Duke Perioperative TEE Protocol

PREPYPASS*

*The red highlighted text apply to patients undergoing mitral valve repair or replacement for mitral valve pathology or aortic valve replacement for aortic valve pathology

ME 4-chamber view with depth optimized for wall motion evaluation and strain (>50 Hz frame rate, 3 beats loop)

Color Doppler of MV, spectral Doppler with CW when significant regurgitation (measure peak velocity) or stenosis present (measure peak velocity, peak gradient and mean gradient)

Color Doppler of TV, spectral Doppler with CW when significant regurgitation or stenosis present

ME 5-chamber view

ME mitral commisural view

Color Doppler of MV

ME 2-chamber view with depth optimized for wall motion evaluation and strain (>50Hz frame rate, 3 beats loop)

Color Doppler of MV

ME left atrial appendage view

LA appendage (zoomed or less depth view, use X-plane), PW Doppler as appropriate (measure velocities)

ME LAX optimized for wall motion evaluation and strain (> 50 Hz frame rate, 3 beats loop)

Color Doppler of MV

Measure vena contracta if mitral regurgitation present

Proximal Isovelocity Surface Area if significant mitral regurgitation or stenosis present (measure PISA radius)

ME AoV LAX

Color Doppler of AoV

M-mode through the AoV

Measure vena contracta if aortic regurgitation present

ME AoV SAX

Color Doppler AoV

ME Right ventricle inflow-outflow

Color Doppler of TV

Color Doppler of PV

ME bicaval view (proximal inferior & superior vena cava shown)

Color Doppler IAS (low Nyquist limit ≤40cm/s) to check for PFO/ASD

ME modified bicaval view

Color Doppler of TV, spectral Doppler with CW when significant regurgitation or stenosis present

TG basal SAX (ensure good endocardial border visible. Use harmonics or a lower frequency if necessary. Ensure all walls visible if possible)

TG mid SAX

TG 2 chamber view

TG LAX

TG RV inflow view

TG RV inflow-outflow view

Deep TG 5-chamber view

Color Doppler of AoV

Spectral Doppler with CW if significant aortic regurgitation (measure pressure half-time) or stenosis (measure peak and mean gradients) present

Calculate AoV area using the continuity equation if aortic stenosis present

Descending aorta LAX and SAX (use X-plane)

UE aortic arch LAX and SAX

ME ascending aorta LAX and SAX

Diastology:

Transmitral flow

Pulmonary vein flow

Tissue Doppler imaging

Propagation velocity

Quick guide to assessment of diastolic function – Cory Maxwell, MD

Renal arterial blood flow: spectral Doppler with PW

3D acquisition prebypass

3D Full Volume left ventricle

3D Full Volume right ventricle at 0 ME view with the RV tilted to be in the center of the image

3D Zoom mitral valve/3D Full Volume zoomed on mitral valve-surgeon’s perspective

3D Full Volume with color Doppler of mitral valve if moderate or greater mitral valve regurgitation or stenosis

If aortic regurgitation or stenosis present:

3D Full Volume of the aortic valve at 120 ME view

3D Full Volume color acquisition of the aortic valve at 120 ME view

POSTBYPASS*

*The red highlighted text apply to patients undergoing mitral valve repair or replacement for mitral valve pathology or aortic valve replacement for aortic valve pathology

ME 4-chamber view with depth optimized for wall motion evaluation and strain (>50 Hz frame rate, 3 beats loop)

Color Doppler of MV

Color Doppler of TV

ME mitral commissural view

Color Doppler of TV

ME 2-chamber view with depth optimized for wall motion evaluation and strain (>50Hz frame rate, 3 beats loop)

Color Doppler of MV

ME LAX optimized for wall motion evaluation and strain (> 50 Hz frame rate, 3 beats loop)

Color Doppler of MV

Measure vena contracta if mitral regurgitation present

ME AoV LAX

Color Doppler of AoV

M-mode through the AoV

ME AoV SAX

Color Doppler AoV

ME Right ventricle inflow-outflow

Color Doppler of TV

Color Doppler of PV

ME bicaval view (proximal inferior & superior vena cava shown)

Color Doppler IAS (low Nyquist limit ≤40cm/s) to check for PFO/ASD

ME modified bicaval view

Color Doppler of TV, spectral Doppler with CW when significant regurgitation or stenosis present

TG basal SAX (ensure good endocardial border visible. Use harmonics or a lower frequency if necessary. Ensure all walls visible if possible)

TG mid SAX

TG 2 chamber view

TG LAX

Deep TG 5-chamber view

Descending aorta LAX and SAX (use X-plane)

UE aortic arch LAX and SAX

ME ascending aorta LAX and SAX

Record gradients through the new prosthetic valve or valve repair

Diastology:

Transmitral flow

Pulmonary vein flow

Tissue Doppler imaging

Propagation velocity

Renal arterial blood flow: spectral Doppler with PW (measure peak systolic flow and minimal diastolic flow)

3D acquisition postbypass

3D Full Volume left ventricle

3D Full Volume right ventricle at 0 ME view with the RV tilted to be in the center of the image

3D Zoom mitral valve/3D Full Volume zoomed on mitral valve-surgeon’s perspective after mitral valve repair or replacement

3D full volume with color acquisition of the mitral valve after mitral valve replacement and repair

3D Full Volume color acquisition of the aortic valve at 120 ME view

VENTRICULAR ASSIST DEVICES PLACEMENT

Additions and exceptions from the postbypass protocol for left ventricular assist devices:

Visualize the inflow cannula in the ME views with and without color

Visualize the outflow cannula in the ascending aorta views. Record velocities with CW Doppler

Do not perform diastology

Do not assess left ventricular wall motion and ejection fraction

Additions to the postbypass protocol for right ventricular assist devices:

Visualize the inflow cannula in the right atrium

Visualize the outflow cannula in the pulmonary artery (ME Asc Ao SAX and/or UE aortic arch SAX). Record velocities with CW Doppler.

HEART TRANSPLANT

Postbypass perform a thorough examination of the transplanted heart following the “Prebypass protocol” above.

LUNG TRANSPLANT

Additions to the postbypass protocol

Image right and left pulmonary veins with and without color

Record velocities in the right and left pulmonary veins using PW Doppler

Image main pulmonary artery and right pulmonary artery with and without color (ME Asc Ao SAX and/or UE Aortic Arch SAX)

TAVR DUKE PERIOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY PROTOCOL

PRE-PROCEDURE At least 2-beat loops, clear ECG signal

3D acquisition

3D Full Volume left ventricle

3D Zoom mitral valve/3D Full Volume zoomed on mitral valve-surgeon’s perspective

3D Full Volume with color Doppler of mitral valve

3D Full Volume of the aortic valve at 120 ME view

3D Full Volume color acquisition of the aortic valve at 120 ME view

2D acquisition

ME 4-chamber view with depth optimized for wall motion evaluation (FR >50 Hz)

Color Doppler of MV, spectral Doppler with CW when significant regurgitation (measure peak velocity) or stenosis present (measure peak velocity, peak gradient and mean gradient)

Color Doppler of TV, spectral Doppler with CW when significant regurgitation or stenosis present

ME bicommisural view

Color Doppler of MV

ME 2-chamber view with depth optimized for wall motion evaluation (FR> 50Hz))

Color Doppler of MV

LA appendage (zoomed, use X-plane), PW Doppler as appropriate (measure velocities)

ME LAX optimized for wall motion evaluation (FR >50Hz)

Color Doppler of MV

Measure vena contracta if mitral regurgitation present

Measure PISA radius if significant mitral regurgitation or stenosis present

ME LAX of the AoV

Color Doppler of AoV

Measure vena contracta if aortic regurgitation present

Measure LVOT, annulus, sinuses of Valsalva, STJ, ascending aorta diameters

ME SAX of the AoV

Color Doppler AoV

ME Right ventricle inflow-outflow

Color Doppler of TV

Color Doppler of PV

ME bicaval view (proximal inferior & superior vena cava shown)

Color Doppler IAS (low Nyquist limit ≤40cm/s) to check for PFO/ASD

TG basal SAX  (ensure good endocardial border visible. Use harmonics or a lower frequency if necessary. Ensure all walls visible if possible)

TG mid SAX

TG 2 chamber view

TG LAX

Deep TG view

Color Doppler of AoV

Spectral Doppler with CW if significant aortic regurgitation (measure pressure half-time) or stenosis (measure peak and mean gradients) present

Spectral Doppler with PW across the LVOT

Calculate AoV area using the continuity equation if aortic stenosis present

Diastology:

Transmitral flow

Pulmonary vein flow

Tissue Doppler imaging

Propagation velocity

Renal arterial blood flow: spectral Doppler with PW (measure peak systolic velocity and minimal diastolic velocity)

Descending aorta LAX and SAX (use X-plane)

Aortic arch LAX and SAX

Ascending aorta LAX and SAX

POST-PROCEDURE

Please evaluate of the new prosthetic aortic valve in the following views:

Record prosthetic aortic valve loops/images after the transvalvular wire has been removed.

ME SAX

Color Doppler of AoV

ME LAX

Color Doppler of AoV

TG LAX

Color of AoV

Spectral Doppler with CW across the prosthetic valve

Deep TG

Color Doppler of AoV

Spectral Doppler with CW across the prosthetic valve

Spectral Doppler with PW across the LVOT

Other images

ME 4-chamber view with depth optimized for wall motion evaluation (FR >50 Hz FR)

Color Doppler of MV

Color Doppler of TV

ME 2-chamber view with depth optimized for wall motion evaluation (FR >50Hz)

Color Doppler of MV

ME LAX with depth optimized for wall motion evaluation (FR> 50 Hz)

Color Doppler of MV

ME Right ventricle inflow-outflow

Color Doppler of TV

Color Doppler of PV

TG basal SAX  (ensure good endocardial border visible. Use harmonics or a lower frequency if necessary. Ensure all walls visible if possible)

TG mid SAX

TG 2 chamber view

TG LAX

Diastology:

Transmitral flow

Pulmonary vein flow

Tissue Doppler imaging

Descending aorta LAX and SAX (use X-plane)

Aortic arch LAX and SAX

Ascending aorta LAX and SAX

3D acquisition

3D Zoom mitral valve/3D Full Volume zoomed on mitral valve-surgeon’s perspective

3D Full Volume with color Doppler of mitral valve

3D Full Volume of the aortic valve at 120 ME view

3D Full Volume color acquisition of the aortic valve at 120 ME view

Faculty and Staff

Faculty

Solomon Aronson, MD, Echo Faculty
Brandi Bottiger, MD, Echo Faculty
Anne Cherry, MD, Echo Faculty
Brian Colin, MD, Echo Faculty
J. Mauricio Del Rio, MD, Echo Faculty
Nicole Guinn, MD, Echo Faculty
Jorn Karhausen, MD, Echo Faculty
Miklos Kertai, MD, Echo Faculty
Rebecca Klinger, MD, Echo Faculty
Yasmin Maisonave, MD, Echo Faculty
Michael Manning, MD, Echo Faculty
Joseph Mathew, MD, Echo Faculty
Mark Newman, MD, Echo Faculty
Alina Nicoara, MD, Echo Faculty
Mihai Podgoreanu, MD, Echo Faculty
Mark Stafford-Smith, MD, Echo Faculty
Madhav Swaminathan, MD, Echo Faculty
Eleanor Vega, MD, Echo Faculty
Ian Welsby, MB, Echo Faculty

Staff

Jaime Cooke, Staff Assistant
Audrey McGregor, Staff Assistant
Dheadra McAdoo, Echo Technician
Cheryl Stetson, CT Fellowship Coordinator