Anesthesiology & Pain Medicine >> Education >> TEE of the Month >> 2010 July – December
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Transesophageal Echocardiogram of the Month

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

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December 2010

December Question:  What is the structure indicated by an arrow in the still?


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

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


December Answer:  The clip shows the mid descending thoracic aorta with a structure that is lined with what appear to be ruggae; in fact this is a hiatus hernia.



November 2010

November Question:  Video 1 shows a heart with an LVAD present. The phenomenon in video 2 occurred, with the result in video 3, which was accompanied by hypotension and an acute reduction of outflow from the LVAD. What is the diagnosis?

What does the arrow in image 1 indicate?


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

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


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

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


November Answer:  The images are of a patient with an LVAD, demonstrating a suction event. When the filling of the LV is impaired, and the LVAD RPM is constant, the ventricle can decrease in size to the point that the ventricular walls close over the inflow cannula and lead to cessation of VAD output. The treatment is to decrease the RPM, and treat the LV filling which involves giving fluid, and addressing any right heart issues.

In the current case, the decreased LV filling was due to RCA air and decreased RV function. Another explanation is that the LV filling decreased for some other reason, and there was entrainment of air into the inflow cannula.

The vascular structure is the coronary sinus with an LV pacing lead in it.



October 2010

October Question: Using the image and it's data, what is the effective regurgitant orifice and regurgitant volume of the MR?


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


October Answer:  As with last month's question, the regurgitant indices are calculated with the PISA method; again this assumes that all the measurements are made at the same period of the cardiac cycle.

The area of the hemisphere is 2pr2; the a angle is 180 so this is factored out. The PISA shell area is therefore 6 cm2. The velocity at the transition between red and blue is 34 cm/sec; DON'T USE THE WRONG VELOCITY- WITH TEE USE THE VELOCITY IN THE DIRECTION THE FLOW IS GOING.

The product of these is the flow rate at the shell interface; that is 203 cm3/sec.

The flow going through the regurgitant orifice is the same; therefore 226 cm3/sec divided by the concurrent velocity of the mitral regurgitant jet of 376 cm/sec (*note the units!), or 203/376 is the regurgitant orifice area of 0.54 cm2.

The regurgitant volume is the the regurgitant orifice area multiplied by the VTI of the MR jet, or 0.54 cm2 multiplied by 111cm, or 60 cm3. Both these indices indicate severe MR.

The ASE guidelines for quantitation of valvular regurgitation can be found at the following link:

http://www.asefiles.org/vavularregurg.pdf


September 2010

September Question:

Regarding images 1 and 1B and video1, what is the diagnosis, and what does the MVA calculate as?

Regarding video2, what is the diagnosis and regarding image2, what is the hemodynamic consequence?

Regarding image 3, what does the MVA calculate as, and why is the number discrepant with respect to the calculation in image 1?

Video 4 is a transgastric image of the tricuspid valve; what is the calculated RVSP (Image 4), and in what instance does it overestimate the PASP?


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

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

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


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

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


Image 3 - Sept 2010 - Tee of the Month
Image 3 (click to enlarge)


Image 3 - Sept 2010 - Tee of the Month
Image 4 (click to enlarge)

Video 4 - Sept 2010 - Tee of the Month
Video 4 (click to enlarge)


September Answer: This is an example of rheumatic mitral stenosis. The posterior mitral leaflet is fixed, and the commissural fusion leads to the so called hockey stick appearance of the anterior mitral leaflet.

The MVA is calculated using the PISA method; this assumes that all the measurements are made at the same period of the cardiac cycle.

The area of the hemisphere is 2pr2 multiplied by the a angle of 91/180, or 5.5 cm2. The velocity at the transition between red and blue is 41 cm/sec; DON'T USE THE WRONG VELOCITY- WITH TEE USE THE VELOCITY IN THE DIRECTION THE FLOW IS GOING.

The product of these is the flow rate at the shell interface; that is 226 cm3/sec.

The flow going through the valve orifice is the same; therefore 226 cm3/sec divided by the concurrent velocity of the mitral inflow of 250 cm/sec (*note the units!), or 221/250 is the MVA of 0.9 cm2.

The second image and video show aortic insufficiency. The MVA calculated with pressure half time (Image 3) is 220/120 or 1.8 cm2.

The discrepancy is because the presence of AR causes the PHT method to overestimate the MVA, because the resultant rapid rise in LV diastolic pressure causes a rapid decrease in the MV inflow velocity. The constant of 220 assumes a stable net compliance of the 2 chambers (LA, LV), and a stable trans valvular pressure gradient between the 2 chambers. This is why after balloon valvuloplasty, the PHT is inaccurate.

The 4th video and still show TR from the transgastric view. The cursor lines up very nicely with the jet so that the RVSP is the PG plus the CVP or 58mmHg. In the presence of pulmonic stenosis or RVOT obstruction, the PASP will be 58mmHg minus the pressure gradient from RV to PA



August 2010

August Question: What do the simultaneous clips in this patient demonstrate?


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


August Answer: The clip shows colour evidence of a left to right shunt through a PFO. With the bubble study, there is no contrast seen in the left atrium; however, when examined closely, there is negative contrast in the right atrium. The causes of false negative bubble study are referred to in the figure, which is taken from the excellent review:

Critical Review of Patent Foramen Ovale
Detection Using Saline Contrast
Echocardiography: When Bubbles Lie.

Timothy D. Woods, MD, and Ashvin Patel, MD
J Am Soc Echocardiogr 2006;19: 215-222.



July 2010

July Question: This patient has undergone a procedure in the cath lab, and does not have the expected result.

Explain the findings in the clip.


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


July Answer: A percutaneous aortic valve that has slipped back into the left ventricular tract is demonstrated. In the left hand frame, the heart is in diastole, and the prosthetic as well as the native aortic valve can be seen. It is abutting the anterior mitral leaflet, but there was no disturbance in mitral function. In the right hand frame, the heart is in systole. The valve housing is illustrated by the 4 arrows; the inset is the valve as it would appear after being deployed. It can be introduced through the femoral artery, or the LV apex.


Video 1 - July 2010 - Tee of the Month
July answer image (click to enlarge)

References:

  1. Role of echocardiography in percutaneous aortic valve implantation. Moss RR, Ivens E, Pasupati S, Humphries K, Thompson CR, Munt B, Sinhal A, Webb JG. JACC Cardiovasc Imaging. 2008 Jan;1(1):15-24.
  2. Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis. Webb JG, Pasupati S, Humphries K, Thompson C, Altwegg L, Moss R, Sinhal A, Carere RG, Munt B, Ricci D, Ye J, Cheung A, Lichtenstein SV. Circulation. 2007 Aug 14;116(7):755-63. Epub 2007 Jul 23.
  3. Transcatheter aortic valve implantation: anesthetic considerations. Billings FT 4th, Kodali SK, Shanewise JS. Anesth Analg. 2009 May;108(5):1453-62.