Anesthesiology & Pain Medicine >> Education >> TEE of the Month >> 2005 July – December
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Transesophageal Echocardiogram of July-Dec 2005

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

December 2005
Question: Describe 4 abnormalities in this TEE.


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Answer: Summarized in Figure A

  1. Pulmonic stenosis-as seen in intraoperative Figure 1, the dilated pulmonary artery is opened revealing a windsock for the pulmonic valve, with the orifice only admitting a suction tip
  2. Dilated pulmonary artery-as seen in Figure 1
  3. RVOT muscuolar obstruction-as seen in intraoperative Figure 2, the RVOT is narrow and muscularly lined
  4. Secundum ASD

Figure A

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Figure 1

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Figure 2

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November 2005
Question:This sequence of clips and image were taken during the utilization of a new technique in cardiovascular support. Clips 1 and 2 show ONE component of the device being placed, and Image 1 shows color Doppler applied to clip 2. Clip 3 was taken during active utilization of the device. (Hint-prior to device activation, there were no valvular abnormalities)

What is the device, what is the resultant abnormality seen in Clip 3?

Answer: This TEE demonstrates the placement of a Tandem cardiac assist device. This is usually done in the cath lab prior to a high risk intervention. A catheter is placed trans-septally into the left atrium; blood is removed and the device pumps the blood into the aorta. In this case, the degree of aortic regurgitation increased substantially.

Images courtesy of Michael Law, MD

Clip #1

Clip #2


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Image #1

Clip #3


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October 2005
Question: What is the structure indicated by the question mark shown in these views?

Answer: The structure is the transverse sinus, a pericardial reflection that insinuates between the great vessels and cardiac chambers at the base of the heart. It is one of 2 pericardial sinuses (also the oblique pericardial sinus) which occur at the points where the visceral and parietal pericardia are continuous with one another. The transverse pericardial sinus lies anterior to the superior vena cava and posterior to the ascending aorta and pulmonary trunk. In view #2, this relationship is clearly identified. In view #1, the sinus is seen as it swings down in front of the leaft atirum, and behind the aorta and pulmonary artery. The clinical significance is that pericardial fat etc, if seen in the sinuses, may be mistaken for thrombus in a cardiac chamber. Seeing the prominent sinus in multiple views as I have shown, clarify the diagnosis.

View #1

View #2


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September 2005
Question: In this deep transgastric view (Figure 1), what type of prosthesis is seen, and what is the concern about its position?

Answer: The image is a deep transgastric view, showing one of the posts of a mitral bioprosthesis in the left ventricular outflow tract (Figure 2). This valve is in the proper position, but raises oncern for LVOT obstruction. The colour Doppler reveals aliasing of flow, but this does not confirm nor refute the diagnosis-CW Doppler would be a more useful modality. It must be remembered that although the image is quite striking, the LVOT is a 3 dimensional structure, and in this context,the obstruction might not be as bad as feared (Figure 3). The preservation of the subvalvular apparatus of the native mitral valve and septal hypertrophy may make the outflow tract obstruction more clinically relevant (European Journal of Cardio-Thoracic Surgery 2002;  22: 825-827). In fact the gradient measured by CW was not clinically significant.

Figure 1


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Figure 2


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Figure 3

August 2005
Question: What is particularly worrisome in this transgastric view of a patient who presents with a type "A" aortic dissection?

Answer: This TEE demonstrates flow in to the pericardial space in a patient with type "A" dissection. Other views showed the effusion more clearly. The patient had signs of tamponade, and improved dramatically after pericardiotomy.

First Observation
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July 2005
Question: This patient had a previous ascending aortic replacement. What pathology is now evident?

Answer: This patient had both a pseudoaneurysm at the base of the aortic graft (single arrow) and an anterior mitral leaflet perforation (asterix), both presumably on the basis of ongoing infection.

First Obsevation
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Obsevation for the Answer
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