TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist
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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?
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 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?
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 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?
April Answer: The image in the ventricle is an artifact. The clues are:
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.
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 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.
(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 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?
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.