The pericardium and pericardial disease

Chapter 16 is a new chapter from earlier editions of Practical Perioperative Transoesophageal Echocardiography. It provides a short summary on the echocardiographic assessment of the normal pericardium and on pericardial disease. The characteristic TOE features of pericardial pathology (cysts, acute pericarditis, pericardial effusion, pericardial tamponade, and constrictive pericarditis) are reviewed. In particular, pericardial constriction is discussed in detail, including outlining the features that distinguish pericardial constriction from restrictive cardiomyopathy. Wherever possible, the spectral Doppler abnormalities associated with pericardial constriction and pericardial tamponade are discussed with reference to patients who are mechanically ventilated.

The right ventricle

The first part of Chapter 12 details the relevant anatomy, physiology, and TOE views required for accurate assessment of the RV. Included are several useful imaging planes that are not presented in Chapter 4: Standard views. Next, the techniques for assessing global, regional, and diastolic RV function are outlined. The characteristic features of RV pressure and volume overload are described. The final part of the chapter brings together the information from the previous sections to provide an approach to assessing RV function during the perioperative period.

The thoracic aorta

The first section of Chapter 12 details an approach to a systematic examination of the aortic root and thoracic aorta. The limitations (due to interposition of the large airways) and artefacts encountered when assessing the thoracic aorta are discussed. Normal aortic dimensions are listed in tabular format. The remainder of the chapter is concerned with the pathologies affecting the thoracic aorta, namely: aortic atheroma, aortic aneurysm, acute aortic syndromes (dissection, intramural haematoma, and penetrating ulcer), and traumatic aortic injury. Where relevant, reference to appropriate guidelines and surgical techniques are made.

Surgical repair of the mitral valve

Chapter 9 is a new chapter from earlier editions of Practical Perioperative Transoesophageal Echocardiography. In the first part of the chapter, the indications for MV repair are reviewed, and areas of controversy are highlighted. Next, the surgical techniques used for valve repair for different mitral pathologies are summarized, in particular the use of leaflet resection or neochordae for repair of degenerative disease. Considerations for minimally invasive mitral repair are briefly reviewed. The bulk of the chapter is given over to TOE assessment prior to, and following, surgical repair. Characteristic features of, and associated complications encountered with, different mitral pathologies are presented. In particular, the risk factors for post-operative systolic anterior motion (SAM) in patients with degenerative disease and failure of a reduction annuloplasty in patients with secondary mitral regurgitation are described. The final section of the chapter details the post-repair assessment, with an emphasis on the features of an optimal repair, quantifying residual mitral regurgitation, mechanisms of repair failure, and assessment and treatment of post-operative SAM.

Anatomical variants and cardiac masses

Chapter 5 is divided into two sections. In Section 1, anatomical variants that can lead to misdiagnosis or that are associated with cardiac pathology are described. Anatomical variants are grouped by location, starting with those in the right atrium and sequentially covering the LA, atrial septum, RV, LV, heart valves, pericardium, and extracardiac structures. In Section 2, cardiac masses and abnormal spaces are reviewed, including thrombi, vegetations, cysts, and tumours. The differences in echo reflectance of different cardiac masses is explained. For cardiac tumours, the incidence and characteristics of primary versus secondary and benign versus malignant lesions are described.

Standard views

In Chapter 4, the 28 standard 2D TOE views, as recommended by the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA), are described. For each view, a line drawing is provided, indicating relevant cardiac structures. Line drawings of normal spectral Doppler waveforms are also provided. 3D images of normal mitral, aortic, and tricuspid valves, displayed in their recommended orientations, are demonstrated. In addition to standard views, a sequential approach to performing a comprehensive TOE examination is described. Tables summarizing the indications and contraindications to TOE examination, as outlined by the ASE/SCA, are provided.

Haemodynamic instability

Chapter 21 brings together many topics that are covered in earlier chapters, notably Chapter 3: Quantitative echocardiography. The chapter is divided into two sections. In the first section, methods for assessing the haemodynamic state are covered, including the measurement of stroke volume, cardiac output, LA pressure, pulmonary artery pressure, preload, and volume responsiveness. The focus of this section is on techniques that are directly applicable to TOE in mechanically ventilated patients. In the second section, the causes of haemodynamic instability are reviewed. Topics include hypovolaemia, low LV afterload, LV systolic dysfunction, LV diastolic dysfunction, RV systolic dysfunction, and cardiac tamponade. An integrated approach to the difficult diagnosis is also provided.

Transoesophageal echocardiography for interventional cardiology procedures

Chapter 17 is a new chapter from earlier editions of Practical Perioperative Transoesophageal Echocardiography. It provides a description of the use of TOE for patients undergoing a range of procedures in the catheter laboratory, including transcatheter AV implantation, LA appendage occlusion, edge-to-edge MV repair, balloon mitral valvotomy, and device closure of ASDs and paravalvular leaks. Important measurements and the associated image planes that are required for each procedure are outlined, along with a description of the ideal imaging plane and puncture site for placing transatrial catheters. Potential complications associated with each procedure are also reviewed.

The aortic valve and left ventricular outflow tract

In the first two sections of Chapter 10, relevant anatomy and standard TOE assessment of the AV and LVOT are reviewed. Next, congenital abnormalities of the AV are described, particularly the different types of bicuspid valve that are encountered in clinical practice. The main focus of the chapter is the aetiology, TOE assessment, and quantification of aortic stenosis and regurgitation. A guideline-based approach to quantification of severity is provided for both conditions. Assessment of endocarditis and LVOT obstruction is also described.

Adult congenital heart disease

In Chapter 18, the common congenital cardiac lesions encountered in adult cardiac surgical practice are reviewed. The focus of the chapter is VSDs, ASDs (and patent foramen ovale), and tetralogy of Fallot (TOF), including reoperation for PV conduit replacement in patients who have undergone repair of TOF in childhood. The different subtypes of VSD and ASD are reviewed, along with their important associations (e.g. pulmonary venous abnormalities in patients with sinus venosus ASD). Complex cardiac abnormalities, such as the Fontan circulation and operation for transposition of the great arteries, are discussed only briefly. Congenital abnormalities of the AV (e.g. bicuspid valve) are discussed in Chapter 10: The aortic valve and left ventricular outflow tract, and persistent left-sided SVC is discussed in Chapter 5: Anatomical variants and cardiac masses.