Anesthesiology & Pain Medicine >> Education >> TEE of the Month >> 2007 January – June
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Transesophageal Echocardiogram of the Month

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

June 2007
Question: What is the abnormality in this clip-the still is provided for anatomic reference only.

Answer: This TEE demonstrates the absence of a left main coronary artery. This is an example of a rare coronary artery anomaly, which was found in 0.67% of consecutive diagnostic coronary angiograms.(Circulation. 2002;105:2449.) In the still, the right hand frame shows the normal position of the right coronary artery. Although in this instance this abnormality was picked up incidentally, the presence of one cardiac anomaly should always prompt the search for other defects. The intraop photo demonstrates the orifices of the LAD and Circumflex, both arising from the left coronary sinus of Valsalva.

Clip for the question

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Still photo for the question

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Still photo for the answer

May 2007
Question: Describe what is seen in each clip, and the cause and effect relationship.

Answer: The clip on the left shows a type"A" dissection, which by definition is present in the ascending aorta. The right hand clip shows a trans gastric short axis, with a wall motion abnormality in the inferior wall, in the distribution of the right coronary artery; the arrow in the image indicates the vicinity of the orifice of the RCA which in this example appears intimately associated with the dissection flap; the flap may be interfering with RCA flow (see still photo).

Clips

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Still photo

April 2007
Question: Video #1 is an intracardiac echo; therefore the RA and LA positions are reversed. It was done in conjunction with the placement of an ASD occluding device. 4 weeks later, TEE was performed (Video #2 and #3). What was seen in each of the 3 clips?

Answer: Video 1, the intracardiac clip, shows an atrial septal aneurysm, with one and possibly several defects. A closure device was placed in the cath lab with good immediate result; however the patient represented and TEE (video 2&3) showed significant interatrial shunting, with several jets-one where the device came off the rim of the ASD, and another, which appears to be a fenestration in the interatrial septum. The intraoperative picture is shown (answer picture).

It is known that the anatomy of the interatrial septum is variable, and the presence of an interatrial septal aneurym may complicate device placement. [Ho SY, McCarthy KP, Rigby ML. Morphological features pertinent to interventional closure of patent oval foramen. Journal of Interventional Cardiology 16 (1), 33-38].


Video #1



Video #2


Video #3


Answer Picture

March 2007
Question: In this high esophageal view, what is seen in this adult presenting with among other things, low diastolic blood pressure?

Answer: This patient had a patent ductus arteriosus, which was not diagnosed until late adulthood. At this time, it was heavily calcified, but successfully closed. The intraoperative picture is shown (answer #1). As well, the typical Doppler pattern is demonstrated (answer #2, showing continuous flow from the aorta to PA, with systolic accentuation, and a large pressure gradient reflecting the difference between systemic systolic pressure and pulmonary systolic pressure.


Animated view click to enlarge


Still view(click to enlarge)


Answer #1


Answer #2

February 2007
Question: This patient had a left ventricular assist device (LVAD) placed for end stage ischemic cardiomyopathy. The device had a continuous axial flow mechanism, as opposed to a pulsatile pump. On the left is the TEE as the patient is separated from cardiopulmonary bypass; the device inflow cannula is seen in the LV apex. As the speed of the axial pump is increased, the BP becomes acutely unmeasureable, and the TEE on the right is seen. What is going on and what is the remedy?

Answer: As suction of the LV cavity is increased, its intra-cavitary volume may decrease to the point where the lateral and septal walls block volume from exiting through the LV apical cannula (which allows inflow to the device.) The acute answer is to decrease the speed of the device to relieve this obstruction, and volume to fill the LV cavity. Another possible culprit is the RV; if its delivery of volume to the LV is acutely compromised, this may be another factor to be addressed. In the current case, RV functon appears to be unchanged.

January 2007
Question: All these images taken together, are part of well recognized symptom complex. What does each figure show, and what is the complex?

  • Video #1 and Still Photo are from a high esphageal view.
  • Video #2 is a mid esophageal long axis focused on the mitral valve.
  • Video #3 is a 4 chamber also focused on the mitral valve
  • Video #4 is a transgastric long axis focused on the aortic valve and LVOT.

Answer: These echos show a patient with Shone's complex, a developemental anomaly involving left sided cardiovascular obstruction at multiple levels (1). The high esophageal view shows the mildly obstructive coarctation with a peak gradient of 24mmHg. The second and third clips shows the parachute mitral valve originating from a single papillary muscle. The mitral valve in this case is not stenotic as it can be in Shones complex. There is no suprvalvular mitral ring, but clip 4 from the deep gastric position shows the classic subaortic membrane circling the LVOT.

The intraoperative figure (still image #2) shows the mitral leaflets, and the complex subvalvular "parachute".

  1. Shone JD, Sellers RD, Anderson RC, et al: The developmental complex of "parachute mitral valve," supravalvular ring of left atrium, subaortic stenosis, and coarctation of aorta. Am J Cardiol 1963;11:714-725.

(With contributions from Ray Liao, MD)
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