Transesophageal echocardiography in the evaluation of the left ventricle
- Elyse Foster, MD
Elyse Foster, MD
- Professor of Clinical Medicine
- University of California, San Francisco
Although transthoracic echocardiography remains the cornerstone of diagnostic cardiac ultrasound, transesophageal echocardiography (TEE) is a valuable complementary tool. As compared with transthoracic echocardiography, TEE offers superior visualization of posterior cardiac structures because of close proximity of the esophagus to the posteromedial heart with lack of intervening lung and bone. This proximity permits use of high-frequency imaging transducers that afford superior spatial resolution (image 1).
TEE displays most of the left ventricle (LV) with definition that is equal or superior to that achieved with transthoracic echocardiography. In particular, the full thickness of the myocardium, including the endocardium with its complex endo-architecture, is seen with clarity. However, most TEE views do not fully display the apical portion of the LV, which is truncated or foreshortened. This shortcoming lowers the sensitivity of TEE for detecting a wall motion abnormality limited to the apex, leads to underestimation of chamber volume, and may result in misinterpretation of global LV systolic function. Importantly, the presence of apical thrombus may be missed on TEE alone.
The use of TEE for the evaluation of the LV will be reviewed here. The specific roles for TEE in ischemic heart disease, valvular disease, and aortic pathology are discussed in detail separately. (See "Transesophageal echocardiography in the evaluation of aortic valve disease" and "Transesophageal echocardiography in the evaluation of mitral valve disease" and "Transesophageal echocardiography in traumatic rupture of the aortic isthmus".)
While quantitative methods to measure LV systolic function and ejection fraction by TEE have been described, most TEE evaluation of the LV is qualitative. Studies by anesthesiologists in the operating room have documented the validity of this approach for recognizing hypovolemia, the adverse effects of proximal cross-clamping of the aorta, and the influence of various anesthetic regimens on LV systolic function [1-6]. When evaluating left ventricular function, it is important to consider the patient's overall condition. Volume status, sedating medications, and general anesthesia may alter both systolic and diastolic function through their effects on preload and afterload.
Ejection fraction — Calculation of end-diastolic and end-systolic volumes by TEE using the biplane method of discs (ie, Simpson's rule) systematically underestimates LV size [7,8]. A non-volumetric method has been described that accurately estimates LV ejection fraction using the descent of the mitral annulus toward the apex as an index of the shortening of the ventricular long axis .
- Beaupre PN, Roizen MF, Cahalan MK, et al. Hemodynamic and two-dimensional transesophageal echocardiographic analysis of an anaphylactic reaction in a human. Anesthesiology 1984; 60:482.
- Leung JM, Levine EH. Left ventricular end-systolic cavity obliteration as an estimate of intraoperative hypovolemia. Anesthesiology 1994; 81:1102.
- Roizen MF, Beaupre PN, Alpert RA, et al. Monitoring with two-dimensional transesophageal echocardiography. Comparison of myocardial function in patients undergoing supraceliac, suprarenal-infraceliac, or infrarenal aortic occlusion. J Vasc Surg 1984; 1:300.
- Mitchell MM, Prakash O, Rulf EN, et al. Nitrous oxide does not induce myocardial ischemia in patients with ischemic heart disease and poor ventricular function. Anesthesiology 1989; 71:526.
- Kikura M, Ikeda K. Comparison of effects of sevoflurane/nitrous oxide and enflurane/nitrous oxide on myocardial contractility in humans. Load-independent and noninvasive assessment with transesophageal echocardiography. Anesthesiology 1993; 79:235.
- Houltz E, Gustavsson T, Caidahl K, et al. Effects of surgical stress and volatile anesthetics on left ventricular global and regional function in patients with coronary artery disease. Evaluation by computer-assisted two-dimensional quantitative transesophageal echocardiography. Anesth Analg 1992; 75:679.
- Smith MD, MacPhail B, Harrison MR, et al. Value and limitations of transesophageal echocardiography in determination of left ventricular volumes and ejection fraction. J Am Coll Cardiol 1992; 19:1213.
- Hozumi T, Shakudo M, Shah PM. Quantitation of left ventricular volumes and ejection fraction by biplane transesophageal echocardiography. Am J Cardiol 1993; 72:356.
- Doerr HK, Quiñones MA, Zoghbi WA. Accurate determination of left ventricular ejection fraction by transesophageal echocardiography with a nonvolumetric method. J Am Soc Echocardiogr 1993; 6:476.
- Grossgasteiger M, Hien MD, Graser B, et al. Assessment of left ventricular size and function during cardiac surgery. An intraoperative evaluation of six two-dimensional echocardiographic methods with real time three-dimensional echocardiography as a reference. Echocardiography 2013; 30:672.
- Cowie B, Kluger R, Kalpokas M. Left ventricular volume and ejection fraction assessment with transoesophageal echocardiography: 2D vs 3D imaging. Br J Anaesth 2013; 110:201.
- Urbanowicz JH, Shaaban MJ, Cohen NH, et al. Comparison of transesophageal echocardiographic and scintigraphic estimates of left ventricular end-diastolic volume index and ejection fraction in patients following coronary artery bypass grafting. Anesthesiology 1990; 72:607.
- Royse CF, Royse AG. Afterload corrected fractional area change (FACac): a simple, relatively load-independent measurement of left ventricular contractility in humans. Ann Thorac Cardiovasc Surg 2000; 6:345.
- Sutton DC, Cahalan MK. Intraoperative assessment of left ventricular function with transesophageal echocardiography. Cardiol Clin 1993; 11:389.
- Cahalan MK, Ionescu P, Melton HE Jr, et al. Automated real-time analysis of intraoperative transesophageal echocardiograms. Anesthesiology 1993; 78:477.
- MacLaren G, Kluger R, Connelly KA, Royse CF. Comparative feasibility of myocardial velocity and strain measurements using 2 different methods with transesophageal echocardiography during cardiac surgery. J Cardiothorac Vasc Anesth 2011; 25:216.
- Kukucka M, Nasseri B, Tscherkaschin A, et al. The feasibility of speckle tracking for intraoperative assessment of regional myocardial function by transesophageal echocardiography. J Cardiothorac Vasc Anesth 2009; 23:462.
- Marwick TH, Leano RL, Brown J, et al. Myocardial strain measurement with 2-dimensional speckle-tracking echocardiography: definition of normal range. JACC Cardiovasc Imaging 2009; 2:80.
- Reckefuss N, Butz T, Horstkotte D, Faber L. Evaluation of longitudinal and radial left ventricular function by two-dimensional speckle-tracking echocardiography in a large cohort of normal probands. Int J Cardiovasc Imaging 2011; 27:515.
- Ernande L, Rietzschel ER, Bergerot C, et al. Impaired myocardial radial function in asymptomatic patients with type 2 diabetes mellitus: a speckle-tracking imaging study. J Am Soc Echocardiogr 2010; 23:1266.
- Muhiudeen IA, Kuecherer HF, Lee E, et al. Intraoperative estimation of cardiac output by transesophageal pulsed Doppler echocardiography. Anesthesiology 1991; 74:9.
- Izzat MB, Regragui IA, Wilde P, et al. Transesophageal echocardiographic measurements of cardiac output in cardiac surgical patients. Ann Thorac Surg 1994; 58:1486.
- Stoddard MF, Prince CR, Ammash N, et al. Pulsed Doppler transesophageal echocardiographic determination of cardiac output in human beings: comparison with thermodilution technique. Am Heart J 1993; 126:956.
- Kuecherer HF, Foster E. Hemodynamics by transesophageal echocardiography. Cardiol Clin 1993; 11:475.
- Royse CF, Connelly KA, MacLaren G, Royse AG. Evaluation of echocardiography indices of systolic function: a comparative study using pressure-volume loops in patients undergoing coronary artery bypass surgery. Anaesthesia 2007; 62:109.
- Beaupre PN, Kremer PF, Cahalan MK, et al. Intraoperative detection of changes in left ventricular segmental wall motion by transesophageal two-dimensional echocardiography. Am Heart J 1984; 107:1021.
- Leung JM, O'Kelly B, Browner WS, et al. Prognostic importance of postbypass regional wall-motion abnormalities in patients undergoing coronary artery bypass graft surgery. SPI Research Group. Anesthesiology 1989; 71:16.
- van Daele ME, Sutherland GR, Mitchell MM, et al. Do changes in pulmonary capillary wedge pressure adequately reflect myocardial ischemia during anesthesia? A correlative preoperative hemodynamic, electrocardiographic, and transesophageal echocardiographic study. Circulation 1990; 81:865.
- Akchurin RS, Tkachuk LM, Lepilin MG, et al. Intraoperative transesophageal echocardiography for detection of myocardial ischemia. Herz 1993; 18:372.
- Rouine-Rapp K, Ionescu P, Balea M, et al. Detection of intraoperative segmental wall-motion abnormalities by transesophageal echocardiography: the incremental value of additional cross sections in the transverse and longitudinal planes. Anesth Analg 1996; 83:1141.
- Shah PM, Kyo S, Matsumura M, Omoto R. Utility of biplane transesophageal echocardiography in left ventricular wall motion analysis. J Cardiothorac Vasc Anesth 1991; 5:316.
- Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989; 2:358.
- Foster E, O'Kelly B, LaPidus A, et al. Segmental analysis of resting echocardiographic function and stress scintigraphic perfusion: implications for myocardial viability. Am Heart J 1995; 129:7.
- Nishimura RA, Housmans PR, Hatle LK, Tajik AJ. Assessment of diastolic function of the heart: background and current applications of Doppler echocardiography. Part I. Physiologic and pathophysiologic features. Mayo Clin Proc 1989; 64:71.
- Nishimura RA, Abel MD, Hatle LK, Tajik AJ. Assessment of diastolic function of the heart: background and current applications of Doppler echocardiography. Part II. Clinical studies. Mayo Clin Proc 1989; 64:181.
- Gorcsan J 3rd, Diana P, Lee J, et al. Reversible diastolic dysfunction after successful coronary artery bypass surgery. Assessment by transesophageal Doppler echocardiography. Chest 1994; 106:1364.
- Hoit BD, Shao Y, Gabel M, Walsh RA. Influence of loading conditions and contractile state on pulmonary venous flow. Validation of Doppler velocimetry. Circulation 1992; 86:651.
- Kuecherer HF, Muhiudeen IA, Kusumoto FM, et al. Estimation of mean left atrial pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow. Circulation 1990; 82:1127.
- Kuecherer HF, Kusumoto F, Muhiudeen IA, et al. Pulmonary venous flow patterns by transesophageal pulsed Doppler echocardiography: relation to parameters of left ventricular systolic and diastolic function. Am Heart J 1991; 122:1683.
- Nishimura RA, Abel MD, Hatle LK, Tajik AJ. Relation of pulmonary vein to mitral flow velocities by transesophageal Doppler echocardiography. Effect of different loading conditions. Circulation 1990; 81:1488.
- Barbier P, Solomon S, Schiller NB, Glantz SA. Determinants of forward pulmonary vein flow: an open pericardium pig model. J Am Coll Cardiol 2000; 35:1947.
- Barbier P, Solomon SB, Schiller NB, Glantz SA. Left atrial relaxation and left ventricular systolic function determine left atrial reservoir function. Circulation 1999; 100:427.
- Rossvoll O, Hatle LK. Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures. J Am Coll Cardiol 1993; 21:1687.
- Ali MM, Royse AG, Connelly K, Royse CF. The accuracy of transoesophageal echocardiography in estimating pulmonary capillary wedge pressure in anaesthetised patients. Anaesthesia 2012; 67:122.
- Klein AL, Stewart WJ, Bartlett J, et al. Effects of mitral regurgitation on pulmonary venous flow and left atrial pressure: an intraoperative transesophageal echocardiographic study. J Am Coll Cardiol 1992; 20:1345.
- Combes A, Arnoult F, Trouillet JL. Tissue Doppler imaging estimation of pulmonary artery occlusion pressure in ICU patients. Intensive Care Med 2004; 30:75.
- SYSTOLIC FUNCTION
- Ejection fraction
- Fractional area change
- Strain analysis
- Doppler echocardiography
- Evaluation of regional wall motion
- - Views used for evaluation
- - Measurement of wall motion abnormalities
- - Limitations
- DIASTOLIC FUNCTION
- Mitral inflow filling pattern
- Pulmonary venous Doppler
- Tissue Doppler measurements
- INFORMATION FOR PATIENTS