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 2016:

coming later in 2016

(click image 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
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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)


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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
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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)



October 2016

October question: Given these 3 images, what procedure was planned, and what actually happened? (RPA=right pulmonary artery)

(Images courtesy of Hagop Karpanian, MD)


Video 1 - TEE of the Month
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Video 2 - TEE of the Month
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Video 3 - TEE of the Month
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October answer: Video 1 shows calcific aortic stenosis. In video 2, a transcatheter aortic valve isseen, but the valve is sitting in the ascending aorta, and in video 3 is seen to migrate to the ascending aorta at the pulmonary artery bifurcation. The valve was retrieved, and a second valve deployed.



September 2016

September question: This CW Doppler indicates MR (jet 1). What are possible explanations of the other 2 jets?


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

September answer: #1 is a jet of MR, and #3 is mitral inflow. There are several possible explanations for #2. First of all it is in systole, and mirrors the MR jet except the signal is fainter.

A) It could be a jet from another source that the CW Doppler is picking up, something always to consider when an unexpected jet appears with CW Doppler. The fact that it is a true representation of the jet above makes this less likely.

B) It could arise from a complex series of reflectors as illustrated in the reference (J Am Soc Echocardiogr 2006;19: 1191.e1-1191.e3).

C) If the angle of insonation is close to 90 degrees, signals may appear on both sides of the baseline. This phenomenom is known as directional ambiguity

D) Cross talk can occur, as described in this highly recommended article: Imaging Artifacts in Echocardiography Huong T. Le, MD,* Nicholas Hangiandreou, PhD, Robert Timmerman, MD, Mark J. Rice, MD, W. Brit Smith, MD, Lori Deitte, MD, and Gregory M. Janelle, MD, FASE. (Anesth Analg 2016;122:633–46):

“Cross talk results from erroneous signal transfers when the echo exceeds the operating range of the circuit and results in the appearance of velocity on both sides of the baseline. On one side, the velocity is usually more intense and brighter (i.e., true Doppler shift) than the one on the other side. Reducing the Doppler gain or output power may eliminate the artifact.”


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



August 2016

August question: This patient comes to the OR with a diagnosis of TR secondary to a pacemaker lead "problem". Describe what you see, and see if there is an alternate explanation. Identify the structure with the question mark.

(Images courtesy of Dr. Andy Bowdle)


Image 1 - TEE of the Month
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Video 1 - TEE of the Month
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Video 2 - TEE of the Month
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Video 3 - TEE of the Month
Video '3'   (click to enlarge)


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

Video 5 - TEE of the Month
Video '5'   (click to enlarge)


August answer: As is seen in image 1 and video 5, there is a left to right shunt at the atrial level, which was not diagnosed prior to surgery. Also of note- right atrial and right ventricular enlargement, normal right and left ventricular function. There was significant central tricuspid regurgitation, but no other valvular lesions. So the question becomes is the right sided chamber enlargement the consequence of tricuspid regurgitation? Although it was thought that the pacemaker might have caused tricuspid valve incompetence, there was no indication of this on TEE. An alternative explanation is that a chronic left to right shunt may have caused right sided chamber enlargement, with secondary TR. The surgeon closed the septal defect and put a ring on the normally appearing tricuspid valve with a good result.

The ? indicates multiple reverberations of the pacing lead which is seen in video 1.



July 2016

July question: This patient was brought to the OR for LVAD placement, for severe LV dysfunction. (Video 1). One of the initial TEE images is seen in the 2nd video. What should you "advise" the surgeon to do?


Video 1 - TEE of the Month
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Video 2 - TEE of the Month
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July answer: This patient has a large mass in his left atrial appendage, which given the clinical circumstances, is most likely thrombus. The concern was that applying negative pressure to the LV would be transmitted to the LA, and might cause the thrombus to enter the VAD circuit, causing either obstruction or systemic embolization. After going on CPB, the Left atrium was opened and the clot material resected. The biggest portion is seen in the attached illustration. the LVAD was completed without incident.


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