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




May 2016

May question: I apologize for omitting April TEE!; however I was busy completing my forthcoming book Intraoperative and Interventional Echocardiography: Atlas of Transesophageal Imaging, 2nd Edition, which will be out later this year.

This 25 year old woman with Ehlers-Danlos syndrome presented to the emergency room of an outside hospital with acute chest pain radiating through to her back. A CT scan at that hospital was read as a type “A” aortic dissection. She is brought to your operating room, hemodynamically stable, and images from the TEE are shown. What should the next step be? (Images courtesy of Stephanie Jones and Jörg Dziersk)

Image - 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
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March 2016

March question: Why might the coronary sinus be enlarged? What is the structure with the question mark?

Image - TEE of the Month
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Video 1 - TEE of the Month
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March Bonus: Not a TEE but interesting. This patient was having a procedure by the thoracic surgeon; what is going on with the CO2 trace (hint-airway procedure)?

Image - TEE of the Month


March answer: Whenever a large coronary sinus is seen, 2 potential explanations come to mind; 1) Right sided volume overload 2) Persistent left SVC.

In this case, the enlargement of the coronary sinus was due to a “coronary sinus ASD”. This occurs in the setting of an unroofed coronary sinus; that is when the left atrium communicates with the coronary sinus, which then drains into the right atrium, creating a left to right shunt. If this occurs in the setting of a persistent left SVC, the shunt is larger.

The usual treatment in the absence of a left SVC is closing off the coronary sinus ostium, allowing coronary sinus drainage into the left atrium and accepting a small right to left shunt; in the presence of a left SVC this would create too large a right to left shunt, and therefore the procedure involves patching the unroofed portion of the coronary sinus and allowing drainage in to the right atrium.




February 2016

February question: You are called to help with the assessment of a left atrial mass (video 1) immediately following separation from cardiopulmonary bypass and a difficult mitral valve replacement. Subsequently you obtain videos 2 and 3. A return to CPB and left atrial exploration is being considered. What do you advise?

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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February answer: This is an example of a phenomenon known as “range ambiguity”. Right off the bat the structure that the arrow is indicating looks pretty amorphous, which should raise the suspicion that it is artefactual. Note that the depth is fairly shallow, which means that the ultrasound is only looking to the depth of the sector; it doesn’t mean that signals returning from a greater depth are not reaching the probe; therefore any signals returning from a greater depth have to be placed within the working image.

In video 2, the color Doppler shows that the prosthetic valve is competent, which would be unlikely if there was an actual mass in the left atrium.

In video 3, the depth has been increased; therefore those signals from a greater depth can be put in their proper place. Therefore, my suggestions to R/O range ambiguity

  1. LOOK AT DIFFERENT VIEWS
  2. LONG CLIP LENGTH (to look for randomness which would suggest that there isn’t an artifact)
  3. USE DOPPLER
  4. CHANGE DEPTH TO SEE IF THE IMAGE DISAPPEARS
  5. USE M MODE

There can be range ambiguity with Doppler, but that is a subject for another discussion.



January 2016

January question: This 27 year old female presented with a primum ASD and subsequent right sided enlargement, as well as a cleft anterior mitral leaflet with moderate MR. (Videos 1 and 2) The mitral annulus measured 43mm by 42 mm. The ASD was successfully closed, the mitral cleft closed and a ring annuloplasty performed. Post operatively her mean mitral gradient was 6 mmHg, and Videos 3 and 4 and image 1 (deep transgastric) were obtained. What are the findings (remember what the underlying condition is!) and what if anything should be done?

Image 2 - TEE of the Month
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Image 1 - TEE of the Month
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Image 2 - TEE of the Month
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Video 1 - TEE of the Month
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Video 2 - TEE of the Month
Video '4'   (click to enlarge)



January answer: The primum ASD and cleft anterior leaflet suggest an AV canal type of defect. These patients are known to already have a predilection for LVOT obstruction secondary to the so called “Goose Neck deformity” involving the long anterior mitral leaflet (Subaortic Stenosis After Atrioventricular Septal Defect Repair. Anesthesia and Analgesia 2011; 113: 236-8). Following repair of the cleft and ring annuloplasty, the LVOT obstruction was made dramatically worse. Because the primary goal of repairing the ASD had been achieved and the AML cleft had been closed, the patient was returned to bypass, the ring was removed, and the LVOT obstruction relieved.