Rescue TEE

Question 1

What is the criteria for determining hypovolemia in the transgastric short axis TEE view of the LV in terms of:

1. End diastolic diameter?

Answer 1

< 2.5 cm

Question 2

What is the criteria for determining hypovolemia in the transgastric short axis TEE view of the LV in terms of:

1. End diastolic area?

Answer 2

End diastolic area <55 cm²

Question 3

What is the normal end-diastolic diameter of the LV in the TEE TG SAX view?

Answer 3

3.7 - 5.3 cm

Question 4

In the TEE TG SAX view, what defines small amount of pericardial fluid?

Answer 4

< 0.5 cm (100-200) - Small

Question 5

In the TEE TG SAX view, what defines moderate amount of pericardial fluid?

Answer 5

0.5 cm - 2 cm (200 - 500 mL) Moderate

Question 6

In the TEE TG SAX view, what defines large amount of pericardial fluid?

Answer 6

>2 cm (>500 mL) Large

Question 7

What is better for evaluating intrapericardial clot and posterior/loculated effusions?

(TTE vs. TEE)

Answer 7

TEE > TTE

Question 8

What is a specific sign of pericardial tamponade?

Answer 8

RV Diastolic collapse

Pericardial Pressure >> RV Pressure

Question 9

What is the sensitivity, specificity and Positive predictive value to atrial compression for cardiac tamponade?

Answer 9

Sensitivity = 95%

Specificity = 82%

PPV.= 50%

Question 10

What is the Specificity and Sensitivity for detecting pulmonary embolism via TEE?

Answer 10

1. Specificity = 95% (If you see thrombus = It’s probably PE)
2. Sensitivity = 46% (If you don’t see thrombus, you can’t say it’s not a PE)

Question 11

What are the associated signs of a PE that can help lean towards a diagnosis of PE if you don’t see a clot?

• Comment on RV
• Chamber sizes
• What’s dilated?
• Comment on the IVC
• Valve changes?
• Specific sign?

Answer 11

1. RV Hypokinesis
2. RV enlargement
3. Small LV
4. Flattening of the Intraventricular septum or paradoxical septal motion
5. Dilated PA
6. Dilated RA
7. Distended IVC with loss of respiratory variation
8. Tricuspid Insufficiency
9. McConnell’s Sign

Question 12

What is McConnell’s Sign?

What is associated with?

Answer 12

Regional wall motion abnormalities sparing the RV apex

Associated = Massive PE with poor prognosis

Question 13

McConnell sign better seen on TTE or TEE?

Answer 13

TTE > TEE

Question 14

What is the basic equation for Blood Pressure?

Answer 14

BP = CO x SVR

BP = HR x SV x SVR

Question 15

What is stroke volume equal to?

Answer 15

End-Diastolic Area - End-Systolic Area

Question 16

What TEE findings for Low SVR?

Answer 16

1. Adequate End Diastolic area (EDA)

- Normal = 3.7 - 5.3 cm

2. Hyperdynamic wall thickening
3. Reduced End-Systolic Area (ESA)

Question 17

What is the equation for SVR?

Answer 17

[(MAP - CVP) / CO] x 80

Question 18

SVR normal values?

Answer 18

700 - 1600 dynes/sec/cm⁵

Question 19

SV = CO / HR

What is the other TEE equation to determine SV?

Answer 19

Cross Sectional Area x Velocity Time Interval

CSA @ LVOT

VTI @ Mitral Valve Inflow

Question 20

What are the key differences between a Low SVR state and Hypovolemia (alone) on TEE TG SAX views?

Answer 20

Low SVR

- EDA normal (3.7 - 5.3 cm) or adequate

• End Systolic Area reduced
• Hyperdynamic Wall thickening

Hypovolemia

- ED Diameter <2.5

End Diastolic area < 55 cm²

Question 21

If you have a patient who has adequate TG Basal SAX contractility but has poor TG SAX and TG Apex contractility, what can be the diagnosis?

Answer 21

Takotsubo Cardiomyopathy

AKA

• Apical Ballooning Syndrome
• Broken Heart Syndrome
• Stress/Ampulla Cardiomyopathy

Question 22

What is the pathophysiology of Takotsubo Cardiomyopathy?

Answer 22

Not known

• Multivessel Epicardial Spasm (Ex: surprise bday party)
• Microvascular Spasm
• Catecholamine induced myocardial stunning
• Myocarditis

Question 23

What population predominates in aquiring Takotsubo Cardiomyopathy?

Answer 23

Post-menopausal women

Question 24

What can a LV Wall motion abnormality in Takotsubo Cardiomyopathy lead to?

Answer 24

LVOT Obstruction –> Hypotension and Refractory Heart Failure

Question 25

Takotsubo Cardiomyopathy has was small percent of presenting sign?

Answer 25

1-2% present with ACS

Question 26

Prognosis of Takotsubo Cardiomyopathy?

Answer 26

\>90% recover \>10% have recurrent

Question 27

What specific wall motion abnormalities are associated with Takotsubo Cardiomyopathy?

Answer 27

*_Moderate-Severe Mid Ventricular Dysfunction_* *_Apical Akinesis/Hypokinesis_* **Basal = Hyperkinetic**

Question 28

Takotsubo Cardiomyopathy LVEF average?

Answer 28

20-49%

Question 29

Is Takotsubo Cardiomyopathy reversible?

Answer 29

Yes

Question 30

What is important to remember about regional wall motion abnormalities of Takotsubo Cardiomyopathy?

Answer 30

Not confined to a single coronary artery distribution (Some have atypical Takotsubo Cardiomyopathy confined to single coronary) ## Footnote **DIAGNOSIS OF EXCLUSION = THEY NEED A CATH & RULE OUT OTHER CAUSES OF CARDIOMYOPATHY**

Question 31

What is Takotsubo Cardiomyopathy Type 1?

Answer 31

Takotsubo Type: Apical Akinesis and Basal Hyperkinesia

Question 32

What is Takotsubo Cardiomyopathy Type 2?

Answer 32

Reversible Takotsubo 1. Basal Akinesis and Apical Hyperkinesia

Question 33

What is Takotsubo Cardiomyopathy Type 3?

Answer 33

Mid Ventricular Type: 1. Mid Ventricular Ballooning with basal and apical hyperkinesia

Question 34

What is Takotsubo Cardiomyopathy Type 4?

Answer 34

Localized type: Any other LV Segmental Ballooning

Question 35

What Takotsubo Cardiomyopathy Type is most common?

Answer 35

**Type 1:** Apical Akinesis anad Basal Hyperkinesia