TEE在心臟手術(shù)中的應(yīng)用

1、心臟手術(shù)中應(yīng)用心臟手術(shù)中應(yīng)用TEE的優(yōu)勢(shì)的優(yōu)勢(shì) 直接觀察左室前負(fù)荷直接觀察左室前負(fù)荷 左室收縮和舒張功能的監(jiān)測(cè)左室收縮和舒張功能的監(jiān)測(cè) 早期監(jiān)測(cè)心肌缺血早期監(jiān)測(cè)心肌缺血 補(bǔ)充診斷及對(duì)手術(shù)效果的評(píng)估補(bǔ)充診斷及對(duì)手術(shù)效果的評(píng)估 指導(dǎo)和評(píng)價(jià)導(dǎo)管的放置指導(dǎo)和評(píng)價(jià)導(dǎo)管的放置麻醉醫(yī)師與術(shù)中TEE In 1996, the House of Delegates of the American Society of Anesthesiologists approved the “Practice Guidelines for Perioperative Transesophageal Echocardiogr

2、aphy.” In current practice in the UK, 90% are performed not by cardiologists but, by cardiac anaesthetists.J. D. Kneeshaw. Transoesophageal echocardiography (TOE)in the operating room. British Journal of Anaesthesia 97 (1): 7784 (2006)術(shù)中TEE放置的指征 Category1:TEE is useful in improving the outcome. Cate

3、gory2:TEE might be useful. Category3:TEE is infrequently useful. For adult patients without contraindications, TEE should be used in all open heart (e.g., valvular procedures) and thoracic aortic surgical procedures and should be considered in coronary artery bypass graft surgeries to: (1) confirm a

4、nd refine the preoperative diagnosis, (2) detect new or unsuspected pathology, (3) adjust the anesthetic and surgical plan accordingly, (4) assess the results of surgical intervention.Practice Guidelines for Perioperative Transesophageal EchocardiographyAn Updated Report by the American Society of A

5、nesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography* Anesthesiology 2010; 112:11探頭放置 盲法置入 放置失敗率 0.18% 術(shù)后吞咽痛發(fā)生率 0.1% 食管穿孔發(fā)生率0.01%Ian J. Kallmeyer et al. The Safety of Intraoperative Transesophageal Echocardiography: A Case Series of 7200

6、 Cardiac Surgical Patients. Anesth Analg 2001;92:1126-1130 經(jīng)食管插管的禁忌癥經(jīng)食管插管的禁忌癥 絕對(duì)禁忌癥：吞咽困難、食管腫瘤、撕裂和穿孔、食管憩室、活動(dòng)性上消化道出血、食管手術(shù)后不久等。 相對(duì)禁忌癥：食管靜脈曲張、嚴(yán)重的頸椎病變等。對(duì)擬行術(shù)中對(duì)擬行術(shù)中TEETEE監(jiān)測(cè)的病人，術(shù)前探視時(shí)一定要仔細(xì)詢(xún)問(wèn)上消化監(jiān)測(cè)的病人，術(shù)前探視時(shí)一定要仔細(xì)詢(xún)問(wèn)上消化道病史。道病史。 TEE探頭 換能器所采用的超聲發(fā)射頻率為3.757.0MHz。 單平面雙平面多平面三維TEE多平面角度與掃描斷面的關(guān)多平面角度與掃描斷面的關(guān)系系 常用標(biāo)準(zhǔn)切面(ASE/SC

7、A) 經(jīng)食管聲窗及相應(yīng)切面 食管上段（25cm): 主動(dòng)脈長(zhǎng)/短軸切面（2） 食管中段（3040cm)：四腔心，二尖瓣葉交界，二腔心，長(zhǎng)軸，右室流入-出，AV短軸，AV長(zhǎng)軸，上下腔靜脈，升主動(dòng)脈長(zhǎng)/短軸，降主動(dòng)脈長(zhǎng)/短軸。（12） 經(jīng)胃(4045cm)：基部短軸，中部短軸，二腔心，長(zhǎng)軸，RV流入。（5） 經(jīng)胃深部(4550cm)：長(zhǎng)軸（1）術(shù)中常用TEE檢查切面食管中段四腔心切面食管中段兩腔心切面食管中段兩腔心切面 食管中段左室長(zhǎng)軸切面 食管中段主動(dòng)脈瓣短軸切面 食管中段升主動(dòng)脈短軸切面 食管中段升主動(dòng)脈長(zhǎng)軸切面 食管上段主動(dòng)脈弓短軸切面 降主動(dòng)脈短軸切面 經(jīng)胃中部短軸切面 食管中段雙腔切面

8、術(shù)中TEE的應(yīng)用完善、補(bǔ)充術(shù)前診斷 TEE在左房血栓, 尤其是左心耳內(nèi)的血栓、主動(dòng)脈夾層破口、瓣膜結(jié)構(gòu)和功能、贅生物的探查方面意義較TTE具有明顯優(yōu)勢(shì)。 瓣膜手術(shù)CPB術(shù)前TEE檢查要點(diǎn) 瓣膜及瓣下結(jié)構(gòu) 跨瓣血流，有助于判斷瓣膜功能 心內(nèi)血栓檢查 瓣環(huán)鈣化？CPB前最后一次明確是rapair，or replace?主動(dòng)脈瓣環(huán)徑測(cè)量，長(zhǎng)軸切面主動(dòng)脈瓣環(huán)徑測(cè)量，長(zhǎng)軸切面主動(dòng)脈瓣環(huán)徑測(cè)量，短軸切面主動(dòng)脈瓣環(huán)徑測(cè)量，短軸切面左心整體功能監(jiān)測(cè) M型法短軸縮短率： FAC=(EDA-ESA)/EDA ; 自動(dòng)邊緣識(shí)別系統(tǒng)（ABD） 二維Simpson法 SV=LVEDV-LVSDV 多譜勒法 SV=時(shí)間速

9、度積分X橫截面積 三維法 M型法主動(dòng)脈Doppler血流頻譜肺動(dòng)脈Doppler血流頻譜降主動(dòng)脈PW血流舒張功能監(jiān)測(cè) PAWP 二尖瓣血流頻譜 E/A 彩色M型多譜勒（color M-mode Doppler, CMD） 組織多譜勒顯像（tissue Doppler imaging, TDI) 聲學(xué)定量(acoustic quantification/automatic borderline determination, AQ) Normal transmitral flow pattern. Pulse wave Doppler profile of normal transmitral f

10、low during diastole sampled at the tip of the mitral leaflets using the apical four-chamber view. Note the early (E) and atrial (A) velocities representing early and late filling. DT, deceleration time.Color M-mode flow propagation velocity. Color M-mode propagation velocities in patient with normal

11、 (left) and abnormal (right) diastolic function. Vp, color M-mode color flow propagation velocity (normal Vpcm/s 45; diastolic dysfunction 45).心肌缺血監(jiān)測(cè) 節(jié)段性室壁運(yùn)動(dòng)異常（SWMA ）左房壓評(píng)估臟器灌注監(jiān)測(cè) 可對(duì)腹主動(dòng)脈、腎動(dòng)脈、脾動(dòng)脈和頸總動(dòng)脈的血管內(nèi)徑和血流量進(jìn)行測(cè)量，為術(shù)中臟器保護(hù)研究和臨床應(yīng)用提供依據(jù)。手術(shù)效果即刻評(píng)價(jià) 瓣膜成形術(shù)二尖瓣前葉裂伴大量返流二尖瓣成形術(shù)后人工瓣置換術(shù)評(píng)價(jià)人工瓣雙葉瓣反流速機(jī)械瓣卡瓣人工瓣正常二維影像二尖瓣位機(jī)械瓣

12、瓣周漏主動(dòng)脈瓣置換術(shù)，主動(dòng)脈開(kāi)放后示冠狀動(dòng)脈血流示冠狀動(dòng)脈血流冠脈搭橋術(shù) 節(jié)段性室壁運(yùn)動(dòng)異常; 合并其它心內(nèi)病變，如瓣膜病等; 粥樣硬化斑塊. 先心病 術(shù)前TTE診斷中，轉(zhuǎn)機(jī)前TEE發(fā)現(xiàn)新的病變者高達(dá)30；轉(zhuǎn)機(jī)前TEE明顯改變治療方案的占116不等；轉(zhuǎn)機(jī)后TEE提示行再次轉(zhuǎn)機(jī)或改變術(shù)后治療的占345%不等。 室缺補(bǔ)片影像指導(dǎo)房間隔缺損封堵主動(dòng)脈手術(shù) TEE不僅能夠顯示主動(dòng)脈病變的部位和范圍，還能顯示主動(dòng)脈夾層原發(fā)破口的部位和大小、夾層是否累及冠狀動(dòng)脈及頭臂動(dòng)脈、同時(shí)還能評(píng)價(jià)主動(dòng)脈瓣功能等，在術(shù)中可以發(fā)揮積極作用 。指導(dǎo)排氣主動(dòng)脈插管后，降主動(dòng)脈氣體指導(dǎo)導(dǎo)管放置 目的目的適用范圍適用范圍地點(diǎn)地點(diǎn)診斷診斷心血管疾病重要輔助診斷性檢查心血管疾病重要輔助診斷性檢查診斷室診斷室指導(dǎo)指導(dǎo)評(píng)價(jià)評(píng)價(jià)缺損封堵術(shù)，球囊擴(kuò)張術(shù)缺損封堵術(shù)，球囊擴(kuò)張術(shù)介入手術(shù)室介入手術(shù)室手術(shù)室手術(shù)室即刻評(píng)價(jià)即刻評(píng)價(jià)所有心臟及大血管手術(shù)所有心臟及大血管手術(shù)手術(shù)室手術(shù)室監(jiān)測(cè)監(jiān)測(cè)需密切監(jiān)測(cè)循環(huán)時(shí)需密切監(jiān)測(cè)循環(huán)時(shí)手術(shù)室手術(shù)室指導(dǎo)治療指導(dǎo)治療循環(huán)相關(guān)問(wèn)題，輔助診斷循環(huán)相關(guān)問(wèn)題，輔助診斷手術(shù)室手術(shù)室/ICUTEE應(yīng)用現(xiàn)狀術(shù)中TEE放置的指征 C