Anesthesiology & Pain Medicine >> Education >> TEE of the Month >> 2005 January – June
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Transesophageal Echocardiogram of Jan-June 2005

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

June 2005
Question: The first image demonstrates a structure (ARROW) in a pathologic position, with the corresponding colour Doppler on its right. The image on the far right is the same structure as it usually appears. What is it?

Answer: The images show the insertion of the right upper pulmonary vein into the SVC, rather than the normal situation of the left atrium. This anomalous drainage is often in the setting of a sinus venosus ASD. This patient had a sinus venosus ASD repaired as a child, and now presented with right sided volume overload. Occasionally anomalous pulmonary veins insert into the IVC and coronary sinus in this condition.

Structure in pathologic position
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Doppler of pathology
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Normal structure
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May 2005
Question: What is the device in this image of the descending aorta? Describe its relationship to the ECG

Answer: This is an image of an intraaortic balloon pump (IABP). This device is used to improve coronary perfusion and afterload reduce the left ventricle. The balloon should deflate in systole and inflate in diastole. In the present example, the balloon inflates in systole, and would therefore be extremely counterproductive. The patient was still on cardiopulmonary bypass when balloon inflation was initiated, and was rectified before coming off bypass.

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Image courtesy of Ray Liao, MD

April 2005
Question: In the still and video clip, what is the abnormality seen in the left atrium?

Answer: The abnormality in the left atrium is cor triatriatum, which develops from failure of resorption of the common pulmonary vein resulting in a left atrium divided by a fibromuscular diaphragm into a posterosuperior and anteroinferior chambers. The posterosuperior chamber, also called accessory left atrial chamber or pulmonary venous chamber, receives the pulmonary veins whereas the anteroinferior chamber, also known as the true left atrium, gives rise to the left atrial appendage and communicates with the mitral orifice. Communication between both chambers is through one or more fenestrations of the left atrial membrane. The degree of obstruction is determined by the size of the fenestration(s). (See Tantibhedhyangkul, W. et al. J Am Soc Echocardiogr 1998;11:837-40.).

Still

Video Clip

Still Video Clip

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March 2005
Question: In this prebypass transgastric short axis (click to view), what is the ventricular abnormality?

The patient had a mitral posterior leaflet flail segment resected, with a ring annuloplasty. There was mild elevation of pulmonary artery pressure, so that milrinone was started as separation from cardiopulmonary bypass was achieved. This led to worsening of the pulmonary artery pressure. Transgastric imaging and Doppler revealed the cause of this paradoxical increase in pulmonary artery pressure. What is the diagnosis?

Answer: The prebypass clip shows concentric LVH with preserved systolic function. After the mitral valve repair and ring annuloplasty, the transgastric imaging shows systolic anterior motion of the anterior mitral leaflet (SAM).CW Doppler through the LVOT shows the typical sawtooth pattern of dynamic outflow tract obstruction, with a peak gradient of 52mmHg.

The milrinone, because of its vasodilation and inotropic properties worsenend the LVOT obstruction, causing increases in the PAP. The management of this condition involves volume loading, vasoconstriction, and avoiding increase in contractility. When these measures were instituted, the outflow tract gradient resolved.

February 2005 (Images courtesy of Jorg Dziersk, MD)
Questions:

  1. What is the abnormality seen in panel A (a transgastric short axis image of the LV)?
  2. Three days later, the patient deteriorated, and developed cardiogenic shock and acute pulmonary edema. What has developed in panel B, this low esophageal view of the LV?
  3. Before placing a left ventricular assist device (LVAD), what procedure must the surgeons perform?

Answer: The TEE on the left shows a transgastric short axis view of the LV. The posterolateral wall is the only one working and the inferior wall is dyskinetic following this acute MI. In the clip on the left, the apex is frankly necrotic, with a VSD-this must be closed prior to placing an LVAD to prevent potential aspiration of air and other debris from the RV to the LV during ventricular emptying into the device.

Panel A

Panel B
Panel A

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January 2005
Question: In panel A, what is the structure indicated by the arrow? The hint is the structure indicated by an arrow in panel B

Answer: Panel "A" shows a massively dilated coronary sinus in a patient who had had  previous surgery for tetralogy of Fallot. The hint in panel "B" is a large persistent left superior vena cava (PLSVC). Whenver the coronary sinus is enlarged, a PLSVC should be looked for-it is usually seen abutting on the lateral border of the left atrium. The presence of a PLSVC and enlarged coronary sinus have implications for central line placement, and for the administration of retrograde cardioplegia. The diagnosis is confirmed by the administration of agitated contrast through a left arm vein, and noting appearance of the contrast in the coronary sinus first, and the right atrium second.

Panel A

Panel B
Panel A

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