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Beyond basic echo anatomy #echofirst 🌟Elevating the way we see the interatrial septum in TEE 🥽 The interatrial septum is more than anatomy 🫀- it’s a procedural roadmap📍 TEE guidance for: 1️⃣ M-TEER (transseptal puncture) 2️⃣ PTC of ostium secundum ASD

Alexander Mladenow MD

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15,572 Aufrufe • vor 1 Monat •via X (Twitter)

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Apical 4-chamber view: a single window that maps cardiac anatomy and relationships. How to obtain it: 🔵 Place the transducer at the point of maximal impulse (LV apex) 🔵 Keep the probe index marker directed toward the patient’s left side (≈3 o’clock) 🔵 Aim the beam toward the base of the heart (toward the right shoulder) 🔵 Fine-tune tilt/rotation until all four chambers are symmetric and the septum is vertical From the LV apex, you see all four chambers in one plane (LV, RV, LA, RA) with correct orientation (apex near the probe, atria deeper). Key structures: 🔵 LV: papillary muscles, chordae, anterior & posterior mitral leaflets 🔵 RV: moderator band, anterior & septal tricuspid leaflets 🔵 Interatrial septum and ventriculoatrial septum (LV–RA separation) 🔵 Right superior pulmonary vein entering the LA near the septum 🔵 Descending aorta seen posterior/lateral to the LA High-yield pearl: The tricuspid valve annulus is normally positioned more apically than the mitral, an important landmark in structural assessment.

Apical 4-chamber view: a single window that maps cardiac anatomy and relationships. How to obtain it: 🔵 Place the transducer at the point of maximal impulse (LV apex) 🔵 Keep the probe index marker directed toward the patient’s left side (≈3 o’clock) 🔵 Aim the beam toward the base of the heart (toward the right shoulder) 🔵 Fine-tune tilt/rotation until all four chambers are symmetric and the septum is vertical From the LV apex, you see all four chambers in one plane (LV, RV, LA, RA) with correct orientation (apex near the probe, atria deeper). Key structures: 🔵 LV: papillary muscles, chordae, anterior & posterior mitral leaflets 🔵 RV: moderator band, anterior & septal tricuspid leaflets 🔵 Interatrial septum and ventriculoatrial septum (LV–RA separation) 🔵 Right superior pulmonary vein entering the LA near the septum 🔵 Descending aorta seen posterior/lateral to the LA High-yield pearl: The tricuspid valve annulus is normally positioned more apically than the mitral, an important landmark in structural assessment.

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👇Transseptal Complication: Aortic Injury👇 The patient was transferred from another hospital due to an aortic injury. During the initial procedure, the clinician inadvertently punctured the aorta. In a moment of panic, the sheath was advanced—an action that should never be taken in such circumstances—before transferring the patient to our facility. Upon arrival, we carefully retracted the sheath under guidewire support, prepared for thoracotomy if needed. Subsequent angiography and TEE assessments revealed no evidence of a shunt or bleeding. Fortunately, this severe complication was resolved without the need for surgical intervention. Key Lessons: 👉 1. Always puncture posteriorly; the left atrium is located in the posterior aspect. 👉 2. Remain calm; never advance the sheath into the aorta. 👉 3. Do not retract the guidewire until ruling out any shunt or bleeding🚨🚨 👉 4. Transseptal puncture should be performed or supervised exclusively by experienced clinicians🚨🚨 👉 5. For challenging anatomical conditions, TEE or ICE guidance is highly recommended🚨🚨 Philipp Sommer Christian Sohns Martin Braun Moneeb Khalaph Vanessa Sciacca Maxim Didenko, MD PhD FESC FEHRA @AleSpoken AGEP Young DGK #EPeeps #CardioTwitter

👇Transseptal Complication: Aortic Injury👇 The patient was transferred from another hospital due to an aortic injury. During the initial procedure, the clinician inadvertently punctured the aorta. In a moment of panic, the sheath was advanced—an action that should never be taken in such circumstances—before transferring the patient to our facility. Upon arrival, we carefully retracted the sheath under guidewire support, prepared for thoracotomy if needed. Subsequent angiography and TEE assessments revealed no evidence of a shunt or bleeding. Fortunately, this severe complication was resolved without the need for surgical intervention. Key Lessons: 👉 1. Always puncture posteriorly; the left atrium is located in the posterior aspect. 👉 2. Remain calm; never advance the sheath into the aorta. 👉 3. Do not retract the guidewire until ruling out any shunt or bleeding🚨🚨 👉 4. Transseptal puncture should be performed or supervised exclusively by experienced clinicians🚨🚨 👉 5. For challenging anatomical conditions, TEE or ICE guidance is highly recommended🚨🚨 Philipp Sommer Christian Sohns Martin Braun Moneeb Khalaph Vanessa Sciacca Maxim Didenko, MD PhD FESC FEHRA @AleSpoken AGEP Young DGK #EPeeps #CardioTwitter

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Are you agile on the sagittals?? Sagittal T1 images are for anatomy, but only if you know how to use them! Here is how I remember the sagittal anatomy 1. Start lateral 2. Find the gyrus that looks like a triangle, that is the pars triangularis of the inferior frontal gyrus 3. In front of it is the pars orbitalis—easy it’s over the orbit 4. Behind it is the pars opercularis. Remember oper sounds like OVER so its OVER the sylvian fissure 5. Behind the pars opercularis is the precentral gyrus 6. Right behind the precentral is the post central—duh post follows pre! 7. Behind the post central is the supramarginal gyrus. Remember supra means above, so it’s above the sylvian fissure. Margin = at the posterior margin of the sylvian fissure 8. Behind the supramarginal gyrus is the inferior parietal lobule. Remember inferior is below supra, so inferior parietal lobule is below the supramarginal 9. More medial is the lateral orbital gyrus. It’s easy, it above the orbit! 10. Even more medial is the gyrus rectus. Rectus means straight, so if you see a gyrus that is straight like a line, that is the gyrus rectus! Hopefully this gives you a handle on the sagittal! Stay tuned for the midline sagittal anatomy!!

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