TEE在心臟手術(shù)中的應(yīng)用1(同名139)課件

1、TEE在心臟手術(shù)中的應(yīng)用Transesophageal Echocardiography monitoring in cardiac surgery魏蔚心臟手術(shù)中應(yīng)用TEE的優(yōu)勢直接觀察左室前負荷左室收縮和舒張功能的監(jiān)測早期監(jiān)測心肌缺血補充診斷及對手術(shù)效果的評估指導(dǎo)和評價導(dǎo)管的放置麻醉醫(yī)師與術(shù)中TEEIn 2019, the House of Delegates of the American Society of Anesthesiologists approved the “Practice Guidelines for Perioperative Transesophageal Echo

2、cardiography.” 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 (2019)術(shù)中TEE放置的指征Category1:TEE is useful in improving the outcom

3、e.Category2: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) confi

4、rm and 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

5、of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography* Anesthesiology 2019; 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 2019;92:1126-1130 經(jīng)食管插管的禁忌癥絕對禁忌癥：吞咽困難、食管腫瘤、撕裂和穿孔、食管憩室、活動性上消化道出血、食管手術(shù)后不久等。相對禁忌癥：食管靜脈曲張、嚴(yán)重的頸椎病變等。對擬行術(shù)中TEE監(jiān)測的病人，術(shù)前探視時一定要仔細詢問上消化道病史。 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)系 常用標(biāo)準(zhǔn)切面(ASE/SCA) 經(jīng)食管聲窗及相應(yīng)切面食管上段（25cm): 主動脈長/短軸切面（2） 食管中段（3040cm)：四腔心，二尖瓣

7、葉交界，二腔心，長軸，右室流入-出，AV短軸，AV長軸，上下腔靜脈，升主動脈長/短軸，降主動脈長/短軸。（12）經(jīng)胃(4045cm)：基部短軸，中部短軸，二腔心，長軸，RV流入。（5）經(jīng)胃深部(4550cm)：長軸（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 食管中段左室長軸切面 食管中段主動脈瓣短軸切面 食管中段升主動脈短軸切面 食管中段升主動脈長軸切面 食管上段主動脈弓短軸切面 降主動脈短軸切面 經(jīng)胃中部短軸切面 食管中段雙腔切面 術(shù)中TEE的應(yīng)用完善、補充術(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

8、明顯優(yōu)勢。 瓣膜手術(shù)CPB術(shù)前TEE檢查要點瓣膜及瓣下結(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?主動脈瓣環(huán)徑測量，長軸切面主動脈瓣環(huán)徑測量，短軸切面左心整體功能監(jiān)測M型法短軸縮短率： FAC=(EDA-ESA)/EDA ; 自動邊緣識別系統(tǒng)（ABD）二維Simpson法 SV=LVEDV-LVSDV 多譜勒法 SV=時間速度積分X橫截面積 三維法 M型法主動脈Doppler血流頻譜肺動脈Doppler血流頻譜降主動脈PW血流舒張功能監(jiān)測PAWP二尖瓣血流頻譜 E/A 彩色M型多譜勒（color M-mode Doppler,

9、 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 flow during diastole sampled at the tip of the mitral leaflets using the apical four-chamber view. Note the

10、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 (left) and abnormal (right) diastolic function. Vp, color M-mode color flow propagation velocity (normal V

11、pcm/s 45; diastolic dysfunction 45).心肌缺血監(jiān)測 節(jié)段性室壁運動異常（SWMA ）左房壓評估臟器灌注監(jiān)測 可對腹主動脈、腎動脈、脾動脈和頸總動脈的血管內(nèi)徑和血流量進行測量，為術(shù)中臟器保護研究和臨床應(yīng)用提供依據(jù)。手術(shù)效果即刻評價 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)評價人工瓣雙葉瓣反流速機械瓣卡瓣人工瓣正常二維影像二尖瓣位機械瓣瓣周漏主動脈瓣置換術(shù)，主動脈開放后示冠狀動脈血流冠脈搭橋術(shù) 節(jié)段性室壁運動異常; 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)機前TEE發(fā)現(xiàn)新的病變者高達30；轉(zhuǎn)機前TEE明顯改變治療方案的占116不等；轉(zhuǎn)機后TEE提示行再次轉(zhuǎn)機或改變術(shù)后治療的占345%不等。 室缺補片影像指導(dǎo)房間隔缺損封堵主動脈手術(shù) TEE不僅能夠顯示主動脈病變的部位和范圍，還能顯示主動脈夾層原發(fā)破口的部位和大小、夾層是否累及冠狀