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CLINICAL MANUAL
AND REVIEW OF
TRANSESOPHAGEAL
ECHOCARDIOGRAPHY
Third Edition
Edited by

Joseph P. Mathew, MD, Alina Nicoara, MD, FASE

MHSc, MBA
Jerry Reves Professor of Anesthesiology
Chairman, Department of Anesthesiology
Duke University Medical Center
Durham, North Carolina
Associate Professor of Anesthesiology
Director, Perioperative Echocardiography
Department of Anesthesiology
Duke University Medical Center
Durham, North Carolina

Chakib M. Ayoub, MD, MBA Madhav Swaminathan, MD,

Professor of Anesthesiology FASE, FAHA
Department of Anesthesiology Professor of Anesthesiology
Duke University Medical Center Vice-Chair, Faculty Development
Durham, North Carolina Department of Anesthesiology
Duke University Medical Center
Durham, North Carolina

New York I Chicago I San Francisco I Athens I London I Madrid I Mexico City
Milan I New Delhi I Singapore I Sydney /Toronto
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 Contents

Contributors ix
Foreword xiii
Preface xv

1. FUNDAMENTALS OF ECHOCARDIOGRAPHY

Chapter 1 PHYSICS OF TWO-DIMENSIONAL AND DOPPLER IMAGING 3

Brian P. Barrick, Mihai V. Podgoreanu, and Edward K. Prokop

Chapter 2 THETEE PROBE 18

Joseph A. Sivak, Jose Rivera, and Zainab Samad

Chapter 3 UNDERSTANDING ULTRASOUND SYSTEM CONTROLS 30

Hillary B. Hrabak, Ashlee Davis, and David B. Adams

Chapter4 TRANSESOPHAGEAL TOMOGRAPHIC VIEWS 50

Ryan E. Lauer andJoseph P. Mathew

Chapter 5 QUANTITATIVE ECHOCARDIOGRAPHY 98

Feroze Mahmood, Rajiv Juneja, and Khurram Owais

Chapter 6 ANATOMICAL VARIANTS AND ULTRASOUND ARTIFACTS 125

Katherine Grichnik, Wendy L. Pabich, and AtifY. Raja

2. AsSESSMENT OF CARDIAC STRUCTURE AND FUNCTION

Chapter 7 ASSESSMENT OF LEFT VENTRICULAR SYSTOLIC FUNCTION 159

Undo D. Gillam, Konstantinos P. Koulogiannis, and Leo Marcoff

Chapter 8 LEFTVENTRICULAR DIASTOLIC FUNCTION 176

Alina Nicoara and Wanda M. Popescu

Chapter 9 RIGHT VENTRICULAR FUNCTION 214

Timothy M. Maus, Dalia A. Banks, Rebecca A. Schroeder, and Jonathan B. Mark

Chapter 10 MITRAL VALVE 237

Johannes van der Westhuizen andJustiaan Swanevelder
iv I Contents

Chapter 11 AORTIC VALVE 264

Mark A. Taylor, Saket Singh, and Christopher A. Troianos

Chapter 12 TRICUSPID AND PULMONIC VALVES 304

George II. Moukarbel Antoine B. Abchee, and Chakib M. Ayoub

Chapter 13 EPICARDIAL ECHOCARDIOGRAPHY AND EPIAORTIC

ULTRASONOGRAPHY 327
Stanton K. Sheman and Kathryn E. Glas

3. CLINICAL ECHOCARDIOGRAPHY

Chapter 14 MITRAL VALVE REPAIR 341

Ghassan Sleilaty, lssam El-Rossi and Victor Jebara

Chapter 15 PROSTHETIC VALVES 365

Brandi A. Bottiger, Blaine A. Kent, Joseph P. Mathew, and Madhav Swaminathan

Chapter 16 AORTIC SURGERY AND ATHEROMA ASSESSMENT 413

Madhav Swaminathan andJoseph P. Mathew

Chapter 17 ASSESSMENT OF MECHANICAL CIRCULATORY

SUPPORT DEVICES 435
J. Mauricio Del Rio, Carmelo A. Milano, and Alina Nicoara

Chapter 18 THORACIC TRANSPLANTATION 466

Sharon McCartney. Susan M. Martinelli, and Priya A. Kumar

Chapter 19 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR

CONGENITAL HEART DISEASE 486
Stephanie S. F. Fischer and Mathew II. Patteril

Chapter 20 CARDIAC MASSES AND PERICARDIAL PATHOLOGY 527

Nikolaos I. Skubas, Anne D. Cherry, and Manuel L Fontes

Chapter 21 VENTRICULAR DISEASES 548

Mahesh Prabhu, Chandrika Roysam, and Stanton K. Sheman

Chapter 22 NONCARDIAC SURGERY 578

Stefaan Bouchez, Svati H. Shah, and Patrick Wouters

4. SPECIAL TOPICS

Chapter 23 THREE-DIMENSIONAL ECHOCARDIOGRAPHY 611

Alina Nicoara, Renata G. Ferreira, and G. Burkhard Mackensen
 Contents I v

Chapter24 STRAIN AND STRAIN RATE IMAGING 649

Kimberly J. Howard-Quijano and Aman Mahajan

Chapter 25 TRAINING AND CERTIFICATION IN PERIOPERATIVE

TRANSESOPHAGEAL ECHOCARDIOGRAPHY 669
Madhav Swaminathan

Chapter 26 ESTABLISHING AND MAINTAINING A QUALITY

PERIOPERATIVE TEE SERVICE 678
Christopher A. Troianos, Bryan P. Noorda, Shahar Bar-Yosef,
Rebecca A. Schroeder, and Jonathan B. Marl<

5. APPENDICES

Appendix A NORMAL CHAMBER DIMENSIONS 699

AppendixB WALL MOTION AND CORONARY PERFUSION 701

Appendix( DIASTOLIC FUNCTION 703

AppendixD NATIVE VALVE AREAS, VELOCITIES, AND GRADIENTS 706

AppendixE MEASUREMENTS AND CALCULATIONS 714

AppendixF MISCELLANEOUS 718

6. ANSWERS 721
7. INSTRUCTIONAL VIDEOS (ONLINE)
Alina Nicoara and Madhav Swaminathan

1 CARDIAC OUTPUT
2 CONTINUITY EQUATION
3 DP/DT
4 ESTIMATING CHAMBER PRESSURES
s PISA: MITRAL REGURGITATION
6 PISA: MITRAL VALVE AREA
7 PRESSURE HALF-TIME
B PROPAGATION VELOCITY
9 SIMPSON'S METHOD
10 STRAIN
11 TISSUE DOPPLER
12 TRANSMITRAL FLOW
13 3D TEE: LIVE IMAGING
14 3DTEE: ZOOM MODE
vi I Contents

15 3DTEE:GATED IMAGING
16 3D TEE: CROPPING
17 3D TEE: MITRAL VALVE MODELING

8. PRACTICE TESTS (ONLINE)

BASIC TEE
Khurram Owais and Robina Matya/

ADVANCED TEE
Mario Montealegre-Gal/egos and Feroze Mahmood

INDEX 749

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To my mentors, Ors. Paul Barash, Jerry Reves, and Mark New-
man. How blessed I have been to have you all as role models and
to learn from such great leaders! Thank you for your commit-
ment, sacrifice, and legacy and most importantly, for instilling
in me a "vision for what can be" as well as the "passion for what
should be".

Joseph P. Mathew

To my parents, Rodica and loan.

Alina Nicoara

I dedicate this book to the many great people who have unself-
ishly given their time and talent to mentor and guide others. To
my mentors, teachers and friends, you have been an integral part
of my career. Working with you has always been a motivating
and memorable journey, which has guided me so far, and always
will. I hope one day to inspire others as you have inspired me.

Chakib M Ayoub

To Ratna, my wife, best friend, and confidante, for her

unconditional support.
My son, Raghav, for always inspiring me.
My son, Ahhinav, for his wit, humor, and sage advice often
beyond his years.

Madhav Swaminathan
This page intentionally left blank
 Contributors

Antoine B. Abchee, MD [12] Anne D. Cherry, MD [20)

Professor of Clinical Medicine .As&istant Profes&or
Department ofinternal Medicine, Cardiology Department of Anesthesiology
American University of Beirut Medical Center Duke Univer!lity Medical Center
Beirut, Lebanon Durham, North Carolina

Chakib M. Ayoub, MD, MBA [12] Ashlee Davis, ACS, RDCS, BSMI [3]
Professor ofAnesthesiology Cardiac Sonographer, III
Department ofAnesthesiology Dula: Univer!lity Medical Center
Duke University Medical Center Durham, North Carolina
Durham, North Carolina

David B. Adams, ACS, RCS, RDCS, FASE [3] J. Mauricio Del Rio, MD [17)
.As&istant Profes&or
Cardiac Sonographer Emeritus
Divisions of Cardiothoracic Anesthesiology & Critical Care
Duke University Medical Center
Durham, North Carolina Medicine
Department of Anesthesiology
Dalla A. Banks, MD, FASE [9] Duke Univer5ity Medical Center
Division Chief Durham, North Carolina
Cardiothoracic Anesthesiology
Professor lssam El-Rassi, MD [14]
Department ofAnesthesiology .As&istant Profes&or
Univer!lity of California San Diego Department of Surgery
San Diego, California American University of Beirut
Beirut, Lebanon
Shahar Bar-Yosef, MD [26)
Department ofAnesthesiology and Critical Care Renata G. Ferreira, MD [23)
Assuta Medical Center .As&ociate Professor
Td-Aviv, Israd Director of Cardiothoracic Anesthesia Education
Department of Anesthesiology
Brian P. Barrick,. MD, ODS [1] University of Washington Medical Center
Professor Seattle, Washington
Department ofAnesthesiology
Univer5ity of North Carolina Hospitals
Stephanie S. F. Fischer, MD [19)
Chapel Hill, North Carolina
Specialist Anesthesiologist
Brandl A. Bottlger, MD [15) Private Practice
Assistant Professor Johannesburg, South Africa
Program Director, Adult Cardiothoracic Anesthesiology
Fellowship Manuel L. Fontes, MD [20)
Department ofAnesthesiology Professor of Anesthesiology
Duke University Medical Center Division Chief, Cardiac Anesthesiology
Durham, North Carolina Director of Clinical Research
Program Director, Cardiothoracic Anesthesiology Fdlowship
Stefaan Bouchez, MD [22) Medical Director of Perfusion Services
Cardiac Anesthesiologist Yale School of Medicine
Ghent University Hospital New Haven, Connecticut
Ghent, Bdgium
x I Contributors
Linda D. Giiiam, MD, MPH, FACC, FASE, FESC [7]
Chair, Department of Cardiovascular Medicine
Atlantic Health System/Morristown Medical Center
Professor of Medicine,
Sidney Kimmd Medical College at Thomas
Jefferson University
Morristown, New Jersey
Kathryn E. Glas, MD, MBA, FASE [13]
Professor
Department of Anesthe.dology
Emory University School of Medicine
Atlanta, Georgia
Katherine Grichnik. MD, MS, FASE [6]
Senior Vice President and ChiefMedical Officer
Indian River Medical Center
Vero Beach, Florida
Kimberly J. Howard-Quijano, MD, MS [:Z4]
Academic Chief, Cardiac Anesthcsiology
Director, Translational Research
Department of Anesthcsiology & Pcriopcrative Medicine
University of Pittsburgh School of Medicine
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Hillary B. Hrabak. BS, RDCS [3]
Cardiac Sonographer II
Cardiac Diagnostic Unit
Duke University Medical Center
Durham, North Carolina
Vidor Jebara, MD [14]
Professor of Surgery
Department ofThoracic and Cardiovascular Surgery
Hotd-Dieu de France Hospital
Saint Joseph University
Beirut, Lebanon
Rajiv Juneja MD, DA, MAMS [5]
Director Cardiac Anesthesia & Critical Care
Medanta Institute of Critical Care & Anesthesia
Medanta The Mcdicity
Gurgaon, India
Blaine A. Kent MD, FRCPC [15]
Associate Professor of Anesthesiology
Anesthesia Site Chief, Halifax Infirmary Hospital
Director, Periopcrative Blood Management Services
Dalhousie University I Nova Scotia Health Authority
Halifax, Nova Scotia, Canada
Konstantinos P. Koulogiannis, MD, FACC [7]
Attending Cardiologist
Morristown Medical Center
Morristown, New Jersey
Prlya A. Kumar, MD [18]
Profusor
Director of Clinical ~eh
Deparonent of Anesthesiology
University of North Carolina Hospital
Chapd Hill, North Carolina
Ryan E. Lauer, MD [4]
Associate Professor
Deparonent of Anesthesiology
Loma Linda University Health
Loma Linda, California
G. Burkhard Mackensen, MD, PhD, FASE [:Z3]
Profusor and Chief
Division of Cardiothoracic Anesthesia
UW Medicine Research & Education Endowed Professor in
Anesthesiology
Deparonent of Anesthesiology & Pain Medicine
University ofWashington Medical Center
Seattle, Washington
Aman Mahajan, MD, PhD, MBA [24]
Perer and Eva Safar Profes&or and Chair
Deparonent of Anesthesiology and Perioperative Medicine
University of Pittsburgh School of Medicine
Director, University of Pimburgh Medical Center Periopcrative
Services
Pittsburgh, Pennsylvania
Feroze Mahmood, MD [5, PE: Advanced TEE]
Profes&or of Anesthesia
Division Chief, Cardiac and Vascular Anesthesia
Harvard Medical School
Boston, Massachusetts
Leo Marcott, MD, FACC, FASE [7]
Assistant Professor of Medicine
Sidney Kimmd Medical College
Thomas Jefferson University
Philaddphia, Pennsylvania
Jonathan B. Mark. MD [9, 26]
Profusor
Dcparonent of Anesthcsiology
Duke University Medical Center
Veterans Affairs Medical Center
Durham, North Carolina
Susan M. Martinelli, MD [18]
Associate Professor
Deparonent of Anesthesiology
University of North Carolina Hospital
Chapd Hill, North Carolina
 Contributors I xi

Joseph P. Mathew, MD, MHSc, Bryan P. Noorda, MD [26]

MBA [4, 15, 16] Associate Professor of Anesthcsiology
Jerry Reves Professor ofAnesthcsiology and Chairman Department of Ancsthcsiology
Department ofAnesthcsiology Allegheny Health Network
Duke University Medical Center Pittsburgh, Pennsylvania
Durham, North Carolina
Khurram Owais, MD [PE: Basic TEE]
Robina Matyal, MD [PE: Basic TEE] dinical Fellow in Anesthcsiology
Associate Professor of Anesthesia Beth Israel Deaconess Medical Center
Harvard Medical School Harvard Medical School
Staff Anesthesiologist Boston, Massachusetts
Beth Israel Deaconess Medical
Center Wendy L. Pabich, MD [6]
Boston, Massachusetts Attending Ancsthcsiologist
US Anesthesia Partners - Washington
Timothy M. Maus, MD, FASE [9] Swedish Medical Center
Associate Clinical Professor Scanle, Washington
Director of Perioperative Echocardiography
Department ofAnesthcsiology
Mathew V. Patteril, MD, FRCA, AFFICM, RCS [19]
University of California San Diego
Consultant Cam.iothoracic Anesthcsiologist
San Diego, California
University Hospitals of Coventry and Warwickshire
Coventry, United Kingdom
Sharon McCartney, MD,
FASE [18]
Assistant Professor Mihal V. Podgoreanu, MD [1]
Department ofAnesthcsiology Associate Professor of Anesthcsiology
Duke University Medical Center Chief, Division of Cardiothoracic Anesthcsiology
Durham, North Carolina Department of Ancsthesiology
Duke University Medical Center
carmelo A. Miiano, MD [17] Durham, North Carolina
Chief, Section of Adult Cardiac Surgery
Surgical Director for LVAD Program Wanda M. Popescu, MD [8]
Professor of Surgery Associate Professor of Anesthesiology
Duke University Medical Center Director, Thoracic and Vascular Ancsthesia Division
Durham, North Carolina Yale University School of Medicine
New Haven, Connecticut
Mario Montealegre-Gallegos, MD
[PE: Advanced TEE] Mahesh Prabhu, MBBS, MD, FRCA, FFICM [21]
Ancsthesiology Resident Consultant, Cardiothoracic Anaesthesia and Intensive Care
Beth Israel Deaconess Medical Center The Newcastle upon Tyne Hospitals
Harvard Medical School NHS Foundation Trust
Boston, Massachusetts Newcastle upon Tyne, England

Edward K. Prokop, MD [1]

George V. Moukarbel, MD [12]
Section Chief, Cardiac Diagnostic Unit
Associate Professor, Division of Cardiovascular Medicine,
New Haven Radiology Associates
Department of Medicine
Woodbridge, Connecticut
Director, Heart Failure and LVAD Program
The University ofToledo Medical Center AtifY. Raja, MD [6]
Toledo, Ohio Vice-Chair Ancsthesiology
Director Cardiothoracic Ancsthesia Services
Alina Nicoara, MD [8, 17, 23] AANC I WakeMed Hospital
Associate Professor of Anesthesiology Raleigh, North Carolina
Director, Perioperative Echocardiography
Department ofAnesthesiology Jose Rivera, RCS [2]
Cam.iothoracic Anesthesiology Division Cam.iac Sonographer
Duke University Medical Center Duke University Medical Center
Durham, North Carolina Durham, North Carolina
xii I Contributors

Chandrlka Roysam, MD, FRCA [21] Ghassan Slellaty, MD, MSc [14]
Consultant Cardiothoracic Anesthcsiologist and lntcnsivist Surgeon
Fttcman Hospital Division of Cardiovascular and Thoracic Surgery
Newcastle upon Tyne, United Kingdom Hotcl-Dieu de France Hospital
Beirut, Lebanon
Zainab Samad, MD, MHS [2]
Associate Professor of Medicine Madhav Swaminathan, MD [15, 16, 25]
Chair, Department of Medicine, Profes&or of Anesthcsiology
Aga Khan University V= Chair of Faculty Development
Karachi, Pakistan Division of Cardiothoracic Anesthcsiology
Department of Ancsthesiology
Rebecca A. Schroeder, MD [9, 26] Duke University Medical Center
Associate Professor Durham, North Carolina
Department of Anesthcsiology
Duke University Medical Center Justlaan Swanevelder, MBChB, FCA(SA), FRCA,
Durham, North Carolina MMED (Anes) [10]
Profes&or and Head of Department
Svati H. Shah, MD, MHS, MS [22]
Consultant Ancsthesiologist
Associate Professor of Medicine
Department of Anesthesia and Periopcra.tive Medicine
Vice-Chief, Translational Research
University of Cape Town
Director, Adult Cardiovascular Genetics Clinic
Groote Schuur and Red Cross War Memorial Children's Hospitals
Division of Cardiology, Department ofMcdicine
Cape Town, South Africa
Co-Director, Clinical Translation
Duke Molecular Physiology Institute
Duke University
Mark A. Taylor, MD, FASE [111
Chair, Surgical Operations
Durham, North Carolina
Clinical Associate of Anesthesiology
Stanton K. Shernan, MD, FAHA, FASE [13, 21] Clcvdand Clinic
Professor and Executive Vice Chair Clcvdand, Ohio
Department of Anesthcsiology, Periopcra.tive and Pain Medicine
Brigham and Women's Hospital Harvanl. Medical School Christopher A. Troianos, MD, FASE [11, 26]
Boston, Massachusetts Profes&or and Chair
Anesthesiology Institute
Saket Singh, MD [11] Clcvdand Clinic Lerner College of Medicine,
Vice Chair fur Quality Case Western Reserve University
Associate Program Director Clcvdand, Ohio
Department of Anesthcsiology
Allegheny Health Network Johannes van der Westhuizen, MBChB, MMed
Clinical Associate Professor [10]
Temple University School ofMedicine Session Consultant Anesthesiologist
Pittsburgh, Pennsylvania Department of Anesthesiology
University of the Free State
Joseph A. Sivak, MD, FACC [2] Haumann and Partners
Assistant Professor ofMedicine Bloemfontein, South Africa
Division of Cardiology
Department of Medicine Patrick Wouters, MD, PhD [22]
University of North Carolina Clinical and Academic Head
Chapel Hill, North Carolina Department of Anesthesia and Perioperative Medicine
Profes&or of Clinical Physiology
Nfkolaos I. Skubas, MD, DSc, FASE, FACC [20] Ghent University and University Hospital
Department Chairman Ghenc, Belgium
Department of Cardiothoracic Ancsthcsiology
Cleveland Clinic
Cleveland, Ohio
 Foreword

Over the past 60 years, echocardiography has become the most important and widely used
imaging modality in cardiovascular medicine. And even though the core technology still re-
lies on the same fundamental physical properties of reflected waves, the variety of innova-
tions and applications that have evolved to enable sophisticated imaging of cardiac structure
and function in three-dimensional space is astonishing. The underlying principles are simple
enough: ultrasound waves are sent from a transducer, then the reflected waves are analyzed
in two domains: a time-intensity domain (to characterize the structure) and a frequency-shift
domain (to assess the speed of motion). With modern transducer technology and computer
processing speeds, echo images have greater spatial and temporal resolution than ever, and
the usefulness of echo across all forms of cardiovascular disease is without parallel. One can-
not be a cardiovascular specialist without an in-depth knowledge of echocardiography.
This volume goes a long way to addressing this need. While transthoracic echocardiog-
raphy is the initial approach for the majority of clinical conditions, transesophageal echo-
cardiography (TEE) remains essential since its introduction in the 1980s, as it provides im-
ages with much higher resolution, particularly in the cardiac base and in technically difficult
studies. This is crucial in the care of the critically ill patient or during cardiac interventions,
where diagnostic accuracy is paramount. Ors. Joseph P. Mathew, Alina Nicoara, Chakib M.
Ayoub, and Madhav Swaminathan lay a solid foundation for understanding the intricacies
of transesophageal echocardiography, from the basic principles of ultrasound to various
clinical applications of TEE, including its role in the critically ill, in monitoring heart function
in the operative theater, and in evaluating the immediate results of cardiac procedures.
This third edition of Clinical Manual and Review ofTransesophageal Echocardiography ac-
complishes the difficult task of speaking with ease to both the novice and the expert, while
updating the text of their second edition to include recent improvements in the field, in-
clusive of strain imaging. The authors cover all the novel uses of three-dimensional imag-
ing with a focus on those that apply to valvular heart surgery and the critical care setting,
offering wisdom accumulated through long experience. The illustrations and instructional
videos included with this volume reflect the authors' deep expertise in both the technique
and the teaching ofTEE; questions at the end of chapters and the TEE practice exams will
help prepare those who intend on taking certification examinations. This third edition also
incorporates a superb online supplement with instructional videos.
In short, this clinical manual and review of transesophageal echocardiography will en-
lighten the reader and promote the expert application of transesophageal echocardiogra-
phy in the care of high-risk patients.
William A. Zoghbi MD, FASE, MACC
Professor and Chair, Department of Cardiology
Methodist DeBakey Heart & Vascular Center
Houston Methodist Hospital
This page intentionally left blank
 Preface

The third edition of the Clinical Manual and Review of Transesophageal Echocardiogra-
phy is intended to be an indispensable resource and the standard reference manual in
the field of transesophageal echocardiography (TEE). Completely updated, reorganized,
and expanded, this edition has been redesigned to offer anesthesiologists, cardiolo-
gists, cardiothoracic surgeons, emergency room physicians, intensivists, and sonogra-
phers a concise yet comprehensive coverage of the key principles, concepts, and cur-
rent practices in TEE.
Since the publication of the first edition in 2005, and the second edition in 2010, the
field has witnessed continuous growth at a rapid pace. Preparing the third edition was a
complex undertaking, as we attempted to balance content, format, style, integration, and
innovation, while recognizing the need to stay in the zone between excessively complex
and over simplified.
This edition features a sectional format, each containing chapters that were reviewed
and updated to provide a comprehensive discussion of the physiology, pathophysiology,
and echocardiographic approach for normal and common disease states. Whenever pos-
sible, important clinical information has been aligned with the principles of cardiovascu-
lar physiology, and echocardiographic techniques. In addition, narrative text, charts, and
graphs have been effectively integrated to provide rapid access to key clinical information
for the purpose of improving clinical management. With a dedicated section highlighting
the practice exam along the numerous multiple-choice questions after almost every chap-
ter, in addition to the online instructional videos provided to our readers, this edition will
serve as an excellent source of current clinical information on TEE for trainees and more ex-
perienced anesthesiologists preparing for board examinations in both basic and advanced
perioperative echocardiography.
In addition to several distinguished new authors, we welcome Dr. Alina Nicoara as a co-
editor. We have been privileged to collaborate with an outstanding group of colleagues
that are prominent experts in their fields. We are grateful and acknowledge their hard work,
dedication, selfless commitment and valued contributions in this collective responsibility.
It is their excellence, attention to detail, passion for echocardiography, and vast knowledge
and experience that allowed this project to proceed smoothly. We are also thankful to the
many readers of the first and second editions who offered words of encouragement and
even advice on how the book could be improved-many of those suggestions have been
incorporated into the current edition. Despite the changes, however, we hope that we
have retained the elements that made the first two editions successful.
Finally, we once again recognize and are indebted to our mentors-those who in-
stilled in us the passion for echocardiography. We gratefully acknowledge the contribu-
tions of Drs. Dinesh Kurian, Martin Sigurdsson, and Nathan Waldron in reviewing all of the
questions and answers in the book. Our sincere appreciation also goes to our assistants,
xvi I Preface

Melinda Macalino, Jaime Cooke, and Rabih Mukalled, for their dedication, enthusiasm, and patience.
In addition, we would like to thank the staff at McGraw-Hill including Brian Belval, Andrew Moyer, Jason
Malley and Christie Naglieri for their continued support with this project.
Joseph P. Mathew
Alina Nicoara
Chakib M. Ayoub
Madhav Swaminathan
Fundamentals of Echocardiography
This page intentionally left blank
 Physics of Two-Dimensional
and Doppler Imaging
Brian P. Barrick, Mihai V. Podgoreanu, and Edward K. Prokop
BASICS OF ULTRASOUND1- 3
Nature and Properties of Ultrasound
Waves
Humans can hear sound waves with frequencies
between 20 and 20,000 hertz. Frequencies higher than
this range are called ultrasound (US). A sountl wave can
be described as a mechanical, longitudinal wave com-
posed of cyclic compressions and rarefactions of mole-
cules in a medium. This is in contrast to electromagnetic
waves, which do not require a medium for propagation.
Three acoustic ftriables identify sound waves:
• Pressure: force within an area (measured in pascals)
• Density: mass within a volume (measured in kg/cm3)
• Distance: motion measured in length (e.g., milli-
meters, centimeters)
Three para.meters can be used to describe the abso-
lute and relative strength ("loudness") of a sound wave:
• Amplitude: The amount of change in one of the
previously mentioned acoustic variables. Amplitude
is equal to the difference between the average and
the maximum values of an acoustic variable (or half
the "peak-to-peak" amplitude).
• Powen The rate of energy transfer, expressed in watts
Qoules/second). Power is proportional to the square
of the amplitude.
• Intemity: The energy per unit cross-sectional area
in a sound beam, expressed in watts per square ccnti-
meter (W/cm2). This is the para.meter used most fre-
quently when describing the biological safety of US.
The operator can modify the three parameters
described, but it should he noted that modifying these
parameters is not the same as adjusting receiver gain,
which is a postproccssing function.
Changes (usually in intensity) can also be expressed
in a relative, logarithmic scale known as decibels
(dB). In common practice, the lowest-intensity audi-
ble sound (10-12 W /M2) is assigned the value of 0 dB.
An increase of 3 dB represents a two-fold increase
in intensity, and an increase of 10 dB represents a
ten-fold increase in intensity. This means that a sound
with an intensity of 120 dB is 1 trillion (10 12) times
as intense as a sound of 0 dB.
Four additional parameters that are inherent to
the sound generator (transducer) and/or the medium
through which the sound propagates are also used.
When referring to a single transducer (piezoelec-
tric) element in a pulsed US system, these cannot be
manipulated by the operator:
• Period: The duration of a single cycle. Typical val-
ues for clinical US range from 0.1 to 0.5 microsec-
onds (µs).
• Frequency (f}: The number of cycles per unit
time. One cycle per second is one hertz (Hz). US is
defined as a sound wave with a frequency greater than
20,000 Hz. Values that are relevant in clinical imag-
ing modalities such as echocardiography and vascular
ultrasound range from 2 to 15 megahertz (MHz).
Period and frequency are reciprocals. Period = l /f
• Wavelength().): The distance travded by sound in
one cycle (0.1 to 0.8 mm).
Wavelength and frequency are inversely pro-
portional and are related by propagation speed
through the formula >.. = elf
• Propagation speed (c): The speed of sound in a
medium, determined by the characteristics of the
medium through which it propagates. Propagation
speed does not depend on the amplitude or fre-
quency of the sound wave. It is directly propor-
tional to the stiffness and inversely proportional to
the density of the medium.
Sound propagates at 1540 m/s for average human
soft tissue, including heart muscle, blood, and valve
tissue. Other useful values are 330 m/s for air and
4080 m/s for skull bone.
Properties of Pulsed Ultrasound
Continuous waves are not useful for structural imag-
ing. Instead, US systems use brief pulses of acoustic
4 I CHAPTER 1
Pulse duration
Pulse repetition period
FIGURE 1-1. Physical parameters describing continuous and pulsed ultrasound waves.
signal. These are emitted from the transducer during
the "on" time and are received during the "off" time.
One pulse typically consists of three to five cycles.
Pulsed US can be described by five parameters
(Fig. 1-1):
• Pulse duration: The time a pulse is "on," which is
very short (0.5 to 3 µs).
• Pulse repetition period: The time from the start of
one pulse to the start of the next pulse, which includes
the listening time. Typical values are 0.1 to 1 ms.
• Spatial pulse length: The distance from the start to
the end of a pulse (0.1 to 1 mm).
• Duty factor. The percentage of time the transducer
is activdy transmitting US, usually 0.1 % to 1%. This
means that the transducer dement acts as a receiver
over 99% of the time.
• Pulse repetition frequency (PRF): The number
of pulses that occur in 1 second, expressed in Hz.
PRF is reciprocal to pulse repetition period. Typical
values are 1OOO to 10,000 Hz (not to be confused
with the frequency of the US within a pulse, which
is many times greater).
PRF is inversdy proportional to imaging depth.
Because sound takes time to propagate, a deeper
image requires more listening time. Therefore, with
a deeper image, the transducer can emit fewer pulses
per second. This concept will also be important for
the discussion of Doppler ultrasound.
The rdation between the depth of a reflector and
the time it takes for an US pulse to travd from the
transducer to the reflector and hack to the transducer
(time-of-flight) is called the range equation:
distance to reflector (mm)= propagation speed (mm/o6)
· time-of-flight (o6)/2
This allows the US system to calculate the distance
to a certain structure by measuring only the time-of-
flight. Assuming that soft tissue has a uniform propa-
gation speed of 1540 m/s, or 1.54 mm/µs, this means
Wavelength Spatial pulse length
,-----,
' '
......._.--+--+-~----'--+-+-1-+~--......_1-+-+-~ Distllnce
Amplitude
that time-of-flight increases by 13 µs for every 1 cm
of depth of the reflector. This value is important for
imaging and for Doppler US.
Propagation of Ultrasound
Through Tissues
The most important effect of a medium on the US
wave is attenuation--the gradual decrease in intensity
(measured in dB) of an US wave. Attenuation results
from three processes:
• Absorption: conversion of sound energy to heat
energy.
• Scattering: diffuse spread of sound from a border
with small irregularities.
• Rdlection: return of sound to the transducer from
a rdatively smooth border between two media. It is
reflection that is important for imaging.
Different tissues attenuate by different processes
and at different rates:
• Air bubbles reflect much of the US that engages
them and appear very echo dense (bright). Because
sound attenuates the most in air, information distal
to an air bubble is often lost as a result.
• Lung, being mostly air filled, causes much scatter and
results in the most attenuation of US by tissue.
• Bone absorbs and reflects US, resulting in somewhat
less attenuation than lung.
• Soft tissue and blood attenuate even less than bone.
• Water attenuates sound very little, mostly by
absorption, with very little reflection. It is therefore
very echo lucent (appears black on images).
Within soft tissue, attenuation is proportional to
both the US frequency and path length, and can be
expressed by the following equation:
Attenuation (dB)= 05 dB/(cm ·MHz)·
path length (cm)· frequency (MHz)
 PHYSICS OF TWO-DIMENSIONAL AND DOPPLER IMAGING I 5

Therefore, one may conchuk that highfaqumcy US

has pater attenWl.tion, has poorer pmewtilm, and is
kn tffictiw at imaging ektptr slrtlaUm.
Less than 1% of the incident US is usually reflected
at the boundary between different soft tissues. The
interfaces between air and tissue and between bone
and tissue arc strong reflectors and can result in sev-
er:i.l types of artifu:ts (see Chapter 6).
As the US beam strikes a boundary between two
media, three phenomena may occur:
• Reflection: can be further broken down into specu-
lar reflection and mjfose reflection or bac!tscattn
• Transmission
• Refraction
Reflection of the transmitted US signal is the basis Medium 1 Medlum2
of US imaging. It can occur only if there is a dllkr-
cncc in the ll&oiutic impetlance (measured in MRayls) FIGURE 7-2. An Illustration demonstrating refrac-
between the two media, and is dependent on the tion. In this example, the propagation speed of medium
angle of incidence of the US beam at the interface. 1 is greater than medium 2, resulting in a lower trans-
.Acoustic impedance is a property of the media, not of mission angle.
the US beam. It is directly proportional to both den-
sity and propagation speed of the material.
Specu/4r reflectors have large, smooth surfaces, or
have irregularities that arc larger than the wavdength
of the US beam. They arc angle dependent, rcffccting
US best at normal incidence (90 degrees, or perpen-
dicular to the boundary).
Samn- ~rs (the "signal" used in US imag- Lens
ing) have irregularities that are about the same size ElectrfCill
or smaller than the wavdength of US that strikes the leads
bounda!y. Scatter reflectors are also not angle depen-
dent. A special type ofscattering is termed Rayleigh «at·
~ng, and this occurs when US strikes an object much Rear and front electrode
smaller than the beam's wavelength (such as a red blood
cell). Sound is scattered uniformly in all directions. FIGURE 7-.J. Anatomy of an ultrasound transducer.
Refraction is a process a!sociated with transmission
and refers to the change of wave direction upon cross-
ing the interface between two media. Refraction can ULTRASOUND TRANSDUCERS
occur only when the propagation speeds in the two
media are different and the incident angle is oblique Simply put, an ultrasound transducer (Fig. 1-3) is
(Fig. 1-2). Refraction is described by Snell's law: a device that converts clcc:trical energy into higb-
frequcncy acoustic energy, and vice versa. US ttansduc-
sine (refracted angle)/sine (incident angle) = speed of er:s contain crystals that change shape when an electrical
sound inmedium21speed of sound in medium 1 potential is applied (mime pia.oelectric tjficf), as dW'-
ing soW\d trammi&sion, and also create voltage when
Thus, if the speed of sound in medium 2 is less mechanically deformed {;inlltkctric efficf), as dwing
than the speed of sound in medium 1, then the trans- sound rec.eption. The most common crystals in US
mission angle is less than the incident angle. Similarly; systems arc composed of lead. zirconate, and titanatc
if the speed of sound in medium 2 is greater than the (PZI). The frequency of the US generated by each
speed of sound in medium 1, then the transmission piezoelectric clement is related to the thickness and the
angle is greater than the incident angle. propagation speed of the crystal by the fonnula:
Because it violatts the assumption that US travels
in a straight line, refraction may result in image arti- Frequency (MHz) = the material's propagation speed
fu:u (e.g., a second copy of a true rdlector). (mmlos)/ twice the thickness (mm)
6 I CHAPTER 1
Focusing method Longitudinal
(mechanical, electronic) resolution
Focal length
FIGURE t-4. Anatomy of an ultrasound beam.
In addition to the crystal, there is a backing
(damping) material with a high characteristic acoustic
impedance and ability to absorb US that is designed
to reduce unwanted rinfng of the crystal This leads
to a shorter pulse length and improves resolution of
the picture. The backing layer also increases the range
of frequencies (or bandwidth) around the resonant
frequency of the crystal. A wide bandwidth in an
imaging transducer is useful because it gives the oper-
ator a limited ability to adjust the frequency of the US
beam, thereby optimizing imaging. Frequencies wed
in ttanscsophageal cchocardfograpby (fEE) typically
range from 2.0 to 7.0 MHz.
There is also a matching layer in front of the crys.-
tal. This layer is de&igned to have an acoustic imped-
ance between that of the traruducer matetial and the
soft tissue it contacts, thus increasing transmission of
US. The ideal matching layer has a thickness of one-
quarter of the wavelength.
The sound beam produced by a single crystal
whose thickness is one-half the wavelength of emitted
sound spreads in a hemispherical pattern. The beam
emitted by an US ttansduce.r composed of several
crystals, however, ha& a cbaractetistic hourglass shape
due to constructive and destructive interference of
the wavdets from each crystal. This is referred to as
Huygens' prindpk. The focal point or focus is the loca-
tion where the beam reaches its maximal intensity
and minimum diameter (Fig. 1-4). Here the beam is
about half the width of the iraruducer. The near area,
or area between the traruducer and focu&, is called the
Fresnd z.one. The far area after the focus is called
the Frawlhofer zone.
The simplest transducer can be composed of a sin-
gle picwclcctric crystal that produces a 20 image via
mechanical scanning. More commonly, multiple ele-
ments are arranged in arrays. In linear switched amt:ys,
the simplest type of array, the elements are arranged in
a line and fire simultaneously. In phased 11rrays (linear,
annular, or convex), the dements fire with very small
time ddays, on the order of 10 nanoseconds. Phased
Focal
point
--- --
Focal
zone
amp allow for electronic focusing and steering of the
US beam.
If all of the elements arc A.red simultaneously, as
in a linear switched array, the image would be n:ct-
angular and the focus would be fured. Changing the
pattern of time delays in element firing, as in phased
arrays, allows for steering of the beam, resulting in
a wider scan area (sector shaped). It also allows for
adjustment of the focal point.
Conventional 2D US transducer5-both tran.stho-
racic and transcsophagcal-havc 64 to 128 elements
arranged in a single row. Current transducers have both
full 20 and 30 capabilities, with fully sampled matrix
anay transducers rontaining a considerably Luxer nwn-
ber of imaging elements per row, for a total ofapproxi-
mately 3000 elements (fable 1-1).4•5 Novd electronic
circuitries, improved ultrasound crystal technology. and
increased computer-processing power have led to 30
transducers with a small footprint and have fu:iliwcd
the use of routine 30 imaging in patient care. This
topic is developed in further dcWl in Chapter 23.
INSTRUMENTATION
Components of an Ultrasound System
Any US system has six components:
Transdu(:Cll Converts electrical energy into acous-
tic energy and vice versa.
Puhen Controls the electrical signals sent to the
transducer. Controls PRF, pulse amplitude, and
pulse repetition period. It is also responsible for
electtonic stce.ring and focusing in phased arrays.
Rece.her: Processes returning signals to produce an
image on a display. Processing occurs in the follow-
ing order:
1. Amplification: overall gain, 50 to 100 dB.
2. Compnulltion: more specifically, time gain com~
peruation. Adjusts for increased attenuation
with depth.
 PHYSICS OF TWO-DIMENSIONAL AND DOPPLER IMAGING I 1
Table 1-1. Summary of transducer properties.
Tr•nsducer Type lm•ge Shape Steering Technique
Mechanical Sector Mechanical
Linear switched array Rectangular None
Linear phased array Sector Electronic
Annular phased array Sector Mechanical
Convex sequential array Blunted sector None
Convex phased array Blunted sector Electronic
Vector array Flat top sector Electronic
Matrix array Sector Electronic
Reproduced with permission from Edelman SK: Understanding Ultrasound Physics, 3rd ed. Woodlands, TX: Education for the
Sonographic Professional, Inc; 2004.
3. Comprt:ssion: reduces the dynamic range of the
signals to match the dynamic range of the sys-
tem's dectrical components. Does not change
the relative value of the returning signals.
4. Demodulation: makes the image more suitable
for viewing.
a. Rectification converts all returning signals
into positive amplitude.
b. Smoothing converts signal bursts into a sin-
gle deflection for each reflector
5. Rejection: elimination of low-level signals.
Display: Formerly a cathode ray tube, now usually
consists of a computer monitor screen.
Storage media: Archiving of data (optical disk,
DVD, network server).
Muter synchronizer. Integrates all the individual
components of the system.
Ultrasound Imaging
The modes of displaying returning echoes are as follows:
A (amplitude) mock: No longer used in clinical
echocardiography. Displays upward deflections with
height proportional to the amplitude of the return-
ing echo and location proportional to the depth of
the reflector (x-axis: reflector depth; y-axis: ampli-
tude of echo). This mode only displays one scan line.
B (brightness) mode: Displays spots with bright-
ness proportional to the amplitude of the echo and
location proportional to the depth of the reflector
(x-axis: reflector depth; z-axis: amplitude of echoes;
there is no y-axis). B mode echocardiography can
be further classified as follows:
• M (motion) mock:: A continuous B-mode dis-
play. Displays one scan line versus time. Allows
for a high frame rate, accuracy of linear mea-
surements, and tracking of motion of reflectors
(x-axis: time; y-axis: reflector depth).
Focusing Technique Crystal Defect
Fixed Image loss
Fixed Vertical line dropout
Electronic Poor steering and focusing
Electronic Horizontal line dropout
Fixed Vertical line dropout
Electronic Poor steering and focusing
Electronic Poor steering and focusing
Electronic Poor steering and focusing
• Two-dimensional imaging is a line of B-mode
echo data moved in an arc through a section of
tissue in a back-and-forth fashion. This can be
achieved with mechanical or dectronic steering
of the B-mode echo beam. Images are generated
as a series of frames displayed in rapid fashion to
produce the impression of constant motion.
• Tluft,.dimensional imaging displays pyramidal
datasets consisting of volume elements or vox-
els. The 30 datasets appear three-dimensional
on the 20 display monitors by creating the per-
ception of depth through a range of colors and
opacities.
Determinants of Two-
Dimensional Resolution
The ability of an US system to image accuratdy is
termed rt:solution. Spatial rt:solution is defined as the
minimum separation between two reflectors where
they can still be identified as different structures.
Spatial resolution has been described in terms of dis-
tinguishing structures parallel to the US beam (lon-
gitutljtud or mtUd rt:solution) or perpendicular to the
US beam (14teral Tt:solution).
Synonyms for longitudinal resolution include
axial radial range, and depth (LARRD). Synonyms
for lateral resolution include angular, transverse, and
azimuth (LATA).
Longitudinal resolution = spatial pulse length/2.
Therefore, longitudinal resolution can be improved
by shortening the spatial pulse length. Given the same
number of cycles per pulse, higher-frequency US will
result in a shorter pulse length. Longitudinal resolu-
tion is typically better than lateral resolution.
Lateral resolution is approximately equal to the
US beam diameter, and it is best at the focus point
where the beam is the narrowest. The distance from
the transducer to the focus point represents the focal
length. Focal length is directly proportional with the
frequency and the transducer diameter. Therefore,
8 I CHAPTER 1

SMHz

lOMHz

lOMHz ~~-.-C.: -
/\ -
Spatial
- - -
Temporal
-
FIGURE 1-5. Transducer size, frequency, and foca l resolution resolution
depth. Sing le focus
Multlfocus Minimize llne density
High llne density Minimize Imaging depth
higher US frequency will result in a deeper area of Use narrow sector
fucu.s (Fig. 1-5) and less divergence in the far field.
Note that both longitudinal and lateral ~1u­ FIGURE 1-7. Relation between frame rate, spatial
tions are improved. with high-frequency US. In choo.t- n!Solutlon, and temporal resolution. Improving temporal
ing the settings of an US syatem, there i.s a tradeoff resolution Is achieved at the expense ofspatial resolution.
between the ability to obtain high-r.:esolution images
and the ability to image deeper structures (Fig. 1-6). 3. Using a nanow sector
The ability to accurately locate moving structures 4. Minimizing line density
at a gi~n time is termed tmtporrd molulion. Temporal
resolution is proportional to the numbers of frames Because using multifucus imaging and high line
per second (foz71U! rate). Factors that improve temporal density results in better lateral resolution, improved
resolution (f,y increasing the frame rate) an:: temporal resolution is achieved. at the expense of spa-
tial resolution {Fig. 1-7).
1. Minimizing imaging depth
2. Uang single fuc::us imaging (one pulse/line) Harmonic Imaging
.& ultrasound travels through tissue, it generates addi-
Ultruound
tional sound frequencies, which are multiple, or har-
frequenq monics, of the transmitted frequency. The farther the
US travels, the more harmonics it producc.s. By prop-
erly filtering the returning signal, which contains the
harmonic frequencies, an US machine equipped for
0 harmonic imaging can selectively display images cre-
ated with harmonic energy.

/\
The tcccption of the transmitted ultrasound at the
second hannonic (double) fu:qucncy improves tissue
visualization. especially in situations of poor-quality
imaging with fundamental fu:qucncy, by enhancing
both myocardial and valvular tissue. Normal structures

- - -
Image quality
- - -
Attenuation (tissue
may appear abnormally thickened; therefore, care should
be taken on interpreting harmonic images. Harmonic
imaging also in~ the signal-to-noise ratio and lim-
(resolution) penetration) ia the creation of anifu:ts, cspccially in the proximity of
the transducer (near ficld) 6 (see Chap~ 6).

PRINCIPLES OF DOPPLER
FIGURE 1-#J. Relation between ultrasound frequency, ULTRASOUND
image resolution, and tissue penetration. Image resolu-
The Doppler effect is defined as the eh~ in the fre-
tion improves at higher frequencies, but at the expense
quency of sound emitted or reflected by a moving
of tissue penetration.
 PHYSICS OF TWO-DIMENSIONAL AND DOPPLER IMAGING I 9
object. The amount of change is termed the Doppler
shift. It is imponant to note that though both the
transmitted and reflected frequency are ultrasonic
(MHz range), the actual Doppler shift is in the audi-
ble range (20 to 20,000 Hz).
The most common applications of Doppler US
are to measure vdocity (magnitude and direction) of
blood flow and, more recently, tissue. The Doppler
equation is as follows:
Doppler shift (expressed in Hz) = (2 · v · Fi cosine 0)/c
• v = the vdocity of the moving object
=
• Fi the incident frequency, or frequency emitted by
the transducer
• 9 = the anid.e between the incident US beam and the
direction of movement
• c = the propagation speed of US in the medium (a
constant 1540 m/s in soft tissue)
If the object is moving directly toward (9 =
0°)
or away from (0 = 180°) the transducer and v is
expressed in units of m/s, then cosine 9 is I and the
equation simplifies to:
Doppler shift= (v· Fi)/770
Because the Doppler shift varies with the cosine of
the angle of beam incidence (9), the maximum mea-
surable velocity decreases as 9 increases. When move-
ment is perpendicular (90 degrees) to the beam, no
Doppler shift is detected. Therefore, only measure-
ments obtained with (9) smaller than 20 degrees are
considered accurate.
In practice, the machine measures a Doppler shift
and cal.culates a velocity. It also assumes 9 is 0 degrees
or 90 degrees. Rearranging the simplified Doppler
equation to reflect this gives us the following:
v = 770· (Doppler shift/Fi)
When reflected (backscatter) signals are received at
the transducer, the difference between the transmitted
and reflected frequency is determined, analyzed by fast
Fourier transform, and then displayed on the screen as
a Doppler envelope. This process is known as spectral
analysis and results in a display of the following:
• Direction of blood flow: Flow toward the trans-
ducer results in an increased frequency (positive
Doppler shift displayed above the baseline), whereas
flow away from the transducer results in a decreased
frequency (negative Doppler shift displayed below
the baseline)
• Velocity of frequency shift
• Signal amplitude
Spectral Doppler (in contrast to color Doppler)
can be further divided into pulsed wave and continu-
ous wave.
Pulsed Wave Doppler
Pulsed wave Doppler uses one crystal that alternates
between sending and receiving an US beam. A timed
pulse allows sampling from a discrete area of about 1
to 3 mm, sdected by the operator, known as the sample
volume. This allows for range discrimination (Fig. 1-8).
Because the same dement acts as both sender and
receiver, the transducer must wait fur the pulse to com-
plete a round trip before emitting another pulse. As
an example, if the sampling volume is S cm from the
probe, the transducer must wait 65 µs (10 cm/154,000
cm/sec) befure sending the next pulse.
Because sampling is intermittent, the pulse repeti-
tion frequency limits the maximum Doppler shift (and
thus maximum velocity) that can be measured accu-
rately. Velocities higher than this maximum vdocity
will appear to wrap around on the display, a phenom-
enon known as aliasing (see Chapter 5). The Doppler
frequency shift at which aliasing occurs, equal to PRF
divided by 2, is termed the Nyquist limit.
For example, if a 5-MHz transducer can only send
out about 15,000 pulses per second, the Nyquist limit
is 7500 Hz (15,000/2). Using the velocity equation
shown earlier, the maximum velocity that can be
measured without aliasing is about I.IS m/s (770 X
(7500/5,000,000)).
Methods to avoid aliasing include:
1. Using continuous wave Doppler (described later)
2. Changing the view to bring the area of interest
closer to the probe (shallower depth)
3. Using a transducer with a lower incident fre-
quency (results in lower Doppler shift for given
flow vdocity; see the equation earlier)
4. Adjusting the scale to its maximum
5. Moving the baseline up or down (makes the pic-
ture "prettier" but does not eliminate aliasing)
From a practical standpoint, pulsed wave Doppler
should be used when measuring relatively low-flow
velocities ( < ~ 1.2 m/s) in specific areas of interest
(e.g., pulmonary vein flow, mitral valve inflow).
Compared to imaging ultrasound, pulsed wave
Doppler requires greater output power, longer pulse
lengths, and a higher pulse repetition frequency.
When the velocity of the tissue becomes the object of
measurement (Doppler tissue imaging), the system is set
as a low-pass filter. This means that low-vdocity, high-
amplitude signals are preferentially displayed. Doppler
tissue imaging is discussed in more detail in Chapter 5.
I0 I CHAPTER 1

Pubed-wave Doppl1r Contln11out-Wn1 Doppl1r

- One ayn;il - Two c~ls: continuous transmission
- Unable to measure high velocities and reception
acam1tely {aliasing) - Able to measure high velocities accurately
- Range resolution - Range ambiguity
FIGURE 1-8. Characteristics of pulsed wave and continuous wave Doppler.

Continuous Wave Doppler

Continuous wave Doppler uses two crystals in the
transducer: one to constantly send US waves and
the other to continuously receive. The PRF can
thus be cruemdy high. This continuous sampling
allows determination of high-vdocity flow. However.
because echoes come from anywhere along the length
of the beam, continuous sampling prevents determi· Multi.gated
nation of the location of maxi.mum measured vdocity, Multiple scan llnes
termed range ambiguity (sec Fig. 1-8).
From a practical standpoint, continuous wave
Doppler should be used when measuring velocities
> .-1.2 mls. (e.g., regurgitant jets, stenotic valves).
Color Flow Doppler
Color flow Doppler is a pulsed US technique that
color-codes Doppler information and superimposes it
on a 2D image, providing information on the direc-
tion of flow and semiquantitative information on
the mean velocities of flow. It has the characteristics
of pulsed wave Doppler (range discrimination and
aliasing). Color flow Doppler uses packets of multi·
ple pulses (3 to 20 per scan line), and therefore has
a low temporal resolution (Fig. 1-9). It then employs
spectral analysis methods to estimate the mean vdoc-
ity at each depth. The information on the direction FIGURE 1-9. Characteristics of color flow Doppler.
 PHYSICS OF TWO-DIMENSIONAL AND DOPPLER IMAGING I 11

. . .-... t _;
Nodopplershlft _____. velocity
(Nyquist limit) '\,.

- \.
··--1
FIGURE 1-10. Characteristics of color flow maps.

of flow and the magnitude of the Doppler shift are MI (> 1) sound beams result in bubble disruption
displayed as color maps, which can be ve/Qdty maps (extreme nonlinear behavior).
or varilln" maps (Fig. 1·10). A variance map contains The U.S. Food and Drug Administration (FDA)
information on the quality of flow (i.e., laminar vs. limits the maximum intensity output of cardiac ultra-
turbulent); however, turbulent flow and signal alias- sound systems to less than 720 W/cm2 due to con~
ing will result in an apparent wide range of vdocities. cerns of possible tissue and neurological dam.age from
Also, in the case of color Bow Doppler, aliasing may mechanical injury.
introduce confusion as to the direction of flow. Color
flow and spectral Doppler are set as a high-pass filter
to eliminate tissue motion artifacts. REVIEW QUESTIONS1-3,s
A typical (but not uniform) convention for color
Doppler velocity maps is for red to indicate flow Basics of Ultrasound
toward the probe and fur blue to indicate flow away Select the one best answer for each item.
from the probe (BART= Blue Away, Red Toward).
A region that is black on color flow Doppler imag- 1. Which of the following is not an acoustic variable?
ing represents an area where there is no measured a. Pressure
Doppler shift. b. Density
c. Distance
d. Intensity
BIOEFFECTS 2. Which of tbe following sound wave frequencies is
US bioeffect:s include thmnal 4/'tcts and cavitation. ultrasonic?
In addition, mechanical effects (Vibration) may be of a. lOHz
concern. Thermal bwtjftas consist of a temperature b. lOMHz
elevation resulting from the absorption and scatter· c. lOkHz
ing of US by biologic tissue and is related to beam d. 10,000 Hz
intensity (tbe spatial peak and temporal average 3. An increase in tbe strength of tbe US pulse will
[SP'TA] intensity). The SPTA limits are 100 mW/cm2 increase:
fur unfocused beams and 1000 mW/cm2 fur fucwed a. Frequency
beams. Cavittllirm resulu from the interaction of US b. Intensity
with microscopic gag bubbles. Stable cavitation refer& c. Pulse duration
to forces that cause the bubbles to contract and d. Pulse repetition &cquenc:y
expand. Transient cavitation results in breaking the
bubbles and releasing energy, producing perhaps more 4. If imaging depth decrease&, pulse repetition fre-
pronounced c£rccts on tissues at tbe microscopic level. quency:
The mechanical irulex (Ml), a calculated and unitless a. Decreases
number, is used to convey the likelihood of bioef.. b. Does not change
fects from cavitation. At low MI (<O.I) the mic~ c. Increases
bubbles expand and contra.et in a linear fashion. High. d. Varies
12 I CHAPTER 1

5. An example of a Rayleigh scatterer is the: c. 60 degrees

a. Red blood cell d. 15 degrees
b. Kidney
c. Mitral valve 13. A sound beam strikes the boundary between two
media at an incident angle of 45 degrees and is
d. Pericardium
partly reflected and transmitted. If the propaga-
6. If the frequency is doubled, the period: tion speed of the second medium is slower than the
a. Increases two-fold propagation speed of the first medium, then the
b. Decreases transmission angle is:
c. Does not change a. Equal to the incident angle
d. Increases ten-fold b. Greater than the incident angle
c. Less than the incident angle
7. The wavelength in soft tissue of sound with a fre- d. Cannot be determined
quency of 2 MHz is:
a. 6.16mm 14. A sound wave leaves its source and travels through a
b. 3.08mm liquid. If the speed of sound through that liquid is
c. 1.54 mm 600 m/s and the echo returns to the source 1 second
d. 0.77mm later, at what distance is the source from the reflector?
a. 1540 m
8. The speed of sound is slowest in: b. 770 m
a. Air c. 600 m
b. Fat d. 300m
c. Soft tissue
d. Bone 15. The amplitude of a wave is:
a. The difference between the average and maxi-
9. Which of the following parameters of sound are mum (or minimum) values of an acoustic vari-
determined by the sound source and the medium? able
a. Frequency b. Determined initially by the medium
b. Wavelength c. Altered by the sonographer
c. Amplitude d. Twice the average amplitude
d. Propagation speed
16. Intensity is inversely proportional to:
10. Reflection occurs when the two media at the bound- a. Beam area
ary have: b. Power
a. Identical acoustic impedances c. Amplitude
b. Different acoustic impedances d. Amplitude squared
c. Identical densities and propagation speeds 17. The speed of sound in a medium increases when:
d. Different temperatures a. Elasticity of the medium increases
11. All of the following are true of refraction except. b. Density of the medium increases
a. Is a change in direction of wave propagation c. Stiffness of the medium decreases
when traveling from one medium to another d. Stiffness of the medium increases
b. Occurs when there are different propagation
18. Increasing the frequency of a transducer:
speeds and oblique incidence a. Increases wavelength
c. Is described by Snell's law
b. Improves axial resolution
d. Occurs with different propagation speeds and c. Increases depth of penetration
normal incidence d. Increases pulse duration
12. A sound beam strikes the boundary between two 19. Propagation speed:
media at an incident angle of 45 degrees and is
a. Can be changed by the sonographer
partly reflected and transmitted. If medium A has b. Is an average of 1540 km/sin soft tissue
an impedance of 1.25 MRayls and a propagation
c. Is slower in a liquid than in a solid
speed of 1540 m/s and medium B has an imped- d. Is determined by the sound source
ance of 1.85 MRayls and a propagation speed of
2.54 km/s, what is the angle of reflection? 20. Attenuation of an ultrasound beam results from:
a. 4 5 degrees a. Absorption
b. 30 degrees b. Reflection
 PHYSICS OF TWO-DIMENSIONAL AND DOPPLER IMAGING I 13

c. Scattering c. 1/2
d. All of the above d. 3/4
21. Compared with backscatter, specular reflections are: 4. All of the following are true of linear switched or
a. Diffuse sequential arrays except:
b. Random a. Produces a rectangular image display
c. Well seen when sound strikes the reflector at 90 b. Defective crystal creates a line of dropout from
degrees top to bottom
d. Occur when the wavelength is larger than the c. Has a fixed transmit focus
irregularities in the boundary d. Elements are fired in a sequence to create an
22. Pulsed ultrasound is described by: image
a. Duty factor
5. In a phased array transducer, beam steering and
b. Repetition frequency
c. Spatial length focusing are produced by:
d. All of the above a. Manually rotating the transducer
b. Mechanically rotating the transducer
23. Pulse repetition frequency: c. Changing the timing of pulses to the piezoelec-
a. Is determined by the sound source and the medium tric elements
b. Can be changed by the sonographer d. Changing the resonant frequency of the piezo-
c. Increases as imaging depth increases electric elements
d. Is directly proportional to the pulse repetition
period 6. In an M-mode tracing, the x-axis represents:
a. Depth
24. When a sound beam strikes a reflector at 90 degrees b. Time
incidence, it is considered: c. Amplitude
a. Obtuse d. Frequency
b. Oblique
c. Normal 7. The damping material in an ultrasound transducer
d. Acute increases the following:
25. Sound waves can be characterized as: a. Pulse duration
a. Electrical b. Spatial pulse length
c. Duty factor
b. Transverse
c. Longitudinal d. Bandwidth
d. Spectral 8. The region or zone between the transducer and the
focal point is known as the:
Ultrasound Transducers a. Farzone
Select the one best answer for each item. b. Fresnel zone
c. Fraunhofer zone
1. Which piezoelectric effect does an US transducer d. Focal zone
use during the transmission phase?
a. Doppler effect 9. At the focus, the beam diameter is:
b. Reverse piezoelectric effect a. One-fourth the transducer diameter
c. Direct piezoelectric effect b. Half the transducer diameter
d. Indirect piezoelectric effect c. Double the transducer diameter
d. Equal to the transducer diameter
2. The most common piezoelectric material currently
used includes all of the following except: 10. In a linear phased array transducer:
a. Lead a. Image shape is a blunted sector
b. Zirconate b. Steering is mechanical
c. Titanate c. Focusing is electronic
d. Tourmaline d. A crystal defect produces a vertical line dropout
3. The optimal thickness for the matching layer as a 11. All of the following statements are true regarding
fraction of the wavelength is: the advantages of the backing material except:
a. 1/8 a. It decreases the Q factor
b. 114 b. It increases the spatial pulse length
14 I CHAPTER 1

c. It improves axial resolution c. Minimizing line density

d. The backing material decreases the transducer's d. Maximizing depth of view
sensitivity to reflected echoes
8. Components of an US system include:
12. The quality factor {Q factor) is defined as: a. Pulser
a. Bandwidth I Resonant frequency b. Receiver
b. Bandwidth I Nyquist limit c. Master synchronizer
c. Nyquist limit I Resonant frequency d. All of the above
d. Resonant frequency I Bandwidth
9. Lateral resolution can be increased by:
a. Increasing beam diameter
Instrumentation b. Decreasing transducer frequency
c. Focusing
Select the one best answer for each item.
d. Increasing gain
1. The US modality providing the best temporal reso-
lution is:
a. Amode
Principles of Doppler Ultrasound
b. B mode
c. Three dimensional Select the one best answer for each item.
d. M mode
1. The difference between the transmitted and
2. Increasing transducer output: reflected frequencies is known as the:
a. Creates identical changes in the image as an a. Bernoulli equation
increase in overall gain b. Doppler principle
b. Cannot be controlled by the sonographer c. Doppler shift
c. Causes no change in the brightness of the image d. Gorlin equation
d. Decreases the energy output of the transducer 2. Velocity is defined by:
3. Which of the following is used to create an image a. Magnitude
of uniform brightness from top to bottom? b. Direction
a. Compression c. Neither
b. Time gain compensation d. Both
c. Demodulation 3. When the angle between the sound beam and the
d. Overall gain
direction of motion is 90 degrees, the measured
4. The ability to distinguish two objects that are paral- velocity is equal to:
lel to the US beam's main axis is called: a. True velocity
a. Axial resolution b. Zero
b. Lateral resolution c. 20% of true velocity
c. Transverse resolution d. 50% of true velocity
d. Azimuth resolution 4. Current spectral analysis is achieved by:
S. If the US image shows no weak reflectors on the a. Fast Fourier transfurm
image, the best corrective action is to: b. Multifllter analysis
a. Increase overall gain c. Zero-crossing detector
b. Increase the transducer output power d. Time interval histogram
c. Decrease the reject level S. Modal velocity represents:
d. Use a high-frequency transducer a. Average Doppler velocity
6. The principal display modes for ultrasound include: b. Greatest amplitude of returned Doppler shift
a. Mmode c. Maximum Doppler velocity
b. Amode d. None of the above
c. B mode 6. Wall motion-induced frequency shifts are:
d. All of the above a. High amplitude, low velocity, low frequency
7. Temporal resolution can be improved by: b. Low amplitude, low velocity, low frequency
a. Using multifucus c. High amplitude, high velocity, high frequency
b. Using a wide sector d. High amplitude, low velocity, high frequency
 PHYSICS OF TWO-DIMENSIONAL AND DOPPLER IMAGING I 15

7. Doppler wall motion fdters are: 12. The color map shown here is a:
a. Lowpass
b. High pass
c. Zero pass
d. Onepass
8. The maximal detectable freque.acy shift. or one-half
of the PRF, is known as:
a. Doppler effect
b. Propagation speed
c. Nyquist limit
d. Peak Doppler shift
9. The following pulsed Doppler spectral display
demonstrates:

...:•:
.=·-z-~ Sef"Y.'5 ·"'·- E
~· --.
-F:
.. 1;:•

~'
HC ~ ~ z .- E ":'.,.,~
:=t•l:O:'t:
~- . .....
::~_T 64
: :: o9E33 El 21' ~ SS
;4 ;2
:4 :~ "'
·F

'
a. Normal map
- -·•1 .-
,
,-- _, / b. Velocity map
v
" :: .
~
+ :z~ c. Variance map
d. Aliased map
13. The color map shown here is a:
~

;:r ::~
..
\'41 l'\·'"
,• o),
-I1~-_J.
, f ..... '
I or: :z

i~
..
_:, z. 3.2$:"1
• 2
,,
D::L~ · ... ; ; ,·;~ . ~ Ee~·;

a. Reverberation
b. .Aliasing
c. Mirroring
d. Side lobe
10. Color flow Doppler measw:es the:
a. Peak velocity
b. Mean velocity
c. Modal velocity
d. Instant2neous velocity
11. When color flow Doppler is used, the number of
US pulses per scan line is called:
a. Line density a. Normal map
b. Fwnerate b. Velocity map
c. Nyquist limit c. Variance map
d. Packet size d. Aliased map
16 I CHAPTER 1

14. In the figure, the anow points to a region (black) 16. If the alWing velocity of the color scale shown here
wbcrc: is 40 emfs, laminar flow toward the probe at 50
cm/a would appear:

a. There is no flow a. Red

b. There is no Doppler shift b. Blue
c. There is turbulent ffow c. Yellow
d. There is laminar flow d. Green
15. A color Doppler examination is performed with 17. When a Doppler shift ia displayed above the zero
the color map shown. If a red blood cell is traveling basdine:
perpendicular to the direction of the sound beam, a. Reflected frequency .is less than the transmitted
the color tha.t will appear on the image for tbia red frequency
blood ccll is: b. Red blood cclls arc moving away from the trans-
ducer
c. The sound source and reflector are approaching
each other
d. It .i5 called a negative Doppler shift
18. Continuous wave Doppler:
a. Cannot mcaswe very high velocities
b. Transmits and tcccives Uiuasound constantly
c. Is prone to aliasing a.rtifu:t
d. Is character.iud u a wid~bandwidth tranaducer
19. The Doppler spccttal display gt'2phically demon-
strates:
a. Direction of blood flow
b. Vdocity of blood flow
c. Duration of blood flow
d. All of the above
20. A 5-MHz transducer with a pulae repetition fre..
a. Red quency of 5600 Hz is imaging to a depth of 5.6 cm.
b. Orange The Nyquist frequency .is:
c. Black a. 2.8MHz
d. Yellow b. 2.8 dB
 PHYSICS OF TWO-DIMENSIONAL AND DOPPLER IMAGING I 17
c. 2.8kHz
d.. 2500 Hz
21. Compared with pulsed imaging (2D), pulsed wave
Doppler:
a. Causes less acoustic exposure
b. Has tower output power
c. Use& shoner pulse repetition periods
d.. Uses shoner pulse lengths
22. Color Doppler:
a. Report& average vdocities
b. Use& continuous wave US
c. Does not provide range resolution
d. Is not subject to aliasing
23. The following principle is true of color Doppler
imaging:
a. Rtd always represents flow toward the trans-
ducer
b. Turbulent flow is indicated as black
c. Blue always .indicates flow away from the trans-
ducer
d. Color Doppler examinations tend to have lower
temporal resolution
24. Blood flow .in the imaged vessd is moving (as
labeled on the image) from:
a. Right to left
b. Right to left and then left to right
c. Left to right
d. Left to right and then right to left
Bioaffects
Select the one but answer for each item.
1. The most relevant intensity with respect to
heating is:
a. Spatial peak temporal average (SPTA)
b. Spatial peak temporal peak (SPTP)
c. Spatial average temporal peak (SATP)
d. Spatial average temporal average (SATA)
2. Which of the following modalities has the lowest
intensity value?
a. Pulsed wave Doppler
b. Continuous wave Doppler
c. M rn.ode/B mode
d. All of the above have the same intensity
3. C.Ontraction and ei;pans.ion ofgas bubbles is known as:
a. Transient cavitation
b. Stable cavitation
c. Attenuation
d. Panide motion
4. US bioeffects can be cawed by all of the following
except:
a. Thermal effects
b. Mechanical effects
c. Scan conversion
d. Cavitation
5. A number developed to predict the likd.ihood of
cavitation-induced bioeffccts is called:
a. Duty factor
b. Mechanical index
c. Pulsatility .index
d. Resistivity index
6. Acoustic exposure to the patient is increased by:
a. Incn:ase .in receiver gain
b. Dec.rease in pulse repetition frequency
c. Application of reject
d. Increase .in examination time
REFERENCES
I. Edelman SK. Untinndrulint Ulmtmnul Phpif:t. 3rd ed. Wood·
lands, TX: Education for die Sonographlc Profcaslo11ial, Inc.;
2004.
2. Edelman SK. U"""'11unJ Physia ltnd IMnRnnlt41io11. Wood-
lancl.. TX: Educ;adon lOr die Sonographlc Profuulonal, Inc.;
2007.
3. Weyman AE. Princi/la aNl Prtzai&e of&hot4rrli"f!t1Pby. Phila-
delphia, PA: Lea&: Pebigcr, 1993.
4. Jungwinh B, M~ GB. R.eal·tlme 3-dlmenslo11al edio·
carcl.iography l.n the operating room. Smt/11 O.wlillthtJrt1e V.-
An.mh. 2008;12(4):248-264.
5. Salgo IS. T~111io11al cchocanliographic tt.chnology.
CttnlWI Ciin. 2007;25(2):231-239.
6. Ca!dahl K. Kart.am E, IJclbctg J, et al. New concept In cchocar-
tissue diography: harmonic imaging of tissue without the usc of con-
uast agent. Lwwer. 1'98;352(9136):1264-1270.
 The TEE Probe
Joseph A. Sivak, Jose Rivera, and Zainab Samad
STRUCTURE AND DESIGN
Transesophageal echocardiogtaphy (TEE) presents
a uni'lue opportunity to overcome the limitations
posed by chest wall acoustic windows while allowing
visualization of cardiac structures with greater spatial
~lution. Since its first reported use to evaluate intra-
cardiac flow in 1971 and to visualize cardiac structures
in 1976, the TEE probe has undergone remarkable
technological advancement in terms of imaging capa-
bility and probe structure and design. l.2 The TEE
probe used by Frazin et al1 consisted of an M-mode
transducer attached to a coaxial cable. Souquet et al3
then rcponed suc:ccssful use of a phased array trans-
ducer attached to the end of a gastroscope, which,
in addition to producing tw<Kiimcnsional images,
allowed for finer control of the transducer position by
using the flcxi.on and angling controls akin to a gastro-
scope. The biplane transducer was then introduced in
1984, followed by the multiplane transducer in 1992:'
Consistent technological developments, including the
introduction of a 8aible endoscope, probe tempera-
rure regulation, miniatwi7.ation, transducer design,
addition of color and spectral Doppler, and three--
dimensional imaging, have led to the widespread
adoption of TEE in clinical care. Currently TEE
accounts for approximatdy 5% to 10% of echocardio-
grapbic procedures. s
Transducer Flexlble sl\aft Transducer Control
lens (gastroscope) controls housing
Dlstaltlp
FIGURE 2-7. Anatomy of aTEE probe.
The modern TEE probe consists of the following
components (sec Fig. 2-1).
Probe Tip
TEE probe tips are miniaturized (adult 3D probes:
-17 X 13.5 X 38 mm and infantlpediatric probes:
-7.5 X 5.5 X 18.5 nun) and feature smooth contours
to allow safe and comfonable insertion into the
oroph.arynx. The acoustic lena and matrix array are
bowed in the probe tip. Modern TEE probes typi-
cally have an extended operating frequency range of
approximately 3 to 7 MHz with a 90-degree field of
view and usually allow 180 degrees of electronic rota-
tion. The probe tip can also be flexed, extended, and
angled left or right using dials on the probe handle.
Generally, probes are capable of fl.exion of up to 120
degrees, cxtcruion of 60 degrees, and 45 degrees of
leftlriitht angulation, with some variation between
manutacturers. TEE probes with three-<ilmensional
imaging capabilities allow fur live, zoom, biplane,
and multibeat acquisition with or without color
Doppler. Three-dimensional imaging is possible by
performing a signmcant portion of beam forming
within the transducer in highly specialized integrated
circuits, which enable the fitting of thousands of
piezoelectric elements into the tip of the transducer
(sec Chapter 23).

FIGURE 2-2. Pin connector.
Probe Shaft
The TEE probe shaft houses flexible, mini-coaxial
cables carrying signals to and from the transducers.
The probe shaft is about 6 to 10 mm in diameter and
0.7 to 1 m in length and is designed to be flexible and
durable with some degree of bite resistance. The probe
shaft is labeled with markers that allow assessment
of the depth of esophageal intubation. The depth
markers at 20 to 30 cm roughly correspond to upper
esopbagcal views, 30 to 40 cm to mid-esophageal
views, 40 to 45 cm to transgastric views, and 45 to
50 cm to deep transgastric: views.
Handle
The band.le of the TEE probe houses the controls
needed to perform dectronic steering of the imaging
elements and mechanical steering of the TEE probe
tip. There arc typically two round dials. The larger
dial allows £lc::x:ion and extension movements of the
probe tip, and the smaller dial allows fur right and left
movements of the probe tip. In addition, the handle
houses two button controls that hdp with dect.ronic
steering. Ultrasound equipment manufacturers try
to optimize the ergonomics of the handle to perm.it
fur an easy one-handed operation. Design feature
i~rovements such as the introduction of a slim,
Ii tweight handle, textured. no-slip grip, and acccs-
si ility of controls have made it more user fiiendly.
Connector
The connector contains an array of pins, which attach
to the echo machine (see Fig. 2-2). It is connected to
the probe handle via the transducer cable. Typically.
THE TEE PROBE I 19
the echo system will run an automatic calibration algo--
rith.m when the probe is nrst connected with the echo
machine. It is generally recommended that the probe
tip position be neutral when this connection is made.
PROBE INSERTION AND SAFETY
Indications for TEE
Before assessing whether a patient is a suitable can-
didate for a TEE, it is prudent to first determine
the appropriateness of the indication fur the study.
General indications for TEE include assessment of
lefHtrial appendage thrombus, atrial masses, detailed
inspection of valvular pathology, and diagnosis of
endocarditis or cardioembolic source. More recently,
TEE has been used to provide anatomical guid-
ance fur percutaneous valve procedures, such as the
MitraClip procedurc.6 In 2011 a multi.society joint
guideline was published fur the a~propriate use of
echocardiography, including TEE. Indications for
the study were scored on a sCale of 1 to 9, and indica-
tions with a score of 7 to 9 were considered appropri-
ate (A = benefit outweighed risk), whereas those with
a score of 4 to 6 were considered uncertain (U), and
those with a score of 1 to 3 were considered inappro-
priate (I = risk outweighed benefit). Table 2-1 shows
the appropriateness score for indications commonly
encountered in clinical practice. Practice guidelines
fur the use of perioperative TEE8 recommend that fur
adult patients without contraindications, TEE should
be used in all open heart (e.g., valvula.r procedures)
and thoracic aortic surgical procedures, and should be
considered in coronary artery bypass graft surgeries as
well "in order to confirm and refine the preoperative
diagnosis, to detect new or unsuspec.ted pathology, to
20 I CHAPTER 2

Table2-1. Guideline-based indications and appropriate use ofTEE

Approprllte
• Guidance during percutaneous noncoronary cardiac interventions, including but not limited to closure device placement,
radiofrequency ablation, and percutaneous valve procedures. (A 9)
• Suspected acute aortic pathology, including but not limited to dissection/transection. (A 9)
• Evaluation of valwlar structure and function to assess suitability for, and assist in planning of, an intervention. (A 9)
• To diagnose infective endocarditis with a moderate or high pretest probability (e.g~ Staphylococcus bacterernia, fungemia,
prosthetic heart valve, or intracardiac device). (A 9)
• Atrial fibrillation/flutter: evaluation to facilitate clinical decision making with regard to anticoagulation, cardioversion, and/
or radiofrequency ablation. (A 9)
• Use ofTEE when there is a high likelihood of a nondiagnostic TTE due to patient characteristics or inadequate visualization
of relevant structures. (A 8)
• Re-evaluation of prior TEE finding for interval change (e.g., resolution of thrombus after anticoagulation, resolution of veg-
etation after antibiotic therapy) when a change in therapy is anticipated. (A 8)
• Evaluation for cardiovascular source of embolus with no identified noncardiac source. (A 7)

• To diagnose infective endocarditis with a low pretest probability (e.g., transient fever, known alternative source of infection,
or negative blood cultures/atypical pathogen for endocarditis). (13)
• Routine assessment of pulmonary veins in an asymptomatic patient status post pulmonary vein isolation. (13)
• Atrial fibrillation/flutter: evaluation when a decision has been made to anticoagulate and not to perform cardioversion. (12)
• Surveillance of prior TEE finding for interval change (e.g., resolution of thrombus after anticoagulation, resolution of vegeta-
tion after antibiotic therapy) when no change in therapy is anticipated. (12)
• Routine use of TEE when a diagnostic TTE is reasonably anticipated to resolve all diagnostic and management concerns. (11)
Data from American College of Cardiology Foundation Appropriate Use Criteria Task Force; American Society of Echocardiography, et al:
ACCF/ASEiAHA/ASNCJHFSA/HRS/SCAl/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the Ameri-
can College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart
Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular
Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardio-
vascular Magnetic Resonance American College of Chest Physicians, J Am Soc Echocardiogr 2011 Mar;24(3):229-267.

adjust the anesthetic and surgical plan accordingly,
and to assess the results of the surgical intervention."
In recent years, TEE in the perioperative period
has been invaluable in guiding percutaneous valve
procedures such as placement of the transcatheter
aonic valve and mitral clip. Indeed, the first setting
in which perioperative TEE was widdy adopted and
routindy employed was the cardiac surgical operating
room. In a large prospective cohort study, Mishra and
colleagues found that 36% of 5016 cardiac surgical
patients beneficed from a pre-bypass TEE study and
a similar number from a post-bypass study.9 The TEE
examination was most useful for identification of intra.-
cardiac thrombus, aortic atheroma. mitral leaflet con-
figuration, changes in valvular function, and in guiding
de-airing procedures before separation from bypass.
In some centers, TEE has replaced transthoracic
echocardiography (TTE) as the preferred initial imag-
ing study in postcardiac surgery patients requiring
emergent evaluation. This is because of its ability to
obtain superior-quality images, whereas TIE imaging
is often limited by sound attenuation from air through
the chest wall acoustic windOWli. In one study the aver~
age time to reach a diagnosis by TEE was 11 minutes,
and the etiology of refractory hrJ'otension was clearly
identified in 76% of patients. As more anesthesi-
ologists have become skilled in the performance and
interpretation of TEE, its use during noncardiac sur-
gery has increased. In a cohort of 98 patients with high
cardiac risk undergoing a broad range of noncardiac
surgery, Schulmeyer and colleagues found that TEE
hdped guide intraoperative and/or postoperative man-
agement in all but 2 patients.11 Suriani and coworkers
reported their use of TEE in 123 cases of orthotopic
liver transplant. 12 In 15% of cases, TEE was critical in
altering surgical or anesthetic technique, treating life~
threatening events, or directing further postoperative
evaluation. In this population, TEE also can be useful
in diagnosing hepatopulmonary syndrome by identify-
ing bubbles in the pulmonary veins after a bubble test.

TEE is of proven value in eval~ hemodynami-
cally unstable patients. Feierman13 reported the we of
inttaopetative TEE to identify unsU&pcctcd dynamic left
venaicular outflow tract obstruction, thereby allowing
crucial rcdircc.tion of management sttatcgy. In addi-
tion, Brandt and usociatcs reviewed 66 cases in which
intraopcrative TEE was cmcrgently applied w diagnose
severe lefi: ventricular dysfunction, aortic dissection, new
myocanlial wall motion abnormalities, patent furamen
ovale, locali2ed. cardiac wnponade, and right ventricu-
lar dilatation consistent with a pulmonary embofWn.14
TEE is commonly used in critical care units. Among
308 TEE studies ronducted in an intensive care unit in
Australia. the most common indications were refractory
or unexplained bypotension (67%), suspca:cd endocar-
ditis (27%), evaluation of ventricular function (15%),
evaluation of pulmonary cdcma of uncertain etiology
(6%), evaluation of the aorta (4%), and search fur a
source of systemic embolU& (4%). Twenty-five percent
of these c:x:aminations were reqUfStcd. after an inad-
equate TTE cwnination. The subsequent TEE exami-
nation led to changes in therapy in 32% of patients
studied and to immediate surgery in 22%, with the
greatest yield in postcan:liac surgery patients. 15 Others
have reported using TEE in ICUs to guide central line
placement, evaluate patients with uncxplained hypox--
emia. or evaluate potential heart donors. f6,t7
The proximity of the esophagus to the aorta allows
for precise and accurate diagnosis of certain types
of aortic pathology when using TEE, and this appli-
cation has found a specific niche in the emergency
room (ER). Minard and colleagues compared TEE
with aortography tt> diagnose traumatic disruption of
the aorta, including intimal flaps, pseudoancurysms,
dissections, and ini:raluminal or e:x:tralwninal bema-
tonw, and gross dis&ec:tions with identification of
false and true lumens. However, the sensitivity and
specificity of TEE were lower than those of aortogra-
phy. most likely due to the inability of TEE to inlage
the ug~ third of the ascending aorta and the aonic
arch. · 9 Even though some forms of aortic pathology
arc not compleu:ly assessed with TEE, this technique
is very valuable in ruling out aonic dis.section. Yalcin
and coworkers reported TEE to be 98% sensitive and
99% specific fur detection of aonic dissection, and
a 2006 meta-analysis of 10 studies ~ortcd similar
results (98% sensitive, 95% specific). 1 In addition,
of significant importance is the fact that TEE is often
safer than other inlaging modalities in hemodynami-
cally unstable patients, as it can be performed at the
bedside. Overall, despite its known deficiencies, TEE
remains the first-line test fur evaluation of the aorta
due to its portability. low cost, low level of invasive-
ness, rapidity, and low complication rate. In the pres-
ence of a negative study, however, it is often necessary
THE TEE PROBE I 21
to proceed to further radiological imaging if the clini-
cal suspicion of aortic pathology remains high.18,21-23
Risks of the TEE Procedure
TEE is generally a well-tolerated and safe procedure.
However, because of its semi-invasive nature, "blind
intubation," and the need fur concomiwit sedation, the
potential fur serious complications exists. It is crucial fur
the procedure team to know potential complications of
TEE so that the risks and benefits of the procedure can
be discussed and the patient assessed fur any preexisting
conditions that may increase the risk of the procedure.
Figure 2-3 highlights the anatomical locations where
reported injuries associated with TEE occur.
In ambulatory, nonoperatlve settings, reported
rates of major complications ofTEE range from 0.2%
to 0.5%. In one European multicenter survey of
10,419 TEE e:wninations, 90 examinatioru (0.88%)
had to be interrupted due to patient intolerance of the
probe (65 cases) or because of pulmonary (8 cases),
cardiac (8 cases), bleeding complications (2 cases), and
7 other causes. One of the bleeding complications was
related to csop~cal infiltration of a lung tumor and
proved to be f.u:af (mortality rate 0.0098%). Of note,
l.Myngnl:
·vocal cord trauma
·airway comprl!!ulon
• tradleal intubation
1E111apln19•I:
- lacer.rtfon
·perforation
·false passage
(dlvertkulum)
GMtrlc:
• lflCel'ltfon
·perforation
·bleeding
FIGURE 2-3. Sites of potential injury.
22 I CHAPTER 2
Tonslllarfauces
m probe lodged In
left plrlform fossa
Esophagus
FIGURE 2-f.. Probe malposltfon examples.
a majority of the cases in this survey were outpatients
who did not receive intravenous sedation for the TEE
procedw:e.24 In the operative setting, manipulation
of a TEE probe in an inrubated patient under general
ancsthcsia carries additional risk, but rcponcd rates of
major complications are similar to nonsurgical patients
and range from 0.2% to 1.2%.25 Several fu.ctors may
inacase risk, including the inability of the patient to
swallow in order to fa.Cilitate probe insertion and the
patient's inability to alert the operator to uncomfort-
able, possibly injurious probe manipulations.
The most dreaded complication of TEE is upper
gutrointestinal (GI) tract perforation, which has a
reported incidence ofabout 2 per 10,000 paticnts26 and
is associated with scvcrc morbidity and mortility.27 It
has been reported that 20% of pcrfurations occur dur-
ing insertion in the hypoph.arynx, and an understand-
ing of the anatomy of the hypoplwynx and potential
._-I-- lEE probe lodged In
Pifif'orm fOSSll
Demi I glnglval
pitfalls during insettion is crucial to limit risk of injury
(Fig. 2-4). If the probe is not centered during insertion,
it can become lodged in one of the pyriform sinuses.
where further advancement of the probe could lead to
injury to dtis area. or can cause severe flexion of the
probe, which could lead co injury during removal The
upper esophagus at the 1.cvcl of the aic:opharynx is also
susceptible to injury due to the potential for spasm or
hyperttophy of the aicoplwyngeal muscle and narrow-
ing of the space secondary to cervical spine disease.25
Manipulation of the probe during the study also
carries a small but real risk of injury. One area of the
upper GI tract that is particularly vulnerable to injury
is the gutrocsophageal (GE) junction. When perform-
ing transgutric views, it is important to make sure that
the probe tip is past the GI junction into the gastrum.
Significant flexion of the probe at the GE junction can
cause mucosa! disruption or Mallory-Weias tears.28 The

risk of upper GI perforation is increased in patients
with GE pathology, such as a Zenker diverticulum,
esophageal strictures or webs, esop~tis, esophageal
mass, or other anatomical anomalies.2 Often the only
indication of a potential problem is a history of dys-
phagia or odynophagia. If the patient has a history of
significant gastritis or gastric ulcers, transgastric views
should be obtained with caution.
In perioperative procedures where the TEE probe
sits in the esophagus for prolonged periods, it is
important to freeze imaging and release flexion on the
probe tip when images are not being acquired to avoid
thermal injury or pressure ulceration of the esophagus.
Assessment of the Patient
The contraindications for performing a TEE are based
on the risk of respiratory compromise, esophageal
injury, and bleeding. Given that the probe is typically
advanced blindly, due diligence must be performed to
ensure that the patient is not at a higher-than-normal
risk for any of these complications. Absolute and rda-
tive contraindications to TEE are outlined in Table 2-2.
A comprehensive preprocedural assessment should
include (1) the assessment of the patient by a physi-
cian; (2) ensuring that the patient has not taken any
solids or liquids by mouth for 6 to 8 hours prior to the
planned procedure; (3) documentation of an informed
consent; (4) review of pertinent laboratory data,
including coagulation and platelet studies; (S) review
of medication and allergies; and (6) review of condi-
tions that might increase procedural risk, including
but not limited to history of sleep apnea, unexplained
dysphagia, history of chest irradiation, esophageal
tumors, varices, strictures or past surgeries, chest radia-
tion, dysphagia, and other esophageal abnormalities.
PROBE INSERTION
Insertion of the 1EE Probe in Patients Under
General Anesthesia. In patients who undergo TEE
as part of their operative procedure, the TEE probe
should be introduced into the esophagus after the
induction of general anesthesia and tracheal intuba-
tion. After the position of the endotracheal tube has
been confirmed and the tube secured, a mouth guard
should be placed between the patient's teeth. The probe
tip can then be lubricated with ultrasound gel and
while holding it like a pencil, the probe can be inserted
into the oropharynx through the mouth guard. An ini-
tial mild resistance may be encountered by the crico-
pharyngeus muscle, but this should be easily overcome.
If there is further resistance, the probe should be with-
drawn, centered, and reintroduced. If probe insertion
is unsuccessful after two or three attempts, direction
laryngoscopy should be employed to aid esophageal
THE TEE PROBE I 23
Table 2-2. Contraindications to TEE
Absolute RelMive
Contraindications Contraindications
Perforated viscous Restricted cervical mobility
(severe arthritis or
atlantoaxial joint disease)
Esophageal pathology History of significant
(stricture, trauma, tumor, radiation to neck and
scleroderma, Mallory- chest
Weiss tear, diverticulum)
Active upper GI bleeding History of GI surgery
Recent upper GI surgery Esophagitis
Esophagectomy, History of dysphagia
esophagogastrectomy
Lack of informed consent Bleeding diathesis
(coagulopathy,
thrombocytopenla)
Barrett's esophagus or
peptic ulcer disease
Symptomatic hiatal hernia
Esophageal varices
Adapted with permission from Hilberath JN, Oakes DA, Sheman
SK: Safety of transesophageal echocardlography, J Am Sac
Echocardiogr. 201 ONov;23(11):1115-1127.
intubation. Although the use of direct laryngoscopy is
not usually necessary for probe placement, one study
did show that its use results in successful placement
with fewer attempts and reduces complications like
odynophagia and minor oropharyngeal injuries.29
Insertion of the TEE Probe Without General
Anesthesia. Before starting the procedure, careful
preparation is necessary to ensure patient safety. The
necessary items include a functioning suction appa-
ratus, oxygen with tubing and facemasks, emergency
medications, access to a defibrillator, and continuous
electrocardiogram (ECG) monitoring. Peripheral intra-
venous access is also necessary before starting the proce-
dure. The mouth should be examined for loose teeth,
and dentures should be removed. Although it is possible
to perform a TEE on an unanesthetized, cooperative
patient, use of light-to-moderate sedation with agents
such as midazolam, fentanyl, or propofol improve com-
fort. Prior to administration of sedation, the mouth and
oropharynx are anesthetized using liquid viscous lido-
caine and lidocaine spray. Because lidocaine dulls the
gag reflex and impairs swallowing, the patient should
not eat or drink for 2 hours after the procedure.
The patient can be positioned in the supine or the
left lateral decubitus position. It is preferred to have the
patient lie on their left side, with the lower (left) hand
rested under a pillow or the patient's head and the upper
(right) hand resting on the patient's side. The bed should
24 I CHAPTER 2
be typically at a 10% to 20% incline, with the legs in a
comfurtable position and the neck slightly flexed. Befure
administering sedation, a mouth guard is placed in the
patient's mouth, as the jaw tends to become rigid and
difficult to manipulate once the patient is sedated.
Befure inserting the probe, it is important to inspect
it for damage, making sure there are no sharp edges,
checking that the controls properly flex and angle the tip,
and that an image is displayed as the probe tip touches
ultrasound gel. Prior to insertion, the probe should be
straightened, with the control wheels unlocked. The end
of the probe is coated with a thin layer of sterile ultra-
sound jelly, which serves to both facilitate insertion of
the probe and improve contact with the esophagus. To
facilitate probe insertion, the index finger of the left
hand should be inserted into the oropharynx (outside
the mouth guard) and the posterior pharynx palpated
to ensure there are no deviations from normal anatomy.
The index finger can also be used to push the posterior
aspect of the tongue and epiglottis forward. At the same
time, the TEE probe is inserted into the oropharynx
with the left finger helping to keep the probe centercd
and guiding it into the esophagus. Often some resistance
is encountered as the probe passes through the hypo-
pharynx, caused by the cricopharyngeus muscle. If this
occurs, gentle forward pressure should be applied to the
probe while the patient is asked to swallow. For many
patients, this verbal instruction is all that is required-
swallowing will close the vocal cords and relax the cri-
copharyngeus muscle. Flexing the patient's neck or
slight flexion of the probe tip may also assist its passage
past the base of the tongue. Neck flexion also prevents
stretching of the esophagus, a condition that might
increase the risk of a mucosa! tear or perforation. It may
also be helpful to hold the small wheel on the housing
at a neutral position to avoid undesirable lateral bend-
ing during probe insertion. The large wheel, controlling
flexion/extension, should never be locked. If there are
feeding or nasogastric tubes in place, the TEE probe can
usually be placed alongside these devices, but often they
must be removed to allow adequate imaging. If further
resistance is encountered, the probe should be with-
drawn, centered, and reintroduced into the esophagus.
It should be kept in mind that unsuspected pathol-
ogy may impede advancement of the probe. Any
unusual resistance to probe insertion should prompt
abandonment of the procedure. Failure to place the
probe is rare. Chee et al found a 1.2% rate of failure
among 901 TEE exams. 30 In another review, 98.5%
of failures were due to lack of cooperation or lack of
operator experience, whereas only 1.5% were due to
anatomical abnormalities.2'' Other authors have iden-
tified prominent vertebral spurs associated with cer-
vical spondylosis as a common cause (16 of 40) of
failure of probe placement.3l In intubated patients,
briefly deflating the endotrachca.l tube cuff should be
considered, as this may ease passage of the probe tip.32
When unusual resistance is encountered during
attempts to advance or withdraw the probe, the physi-
cian should consider that the tip may have "folded"
180 defrees onto itself, so-called "buckling" of the
probe.3 This mechanical problem should be sus-
pected when probe movement is difficult, image qual-
ity is very poor, and the control wheels are bound
and difficult to move. If the physician believes this
has occurred, the probe should be advanced gently
into the stomach, the tip straightened, and the probe
removed and inspected. Under the rare circumstance
that the TEE probe cannot be moved without exert-
ing undue force, a radiograph may help determine
the probe position and guide the next intervention.
In very unusual circumstances, if the deflector mecha-
nism is completely jammed inside the patient and all
efforts to release it have failed, the probe should be
removed from the unit, and the entire probe shaft
should be cut with heavy-duty pliers or other suitable
tool. This will release the deflecting mechanism, allow
the tip to straighten, and facilitate probe removal.
CARE/STORAGE
Proper care, disinfection, and storage of the TEE
probe is essential for patient safety, as well as to extend
the life of the probe. Modern TEE probes cost any-
where from $30,000 to $60,000, and a simple careless
mistake such as submerging the multipin connector
in cleaning solution can cost over $10,000.
Proper Cleaning Technique
Because TEE is a semi-invasive procedure and the
probes are reusable, there is a real potential for trans-
mission of infection (Table 2-3). Although there are
Table 2-3. Infectious risks
Closs-infection from patient to patient and patient to staff
Bacteria-Helicobacter pyfori, Pseudomonas oeruginoso,
Salmonella species, Mycobacterium species
Viruses-Hepatitis Band C, human immunodeficiency virus
Prions-Creutzfeldt-Jakob disease
Contamlnlltion of patients from the decontamlnldlon
procedure
Bacteria-Pseudomonas aeruginosa, J.egionella
pneumophila, Mycobacterium species
Reproduced with permission from Kanagala P, Bradley(, Hoffman P,
et al: Guidelines for transoesophageal echocardiographic probe
cleaning and disinfection from the British Society of Echocardio-
graphy, Eur J Echocardiogr 2011 Oct;l 2(1O):il7-i23.
 THE TEE PROBE I 25

no concrete data for infection rates with TEE pro-
cedwe&, it i& piuwned that the infection rates and
implicated infectious organisms associated with
TEE would be comparable to upper GI endoscopy
or bronchoscopy (1 in 1.8 million studies).33 Proper
deaning and disinfection of the TEE probe after
each procedure is thus essential to preventing trans-
missible disease from the procedure. Sterilization
of the TEE probe is impractical and not warranted
because the TEE probe does not penetrate sterile
areas of the body.
Cleaning and disinfection of the probe is a mul-
tistep pro~ (Fig. 2-5) that starts at the patient's
bedside aa soon as the procedure is over. The probe
tip and shaft should be wiped sequentially starting
from the leading end, while being introduced into a
biohazard bag, with a single-use sponge presoaked in
a detergent solution to remove gross contamination.
A similar second wipe should be used to wipe off the
remaining parts of the probe, including the handle
and controls, cord, and the nonimmersible connec-
tor.33 The second wipe disinfects contamination from
the operator's hand.
The probe should then be covered and transferred
to the designated decontamination room where
it should be visually inspected for any damage.

A B

C D
FIGURE 2-5. Probe disinfection process. (A} Protective attire. (8) Pre-soak wipe of handle and pin connector.
Note that pin connector has protective cover in place. (C) Dilute detergent in basin per manufacturer's instructions.
(D) Immerse 'TEE probe, but not the connector, in detergent solution for the specified time period (typically 3 to
S minutes). (E) Post-immersion rinse and {F} dry. (G) Automated endoscope reprocessor for further disinfection.
(H) Protective covering applied to probe and stored in clean 'TEE closet
26 I CHAPTER 2
E F
G H
FIGURE 2-5. (Continued)
Decontamination rooms should have demarcated
"dirty" and "clean" areas so that nondecontami-
nated "dirty" probes are not inadvertently confused
with decontaminated "clean" probes. The "dirty"
probe should be immersed in a wash bin utilizing a
detergent made up to the dilution and contact times
recommended by the manufacturer. The choice of
a detergent solution is guided by its microbicidal.
activity and compatibility with the TEE probe mate-
rials. Ca.re should be tahn to prevent the pin con-
nector from becoming immersed with the probe.
After this initial decontamination step, probe dis-
infection is then pcrfurmed via an automated endo-
scope reprocessor (AER). In addition to deaning
and disinfection, the Intersodetal Accreditation
Commission for echocardiography recommends that
the structural and electrical integrity of the probe
be checked between each use, using an ult.rasowtd
transducer leakage tester.~ Following disinfection,
the probe tip and shaft are placed in a diaposable
protective sheath.
Proper Care and Storage
Guideline documents advise against storing TEE
probes in their delivery cases. This is because a
suboptimally deaned probe, if placed in the deliv-
ery case, will contaminate the case, which might
then become the nidus for cross-contamination of
subsequent probes. In addition, a failure to fully
suaighten the probe between studies may result in
distortion of the probe shaft. Manufacturers typi-
cally recommend that the probes be stored fully
straight, which can be achieved by hanging them in a
locked cupboard. There is no time limit to storage of
a clean probe with this type of setup. Table 2~4 pres-
ents general rules that should be followed to improve
probe longevity.
 THE TEE PROBE I 27

Table 2-4. Recommendations to promote probe d. Routine assessment of pulmonary veins in an

longevity asymptomatic patient status post pulmonary vein
isolation
Inspect probe before each use S. Which of the following is the most common reason
• Integrity of seal connecting probe tip to shaft for performing a TTE in the surgical ICU?
• Scratches or damage to probe tip and lens a. Refractory or unexplained hypotension
• Cracks. holes, or bite marks in bending rubber around shaft b. Suspected endocarditis
• Lost or damaged controls on TEE handle c. Evaluation ofventricular function
• Damage to cable or pin connector d. Evaluation of pulmonary edema of uncertain
Routine maintenance etiology
• Proper cleaning and storage of probe between each use
• Probe testing every six months to test each crystal 6. The reported rate of upper GI tract perforation
within the array caused by the TEE procedure is:
• Recoat and relabel TEE probe markers showing signs of a. 1in1000
fading b. 1 in 100,000
During the procedure c. 1 in 50,000
• Use of bite guards during procedures d. 1 in 5000
• Use of approved ultrasound gel 7. The is located laterally to the pharynx and
• Freeze image or tum off transducer before connection is a potential space for the probe to become lodged
or removal during insertion.
a. Tonsillar fossa
b. Piriform fossa
c. Laryngeal fossa
d. Epiglottic fossa
REVIEW QUESTIONS
8. The rate of complications from the TEE procedure
1. An adult TEE probe tip is approximately _ _ in the ambulatory setting is estimated to be:
wide a. 1 in SOO
a. 10 mm b. 1in1000
b. 15 mm c. 1in2000
c. 20 mm d. 1 in 5000
d. 25 mm
9. Which of the following is considered an absolute
2. The first docwnented use ofTEE was in: contraindication to performing a TEE?
a. 1965 a. Atlantoaxial disease
b. 1971 b. History of dysphagia
c. 1980 c. Recent upper GI bleed
d. 1984 d. Recent upper GI surgery
3. In general, TEE probes are capable of_ degrees
10. What percentage of GI tract perforations occur at
of anteflexion and _ degrees of retroflexion
the hypopharynx?
a. 120, 60 a. 5%
b. 60, 120
b. 20%
c. 90, 45 c. 40%
d. 45, 90
d. 60%
4. Which of the following indications received an
11. Which location in the GI tract is most susceptible
appropriateness score of 9 (most appropriate) in the
to Mallory-Weiss tears from flexion of the probe?
2011 appropriate use guidelines?
a. GE junction
a. Use of TEE as initial test when there is a high
b. Gastric fundus
likelihood of a nondiagnostic TIE due to
c. Mid-esophagus
patient characteristics or inadequate visualiza-
d. Gastric body
tion of relevant structures
b. Evaluation for cardiovascular embolic source 12. Dysphagia can be a potential sign of which of the
with no identified noncardiac source following GI tract abnormalities?
c. To diagnose endocarditis with a moderate pre- a. Zenker diverticulum
test probability b. Esophageal strictures or webs
Another random document with
no related content on Scribd:
 — Vaan sinäpä et nukkunut, pyssynlaukaukset sinut herättivät.

— Sinä luulet siis, että teidän pyssynne pitävät semmoista melua?

Isäni tussari pamahtaa paljon kovemmin.

— Vieköön sinut saakeli, senkin kirottu vetelys! Että sinä olet

nähnyt Gianetton, siitä olen varma. Kenties olet hänet kätkenytkin.
Hoi, kumppalit, käykää tupaan ja katsokaa, eikö junkkarimme ole
siellä. Hän nilkutti enää vain yhdellä käpälällä, ja se lurjus on liian
viisas lähteäkseen sillä tavoin palolle asti pyrkimään. Sitäpaitsi
loppuvat verijäljetkin tähän.

— Vaan mitäs isä sanoo, kysyi Fortunato ilkamoiden, jos saa

tietää, että te olette hänen poissa ollessaan tunkeutuneet tupaan?

— Kuules, junkkari, sanoi ajutantti Gamba nipistäen poikaa

korvasta, tiedätkös sinä, että minä voin helposti saada sinut toista
virttä veisaamaan? Ehkäpä sinä vielä sanotkin, jos saat parisen
kymmentä lyöntiä sapelin lappeella.

Fortunato vain naureskeli pilkallisesti.

— Isäni nimi on Mateo Falcone! sanoi hän juhlallisesti.

— Tiedätkös sinä, pikku veijari, että minä voin viedä sinut joko
Corteen tai Bastiaan. Panen sinut vankeuteen, raudat jaloissa
olkivuoteelle makaamaan, ja mestautan sinut, jos et sano missä
Gianetto
Sanpiero piileksii.

Poika remahti suureen nauruun kuullessaan tämän lystikkään

uhkauksen.
Hän vain toisti:
 — Isäni nimi on Mateo Falcone.

— Ajutantti, sanoi aivan hiljaa eräs jääkäreistä, älkäämme

riitaantuko
Mateon kanssa.

Gamba näytti todellakin joutuneen ymmälle.

Hän puheli kuiskaten sotamiesten kanssa, jotka olivat tarkastaneet

koko talon, toimitus, joka muuten ei kauan kestänytkään, sillä
korsikkalaisen asuntoon ei kuulu muuta kuin yksi neliskulmainen
tupa. Huonekaluja on pöytä, penkkejä, kirstuja ja metsästys- sekä
talouskapineita. Sillä aikaa pikku Fortunato hyväili kissaansa ja näytti
ilkamoiden nauttivan jääkärien ja sukulaisensa hämmennystilasta.

Eräs sotamiehistä lähestyi heinäsuovaa. Hän huomasi emäkissan

ja sohaisi pistimellä huolettomasti heinäsuovaan kohauttaen
olkapäitään merkiksi, että tämä teko tuntui hänestä naurettavalta.
Suovassa ei mikään liikahtanut, eivätkä pojan kasvotkaan ilmaisseet
vähintäkään mielenliikutusta.

Ajutantti ja hänen joukkonsa miettivät heittää hiiteen koko

toimituksen ja katselivat jo totisina nummelle päin ikäänkuin aikoen
palata takaisin samaa tietä, jota olivat tulleetkin, kun päällikkö,
vakuutettuna siitä, etteivät uhkaukset vaikuttaneet mitään Mateo
Falconen poikaan, päätti tehdä vielä viimeisen ponnistuksen ja
koettaa hyväilyjen ja lahjojen mahtia.

— Kuules, pikku serkkuni, sanoi hän, sinä näyt olevan hyvin

kasvatettu viikari ja tulet varmaankin vielä menemään pitkälle. Mutta
nyt sinä lasket minusta ilkeää leikkiä, ja ellen minä pelkäisi
suututtavani sukulaistani Mateo Falconea, niin piru vieköön
ottaisinkin sinut mukaani.

— Hui-hai!

— Vaan kun sukulaiseni tulee kotiin, niin kerron koko jutun

hänelle, ja silloin saat valheistasi verisen selkäsaunan.

— Jokohan?

— Saat nähdä… Vaan kuuleppa… ole nyt siivo poika, niin minä
annan sinulle jotain.

— Ja minä annan sinulle, serkku, erään neuvon: että jos te vielä

viivyttelette, niin Gianetto ehtii jo palolle, ja silloin täytyy olla
useampia sinunlaisiasi uskalikkoja, jos mieli häntä sieltä etsiä.

Ajutantti otti taskustaan hopeakellon, joka maksoi ainakin

kolmekymmentä frangia, ja huomatessaan, että pikku Fortunaton
silmät säteilivät sitä katsellessa, hän riiputti sitä teräksisten vitjojen
nenästä sanoen:

— Sinä veijari tahtoisit kai mielelläsi tämmöisen kellon kaulaasi ja

astuskelisit Porto-Vecchion katuja ylpeänä kuin riikinkukko; ja ihmiset
kyselisivät sinulta: »paljonko kello on?» ja sinä vastaisit: »katsokaa
kelloani».

— Kun tulen isoksi, niin korpraali-enoni kyllä antaa minulle kellon.

— Antaa jos antaa, vaan enosi pojallapa on jo kello… ei sentään

niin kaunis kuin tämä… Ja hän on kuitenkin sinua nuorempi.

Poikanen huokasi.
 — No, tahdotkos tämän kellon, pikku serkku?

Fortunato näytti syrjäsilmällä kelloa katsellessaan kissalta, jolle

tarjotaan kokonainen kananpoika. Tuntien itseään vain härnättävän
ei se uskalla iskeä siihen kynsiänsä, vaan kääntää tuontuostakin
silmänsä poispäin, ettei houkutus kävisi liian suureksi; kuitenkin se
nuoleksii myötäänsä suupieliänsä ja näyttää tahtovan sanoa
isännälleen: »Teidän leikkinne on liian julmaa!»

Ajutantti Gamba tuntui sentään todenteolla tarjottelevan kelloansa.

Fortunato ei ojentanut kättänsä, vaan sanoi happamesti hymyillen:

— Mitä te minua suotta pilkkaatte?

— En, jumal’avita, pilkkaakaan. Sano vain missä Gianetto on, niin

on kellokin sinun.

Fortunaton huulille ilmestyi epäilyksen hymy, ja katsoen mustilla

silmillänsä ajutantin silmiin koetti hän niistä lukea, minkä verran
tämän sanoihin oli luottamista.

— Vietäköön minulta olkaliput, huudahti ajutantti, jollen anna

sinulle kelloa sillä ehdolla! Kumppalini tässä ovat todistajina, enkä
minä saata lupaustani rikkoa.

Tätä sanoessaan hän vei kelloa yhä lähemmäksi, kunnes se

melkein kosketti pojan kalpeata poskea. Tämän kasvoilla kuvastui
selvästi sisällinen sieluntaistelu pyyteen ja vierasvaraisuuden
kunnioittamisen välillä. Paljas rinta kohoili kiihkeästi, ja hän näytti
olevan tukehtumaisillaan.

Sillä välin kello heilui ja kääntelihe koskettaen toisinaan hänen

nenänsä päätä. Vähitellen alkoi vihdoin pojan oikea käsi kohota
kelloa kohti: sormen päät jo koskettivat sitä, ja pian se lepäsi
kokonaan hänen kädessään, vaikka ajutantti yhä piteli sitä vitjojen
toisesta päästä… Numerotaulu oli taivaansininen… kuori vasta
kiillotettu… päivänpaisteessa se tulena välähteli… Houkutus oli liian
suuri.

Fortunatolla nousi jo vasen käsikin, ja olkansa yli hän viittasi

peukalollaan heinäsuovaa, jota vastaan hän nojasi. Ajutantti
ymmärsi hänet heti. Hän päästi vitjat kädestään, ja Fortunato tunsi
olevansa kellon ainoa omistaja. Hän hypähti pystyyn vikkelästi kuin
metsäpeura ja poistui kymmenen askeleen päähän heinäsuovasta,
jota jääkärit heti kävivät penkomaan.

Pian nähtiinkin heinäsuovan liikahtelevan: sieltä ilmestyi verissään

oleva mies, puukko kädessä; mutta koettaessaan nousta seisoalleen
ei hän hyytyneeltä haavaltaan jaksanutkaan pysyä pystyssä, vaan
suistui maahan. Ajutantti syöksyi heti hänen kimppuunsa ja väänsi
tikarin hänen kädestään. Samassa hänet lujasti köytettiin
vastustuksestaan huolimatta.

Maaten kentällä pitkällään, sidottuna kuin mikäkin lyhde, Gianetto

käänsi päänsä lähestynyttä Fortunatoa kohti.

— Senkin… sikiö! sanoi hän tälle enemmän ylenkatseellisesti kuin

vihaisesti.

Poika heitti hänelle saamansa hopearahan takaisin tuntien, ettei

sitä enää ansainnut; mutta vangittu ei näyttänyt huomaavankaan tätä
liikettä. Vallan kylmäverisesti hän sanoi ajutantille:

— Kuulkaas, hyvä Gamba, minä en jaksa kävellä, teidän täytyy

kantaa minut kaupunkiin.
 — Äsken sinä kuitenkin juoksit kuin vuorikauris, vastasi julma
voittaja; mutta olehan huoletta: minä olen niin hyvilläni siitä, että
sinut vihdoinkin sain kiinni, jotta vaikka selässäni kantaisin sinua
penikulman väsymystä ensinkään tuntematta. Muuten aiomme
valmistaa sinulle paarit oksista ja päällystakistasi; ja Crespolin
vuokratalolla on meillä hevosetkin.

— Hyvä, sanoi vangittu; kai te panette hiukan olkia paareille, jotta

minun on mukavampi olla.

Sillä välin kuin muutamat jääkäreistä puuhailivat valmistellen

jonkinlaisia kantopaareja kastanjan oksista ja toiset sitoivat
Gianetton haavaa, ilmestyi Mateo Falcone vaimoineen äkkiä erään
palolle vievän polun käänteestä. Vaimo asteli hyvin kumarassa
kantaen tavattoman suurta kastanjasäkkiä, sillä aikaa kuin hänen
miehensä kulki herrana edellä, ainoastaan pyssy kädessä ja toinen
kantohihnassa; miehen arvo ei näet salli hänen kantaa muita
taakkoja kuin aseensa.

Nähdessään sotamiehet arveli Mateo heti, että ne olivat tulleet

häntä vangitsemaan. Mutta mistä tämä ajatus? Oliko Mateolla
mitään oikeuden kanssa tekemistä? Ei. Hänhän oli päinvastoin
hyvässä maineessa. Hän oli, kuten sanotaan, hyvämaineinen ja
itsenäinen mies; mutta hän oli korsikkalainen ja vuoristolainen, eikä
Korsikan vuoristolaisten joukossa ole monta, joka ei tarkoin
muistellessaan löytäisi menneisyytensä ansioluettelosta jotakin pikku
rikosta, sellaista kuin pyssynlaukausta, tikarinpistoa tai jotakin muuta
vähäpätöisyyttä. Mateolla oli parempi omatunto kuin ehkä
kenelläkään muulla, sillä ainakaan kymmeneen vuoteen ei hän ollut
tähdännyt pyssyänsä ihmistä kohti; mutta siitä huolimatta hän oli
varovainen ja varustausi ankaraan itsepuolustukseen, jos tarvis
sellaista vaati.

— Vaimo, sanoi hän Giuseppalle, heitä maahan säkkisi ja ole

varuillasi.

Tämä tottelikin silmänräpäyksessä. Mateo antoi hänelle pyssyn,

joka oli ollut kantohihnassa ja joka ehkä olisi ollut vain vastuksena.
Sitten hän latasi kädessään olevan tuliputken ja astui verkalleen
taloansa kohti pujotteleiden tien varrella kasvavien puiden välitse ja
ollen valmiina pienimmänkin vihamielisyyden huomatessaan
viskautumaan paksuimman puunrungon taakse, mistä saattoi
turvassa ollen itse ampua. Vaimo astui hänen jälkiään kantaen
varapyssyä ja patruunalaukkua. Hyvän aviovaimon velvollisuus on
näet taistelun tullessa ladata miehensä ampuma-aseet.

Ajutantille taas tuli aika hätä, kun näki Mateon lähestyvän näin
verkkaisin askelin, pyssy tanassa ja sormi liipasimella.

— Jos Mateo, ajatteli hän, sattuisi olemaan Gianetton sukulainen

tai ystävä ja tahtoisi häntä puolustaa, niin tulisivat luodit hänen
molemmista pyssyistään kahteen meistä yhtä varmasti kuin kirjeet
postissa; ja jos hän tähtää minuun, sukulaisuudesta huolimatta…

Tällaisessa hämmennystilassa hän teki sangen rohkean

päätöksen: hän astui näet yksin Mateota kohti kertoakseen hänelle
koko tapauksen ja lähestyi häntä kuin ainakin vanhaa tuttavaa; mutta
tuo pieni välimatka, joka erotti hänet Mateosta, tuntui hänestä
hirveän pitkältä.

— Hei, kuules, vanha toveri, huusi hän, — mitäs sinulle kuuluu,

hyvä ystävä? Tunnetko sinä minua, Gamba serkkuasi?
 Sanaakaan vastaamatta Mateo pysähtyi, ja sillä aikaa kuin toinen
puheli, nosti hän verkalleen pyssyänsä, niin että sen suu oli taivasta
kohti ajutantin likelle saapuessa.

— Hyvää päivää, veliseni [Buon giorno, fratello, korsikkalaisten

tavallinen tervehdys], sanoi ajutantti ojentaen hänelle kätensä. Onpa
siitä aikoja, kun olen sinua nähnyt.

— Päivää, veli.

— Tulin ohikulkiessani sanomaan sinulle ja serkku Pepalle

hyvänpäivän. Olemme tänään olleet pitkällä matkalla, vaan ei sovi
valitella vaivojaan, kun on saanut sellaisen saaliin kuin me. Saimme
näet juuri kiinni Gianetto Sanpieron.

— Jumalan kiitos! huudahti Giuseppa. Viime viikolla hän varasti

meiltä lypsyvuohen.

Gambaa nämä sanat ilahuttivat.

— Kurja raukka, sanoi Mateo, hän oli nälissään.

— Se veijari puolustihe kuin jalopeura, jatkoi ajutantti hiukan

nolostuneena, — hän tappoi minulta yhden jääkärin eikä tyytynyt
vielä siihenkään, vaan katkaisi korpraali Chardonilta käsivarren… no,
vahinko ei ollut suuri, olihan tämä vain ranskalainen… Sitten hän oli
piiloutunut niin viisaasti, ettei lempokaan olisi häntä keksinyt. Ilman
pikku Fortunatoa en olisi häntä ikinä löytänyt.

— Fortunatoa! huudahti Mateo.

— Fortunatoa? toisti Giuseppa.

 — Niin, Gianetto oli kätkeytynyt tuohon heinäsuovaan, mutta pikku
serkkunipa ilmaisi viekkauden. Minä aionkin sanoa hänen enolleen,
korpraalille, että lähettää Fortunatolle kauniin lahjan palkinnoksi. Ja
hänen sekä sinun nimesi tulevat raporttiin, jonka lähetän yleiselle
syyttäjälle.

— Kirous! mutisi hiljaa Mateo.

He olivat saapuneet jääkärijoukon luo. Gianetto lepäsi jo

paareillaan valmiina lähtöön. Nähdessään Mateon tulevan Gamban
seurassa hän hymyili omituisesti, käänsihe talon ovelle päin ja
sylkäisi kynnykselle sanoen:

— Kavaltajan asunto!

Täytyi olla valmis kuolemaan sen, joka uskalsi käyttää kavaltajan

nimeä Falconesta. Tarkka tikarinpisto, jota ei tarvitse uusia, olisi
tavallisissa oloissa loukkauksen heti kostanut. Mateo ei nyt
kuitenkaan tehnyt muuta liikettä kuin nosti murtuneen näköisenä
kätensä otsalleen.

Nähdessään isänsä tulevan oli Fortunato vetäytynyt tupaan. Sieltä

hän ennen pitkää palasi tuoden maitotuopin, jonka hän katse
maahan luotuna tarjosi Gianettolle.

— Pysy loitolla minusta! ärjäisi vangittu jyrkästi.

Kääntyen sitten erään jääkärin puoleen hän virkkoi: — Toveri

hyvä, annas minulle juotavaa!

Sotamies antoi litteän juomapullonsa hänelle käteen, ja rosvo joi

sen miehen antamaa vettä, jonka kanssa äsken oli laukauksia
vaihtanut. Sitten hän pyysi, että kätensä, jotka olivat köytetyt selän
taakse, sidottaisiin ristiin rinnalle.

— Lepään mieluummin mukavasti, sanoi hän.

Pyyntö täytettiin oitis; sitten antoi ajutantti lähtömerkin, lausui

jäähyväiset Mateolle mitään vastausta tältä saamatta, ja niin
lähdettiin kiireisin askelin nummelle päin.

Kului lähes kymmenen minuuttia, ennenkuin Mateo suunsa avasi.

Poikanen katseli levotonna vuoroin äitiänsä, vuoroin isäänsä, joka
pyssyynsä nojaten tuijotti häneen tuimasti.

— Sinä alottelet hyvin, sinä! sanoi Mateo vihdoin tyynellä äänellä,

joka kuitenkin värisytti sitä, ken miehen tunsi.

— Isä! huudahti poika lähestyen kyyneleet silmissä ikäänkuin

aikoen heittäytyä hänen jalkojensa juureen.

Mutta Mateo ärjäisi hänelle:

— Pois minusta!

Poika pysähtyi ja seisoi nyyhkyttäen liikkumattomana muutaman

askeleen päässä isästään.

Giuseppa tuli lähemmäksi. Hän oli huomannut kellonvitjat, joiden

pää pisti Fortunaton paidan aukeamasta esille.

— Kuka sinulle tämän kellon antoi? kysyi hän ankarasti.

— Serkkuni, ajutantti.
 Falcone tempasi kellon ja lennätti sen sellaisella voimalla vasten
kiveä, että se pirstausi tuhanneksi muruksi.

— Vaimo, sanoi hän, onko tuo poika minun tekemäni?

Giuseppan ruskeat posket lensivät tulipunaisiksi.

— Mitä sinä sanotkin, Mateo, ja muistatko kenelle puhut!

— No niin, tuo poika on siis heimonsa ensimäinen kavaltaja.

Fortunaton nyyhkytykset kävivät kahta vertaa äänekkäämmiksi, ja

Falcone tuijotti häneen yhäti ilveksensilmillään. Vihdoin hän löi
pyssynsä perällä kerran maahan, heitti sen sitten olalleen ja lähti
astumaan palolle päin huutaen Fortunatoa tulemaan perästä. Poika
totteli.

Giuseppa juoksi Mateon jälkeen ja tarttui häntä käsivarteen.

— Hän on sentään sinun poikasi, sanoi hän vapisevalla äänellä ja

katsoi mustilla silmillään miestänsä silmiin nähdäksensä mitä hänen
mielessään liikkui.

— Laske irti minut! vastasi Mateo. Minä olen hänen isänsä.

Giuseppa syleili poikaansa ja meni itkien tupaan. Siellä hän

heittäysi polvilleen pyhän Neitsyen kuvan eteen ja rukoili kiihkeästi.
Sillä välin astui Falcone pari sataa askelta polkua myöten eikä
pysähtynyt ennen kuin tuli erään laakson luo, jonne laskeusi. Siinä
hän tutki maaperää pyssynsä perällä ja huomasi sen olevan
pehmeän ja helpon kaivaa. Paikka tuntui hänestä tarkoitukseen
soveliaalta.
 — Fortunato, mene tuon suuren kiven luo.

Poika teki niinkuin käskettiin ja laskeusi sitten polvilleen.

— Lue rukouksesi.

— Isä, isä, älkää tappako minua.

— Lue rukouksesi! toisti Mateo hirvittävällä äänellä.

Supattaen ja nyyhkyttäen poikanen luki Isämeidän ja

uskontunnustuksen.
Isä vastasi kovalla äänellä: Amen! kummankin rukouksen jälkeen.

— Siinäkö ovat kaikki rukoukset, mitä osaat?

— Isä, osaan minä vielä Ave Marian ja sen, jonka täti minulle
opetti.

— Se on kovin pitkä, mutta menköön.

Poika luki rukouksensa sammuvalla äänellä.

— Oletko lopettanut?

— Voi, isä hyvä, armahtakaa! Antakaa anteeksi! En minä koskaan

enää semmoista tee! Ja minä rukoilen niin kauan korpraali-enoa,
että hän armahtaa Gianettoa!

Hän puhui vielä, kun Mateo jo oli virittänyt pyssynsä ja painoi

perän poskelleen lausuen:

— Jumala antakoon sinulle anteeksi!

 Poika teki epätoivoisen yrityksen noustakseen isänsä polvia
syleilemään, mutta hänellä ei ollut siihen aikaa. Mateo laukaisi, ja
Fortunato kaatui kuolleena paikalle.

Luomatta silmäystäkään ruumiiseen lähti Mateo talollensa päin

hakemaan lapiota haudatakseen poikansa. Tuskin oli hän ehtinyt
astua muutamia askeleita, kun tapasi Giuseppan, joka laukauksesta
säikähtyneenä juoksi murhapaikalle.

— Mitä sinä olet tehnyt? huusi hän.

— Oikeutta.

— Ja missä hän on?

— Laaksossa. Aion juuri haudata hänet. Hän kuoli kristittynä, ja

minä luetan hänelle messun. Käy sano vävylleni Tiodoro Bianchille,
että hän muuttaa meille asumaan.

Etuvarustuksen valloitus.

Eräs ystäväni, upseeri, joka joitakuita vuosia sitten kuoli

kuumetautiin Kreikassa, kertoi minulle muutamana päivänä
ensimäisestä ottelusta, jossa hän oli ollut mukana. Hänen
kertomuksensa vaikutti minuun niin voimakkaasti, että heti
lomahetken saatuani kirjoitin sen muististani paperille. Tässä se nyt
on:

Saavuin rykmenttiin syyskuun 4:nnen päivän iltana. Everstin

tapasin leirikentällä. Ensin hän otti minut jotenkin tylysti vastaan;
mutta kenraali B:n antaman suosituskirjeeni luettuansa hän muutti
käytöstänsä ja lausui muutamia kohteliaita sanoja.

Hän esitti minut kapteenilleni, joka juuri palasi eräältä

partioretkeltä. Tämä kapteeni, jota minulla tuskin oli aikaa tarkastaa
tunteakseni, oli kookas, tummaverinen ja ulkomuodoltaan ankaran ja
tylyn näköinen mies. Tavallisena sotamiehenä hän oli alkanut uransa
ja voittanut sekä olkalippunsa että kunniamerkkinsä
taistelutantereella. Hänen äänensä oli käheä ja heikko ollen
omituisesti vastakkainen hänen melkein jättiläismäiselle vartalolleen.
Syynä tähän outoon äänenkäheyteen sanottiin olevan erään luodin,
joka oli kerrassaan lävistänyt hänet Jenan tappelussa.

Kuultuaan, että minä olin juuri päässyt Fontainebleaun

sotakoulusta, hän väänsi kasvonsa irvistykseen sanoen:

— Luutnanttini kaatui eilen…

Minä ymmärsin hänen tällä tahtovan sanoa: »Teidän pitäisi muka

täyttää hänen sijansa, mutta siihen ette kykene.» Huulillani pyöri jo
pisteliäs vastaus, mutta minä hillitsin itseni.

Kuu nousi Cheverinon etuvarustuksen takaa, joka sijaitsi kahden

kanuunanhan tämän päässä leirituliltamme. Suuri ja punainen se oli,
kuten tavallisesti noustessaan. Mutta tuona iltana se näytti
tavallistaan suuremmalta. Hetken ajan häämötti koko varustus vallan
synkkänä kuun heleässä hohteessa. Se muistutti purkautumaisillaan
olevan tulivuoren kartiomaista huippua.

Vierelläni oleva vanha sotamieskin huomasi kuun värin.

 — Onpa se punainen, sanoi hän. Se merkitsee, että tuon
kuuluisan varustuksen valloitus käy meille kalliiksi!

Minä olen aina ollut taikauskoinen, ja varsinkin tällä hetkellä teki

tuo ennustus minuun syvän vaikutuksen. Laskeusin levolle, mutta en
saanut unta. Nousin makuulta ja kävelin jonkun aikaa katsellen
tavatonta tulijuovaa, joka kultasi Cheverinon kylän takaiset kukkulat.

Kun arvelin yön raittiin ja virkistävän ilman tarpeeksi vilvoittaneen

veriäni, palasin nuotiolle; kietoutuen huolellisesti päällystakkiini suljin
silmäni toivossa, etten avaisi niitä ennen päivän nousua. Mutta uni
vain ei tullut. Tahtomattani kävivät ajatukseni surullisiksi. Tuumin
itsekseni, ettei minulla noiden kentällä makaavien sadantuhannen
miehen joukossa ollut ainoatakaan ystävää. Jos haavoittuisin, niin
joutuisin sairashuoneeseen, missä tietämättömät välskärit minua
armotta kohtelisivat. Mieleeni johtui kaikki, mitä olin kirurgisista
leikkauksista kuullut. Ankarasti tykytti sydämeni, ja koneellisesti minä
asettelin nenäliinan ja lompakon rinnalleni jonkinlaiseksi panssariksi.
Väsymys valtasi minut, nukahdin aina hetkeksi, mutta samassa sai
joku surullisempi ajatus suuremman voiman, niin että hytkähtäen
heräsin. Väsymys voitti kuitenkin vihdoin, ja kun herätysrumpu soi,
nukuin minä makeinta untani. Asetuimme rintamaan, aamuhuuto
tapahtui, sitten pantiin aseet takaisin ristikoilleen ja kaikki näytti siltä,
kuin olisi meillä ollut aikomus viettää päivä aivan levollisesti.

Noin kolmen aikaan saapui ajutantti tuoden käskyn. Meidät

kutsuttiin uudelleen aseihin, jääkärimme hajoitettiin ympäri kenttää,
me seurasimme heitä verkalleen, ja kahdenkymmenen minuutin
kuluttua näimme venäläisten etuvartijoiden järjestäytyvän ja
palaavan varustukseen takaisin.
 Eräs tykkipatteri asettui oikealle, toinen vasemmalle meistä, mutta
molemmat jotenkin kauas edellemme. Ne alkoivat sangen kiivaan
tulen vihollista kohti, joka yhtä tuimasti vastasi, ja pian peittyi
Cheverinon varustus paksuihin savupilviin.

Eräs ylänkö melkein suojasi rykmenttimme venäläisten tulelta.

Kuulat, joita meitä kohti ei monta tullutkaan (vihollinen kun
etupäässä ahdisti tykkiväkeämme), lensivät ylitsemme tai viskelivät
meitä vastaan multaa ja pieniä kiviä.

Niin pian kuin käsky marssia eteenpäin oli annettu, katsoi kapteeni
minuun niin tutkivasti, että minun täytyi pyyhkäistä pari kertaa nuoria
viiksiäni näyttääkseni niin huolettomalta kuin mahdollista. Muuten ei
minua pelottanutkaan, ja ainoa huoleni oli se, että muut ehkä luulivat
minun pelkäävän. Nuo vaarattomat kuulat vaikuttivat nekin siihen,
että pysyin sankarillisen kylmäverisenä. Itserakkauteni taas toisti,
että todellakin olin vaarassa, koskapa kuitenkin olin patteritulen alla.
Tunsin itseni vallan iloiseksi hyvinvoinnistani ja mietiskelin, kuinka
hauskaa on kertoa Cheverinon varustuksen valloituksesta rouva B:n
salongissa Provencen-kadun varrella.

Eversti kulki juuri komppaniamme ohitse virkahtaen minulle: »Kas

nyt te saatte jo alkajaisiksenne totuuden tuntea.»

Minä hymyilin kuin sodan jumala ja pyyhkäisin hihaltani pois

multaa, jota eräs kolmenkymmenen askeleen päähän pudonnut
kanuunankuula oli viskannut päälleni.

Venäläiset näyttivät huomaavan luotiensa huonon menestyksen,

sillä he rupesivat nyt ampumaan räjähdyskuulilla, jotka paremmin
yllättivät meidät notkelmassamme. Eräs suurehko kranaatinsirpale
pyyhkäisi lakin päästäni ja tappoi miehen sivultani.
 — Onnittelen teitä, sanoi kapteeni minulle, juuri kun olin saanut
lakkini maasta; kas nyt te olette turvattuna täksi päiväksi.

Minä olen usein huomannut tämän taikauskon sotamiehissä, jotka

uskovat, että selviö non bis in idem pitää paikkansa yhtä hyvin
taistelutantereella kuin oikeussalissa. Panin ylpeästi lakin jälleen
päähäni.

— Kas sepä oli suora tapa tervehtiä ihmisiä, sanoin niin iloisesti
kuin voin. Oloihin nähden pidettiin tätä huonoa sukkeluutta vallan
mainiona.

— Onnittelen teitä, toisti kapteeni vielä, muuta vahinkoa ei teille

tule tapahtumaan, ja vielä tänä iltana on teillä komppania
komennettavana, sillä kovin minun korviani tänään kuumennetaan.
Joka kerta kun olen haavoittunut, on vierelläni seisova upseeri
saanut kuolettavan luodin ja — lisäsi hän hiljempää ja melkein
häpeissään — heidän nimensä ovat aina alkaneet P:llä.

Tekeysin urhoolliseksi, ja useat olisivat kai tehneet minun tavallani;

moneen olisivat nämä ennustavat sanat vaikuttaneet niinkuin
minuunkin. Ensikertalaisena minä tunsin, etten voinut uskoa
ajatuksiani kenellekään, vaan että minun aina tuli näyttää
kylmäveriseltä ja urhoolliselta.

Puolen tunnin kuluttua venäläisten tuli hiljeni tuntuvasti; silloin

astuimme mekin esille suojapaikastamme marssiaksemme
varustusta kohti.

Rykmenttiimme kuului kolme pataljoonaa. Toinen pataljoona sai

tehtäväkseen käydä varustuksen kimppuun kiertämällä laakson
puolelta; molemmat toiset määrättiin rynnäkköä varten. Minä olin
kolmannessa pataljoonassa.

Tultuamme ulos rintavarustusten takaa, missä olimme olleet

suojattuina, kohtasi meitä moneen kertaan jalkaväen linjatuli
voimatta kuitenkaan suuria aukkoja riveihimme tuottaa. Kuulain
vinkuminen oudostutti minua: usein käänsin päätäni sinnepäin
saaden vain leikkisanoja vastaani tähän ääneen tottuneemmilta
tovereiltani.

— Tappelu ei lopulta olekaan niin hirvittävä asia, arvelin itsekseni.

Rientoaskelin astuimme eteenpäin, jääkärit etunenässä; yhtäkkiä

venäläiset kiljaisivat kolme hurraata, kolme eri kertaa, pysyen sitten
vallan hiljaa ja ampumatta.

— En pidä tuosta hiljaisuudesta, sanoi kapteeni, se ei ennusta

hyvää.

Mielestäni meikäläiset melusivat liian kovasti, enkä voinut olla

sisässäni vertaamatta heidän rähiseviä huutojansa vihollisen
juhlalliseen äänettömyyteen.

Jouduimme pian varustuksen juurelle, vallisuojukset olivat

kuulamme rikkoneet ja mullistelleet. Sotamiehet ryntäsivät näille
uusille raunioille huutaen eläköön keisari! kovemmin kuin olisi voinut
odottaakaan ihmisiltä, jotka jo olivat niin paljon kirkuneet.

Loin katseeni ylöspäin enkä ikinä unohda silloista näkyä. Enin osa
savua oli kohonnut ilmaan ja riippui kuin telttakatos noin
kahdenkymmenen jalan korkealla varustuksen yllä. Sinertävän
usvan läpi näkyivät puoleksi hajonneen rintasuojuksensa takana
venäläiset krenatöörit, jotka seisoivat pyssyt koholla ja
liikkumattomina kuin patsaat. Olen vieläkin näkevinäni jokaisen
sotamiehen, vasen silmä meihin luotuna ja oikea kohotetun pyssyn
peitossa. Eräässä ampumareiässä muutamia askeleita meistä seisoi
mies tulisoihtu kädessä kanuunansa vieressä.

Minua värisytti, ja luulin jo viimeisen hetkeni tulleen.

— Kas nyt alkaa tanssi, pojat, huusi kapteeni. Hyvästi!

Ne olivat viimeiset sanat, mitkä kuulin hänen lausuvan.

Rummunpärinää kuului varustuksesta. Näin kaikkien pyssyjen

laskeutuvan. Ummistin silmäni ja kuulin hirmuisen paukkeen, jota
seurasi huudot ja voihkaukset. Avasin jälleen silmäni kummastellen,
että vielä olin hengissä. Varustus oli taas savun peitossa. Ympärilläni
haavoitettuja ja kuolleita. Kapteenini makasi jaloissani: hänen
päänsä oli eräs kuula murskannut, ja hänen aivojansa sekä vertansa
oli hulmahtanut vaatteilleni. Koko komppaniastani ei ollut pystyssä
enää kuin kuusi sotamiestä ja minä.

Tämän verisaunan saatuamme olimme hetken aikaa kuin

ällistyksissä. Asettaen lakkinsa miekkansa kärkeen kapusi eversti
ensimäisenä rintasuojukselle huutaen: eläköön keisari! ja hänen
jäljessään heti kaikki muut eloon jääneet. En paljon muista mitä
sitten seurasi. Me jouduimme varustuksen sisään, en tiedä millä
tavoin. Taisteltiin käsikähmässä niin paksussa savussa, ettei voitu
nähdä toisiaan. Luulen lyöneenikin, koskapahan sapelini oli vallan
verinen. Vihdoin kuulin huudettavan: »voitto on meidän!» ja savun
hälvetessä näin koko varustuksen kentän verta ja kuolleita täynnä.
Varsinkin kanuunat olivat vallan haudattuina ruumiskasojen alle.
Noin kaksisataa miestä ranskalaisissa univormuissa seisoi ryhmässä
ilman järjestystä, toiset ladaten pyssyjänsä, toiset puhdistaen
pistimiänsä. Yksitoista venäläistä vankia oli heidän keskessään.

Eversti lepäsi vallan verisenä särkyneiden vaunujen päällä linnan

portin suulla. Muutamia sotamiehiä tunkeili hänen ympärillään;
minäkin lähestyin häntä.

— Missä on vanhin kapteeni? kysyi hän eräältä kersantilta.

Kersantti kohautti olkapäitään sangen merkitsevällä tavalla.

— Entä vanhin luutnantti?

— Tämä eilen saapunut herra tässä, sanoi kersantti vallan tyynellä

äänellä.

Eversti hymyili happamesti.

— No niin, hyvä herra, te siis komennatte päällikkönä; varustakaa

heti linnoituksen portti näillä muonavaunuilla, sillä vihollinen on vielä
voimakas, mutta kenraali C… tulee avuksenne.

— Eversti, sanoin minä, te olette kai pahoin haavoittunut?

— Yks'kaikki, ystäväni, mutta varustus on valloitettu!

Arpapeli.

Liikkumattomina riippuivat purjeet mastoja vasten; meren pinta oli

kirkas kuin peili, ilma tukahuttavan kuuma ja tyven vallan toivoton.