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Expert Transesohageal Echocardiography
(Basic and Advanced)
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The Expert Transesohpageal Echocardiography (eTEE ®)section covers an extensive list of topics on basic and advanced transesophageal echocardiography.  This section is intended for cardiac anesthesiologists, cardiologists, and cardiac sonographers.  This section will cover the basics in ultrasound, probes, imaging, orientation, hemodynamics, the chambers, the valves, aorta, congenital diseases and artifacts or pitfalls.  Each chapter is formated for quick and easy access and readability with videos and images or animations embeded in the page.  Content is always being added and updated so check back frequently.  A subscription for this area automatically gives you access to the iTEE ® or introduction to Transesohpageal Echocardiography area.
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 The Chapters covered in the Expert TEE ® section are:
Other chapters are planned. Each page is fully referenced. Users can get CME after reviewing the relevant section and taking a CME exam.  Self Assessment Exams are being planned for each chapter.  A comprehensive Self Assessment Exam is available. 
 General Principles of a Cardiac Murmur Evaluation
 Cardiac auscultation is the most common and the first method of cardiac murmur discovery and evaluation.   Murmurs are due to:
  • High Blood Flow Rate through an orifice (normal or abnormal)
  • Forward Flow through a narrowed or irregular orifice
  • Backward Flow through an incompetent valve
 Heart Murmur Classification
  1. Systolic Murmurs
    1. Holodiastolic
    2. Midsystolic
    3. Early Systolic
    4. Mid to Late Systolic
  2. Diastolic Murmurs
    1. Early Diastolic (High Pitched)
    2. Mid Diastolic
    3. Late Diastolic (Presystolic)
  3. Continuous Murmurs
 Most systolic murmurs do not signify pathological conditions, whereas diastolic murmurs almost always indicate a pathological condition.
 Heart Murmur Assessment
  • Cardiac Cycle Timing
    • Systolic
      • Holodiastolic
      • Midsystolic
      • Early Systolic
      • Mid to Late Systolic
    • Diastolic
      • Early Diastolic
      • Mid Diastolic
      • Lat Diastolic
    • Continuous
  • Configuration
    • Crescendo
    • Decrescendo
    • Crescendo-Decrescendo (Diamond shaped)
    • Plateau
  • Location
  • Radiation
  • Pitch
  • Intensity (Grade I - VI)
  • Duration
Murmurs that are holosystolic require a large pressure differential throughout systole such as what occurs between the cardiac chambers or the LV and LA. 
Midsystolic murmurs occur when in early systole a differential in pressures either does not occur or a valve has not opened yet to allow the ejection of blood.  Midsystolic murmurs are often diamond shaped an start after a S1 when the pulmonary or aortic valve opens. As systole continues, the pressure differential decreases and the murmur has a decrescendo effect.  Midsystolic murmurs can be due to flow in the presence of a normal valve such as pregnancy, pregnancy, thyrotoxicosis, anemia, AV fistula or a thin chest wall (enhanced tramsmission).

Midsystolic murmurs that are pathological are usually due to valvular, subvalvular, or supravalvular stenosis (AV or PV).  In functional MR (or functional TR), the MR does not occur in systole until the leaflets are displaced enough to prevent coaptation.  As the functional MR worsens, the MR murmur occurs earlier in systole.
 Early systolic murmurs are usually due to TR or a VSD.  In TR, the murmur occurs in early systole because the pressure differential is high.  As systole continues, the RAP rises and the murmur decreases or ends in mid systole.  VSDs with pulmonary hypertension may end in mid systole because the pressure differential equalizes at the end of systole.
Late systolic murmurs occur after ejection peaks and end before S2.  Apical tethering or poor coaptation of the mitral valve leaflets due to the functional changes in the annulus and/or ventricle.  If a midsystolic click occurs before the murmur then mitral valve prolapse may be the etiology.
 Early diastolic murmurs start after S2 when the ventricular pressure drops below the aortic or pulmonary pressure.  Aortic regurgitation or pulmonary regurgitation due to pulmonary hypertension are usually decrescendo murmurs.  If the murmur is long or pandiastolic then the valve disease is usually mild whereas a short diastolic murmur indicates more severe disease because the pressure differential equalizes earlier in diastole.
Mid diastolic murmurs are usually from mitral or tricuspid stenosis or from severe mitral or tricuspid regurgitation when the flow is the highest.  A VSD, PDA, or ASD can also result in mid diastolic murmurs.  In chronic AR a low pitched, rumbling murmur (Austin-Flint murmur) is often present in the LV apex. 
Presystolic murmurs are from ventricular filling from an atrial contraction through a stenotic mitral or tricuspid valve.  An atrial myxoma can also cause this murmur.
 Continuous murmurs are from a high pressure to a low pressure chamber/vessel that is present throughout the cardiac cycle.  They peak in systole but continue during diastole.
Manuvers to Alter Cardiac Murmur Intensity
 Manuver  Effect
 Respiration  Right sided murmurs increase with inspiration.  Left sided murmurs increase with expiration.
 Valsalva**  HOCM becomes louder.  MVP becomes longer and louder.  Most murmurs decrease in length and intensity. 
 Valsalva Release Right sided murmurs decrease to baseline earlier than left sided murmurs.
 Exercise*  Isometric exercise increase flow and stenotic murmurs. MR, VSD, and AR also increase with isometric exercise.
 Positional Change  MVP and HOCM increase with standing whereas most murmurs decrease.  With squatting, most murmurs increase whereas HOCM and MVP will decrease.
 PVC  The beat after a PVC will increase normal or stenotic murmurs wheras regurgitant murmurs do not change or diminish.
 *Increase SVR, **Increase Venous Return
 Echocardiography Recommendations
 Class I
  • Diastolic, continuous, holosystolic, late systolic, murmurs that radiate or are associated with a click should get an echocardiogram, even if asymptomatic (Level of Evidence C)
  • Heart murmurs and symptoms of heart failure, myocardial ischemia/infarction, syncope, thromboembolism, infective endocarditits or evidence of structural heart disease. (Level of Evidence C)
  • Systolic murmurs that peak in midsystole (crescendo-decrecsendo) grade 3 or louder even if asymptomatic. (Level of Evidence C)
 Class II
  • Murmurs associated with an abnormal CXR or ECG or other test. (Level of Evidence C)
  • Signs and symptoms that are likely noncardiac in origin but cardiac origin cannot be ruled out. (Level of Evidence C)
 Class III
  • Grade 2 or softer midsystolic murmur. (Level of Evidence C)


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