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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


July 2014

July Question: What is the rare abnormality seen in the video and image (images courtesy of Burkhard Mackensen)?


Image 1 - July 2014 - Tee of the Month
Image '1'   (click to enlarge)

Video 1 - July 2014 - Tee of the Month
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June 2014

June Question: What is the structure indicated by the question marks?


Video 1 - June 2014 - Tee of the Month
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Video 2 - June 2014 - Tee of the Month
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Image 1 - June 2014 - Tee of the Month
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June Answer: The structure in question is a pseudoaneurysm of the mitral aortic intervalvular fibrosa, an area which is especially prone to complications following aortic valve endocarditis. In the current case, the patient had a previous tissue aortic valve replacement. It is likely that he subsequently developed endocarditis with pseudoaneurysm formation posterior to the aortic root. Color flow Doppler establishes to and fro movement form the LVOT to the pseudoaneurysm, and the absence of any communication with the left atrium. The asterix indicates the orifice of the pseudoaneurysm in the 3D image:

Answer Image 1 - June 2014 - Tee of the Month
Answer Image '1'   (click to enlarge)


May 2014

May Question:  Your colleague calls you to help define an image- an object seen above the right coronary cusp. (Videos 1 & 2, Images 1 & 2 arrows); however when he images the aortic valve while imaging the mitral valve, the object is not there (Video 3). Returning to the original window, the object returns. What do you do to further define this object? What is your suspicion?


Video 1 - May 2014 - Tee of the Month
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Video 2 - May 2014 - Tee of the Month
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Video 3 - May 2014 - Tee of the Month
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Video 4 - May 2014 - Tee of the Month
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Image 1 - May 2014 - Tee of the Month
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Image 2 - May 2014 - Tee of the Month
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May Answer: This is an artifact. As seen in the first still, the arrow points to the artifact in 2D, and the M-mode shows fairly predictable motion. In the second still, the green arrow is the left atrial-aorta interface, and the red arrow is the reflection artifact. 3D artifacts have some unique features such as "blooming", seen here and often seen with prosthetic valves. See reference JASE 2014; 27:453-62.

Answer Image 1- May 2014 - Tee of the Month
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Answer Image 2- May 2014 - Tee of the Month
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April 2014

April Question:  At surgery for a type "A" dissection, the surgeon asks you to examine the descending aorta, and you come upon this image. What is indicated by the arrow?


Video 1 - April 2014 - Tee of the Month
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Still 1 - April 2014 - Tee of the Month
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April answer: The probe is imaging posteriorly. I suspect the disk facilitates ultrasound transmission allowing imaging of the spinal canal and dural sac. (See image '1' below.)

Answer Image 1- April 2014 - Tee of the Month
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March 2014

March Question:  What's wrong with this picture?


Video 1- March 2014 - Tee of the Month
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March answer: The 2 videos and 1 still explain the situation. The 2D RV inflow-outflow and the midesophageal long axis are missing the aortic valve! In fact this patient had previously had a prosthetic valve placed, which subsequently became infected. At reoperation, the annulus was so destroyed that the surgeon had to place the new prosthesis in a supra-annular position. Several years later a cath was performed because of progressive chest pain. The valve (red arrow) is seated just below the obstructed LMCA (white arrow).

Answer video 1 - March 2014 - Tee of the Month
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Answer video 2 - March 2014 - Tee of the Month
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Answer Image 1 - March 2014 - Tee of the Month
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February 2014

February Question:  What device is illustrated? (In some views, the A-V valve seen does not appear to be opening properly; ignore this; it is just the way the valve is cut; in fact it opens normally). Images courtesy of Peter Von Homeyer.


Video 1- February 2014 - Tee of the Month
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Video 2- February 2014 - Tee of the Month
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Video 3- February 2014 - Tee of the Month
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February answer: This is a double lumen cannula placed for V-V ECMO for respiratory failure. The attached image shows the anatomic relationships. This view was obtained from the transgastric view of the RV in long axis. Deoxxygenated blood is drained from the IVC and SVC to the device, and returned via another lumen to the RA; it is essential that this lumen faces the tricuspid so that blood leaving the device enters the RV and does not recirculate in RA.

Answer Image 1- February 2014 - Tee of the Month
Answer Image '1'   (click to enlarge)


January 2014

January Question:  In this patient with a history of a myocardial infarction, which coronary artery is most likely affected? Assuming there is no other major coronary disease, is the circulation right or left dominant? (Video clips 1,2,3) What about in the patient represented in video clip 4?


Video 1- January 2014 - Tee of the Month
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Video 2- January 2014 - Tee of the Month
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Video 3- January 2014 - Tee of the Month
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Video 4- January 2014 - Tee of the Month
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January answer: In first 3 clips, there is evidence of a basal inferior and posterior wall infarction. This implies RCA involvement with a right dominant circulation. The dominance means that the PDA or posterior descending artery, which supplies the posterior wall, originates from the RCA. In the last video clip the anterior, lateral and posterior walls are affected; this means that the left main coronary is affected and the circulation is left dominant, that is, the PDA comes off the circumflex. See image.

Answer Image 1- January 2014 - Tee of the Month
Answer Image '1'   (click to enlarge)