Anesthesiology & Pain Medicine >> Education >> TEE of the Month >> 2010 January – June
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Transesophageal Echocardiogram of the Month

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

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June 2010

June Question: This patient had a mitral valve replacement previously, and now presents with fevers and severe shortness of breath.

What is the clinical scenario and what does the arrow in Image 2 indicate?


Image 1 - June 2010 - Tee of the Month
Image 1 (click to enlarge)


Video 1 - June 2010 - Tee of the Month
Video 1 (click to enlarge)


Image 2 - June 2010 - Tee of the Month
Image 2 (click to enlarge)


Video 2 - June 2010 - Tee of the Month
Video 2 (click to enlarge)


June Answer: The patient has prosthetic endocarditis. The valve ring has completely dehisced from the native annulus resulting in a rocking motion. The defect is large, and there is severe paravalvular MR and paravalvular inflow. In the midesophageal short axis, the dehisced valve is seen to prolapse during systole, rising behind the left and non-coronary cusps.



May 2010

May Question: This 70 year old patient underwent a septal myomectomy for hypertrophic obstructive cardio! myopathy (HOCM). A week later he has increased shortness of breath.

What do Image1/Video1 and Image2/Video 2 illustrate?


Image 1 - May 2010 - Tee of the Month
Image 1 (click to enlarge)


Video 1 - May 2010 - Tee of the Month
Video 1 (click to enlarge)


Image 2 - May 2010 - Tee of the Month
Image 2 (click to enlarge)


Video 2 - May 2010 - Tee of the Month
Video 2 (click to enlarge)


May Answer: Image 1 and video 1 shows an abnormal jet entering the right ventricle from the vicinity of the LVOT. The jet occurs in systole and its directionality is confirmed with colour Doppler.

Image 2 and video 2 show the 4 chamber view of the same information. Although the jet might mistakenly be attributed to tricuspid regurgitation, it is in the wrong direction, and goes under the septal leaflet of the tricuspid valve.

This is a postoperative VSD, one of the complications of septal myomectomy. Other complications include heart block, injury to the aortic valve, and mitral regurgitation.



April 2010

April Question: This patient had a catheter inadvertently placed in her aorta as seen on the still image. Further radiologic (CT, CXR) images indicate that the catheter stops well short of the aortic valve, but a colleague shows you a TEE clip (April 1) that he feels demonstrates the catheter in the left ventricle.

How do you reconcile these disparate findings?


Video 1 - Apr 2010 - Tee of the Month
Video 1 (click to enlarge)


Figure 1 - Apr 2010 - Tee of the Month
Figure 1 (click to enlarge)


April Answer: The image in the ventricle is an artifact. The clues are:

  1. The image goes right across the LV wall
  2. Changing interrogation angles does not lead to a corresponding change in the appearance of the image. The structure in the LV would to be in cross-section at 0 degrees if it were real.

Answer 2 - Apr 2010 - Tee of the Month
Figure April answer (click to enlarge)

It is a reflection or mirror image artifact. The very bright pericardium displays excessive reflection of the ultrasound beam which goes back to the transducer and back again to the structure. The clue is that the artifact is twice as far form the transducer as the reflective surface (Figure April answer). It is not a side lobe artifact, because in that instance, the artifact is at the same depth as the real structure.



March 2010

March Question: This patient, who had heart surgery 12 years ago, presents with increasing shortness of breath, especially when recumbent. All of these clips were taken at the same depth in the esophagus. What structures are identified by the letters, and what is the most likely clinical scenario.


Video 1 - Mar 2010 - Tee of the Month
Video 1 (click to enlarge)

Video 2 - Mar 2010 - Tee of the Month
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Video 3 - Mar 2010 - Tee of the Month
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Video 4 - Mar 2010 - Tee of the Month
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Figure 1 - Mar 2010 - Tee of the Month
Figure 1 (click to enlarge)


March Answer: This patient had previously undergone a Bentall procedure, consisting of an ascending aortic graft and a mechanical aortic valve. The graft is seen as "B", flanked on the right by the pulmonary artery and pulmonic valve (C). With the probe remaining at the same depth in the esophagus, the imaging angle is rotated, and the aortic graft is seen to open into a large structure, with dramatic flow demonstrated by colour Doppler. This is a larger pseudoaneurysm (A), which has resulted from partial dehiscence of the ascending aorta graft. The right pulmonary artery is compressed. The patient had the pseudoaneurysm repaired under deep hypothermic circulatory arrest, and made a good recovery. Some hoarseness secondary to left recurrent laryngeal nerve compression by the pseudoaneurysm was present.



February 2010

February Question: This 32 year old previously healthy, pregnant (20 weeks) individual presented with a 3 hour history of substernal chest pain, and several TEE images are presented. Put them all together.


Video 1 - Feb 2010 - Tee of the Month
Video 1 (click to enlarge)


Video 2 - Feb 2010 - Tee of the Month
Video 2 (click to enlarge)

(Images courtesy of Jorg Dziersk, MD)


February Answer: This patient had an aortic valve replacement and the pathologic diagnosis was a papillary fibroelastoma. It was theorized that part of it had embolized down the left coronary artery occluding the LAD; this was confirmed at cardiac cath.

A papillary fibroelastoma is a benign cardiac tumor that typically occurs on the aortic or mitral valve. Unlike valvular vegetations, these tumors tend to be located on the downstream (instead of upstream) side of the valve and are not associated with destruction of the underlying valve disease. The macroscopic appearance of these tumors is a frond-like mass, sometimes with superimposed thrombus. Microscopically, there is abundant elastic and fibrous tissuesimilar to the normal component of the valve leaflet. The prevalence of papillary fibroelastomas increases with age, although the gender distribution is about equal. The most common valve sites (in order of prevalence) are aortic (44%), mitral (35%), tricuspid (13%) and pulmonic (8%) valves, with size at the time of detection ranging from 2 to 70 mm.

Reference: Gowda RM, Khan IA, Nair CK et al. Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases. Am Heart J 2003; 146:40410



January 2010

January Question: This patient had previously undergone aortic valve replacement for chronic AR, but developed progressive LV dilation and reduced systolic function. He now presents for LVAD placement.

1) What do the images of the mitral valve show?

2) What procedure would have to be done in conjunction with the LVAD placement?


Video 1 - Jan 2010 - Tee of the Month
Video 1 (click to enlarge)


Video 2 - Jan 2010 - Tee of the Month
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Video 2 - Jan 2010 - Tee of the Month
Video 3 (click to enlarge)

 

January Answer: This patient had a dilated cardiomyopathy secondary to aortic valve disease, and presented for LVAD placement. The perturbation in his LV geometry led to extreme tethering of his posterior mitral leaflet, with abnormal coaptation and MR. Because his AV prosthesis was mechanical, it was explanted and replaced with a tissue prosthesis; because the AV opening after LVAD placement is minimal, there is an increased risk of thrombosis and embolization.