Cardiac Examination Techniques

What is a transesophageal echocardiogram (TEE)?

Procedure in which probe is inserted down a patient’s throat to image heart structures at varied levels within stomach and esophagus

What temperature should the TEE probe be kept at?

< 40 degrees celsius because excessive heat can cause damage to organs

What are the advantages of a TEE?

1. Higher resolution imaging

2. Better visualization of small structures and valves

3. Evaluation of LAA and atrial thrombus formation

4. Provides multiplane imaging techniques not possible with TTE

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TEE midesophageal four chamber taken at 0-10 degrees

1. RA

2. RV

3. LA

4. LV

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TEE two chamber taken at 30-60 degrees

1. AV

2. LA

3. Left upper PV

4. LAA

5. Coumadin ridge

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TEE midesophageal LAX taken at 120-140 degrees

1. LA

2. LV

3. AV

4. RVOT

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TEE midesophageal SAX base taken at 40 degrees

1. LA

2. RA

3. RVOT

4. AV

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TEE transgastric SAX basal taken at 0 degrees

1. Posterior MV leaflet

2. Anterior MV leaflet

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TEE transgastric SAX mid LV taken at 0 degrees

1. LV

2. RV

3. Inferior

4. Anterior

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TEE bicaval taken at 90-110 degrees

1. LA

2. IVC

3. SVC

4. RA

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TEE Midesophageal descending thoracic aorta SAX taken at 0 degrees

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TEE Midesophageal descending thoracic aorta LAX taken at 90-100 degrees

What is POCUS?

Point of care ultrasound used to evaluate effusion, wall motion abnormalities, and EF with a limited exam

What are the indications for a stress echocardiogram?

1. CAD screening

2. Assess systolic function

3. Evaluate MI improvement

4. Evaluate hemodynamic effects of valvular disease

5. Assess diastolic dysfunction in those with dyspnea

What are contraindications for a stress echocardiogram?

1. Unstable angina

2. Acute MI

3. Severe ventricular arrhythmias

4. Resting BP > 200/100

5. SYMPTOMATIC severe AV stenosis

6. Severe LVOT gradient at rest with HOCM

7. ST elevation in resting EKG

What is the Bruce protocol?

Standardized treadmill test used to assess LV function and wall motion changes

What is the protocol for an exercise stress echocardiogram?

1. Nurse or physiologist will obtain resting EKG and BP

2. Obtain resting images: A4C, A2C, A3C, PLAX, PSAX

3. Patient will begin treadmill test with speed and incline increasing every 3 minutes (Bruce protocol)

4. Nurse or physiologist will obtain BP every two minutes

5. Patient exercises until symptoms occur or target HR is reached

6. Obtain post images in 60 seconds or less AT SAME DEPTH AS RESTING: A4C, A2C, A3C, PLAX, PSAX

What are the results of a normal exercise stress echocardiogram?

1. BP increases during exercise and returns to normal after cessation

2. No EKG changes or symptoms (ST remains normal, no AFIB or SVT)

3. Increased EDV and EF

4. Decreased ESV

5. Hyperkinesis

6. Increased velocity of contraction

What is a pharmacologic stress echocardiogram?

Usage of dobutamine or atropine to simulate exercise in patients unable to perform exercise

What is the protocol for a pharmacologic stress echocardiogram?

1. Nurse or physiologist will obtain resting EKG and BP

2. Obtain resting images: A4C, A2C, A3C, PLAX, PSAX

3. Gradual intravenous infusion of dobutamine for up to 15 minutes

4. Obtain low-dose, pre-peak, and peak stress images during infusion

5. Obtain recovery images 5 minutes post-infusion

   * Atropine may be administered to increase heart rate in those who cannot reach target HR with Dobutamine alone

What are the results of a normal pharmacological stress echocardiogram?

1. BP increases during infusion and returns to normal after cessation

2. No EKG changes or symptoms (ST remains normal, no AFIB or SVT)

3. Increased EF

4. Decreased EDV and ESV

5. Hyperkinesis

6. Increased velocity of contraction

What is speckle tracking?

Test that evaluated for early LV systolic dysfunction

What is global longitudinal strain (GLS)?

Test used to evaluate maximal deformation of LV myocardium at peak systole

What is the normal value for global longitudinal strain (GLS)?

-17 to -26%

• Expressed as negative because it describes amount of shortening

• GLS values close to 0 indicated severe LV dysfunction

Who is recommended for strain imaging?

Patients at risk of chemotherapy-related LV systolic dysfunction

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Normal GLS

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Abnormal GLS

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Abnormal GLS due to amyloidosis (“cherry on top” or bullseye)

What is an agitated saline ultrasound enhancing agent (UEA)?

Agitated salt solution that creates bubbles for PFO or ASD detection

How is a bubble study performed?

1. IV established for injection of saline

2. Obtain A4C without bubbles

3. Obtain A4C with bubble at rest, with a cough, and with valsalva or abdominal compression

What are the results of a positive bubble study?

1. Bubbles on left side in 1-3 beats indicates PFO or ASD

2. Bubbles in left side in 4-8 beats indicates pulmonary AVM

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Positive bubble study

What is a perfluorocarbon ultrasound enhancing agent (UEA)?

FDA-approved contrast agent such as Definity, Sonovue, Lumason, or Optison used for evaluation of LV function or detection of LV thrombus, aneurysm, or mass

How is a contrast echocardiogram performed?

1. IV established for injection of contrast

2. Reduce output power and overall gain

3. Reduce MI < 0.3 to prevent bursting microbubbles

4. Place focal zone at MV annulus

5. Obtain images with contrast: A4C, A2C, A3C, PLAX, PSAX

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LV thrombus detected with contrast

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Biplane imaging

What is a cardiac catheterization or coronary angiography?

Procedure performed by inserting catheter into brachial or superficial femoral artery to assess coronary arteries for blockages

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Cardiac catheterization or coronary angiography