Comprehensive Examination

In addition to the 8 cross sections described in the previous section, 12 other cross sections are required to complete the comprehensive perioperative TEE examination delineated in the 1999 ASE/SCA task force recommendations.^[7] When time permits or the diagnostic question or questions require, the comprehensive examination can be completed in any order deemed most appropriate by the operator. Shanewise and associates described an examination sequence based on anatomic structures, and the reader is referred to this very detailed reference for one excellent approach. ^[7] However, when a single individual is responsible for anesthetic care and TEE, the comprehensive examination is completed as time permits after the basic examination has been recorded. When such is the case, the operator can use 3 of the 8 basic cross sections as takeoff points for the other 12 cross sections to make completion of the comprehensive examination a relatively easy sequence to remember and quick to perform.

With the probe positioned for the AV SAX cross section, the other six cross sections of the aorta are easily achieved. First, the probe is withdrawn slowly 1 to 3 cm while keeping the aorta in the center of the video screen to view the ascending aorta in SAX ( Fig. 33-8O ). As the probe is withdrawn, the operator views progressively more superior SAX cross sections of the aorta, beginning with the sinotubular junction, until the image is lost because of interposition of the trachea between the esophagus and aorta. Next, the multiplane angle is rotated forward to 100 to 120 degrees and advanced slowly 1 to 3 cm while keeping the aorta in the center of the video screen to view the ascending aorta in LAX ( Fig. 33-8P ). These two cross sections are ideal for assessment of pathology of the ascending aorta, such as type I aortic dissection and aortic atheromas. However, the most superior aspect of the aorta is rarely seen, including the takeoff of the innominate artery, because of the aforementioned tracheal interposition. Next, the transducer is returned to 0 degrees, the image depth decreased to 6 cm, and the probe turned leftward past the cardiac structures to reveal the descending aorta in SAX ( Fig. 33-8Q ). The probe is withdrawn and advanced with the aorta maintained in the center of the screen until the entire descending aorta has been examined in SAX. This maneuver is repeated with the transducer at 90 degrees to examine the descending aorta in LAX ( Fig. 33-8R ). Next, the transducer is returned to 0 degrees and the probe withdrawn until the distal aortic arch in LAX comes into view ( Fig. 33-8S ). Rotating the transducer to 90 degrees reveals the distal arch in SAX ( Fig. 33-8T ). The probe is turned leftward until the aorta just disappears from view and then turned slowly rightward to identify the takeoff of the left subclavian artery (well seen in most patients) and the left carotid artery (well seen in a minority of patients). These cross sections of the descending aorta and distal aortic arch reliably reveal dissections and atheromatous disease.

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With the probe positioned for the ME four-chamber cross section, the ME mitral commissural cross section is achieved easily by centering the coaptation point of the mitral valve in the center of the video screen and rotating the multiplane angle forward to about 60 degrees ( Fig. 33-8G ). This maneuver positions the ultrasound beam parallel to the closure line of the mitral leaflets and completes the LAX examination of the mitral valve. Although a detailed discussion of mitral leaflet structure and function is beyond the scope of this chapter, Figure 33-10 summarizes an excellent approach to this challenging task.^[35]

With the probe positioned for the TG mid SAX cross section, the remaining five cross sections of the comprehensive

Figure 33-10 Systematic examination of the mitral valve. In this examination, the mitral valve is viewed in multiple cross sections to delineate leaflet anatomy. The "5-chamber" cross section is accomplished by withdrawing the probe slightly from the standard 4-chamber cross section until the left ventricular outflow track is in view. The center column shows the planes of the different cross sections as viewed from directly above the base of the heart. The 2-chamber "anterior," "mid," and "posterior" cross sections are variations of the standard 2-chamber cross section and are accomplished by turning the probe from the patient's right to left. "P1, P2, and P3" refer to the three scallops of the posterior mitral leaflet, and "A1, A2, and A3" refer to the juxtaposed segments of the anterior mitral leaflet. The right column shows the leaflet segments seen in the corresponding cross section. (Redrawn from Lambert AS, Miller JP, Foster E, et al: Improved evaluation of the location and mechanism of mitral valve regurgitation with a systematic transesophageal echocardiography examination. Anesth Analg 88:1205–1212, 1999.)

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