Anesthesiology & Pain Medicine >> Education >> TEE of the Month >> 2009 July – December
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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


December 2009

December Question: What do each of the images show, and what is the underlying pathophysiology?

Dec Video 1

Video 1

Dec Video 2

Video 2

 

December Answer: Both video clips show enlarged right ventricles. In video 1, the septum is flat, and although the septal motion is paradoxical, the septum remains flat during the whole cardiac cycle giving the characteristic “D” shape. This indicates RV pressure overload; the patient in question had chronic pulmonary emboli. In video 2, although there is paradoxical septal motion, the septum retains its normal curvature, especially in systole. This indicates RV volume overload. In both video clips, there are prominent RV papillary muscles.



November 2009

November Question: A 45 year old male presents with severe backpain. Based on the figure and 3 video clips, what is the differential, what is your diagnosis and why.

Image 1

Image 1

Video 1

Video 1

Video

Video 2

Video 3

Video 3

November Answer: Any time an echoic space is present around a valve, especially the aortic, one must be suspicious of endocarditis with abscess formation. Although it is obvious that the patient has a bicuspid valve, there is no evidence whatsoever of endocarditis. Closer examination shows what appears to be an aortic ulcer in the non coronary cusp. Video #3 shows the resultant pericardial effusion. The patient was taken to the OR, where the diagnosis was confirmed (See image).

November answer



October 2009

October Question: This patient had a HeartMate II® implanted for an ischemic cardiomyopathy The HeartMate II® is a high-speed, axial flow, rotary blood pump, and as an axial flow device, produces no pulsatile action. The patient presented 6 weeks later with ventricular tachycardia. There was also evidence of significant hemolysis. The patient was cardioverted and a TEE was performed. Videos 1 and 2 show the inflow cannula from the left ventricle to the device. Images 1 and 2 are still frame during systole and diastole respectively, and image 3 is a pulse Doppler recording from the proximal end of the inflow cannula. Describe LVAD function and the interpretation of the videos and images.


Video 1
Video 1

Video 2
Video 2


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Image 1

Image 2
Image 2

Image 3
Image 3

October Answer: This series of clips shows the TEE of a patient with a HeartMate II® left ventricular assist device. The non pulsatility of the design means that there should be continuos flow during the whole cardiac cycle. A slight pulsatility may be observed if the ventricle ejects a significant amout of blood through the inflow cannula. One instance where flow may be interrupted is if the LV is very underfilled; a "suction event" may occur in which the LV walls are literally sucked down on the inflow cannula (to the device) thereby occluding it.

In this case, the inflow cannula is misdirected toward the septum. During systole, the paradoxical motion of the septum opens the way for blood to flow into the device, but during diastole, the septum moves inward and occludes the orifice of the inflow cannula. This is obvious with colour Doppler, and the dropout of the pulse wave Doppler signal during diastole.



September 2009

Question:As an infant, this 26 year old patient had a Rastelli procedure for transposition of the great vessels with VSD and pulmonic stenosis. What is seen in each of the 2 video clips and corresponding still images? Calculate the pulmonary artery systolic pressure.


still question 1

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video 1

Video 1

question 2

Image 2

video 2

Video 2

September Answer: Video 1 shows and extremely dilated right atrium and a hypertrophied right ventricle. Image 1 shows the CW through a jet of tricuspid regurgitation. According to the simplified Bernoulli's equation, and assuming the proximal velocity is small, the peak gradient across an orifice=4V2. In this case, this works out to 4 x (3.6 x 3.6) or 52.4 mmHg. If one then adds the CVP of 22, this means that the right ventricular systolic pressure is 72.4mmHg. It is usually assumed that this value is the same as the pulmonary artery systolic pressure, but not in this case where there is obstruction of the RV to PA conduit as seen in video 2 and figure 2. The peak systolic gradient from RV to PA is 54.5 making the the PA systolic pressure 72.4-54.5 or 18mmHg.



Question: In video clips 1 and 2 a mass is evident on the mitral valve. What is the differential of the mass, and can one determine what portion of the mitral valve is involved? Video #3 is placed as reference.

video 1

Video 1

video_2

Video 2

Video 3

Video 3

July/August Answer:

The mass was a myxoma, but it is impossible to know definitively if it was thrombus, tumor or vegetation-one might have suspicion, but as always, "clinical correlation is required".

In terms of localization,see the attached figure (July August answer) which I have modified to show the lesion. It was on P3,but so close to the posterior commissure that it is difficult to tell if A3 was involved. I neglected to mention that at zero degrees, the probe was retroflexed, so it was probably catching the lesion. I think the clincher was the bicommissural view, as if it was on A3, it probably would have dropped out of view in systole.

Leaflet involvement is perhaps easier if there is a colour jet involved; see November 2008 of my site.

July / August Answer