TEE在心脏手术中的应用1教学提纲.ppt

1单击此处编辑母版标题样式单击此处编辑母版副标题样式w TEE在心脏手术中的应用Transesophageal Echocardiography monitoring in cardiac surgery魏蔚心脏手术中应用TEE的优势w 直接观观察左室前负负荷w 左室收缩缩和舒张张功能的监测监测w 早期监测监测 心肌缺血w 补补充诊诊断及对对手术术效果的评评估w 指导导和评评价导导管的放置麻醉医师与术中TEEw In 1996, the House of Delegates of the American Society of Anesthesiologists approved the “Practice Guidelines for Perioperative Transesophageal Echocardiography.” w 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)w 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 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 Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography* Anesthesiology 2010; 112:11探头放置w 盲法置入w 放置失败率 0.18%w 术后吞咽痛发生率 0.1%w 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;92:1126-1130 经经食管插管的禁忌症w 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。

w 相对禁忌症：食管静脉曲张、严重的颈椎病变等对拟对拟 行术术中TEE监测监测 的病人，术术前探视时视时 一定要仔细询问细询问 上消化道病史 TEE探头w 换能器所采用的超声发射频率为3.757.0MHz w 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w 食管上段（25cm): 主动脉长/短轴切面（2） w 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/短轴12）w 经胃(4045cm)：基部短轴，中部短轴，二腔心，长轴，RV流入5）w 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w 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w 瓣膜及瓣下结构w 跨瓣血流，有助于判断瓣膜功能w 心内血栓检查w 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w M型法短轴缩短率： FAC=(EDA-ESA)/EDA ; 自动边缘识别系统（ABD）w 二维Simpson法 SV=LVEDV-LVSDV w 多谱勒法 SV=时间速度积分X横截面积 w 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w PAWPw 二尖瓣血流频谱 E/Aw 彩色M型多谱勒（color M-mode Doppler, CMD）w 组织多谱勒显像（tissue Doppler imaging, TDI)w 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 (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 dysfunction 45).心肌缺血监测 w 节段性室壁运动异常（SWMA ）左房压评估脏器灌注监测 w 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 w 节段性室壁运动异常; w 合并其它心内病变，如瓣膜病等;w 粥样硬化斑块. 先心病 w 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 w 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 目的适用范围围地点诊诊断心血管疾病重要辅辅助诊诊断性检查检查诊诊断室指导导评评价缺损损封堵术术，球囊扩张术扩张术 介入手术术室手术术室即刻评评价所有心脏脏及大血管手术术手术术室监测监测需密切监测监测 循环时环时 手术术室指导导治疗疗循环环相关问题问题 ，辅辅助诊诊断手术术室/ICUTEE应用现状。