CLINICAL TECHNIQUE |
https://doi.org/10.5005/jp-journals-10034-1132 |
A Novel View for Performing Left Atrial Strain Analysis by Transesophageal Echocardiography
Department of Cardiac Anaesthesiology, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
Corresponding Author: Kedar Bangal, Department of Cardiac Anaesthesiology, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India, Phone: +91 8412095179, e-mail: kedar4xcell@gmail.com
Received: 27 May 2023; Accepted: 16 August 2023; Published on: 20 February 2024
ABSTRACT
Aim: To devise a technique for producing a view that can be utilized to perform strain analysis of the left atrium (LA) by transesophageal echocardiography (TEE).
Background: Advancement in the field of echocardiography has led to the development of strain and speckle tracking. The magnitude of LA deformation is utilized to determine the diastolic function by means of strain rate imaging. It is difficult to accommodate all the borders of LA in an image by TEE.
Technique: Hereby, I would like to present a TEE view that is identical to the subcostal view of transthoracic echocardiography (TTE). This may be named as “deep transgastric four-chamber view” (deep TG-4C), and it is unique compared to the 28 TEE views. I have devised a technique for producing this view on TEE, and I have used it to analyze LA strain intraoperatively for 50 cases. Echocardiography was performed using a CVx TEE probe (Philips Healthcare, Andover, Massachusetts) and strain analysis was performed by Tomtec Autostrain software. The exact maneuvers to produce this view are also devised by me.
Conclusion: The deep TG-4C view is helpful in performing LA strain analysis by TEE.
Clinical significance: The deep TG-4C view of TEE accommodates all the borders of the LA and is helpful in performing LA strain analysis.
How to cite this article: Bangal K. A Novel View for Performing Left Atrial Strain Analysis by Transesophageal Echocardiography. J Perioper Echocardiogr 2021;9(2):48–50.
Source of support: Nil
Conflict of interest: None
Keywords: Echocardiography, Perioperative transesophageal echocardiography, Speckle tracking echocardiography, Transesophageal echocardiography, Transthoracic echocardiography
BACKGROUND
Advancement in the field of echocardiography has led to the development of strain and speckle tracking. The extent of left atrial (LA) deformation (LA strain) is utilized to determine the diastolic function by means of strain rate imaging.
TECHNIQUE
I would like to present a novel transesophageal echocardiography (TEE) view which is identical to the subcostal view of transthoracic echocardiography (TTE). This view may be named the “deep transgastric four-chamber view” (deep TG-4C) (Video 1 and Fig. 1). It is unique compared to the 28 TEE views. I have devised a technique for producing this view on TEE, and I have used it to analyze LA strain intraoperatively (Fig. 2). One can perform LA strain analysis by TTE, which is otherwise not possible in any other TEE view, as all the left atrial borders are not accommodated. Using the deep TG-4C view, the LA strain analysis was performed intraoperatively in 50 cases undergoing off-pump coronary artery bypass grafting (Table 1). This was performed using a CVx TEE probe (Philips Healthcare©, Andover, Massachusetts) and strain analysis was performed by Tomtec© Autostrain software.
Patient demographics | Mean (± standard deviation) and percentage of sample size |
---|---|
Male/female (number of patients) | 45/5 |
Age (years) | 55.31 (±6.33) |
Weight (kg) | 66.1 (±10.15) |
Height (cm) | 169.55 (±7.08) |
Ejection fraction (%) | 52.94 (±6.65) |
LA reservoir strain | 19.2 (±6.12) |
LA conduit strain | −12.43 (±3.90) |
LA contractile strain | −9.84 (±3.69) |
Diabetes mellitus | 25 (50%) |
Hypertension | 28 (56%) |
Recent acute coronary syndrome | 08 (16%) |
Old myocardial infarction | 03 (6%) |
Hypothyroidism | 03 (6%) |
Fig. 1: Deep TG-4C view
Fig. 2: LA strain measurement in the deep TG-4C 0° by using the first maneuver
After producing the deep TG-5C view, either of the two maneuvers is required to produce the deep TG-4C view, due to interpatient anatomical variations. The first maneuver was successful in a majority of the patients, where the deep TG-4C view was obtained by advancing the TEE probe from the deep TG-5C view, followed by anteflexion. If the first maneuver is not feasible, then alternatively, from the deep TG-5C view, the multiplane angle can be adjusted to be set between 0 and 60°. Thereafter, a clockwise rotation of the anterior aspect of the TEE probe (turning to the patient’s right side) is required till the ultrasound beam intersects the atria and the ventricles to produce the deep TG-4C view in the best possible way. One must repeatedly review the image by making fine adjustments in the multi-plane angulations between 0 and 60°, as the beam must intersect all the heart chambers simultaneously and precisely (Video 2 and Figs 3 and 4).
Fig. 3: Deep TG-4C at 30° obtained using the second maneuver
Fig. 4: Maneuver required for deep TG-4C view
DISCUSSION
The LA strain is included in the assessment of LV diastolic function in current guidelines.1 LA strain analyzes all the phases of LA functions (reservoir, conduit, and contractile) and has an added advantage in addition to volumetric assessment.2,3
Left atrial (LA) strain has been analyzed by TTE in apical four-chamber view, by TEE in deep TG-5C view, and LA appendage strain has also been derived by TEE.4 It is difficult to accommodate all the borders of LA in an image by using TEE.
The deep TG-4C view has not been described previously.5
Clinical Significance
With this view, one can perform the strain analysis of LA, as well as the evaluation of the interatrial septum, interventricular septum, subvalvular apparatus of mitral and tricuspid valves, M-mode analysis of LV septal and lateral walls, and tricuspid annular plane systolic excursion.
SUPPLEMENTARY MATERIAL
The supplementary videos 1 to 2 are available online on the website of www.jpecardio.com
Video 1: Deep TG 4 Chamber View Obtained Using the First Manoeuvre. Mitral valve prolapsed into the left atrium.
Video 2: LA Strain Measurement in The Deep TG 4C View at 45 Degrees Obtained Using the Second Manoeuvre.
ORCID
Kedar Bangal https://orcid.org/0000-0001-9779-2582
REFERENCES
1. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2016;29(4):277–314. DOI: 10.1016/j.echo.2016.01.011
2. Sarvari SI, Haugaa KH, Stokke TM, et al. Strain echocardiographic assessment of left atrial function predicts recurrence of atrial fibrillation. Eur Heart J Cardiovasc Imag 2016;17(6):660–667. DOI:10.1093/ehjci/jev185
3. Donal E, Behagel A, Feneon D. Value of left atrial strain: a highly promising field of investigation. Eur Heart J Cardiovasc Imag 2015;16(4):356–357. DOI: 10.1093/ehjci/jeu230
4. Rong LQ, Menon A, Lopes AJ, et al. Left atrial strain quantification by intraoperative transesophageal echocardiography: validation with transthoracic echocardiography. J Cardiothorac Vasc Anesth 2022;36(8 Pt A):2412–2417. DOI: 10.1053/j.jvca.2021.11.017
5. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26(9):921–964. DOI: 10.1016/j.echo.2013.07.009
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