The Feasibility of Simultaneous Orthogonal Plane Imaging with Tilt for Short-Axis Evaluation of the Pulmonic Valve by Transesophageal Echocardiography

Abstract

Simultaneous orthogonal plane imaging with tilt enables the display of two 2D, real-time images and the evaluation of structures that cannot be seen by conventional single-plane transesophageal echocardiographic (TEE) imaging. After a step-wise examination protocol, we used simultaneous orthogonal plane imaging to obtain the short-axis view of the pulmonic valve (PV) and assessed flow in both images simultaneously using color Doppler imaging in 100 consecutive patients undergoing intraoperative TEE. Our goals were to assess the ability of this technique to visualize all 3 leaflets of the PV, assess feasibility of planimetry to measure valve area, and assess flow using color Doppler imaging. All study images were obtained by anesthesiologists who are diplomates in Advanced Perioperative Transesophageal Echocardiography. All 3 leaflets of the PV were successfully visualized in the short-axis view in 65% of cases, 2 leaflets were visualized in 32% of cases, and only 1 leaflet could be imaged in 3%. The flow across the valve could be evaluated using color Doppler imaging in all cases. Planimetry for valve area was possible when all 3 leaflets were seen. It is important to inspect the PV during a routine TEE examination; however, the orientation of the PV in respect to the esophagus makes this evaluation challenging. We present a simple protocol to evaluate the PV in long-axis and short-axis views simultaneously that can potentially help evaluate for pathologies involving the PV.

Feasibility of pulmonary valve imaging using transesophageal echocardiography upper esophageal view

“…13,16,22,26,27 Finally, the thin nature of the pulmonary valve leaflets is the significant obstacle for visualization of PV. 13,16,22,26,27 Finally, the thin nature of the pulmonary valve leaflets is the significant obstacle for visualization of PV.…”

“…13,16,22,26,27 Finally, the thin nature of the pulmonary valve leaflets is the significant obstacle for visualization of PV. 1,10,11,13,17,29 Cardiac MRI and ECG-gated cardiac multidetector CT can be used in this group to provide more anatomic data despite also significant limitations to these axial imaging techniques, most notably the lack of portability. This finding will be helpful when imaging the PV for suspicion of endocarditis, since it would be anticipated that the valve would be thickened given the pathophysiology of this diagnosis.…”

“…2D TEE and particularly TAUE view of PV should be considered a complementary study to TTE images of PV study in many conditions like endocarditis, congenital abnormality, and valvular mass. 13,16,22,26,27 Finally, the thin nature of the pulmonary valve leaflets is the significant obstacle for visualization of PV. This study confirmed the previously known positive correlation between increased valve thickness and high PV image quality.…”

“…1,[10][11][12][13] The TAUE, described in several publications regarding standard TEE views, is the only view with an unobstructed view because of the imaging plane provided by the transverse aorta. Transesophageal echocardiography (TEE) also is no panacea.…”

“…In fact, the PV can be imaged by TEE from multiple described views but in all of them except the transaortic upper esophageal (TAUE) view, the PV is in the far field and is partially obstructed by multiple other structures. 1,[10][11][12][13] The TAUE, described in several publications regarding standard TEE views, is the only view with an unobstructed view because of the imaging plane provided by the transverse aorta. As such, there are many less issues with near field shadowing and when present, this view provides the highest resolution of the PV.…”