Assessing the left-sided pulmonary veins with the help of TEE

In this video from our Transesophageal Echocardiography Essentials course, Andrew Houghton, MD will teach you how to find the left-sided pulmonary veins using TEE, how to assess flow using colour and PW Doppler, and when to use each method.

Targeted towards cardiologists in training, internists, anesthesiologists, emergency physicians, cardiac physiologists, and cardiac sonographers, this course teaches you everything you need to know about performing a standard TEE exam. You’ll learn when a TEE should be ordered and what needs to be done to ensure the safety of your patient during the process. You’ll also learn how to obtain the standard views and how the standard views can be modified to obtain some of the more atypical views.

[00:00:00] In this lesson, we're going to learn how to locate and assess the left-sided pulmonary veins and let's begin with the left upper pulmonary vein and find this vessel. Let's begin with the four-chamber view. This view is found with the TEE probe in the mid-esophageal position. And I would suggest starting with a transducer imaging plane angle of 0 degrees. Though this may require some optimization

[00:00:30] to avoid any foreshortening but the optimal four-chamber view is normally found somewhere between 0 and 20 degrees. So here, we have the mid-esophageal four-chamber view. We have both atria and both ventricles clearly in the image. Now, the left upper pulmonary vein that we're looking for is located just off the edge of the sector, just here, adjacent to the left atrium. So, in order to bring the left upper pulmonary vein into view,

[00:01:00] we're going to have to make one or two further manipulations. Our manipulations that we're going to make are to turn the TEE probe towards the patient's left and also to withdraw the probe very slightly. And this should start to bring the left upper pulmonary vein into view. And so here, we've made those probe manipulations and you'll notice that we've also increased the transducer imaging plane angle to around 30 degrees. And making all those changes has now brought the left upper pulmonary vein into view. And you'll notice that the left upper pulmonary vein

[00:01:30] inserts into the left atrium, in a relatively vertical orientation. This is in contrast to a left lower pulmonary vein, which we'll see shortly, inserts in a more horizontal orientation. Here, we have a different patient and this serves to illustrate that sometimes we need very different imaging plane angles, here, 75 degrees to obtain views of the left upper pulmonary vein.

[00:02:00] The vein is located, here and just adjacent to it is the left atrial appendage and in between the two is the posterolateral ridge, also known as the ligament or fold of Marshall. The pulmonary veins are often easier to see when we switch on color Doppler. We can see then the flow in the pulmonary vein, which is entering the left atrium. In fact, I'd suggest that you switch on color Doppler from the outset

[00:02:30] when you're hunting for each of the four pulmonary veins because it does make it somewhat easier to locate them. As well as color Doppler, we should also perform pulsed wave Doppler and we do this by placing the sample volume approximately 1 cm into the mouth of the pulmonary vein. Current guidelines recommend that we should do this in any two of the four pulmonary veins, in order to thoroughly assess flow patterns. And here's the characteristic appearance

[00:03:00] of pulsed wave Doppler, in the left upper pulmonary vein and the flow pattern has three distinct components. First of all, we have what is called the S wave, which corresponds to antegrade flow in the pulmonary vein, entering the left atrium, during ventricular systole. Immediately following the S wave, we have the D wave and that also corresponds to a further phase of antegrade flow