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Board Stiff TEE Content Strategist: William Schmitt Content Development Specialist: Rachael Harrison/Nani Clansey Content Coordinator: Lee Hood Project Manager: Sukanthi Sukumar Designer: Steven Stave Illustration Manager: Lesley Frazier Illustrator: Dartmouth Publishing Marketing Manager (UK/USA): Abby Swartz Board Stiff TEE Transesophageal Echocardiography Second Edition Christopher J. Gallagher, MD Professor and Residency Director Stony Brook Department of Anesthesia Stony Brook University Stony Brook, NY, USA John C. Sciarra, MD Assistant Professor Cardiovascular and Thoracic Anesthesiology Fellowship Program Director University of Miami Miami, FL, USA Steven Ginsberg, MD Associate Professor of Anesthesiology Program Director of Cardiothoracic Anesthesia Fellowship UMDNJ-Robert Wood Johnson Medical School New Brunswick, NJ, USA For additional online content visit www.expertconsult.com London, New York, Oxford, St Louis, Sydney, Toronto 2013 SAUNDERS an imprint of Elsevier Inc. © 2013 Elsevier Inc. All rights reserved. First edition 2004 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN: 978-1-4557-3805-2 ebook ISBN: 978-1-4557-3759-8 Printed in United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 Contents Preface to the First Edition vii Preface to the Second Edition List of Contributors ix xi Introduction: Neither Rain nor Snow 1 CHAPTER   The Yellow Brick Road CHAPTER CHAPTER CHAPTER CHAPTER CHAPTER 2  xv 1 Christopher J. Gallagher Principles of Ultrasound 3 Christopher J. Gallagher and John C. Sciarra 3  Transducers and Instrumentation 4  Equipment, Infection Control, and Safety 19 5  Principles of Doppler Ultrasound 6  9 Christopher J. Gallagher and John C. Sciarra Steven Ginsberg and Jonathan Kraidin 25 Jonathan Kraidin, Steven Ginsberg, William Jian and Kevin A. Jian Quantitative M-mode and Two-dimensional Echocardiography 39 Varun Dixit, John C. Sciarra and Christopher J. Gallagher CHAPTER 7  Quantitative Doppler 47 Christopher J. Gallagher, Christina Matadial and Jadelis Giquel CHAPTER CHAPTER 8  Doppler Profiles and Assessment of Diastolic Function Christopher J. Gallagher and John C. Sciarra 9  Cardiac Anatomy 67 Christopher J. Gallagher and John C. Sciarra CHAPTER 10  Pericardium and Extra-Cardiac Structures: Anatomy and Pathology 77 Enrique Pantin and F. Luke Aldo CHAPTER 11  Pathology of the Cardiac Valves 97 F. Luke Aldo and Enrique Pantin CHAPTER 12  Intra-cardiac Masses and Devices 115 13  Left Ventricular Systolic Function 123 Al Solina, F. Luke Aldo and Salvatore Zisa CHAPTER Eric W. Nelson CHAPTER 14  Segmental Left Ventricular Systolic Function John C. Sciarra and Christopher J. Gallagher 131 55 vi Contents CHAPTER 15  The 17 Segment Model 139 John C. Sciarra CHAPTER 16  Assessment of Perioperative Events and Problems Ricardo Martinez-Ruiz and Christopher J. Gallagher CHAPTER 17  Congenital Heart Disease 163 Liliana Cohen and Daniel M. Shindler CHAPTER 18  Artifacts and Pitfalls 173 Christopher J. Gallagher and Gian Paparcuri CHAPTER 19  Related Diagnostic Modalities 191 Steven Gill, John C. Sciarra and Christopher J. Gallagher CHAPTER 20  Intraoperative 3-D Echocardiography Gian Paparcuri CHAPTER 21  The Structured TEE Examination John C. Sciarra CHAPTER 22  Sonographic Formulas 209 John C. Sciarra CHAPTER 23  Hemo-dynamo Doc 211 Christopher J. Gallagher CHAPTER 24  Test Questions 249 William R. Grubb and Andrew T. Burr Epilogue: Smooth Sailing 273 Index 275 203 195 147 Preface to the First Edition If you are doing cardiac anesthesia, cardiac surgery, or intensive care work, and you don’t know Transesophageal Echocardiography, you are yesterday’s newspaper. You are a repairman for 8-track cassette players. You are selling slide rules. You need to know TEE. Board Stiff TEE is just the ticket. I wrote this book to give you a complete introduction to the subject, from the physics of ultrasound to the images you need to recognize to the hemodynamic calculations you can make with TEE. The whole nine yards. Plus, I direct you to those places where you can deepen your understanding of TEE. Board Stiff TEE is the perfect launch pad. Board Stiff TEE is for the medical student, the anesthesiologist, the surgeon, the intensivist, who asks, “Just where do I start?” The book details n Why you need to know TEE n Which books and meetings will help the most n Everything you need to know if you take the PTEeXAM n How to work through the quantitative aspects of TEE Board Stiff TEE is jam-packed with simplified drawings to illustrate all the points you need to know. No need to decipher a small photograph of a TEE image; everything here is laid out with the student in mind. Especially when you start out, it’s hard to tell what’s what in a photograph of a TEE image. These drawings will lay it out for you. Best of all, learning TEE does not have to be a replay of your root canal. Board Stiff TEE has a dollop of humor here and there to keep your eyes open and your airway from obstructing. Several people helped in this affair. Alicia Borus gave expert secretarial help; my editor Natasha Andjelkovic reined in my more outlandish prose; Elsevier’s illustrators redid all the drawings, improving on my “magic marker in a Crayola pad” work; and J.C. Duffy did the cover and the cartoons. Through it all, my wife endured my manic ravings. And final thanks to my daughter Rachel, who is a blast. Christopher J. Gallagher, MD This page intentionally left blank Preface to the Second Edition A long time ago in a galaxy far, far away…AND SO FORTH. John C. Sciarra, MD University of Miami