Bicaval view is an Important TEE view to visualize, the LA, IAS, and right atrium. I used to have some trouble getting oriented to this view. Hence this post. It is obtained in the 90-120 degree view at the mid esophageal position. Imagine the patient is lying on his left side and the probe comes from above down between the spine and heart to the LA from within the esophagus. This is the best view to see IAS in the profile.(Subcostal TTE can also do it) Note how the LA hugs the right atrium which is actually an ill-defined (In TEE I mean) common meeting point of both IVC and SVC. Also important is the relationship of RUPV with SVC & the horizontally running RPA sitting right over the top of LA.
The relationship between RUPV and SVC is crucial in device closure of large ASD, especially in sinus venous defect.
Clinical Importance of this view
- Very useful in ASD rim morphology especially in the posterosuperior rim.
- Delineates clearly the defect boundaries in SVC ASD.
Sinus venosus defect: Image source not known. Thanks to the creator.
- This view doesn’t miss even the smallest PFO (With Contrast )
- Can be used to guide IAS puncture in structural heart Interventions.
- IVC /SVC mass extension into RA well visualized.
RA myxoma attached to septum: Image source -Michael Essandoh from Research gate
Final message
Getting oriented to TEE planes and images is so useful in structural heart interventions, like TAVRs, mitral clip, LAA occluder, tandem heart, valve in valves, etc. It is indeed a tough exercise and requires re-learning of cardiac anatomy with fluoroscopic overlay*.I wish, I go back and sit with first-year medical school students and start all over again.
*Current hybrid cath labs do provide Echo/Fluro co-registration, still it demands core 3D anatomical Imagination.
Dr.S.Venkatesan MD 