror
images
3. Scattering - signals from
deeper structures are
weaker
4. Attenuation – acoustic
shadowing

4. Optimization of 2D images
1. Transducer
a. High frequency
b. Low frequency
2. Depth
a. Deeper image: slow frame rate
b. Nearer
3. Focus: max resolution and U/S beam narrowest
4. Gain

5. Gain

6. Epicardial echo
• Sterilize x-ducer. Glutaraldehyde for10min, wipe
with saline. Sterile gel 20ml
• Stand offs: near field clutter with epiaortic scan
• Views
1. SAX: orientation mark to left side of the patient
2. LAX view: orientation mark to the patient’s head
3. AV SAX : transducer on proximal ascending aorta
•

7. TEE probes

8. TEE views: LV function assessment
1, ME 4C, 2C, LAX
2. TG SAX: basal, mid
3. TG 2C

9. LV Function assessment
• Preload: LVEDV
• Contractility: EF & SV do
no change in parallel.
a. EF normal, SV reduced
 hypovolemia
b. Both EF & SV reduced
 acute LV failure
c. EF reduced & SV
normal  chronic LV
dysfunction

10. IHD assessment
• Anatomical assessment in asymptomatic
patient to exclude disease and,
• Functional assessment helpful in symptomatic
patients.

11. Coronary CT Angiogram
• Coronary CT Angiogram:
anatomic test to rule
out CAD
• Stress ECHO:
functional tests have a
greater ability to predict
benefit from
revascularization

12. Stress TEST
• Stress-induced segmental wall motion and
perfusion abnormalities detected by stress
tests such as stress ECG, ECHO, SPECT, MRI.
• Pharmacological stress test only when unable
to exercise

13. Multimodality Detection and Risk Assessment of
IHD Appropriate Use Criteria: Symptomatic
PatientsIndication Text
Exercise
ECG
Stress RNI Stress Echo Stress CMR Calcium
Scoring
CCTA Invasive Coronary
Angiography
1
Low pretest probability of CAD,
ECG interpretable, and able to
exercise
A R M R R R R
2
Low pretest probability of CAD,
ECG uninterpretable, or unable to
exercise
– A A M R M R
3
Intermediate pretest
probability of CAD, ECG
uninterpretable, and able
to exercise
A A A M R M R
4
Intermediate pretest probability of
CAD, ECG uninterpretable, or unable
to exercise
– A A A R A M
5
High pretest probability of CAD,
ECG interpretable, and able to
exercise
M A A A R M A
6
High pretest probability of CAD,
ECG uninterpretable, or unable to
exercise
– A A A R M A

14. Multimodality Detection and Risk Assessment of Ischemic Heart
Disease Appropriate Use Criteria: Asymptomatic Patients
Indication Text Exercise ECG Stress RNI Stress Echo Stress CMR Calcium Scoring CCTA Invasive Coronary
Angiography
7
Lowglobal CHD risk
regardless of ECG
interpretability and
ability to exercise
R R R R R R R
8
Intermediate global
CHD risk, ECG
interpretable and able
to exercise
M R R R M R R
9 Intermediate global
CHD risk, ECG
uninterpretable or un
able to exercise
– M M R M R R
10
High global CHD risk,
ECG
interpretable and able
to exercise
A M M M M M R
11
High global CHD risk,
ECG
uninterpretable or un
able to exercise
– M M M M M R

15. Stress echocardiography
Regional wall motion is
assessed from parasternal
and apical images
• Each segment is
described as either
normal,
• hypokinetic,
• akinetic, or
• dyskinetic,

16. Normal Function
*All performed without the need for contrast

17. Pharmacologic Stress
Echocardiography
• Intravenous (IV) dobutamine, dipyridamole, or
adenosine.
• Dobutamine: continuous infusion at
incremental rates starting from 5 up to 50
μg/kg/min. It is often complemented by
handgrip exercise and/or IV atropine (0.5 to
2.0 mg) to increase the heart rate.

18. STRESS RESPONSE
1. Inducible Ischemia: new RWMA that gets
progressively worse
2. Ischemia: existing RWMA that worsens
3. MI: existing RWMA that is unchanged
4. Stunning: existing RWMA that improves
5. Hibernation: existing RWMA that shows
biphasic response
6. Other signs if MI: DD, MR, aneurysm

19. Abnormal stress responses
associated with an increased risk of
adverse events• Extensive resting regional wall motion
abnormalities,
• Stress-induced ischemia,
• Worsening LV ejection fraction (LVEF) with
stress
• Absence of viability

20. Acute MI

21. Myocardial Viability
Normal
Normal

22. Stress MRI
Stress apex Stress mid

23. Perioperative Causes of RWMA
• Myocardial ischemia: hypokinesia, LVEDA normal
• Stunning: due to inadequate myocardial protection,
normal CBF, RWMA +
• Hibernation: Reduced ventricular reserve & CBF,
biphasic response to dobutamine
• Intracoronary air
• Direct coronary occlusion: during AVR, MV repair
• Severe MS ( basal segments)
• Normal post CPB finding( inferoseptal wall)
• Hypovolemia: RWMA of the septum
• Paradoxical motion: CP, tamponade, RV dysfn. Myocardial
thickening preserved

24. A new RWMA that appears after CPB
Is the MR worsening?
New RWMA at the time of chest closure? Mechanical occlusion of the graft
Does RWMA fit with marginal graft fn?
Is the RWMA severe? Is the patient hemodynamically unstable?
Is the heart adequately filled, is the gas trapped in the heart?
New RWMA different from pre-CPB? Does it improve with dobutamine?

25. TEE and CPB
1. During cannulation: CS, IVC, SVC, AR
2. Weaning from CPB:
a. deairing
b. TG SAX; volume status, contractility
3. After weaning: assess valve repairs, IABP/
LVAD position

27. TEE views for aortic valve
1. ME AV SAX: AS, AR
2. ME AV LAX: root
measurements
3. DTG LAX : AV, LVOT VTI

28. Aortic valve

29. Four categories of
aortic stenosis (AVA<1sqcm)
1. High-gradient aortic stenosis
2. Low-flow, low-gradient aortic stenosis with reduced
ejection fraction [valve area <1 cm2, mean gradient
<40 mmHg, ejection fraction <50%, stroke volume index
(SVi) ≤35 mL/m2].
3. Low-flow, low-gradient aortic stenosis with preserved
ejection fraction (valve area <1 cm2, mean gradient
<40 mmHg, ejection fraction ≥50%, SVi ≤35 mL/m2).
4. Normal-flow, low-gradient aortic stenosis with preserved
ejection fraction (valve area <1 cm2, mean gradient
<40 mmHg, ejection fraction ≥50%, SVi >35 mL/m2). These
patients have only moderate aortic stenosis

31. TEE during AVR
Pre- CPB
• To modify the planned
procedure
• Helping retrograde cannula
position
Post CPB
• Prosthesis dysfunction
• Ventricular dysfn
• Air embolism
• Dynamic LVOTO

32. SAM

33. Aortic regurgitation

34. AR

36. INDICATIONS FOR AVR
• presence of symptoms
(spontaneous or on exercise
testing)
• LVEF <50% and/or
• end-systolic diameter
>50 mm.

37. Mitral valve
MV views
• 1. ME 4C, 2C, commissural,
LAX
• 2. TG basal SAX, 2C

38. MS with clot in LA

39. 3D TEE for surgical repair of MV
• Accuracy of 3D TEE to detect AML prolapse
100%, bileaflet prolapse 98%. ( 2D TEE 50%)
• Information of prolapsed segment length can
guide the surgeon to decide extent of MV
resection
• Paravalvular leaks accurately detected
• Accurate estimation of coaptation zone
• Three D echo and 3D TEE for MV disease. Ashok Kumar Omar et al; JIAE; vol 3 sept-Dec
2019

40. MVP, P2P3 segment with chordae rupture real-time 3D TEE:
zoom enface view

41. PML prolapse

42. MR

43. • 1. non-coaptation
• 2.Large jet/LA
• 3.CW- dense triangular
• 5. JVC- >7mm
• 6. Systolic pulm vein flow
reversal
• 7. E wave> 1.5m/sec
• 8. PISA, EROA> 40
• 9. RV> 30

44. IMR: FMR that occurs in the setting of CAD

45. ACC/AHA guidelines 2014

46. Case: IMR with reduced EF – 31%

47. Echo - Seagull shaped AML

49. Asymptomatic MR
and abnormal exercise stress
echocardiography responses.
• - RWMA consistent with ischemic territory.
• - Development of acute pulmonary edema
without obvious cause.
• - Effective regurgitant orifice area increase
>13.

50. Indication for MV surgery
(for moderate IMR), during CABG
• If myocardial viability is present
• Low comorbidity
• AF, VT or PH
• Exercise induced,
• dyspnea,
• large increase in MR severity and
• PAH

51. Anatomy: Lateral wall MI is
associated with increase in IMR

52. Anatomy

53. 3D main advantage
1. for identifying abnormalities in the subvalvar
apparatus
2. for early valve repair failure to decide on re-
repair.
3. 3DE identifies regurgitation in the
commissural region that surgical saline
testing misses.

54. 1. Closing and tethering forces

55. Surgery
CABG
Annuloplasty

56. Surgery in IMR

57. Ring annuloplasty
• Classic ring – for RHD,
Titanium core, rigid, open.
• Physio ring -degenerative
valvular diseases, semirigid
structure.
• Ischemic ring - ischemic,
type IIIb dysfunction, rigid,
titanium structure to ensure
non-deformability

58. Congenital heart disease

59. OS ASD (ME 4C) LR shunt in diastole

60. Primum ASD

61. Bicaval View: SV ASD

62. ASCENDING AORTA SAX- SVC
SVC
RUPV

63. Deairing

64. VSD
• Number and location
• LV, RV function
• Presence and severity of AR, TR
• Qp/Qs
• PAP
• Other lesions

65. Outlet VSD LR shunt (systolic)

66. VSD- perimembranous

67. RV dysfunction

68. TOF

69. TGA

70. THANK
YOU