Anesthesiology & Pain Medicine >> Education >> TEE of the Month

Transesophageal Echocardiogram of the Month

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

You might also like to visit the Canadian Society of Echocardiography-Cardiomath Echo Calculator

For those with smartphones or iPads I recommend the following apps as excellent reference guides. The first is from the University of Toronto (same folks who brought you the Virtual TEE website) and the next 3 are from the American Society of Echocardiography


TEE Standard Views on Apple iPad App icon

iTunes Preview

Echo AUC App icon

American Society of Echocardiography
Echo AUC

iTunes Preview

ASA Pocket Guidelines App icon

American Society of Echocardiography
ASE Pocket Guidelines

iTunes Preview

iASE App icon

American Society of Echocardiography
iASE

iTunes Preview


Coming later in 2017:

coming later in 2016

(click image to enlarge)




February 2017

February question: This patient was being worked up for hemolysis. TEE is shown. What is the problem and where is it located? Any other investigations warranted?

Video 1 - TEE of the Month
Video'1'   (click to enlarge)

Video 2 - TEE of the Month
Video'2'   (click to enlarge)


Submit Your Answer Here


January 2017

January question: What congenital abnormality is seen in this patient? What is the significance of what the arrow in the spectral Doppler is pointing to? The second video is a cardiac MRI resembling a trans-gastric short axis.

Video 1 - TEE of the Month
Image'1'   (click to enlarge)

Video 1 - TEE of the Month
Video'1'   (click to enlarge)

Video 2 - TEE of the Month
Video'2'   (click to enlarge)


January answer:This patient had a double chamber right ventricle-essentially 2RV “chambers” separated by a muscular narrowing in the RVOT
History: angina, dyspnea, dizziness, syncope
PE: harsh systolic ejection murmur at left sternal border
EKG: right ventricular hypertrophy
Diagnosis: TTE, TEE and cardiac MRI.

Associated Abnormalities

VSD (~ 75%)
Valvular pulmonary stenosis
Tetrology of Fallot
Double-outlet RV
Subaortic obstruction
Persistent left SVC

Surgery

  • Indications
  • Symptomatic patient
    Peak gradient > 50 mmHg
  • Usually repaired in childhood or adolescence
  • Approach
  • Right transatrial
    Right transatrial-pulmonary
    Right ventriculotomy

Our patient’s operative procedure: Resection of right ventricular outflow muscle and enlargement, reconstruction of the distal main pulmonary artery, the anterior one third of the pulmonic valve annulus, and the right ventricular outflow tract with CorMatrix oval patch. The postoperative gradient was small. (Images and discussion courtesy of Peter Von Homeyer an Srdjan Jelacic.) In the postoperative video, the small jet at the inter-ventricular septum was thought to be an anomalous coronary artery.


Answer Image - TEE of the Month
Answer Image'1'   (click to enlarge)

Answer Video - TEE of the Month
Answer Video'1'   (click to enlarge)



December 2016

December question: 6 months earlier, the patient received a bioprosthetic “Perceval Valve” (©Sorin Group; see excerpt from Oxorn: Intraoperative and Interventional Echocardiography: Atlas of Transesophageal Imaging, 2e). Postop images show the valve and the small transvalvular gradient (Videos 1 and 2, Image 1). 5 months later, TTE shows the increased gradient across the valve (Image 2), and subsequent TEE (Videos 3 and 4) show the valve. Can you offer an explanation for the change in Doppler tracings?

Video 1 - TEE of the Month
Image'1'   (click to enlarge)

Video 2 - TEE of the Month
Image'2'   (click to enlarge)


Video 1 - TEE of the Month
Video'1'   (click to enlarge)

Video 2 - TEE of the Month
Video'2'   (click to enlarge)


Video 1 - TEE of the Month
Video'3'   (click to enlarge)

Video 2 - TEE of the Month
Video'4'   (click to enlarge)


December answer: This case proved to be a diagnostic conundrum, not yet fully sorted out. Clearly there was no gradient across the prosthetic AV or LVOT in the immediate postop period.

However, 3 months later there was a SIGNIFICANT gradient across the prosthetic AV. The leaflets seem to fluttering in systole which is often an indication of LVOT obstruction, and many readers felt this was the cause; however there is no visible SAM, and no obvious fixed sub aortic obstruction. I didn't present the postop LVOT gradient but it is posted as December answer, and the PW reveals no significant increase in velocity in the outflow ract. There were no visible thrombii seen in or around the valve.

My conclusion was that the abnormal leaflet motion was the result of some distortion of the supporting cage; remember the Perceval is very much like a valve used in TAVR. The patient is not symptomatic and will be followed.

TEE of the Month
Answer Image (click to enlarge)




November 2016

November question: This patient is to undergo a tricuspid valve replacement. The surgeon wants to perform surgery without a cross clamp with the heart beating. He asks if there is a PFO-a color Doppler study is equivocal so you preform a bubble study via an internal jugular injection. The pre bubble clip and the post injection are seen. Are you confident in telling the surgeon he can go ahead as he has planned? Are there any other diagnostic maneuvers you would consider?
Images courtesy of Renata Ferreira/Sara Reader.


Video 1 - TEE of the Month
Video'1'   (click to enlarge)

Video 2 - TEE of the Month
Video'2'   (click to enlarge)


November answer: Doing a tricuspid valve procedure without arresting the heart and cross clamping the aorta requires the confirmation the absence of left and right chamber communication. It is incumbent on the operator to determine the if likelihood of a false negative is high. Causes of this that must be considered include:

1. Inadequate opacification of the left atrium
2. Elevated left atrial pressure. This may be addressed by looking for negative contrast in the right atrium (Nov answer1), and by doing a Valsalva maneuver to artificially increase right atrial pressure.
3. Washout of SVC contrast by IVC flow
4. Diversion of contrast to TV by Eustacian valve

Number 4 would be a concern with this patient. It is clear that very little contrast reaches the interatrial septum. One approach to confirm or refute this is by injecting contrast via the IVC; in utero, IVC oxygenated blood returning from the placenta is directed to the fossa ovalis as to allow arterial blood to pass in to the LA (November Answer Image 2).

Video 1 - TEE of the Month
Answer Image'1'   (click to enlarge)

Video 2 - TEE of the Month
Answer Image'2'   (click to enlarge)