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1、心脏手术中应用TEE的优势,直接观察左室前负荷 左室收缩和舒张功能的监测 早期监测心肌缺血 补充诊断及对手术效果的评估 指导和评价导管的放置,麻醉医师与术中TEE,In 1996, the House of Delegates of the American Society of Anesthesiologists approved the “Practice Guidelines for Perioperative Transesophageal Echocardiography.” In current practice in the UK, 90% are performed not b
2、y cardiologists but, by cardiac anaesthetists.,J. D. Kneeshaw. Transoesophageal echocardiography (TOE) in the operating room. British Journal of Anaesthesia 97 (1): 7784 (2006),术中TEE放置的指征,Category1:TEE is useful in improving the outcome. Category2:TEE might be useful. Category3:TEE is infrequently u
3、seful.,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 and refine the preoperative diagnosis, (2) detect new or un
4、suspected pathology, (3) adjust the anesthetic and surgical plan accordingly, (4) assess the results of surgical intervention. Practice Guidelines for Perioperative Transesophageal Echocardiography An Updated Report by the American Society of Anesthesiologists and the Society of Cardiovascular Anest
5、hesiologists Task Force on Transesophageal Echocardiography* Anesthesiology 2010; 112:11,探头放置,盲法置入 放置失败率 0.18% 术后吞咽痛发生率 0.1% 食管穿孔发生率0.01%,Ian J. Kallmeyer et al. The Safety of Intraoperative Transesophageal Echocardiography: A Case Series of 7200 Cardiac Surgical Patients. Anesth Analg 2001;92:1126-
6、1130,经食管插管的禁忌症,绝对禁忌症：吞咽困难、食管肿瘤、撕裂和穿孔、食管憩室、活动性上消化道出血、食管手术后不久等。 相对禁忌症：食管静脉曲张、严重的颈椎病变等。 对拟行术中TEE监测的病人，术前探视时一定要仔细询问上消化道病史。,TEE探头,换能器所采用的超声发射频率为3.757.0MHz。 单平面双平面多平面三维,TEE多平面角度与扫描断面的关系,常用标准切面(ASE/SCA),经食管声窗及相应切面,食管上段（25cm): 主动脉长/短轴切面（2） 食管中段（3040cm)：四腔心，二尖瓣叶交界，二腔心，长轴，右室流入-出，AV短轴，AV长轴，上下腔静脉，升主动脉长/短轴，降主动脉长
7、/短轴。（12） 经胃(4045cm)：基部短轴，中部短轴，二腔心，长轴，RV流入。（5） 经胃深部(4550cm)：长轴（1）,术中常用TEE检查切面,食管中段四腔心切面,食管中段两腔心切面,食管中段左室长轴切面,食管中段主动脉瓣短轴切面,食管中段升主动脉短轴切面,食管中段升主动脉长轴切面,食管上段主动脉弓短轴切面,降主动脉短轴切面,经胃中部短轴切面,食管中段双腔切面,术中TEE的应用,完善、补充术前诊断,TEE在左房血栓, 尤其是左心耳内的血栓、主动脉夹层破口、瓣膜结构和功能、赘生物的探查方面意义较TTE具有明显优势。,瓣膜手术CPB术前TEE检查要点,瓣膜及瓣下结构 跨瓣血流，有助于判断
8、瓣膜功能 心内血栓检查 瓣环钙化？ CPB前最后一次明确是rapair，or replace?,主动脉瓣环径测量，长轴切面,主动脉瓣环径测量，短轴切面,左心整体功能监测,M型法 短轴缩短率： FAC=(EDA-ESA)/EDA ; 自动边缘识别系统（ABD） 二维Simpson法 SV=LVEDV-LVSDV 多谱勒法 SV=时间速度积分X横截面积 三维法,M型法,主动脉Doppler血流频谱,肺动脉Doppler血流频谱,降主动脉PW血流,舒张功能监测,PAWP 二尖瓣血流频谱 E/A 彩色M型多谱勒（color M-mode Doppler, CMD） 组织多谱勒显像（tissue Dop
9、pler imaging, TDI) 声学定量(acoustic quantification/automatic borderline determination, AQ),Normal transmitral flow pattern. Pulse wave Doppler profile of normal transmitral flow during diastole sampled at the tip of the mitral leaflets using the apical four-chamber view. Note the early (E) and atrial (
10、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 (left) and abnormal (right) diastolic function. Vp, color M-mode color flow propagation velocity (normal Vpcm/s 45; diastolic d
11、ysfunction 45).,心肌缺血监测,节段性室壁运动异常（SWMA ）,左房压评估,脏器灌注监测,可对腹主动脉、肾动脉、脾动脉和颈总动脉的血管内径和血流量进行测量，为术中脏器保护研究和临床应用提供依据。,手术效果即刻评价,瓣膜成形术,二尖瓣前叶裂伴大量返流,二尖瓣成形术后,人工瓣置换术评价,人工瓣,双叶瓣反流速,机械瓣卡瓣,人工瓣正常二维影像,二尖瓣位机械瓣瓣周漏,主动脉瓣置换术，主动脉开放后,示冠状动脉血流,冠脉搭桥术,节段性室壁运动异常; 合并其它心内病变，如瓣膜病等; 粥样硬化斑块.,先心病,术前TTE诊断中，转机前TEE发现新的病变者高达30；转机前TEE明显改变治疗方案的占116不等；转机后TEE提示行再次转机或改变术后治疗的占345%不等。,室缺补片影像,指导房间隔缺损封堵,主动脉手术,TEE不仅能够显示主动脉病变的部位和范围，还能显示主动脉夹层原发破口的部位和大小、夹层是否累及冠状动脉及头臂动脉、同时还能评价主动脉瓣功能等，在术中可以发挥积极作用 。,指导排气,主动脉插管后，降主动脉气体,指导导管放置,TEE应用现状,Thank You !,