June 2008
Question: This patient is brought to the OR from the cath lab severely hypotensive. TEE is done and the 3 clips (with corresponding graphic) are obtained. What is the clinical scenario?

Answer: Clip 1 shows a wire in the ascending aorta in the long axis, and the wire entering the LMCA ostium in the short axis. There is a mass associated which is probably thrombus. Clip 2 shows a transgastric short axis of the LV. The only wall that is contracting is the inferior; the posterior, lateral, and anterior are akinetic. This is compatible with a LMCA occlusion in a left dominant circulation. Clip 3 shows 2 images in the descending aorta-one is the IABP and the other is the wire from the groin. The scenario is the patient had multiple previous stents and on this occasion, the stent became stuck and led to coronary occlusion.

Video Clip #1	Video Clip #2
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Video Clip #3	Video Clip #3 Still
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May 2008
Question: In video clip 1, describe what is seen. A month after treatment, the patient presented with increasing SOB, and ventricular arrythmias, and which time video clip 2 was obtained. Describe what is seen.

Answer: The first clip is a long and short axis of the aortic valve with obvious vegetation. The second clip shows an inferior wall infarction. He had resolution of the mass on the valve, but had persistent severe AI, and was scheduled for AVR. There was no history of coronary artery disease, and it was theorized that the lesion had in part embolized down the right coronary artery.

Video Clip #1	Video Clip #2
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April 2008
Question: Using the 2 video clips as guides, Find the corresponding jet in the CW images for each of the 3 CD images.

Answer: The first video clip is a long axis of the LV demonstrating severe LVH, and CD evidence of mid cavitary obstruction during systole. The second clip shows systolic accelaration in the LVOT , a whiff of MR, and mitral inflow.

CD images A, B, and C show LVOT flow, mitral regurgitation, and mitral inflow respectively.

The CW image 1 demonstrates aortic regurgitation; image 2 reveals mitral inflow; image 3 shows the dagger shape typical of dynamic outflow tract obstruction ; and image 4 shows mitral regrugitaion.

When analyzing a Doppler trace, the most important things to consider are the phase of the cardiac cycle, the direction, and the shape. There is no evidence in any of the clips for AR, and in the CW tracing, the deceleration slope indicates that the AR is probably severe. The second CW trace occurs in diastole and is away from the transducer-it is typical of mitral inflow (no A wave-probably in afib at the time), and is seen in CD image “C”. The third trace is typical of LVOT obstruction-it is in systole and moving towards the transducer-it is the jet in CD image “A”. The trace in image 4 is typical in shape, direction and phase of the cardiac cycle for MR and is seen in CD image “B”.

The clinical scenario is that the patient had severe aortic stenosis and LVH. After the valve was replaced, the effect was a decrease in the resistance to flow which prompted the dynamic LVOT obstruction. Conservative treatment with volume, alpha agonists and beta blockers sufficed.

March 2008
Question: Describe what is seen in the clip.

Answer: This is a classic presentation of a myxoma, although a thrombus cannot be ruled out. On other images, the mass can be seen arising from the fossa ovalis, which is also typical for a myxoma. Although it almost completely occludes the MV inflow, the patient’s symptoms were chest pain from associated coronary artery disease which had only recently begun; the myxoma was found on the workup for this later condition.

February 2008
Question: This patient had a Heartmate 2 (non-pulsatile LVAD) placed, and 2 hours later he returned to the OR for mediastinal exploration because of bleeding and hypotension. The first clip shows the 2D and colour images after arrival in the OR for the re-exploration, and the second clip shows the same patient after several theraputic maneuvers.

What is the colour jet in the first clip indicative of, and what theraputic maneuvers were undertaken prior to the second clip?

Answer: The first clip shows complete collapse of the left heart,the mitral annulus and dilation and hypokinesis of the RV. Colour Doppler shows turbulent inflow through the mitral orifice. This indicates that either blood is leaving the LV too fast, or not getting into it fast enough. The immediate crisis may be that if the walls of the LV get too close together, they may block device inflow through the LV apical cannula (Figure-febanswer). In this case the immediate response should be turning down the rotational speed of the device so that blood does not leave the device too fast, combined with measures to increase LV filling such as volume administration and increased RV output (inotropes, maintenance of sinus rhythm, decreasing PVR, etc.)

January 2008
Question: Between the left hand frame and the right hand frame, the patient has undergone a theraputic procedure. What are the possibilities?

Answer: The clip on the left shows a small LV, a large hypokinetic RV, early systolic paradoxical motion of the interventricular septum, and late systolic flattening of the interventricular septum, the so-called “D” shape. These findings indicate RV volume and more importantly pressure overload. In the right hand clip, the motion of the interventricular septum has normalized, the LV is bigger, and notwithstanding the transducer angle, the RV is smaller and contracting more normally. The likely theraputic interventions would be relief of pulmonic stenosis, PA dilation, pulmonary embolectomy, and in this patient with cor pulmonale second to pulmonary fibrosis, bilateral lung transplantation.

In patients with significant RVH who undergo lung transplantation, the drop in RV afterload is sometimes so profound that dynamic RVOT obstruction develops; the theraputic maneuvers would be similar to those in patients with HOCM.