Anesthesiology & Pain Medicine >> Education >> TEE of the Month
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Transesophageal Echocardiogram of the Month

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

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June 2011

June Question:  After viewing the 2 videos, what do structures "A" & "B" in the figure indicate?
(Note: video 2 is obtained by slightly rotating the probe to the left)


Video 1 - June 2011 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - June 2011 - Tee of the Month
Video '2'   (click to enlarge)

Image 1 - June 2011 - Tee of the Month
Image '1'   (click to enlarge)


June Answer:  After reviewing these images, and looking at some of the answers, I remain uncertain. What is clear to me is that both are artifacts. The fact that they both move in such perfect synchrony suggests that they are related. The main structure seen in the first video is the ascending aorta, and in the second video it is the main pulmonary trunk. Structure "A" is not a dissection-it just sits there, and does not have the characteristics of an intimal flap. My best guess is that it is a beam width artifact of the interface between the left atrium and the pulmonary trunk. Beam width artifacts are structures that are echogenic and imaged in the elevational plane, thus the source is not obvious. Structure "B" is most likely a reverberation artifact from "A".



May 2011

May Question:  What disease process is evident, and what is the significance of
the distance measured in the still image?


Video 1 - May 2011 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - May 2011 - Tee of the Month
Video '2'   (click to enlarge)

Image 1 - May 2011 - Tee of the Month
Image '1'   (click to enlarge)


May Answer:  This case is an example of Ebstein's anomaly. Typical features are the blighted septal leaflet of the tricuspid valve and the non-coaptation of the anterior and septal tricuspid leaflets. In the second video clip, the interatrial septum bulges toward the left during systole; this is secondary to wide open TR. In the figure, the distance shown is the atrialized portion of the right ventricle, measured from the insertion point of the septal leaflet, to the end of the atrialized portion of the RV. If valve repair is to be attempted, then this portion must be "imbricated", or overlapped, much like the shingles on a roof. This is illustrated in the figure. An annuloplasty ring is then placed. If repair is not possible, valve replacement is undertaken.


Answer Image 1 - May 2011 - Tee of the Month
May Answer Image   (click to enlarge)



April 2011

April Question:  Which of the following is not a contraindication for LVAD placement?


Video A - April 2011 - Tee of the Month
Video 'A'   (click to enlarge)

Video B - April 2011 - Tee of the Month
Video 'B'   (click to enlarge)


Video C - April 2011 - Tee of the Month
Video 'C'   (click to enlarge)

Video D - April 2011 - Tee of the Month
Video 'D'   (click to enlarge)


Video E - April 2011 - Tee of the Month
Video 'E'   (click to enlarge)


April Answer:  The correct response is "E". Most patients coming for LVAD have some degree of MR.

In "A", a mechanical aortic valve is in place. Because the aortic valve does not always open with a functioning LVAD, the risk of thrombosis and embolization, especially if the INR drops to subtheraputic levels, is too great.

In "B", the presence of severe AR would create a vicious cycle of blood going from the LV to the LVAD, through the outflow cannula, and regurgitating back to the LV. The valve must be replaced or oversewn.

In "C", the presence of a PFO would facilitate the movement of desaturated blood to the LA as the LVAD creates a suction effect on the left side of the heart.

In "D", a clot in the LAA could be drawn into the LVAD causing device malfunction and creating embolization potential.



March 2011

March Question:  This 42 year old male had just undergone a double lung transplant for longstanding alpha-1 antitrypsin deficiency with pulmonary vascular resistance (PVR) of 9 Woods units. You are called because the cardiac index is low, the blood pressure is 70/30, and the heart rate is 105, normal sinus. You place a TEE probe and see the following 4 clips. The image is a spectral Doppler recording across the color Doppler of the third video clip.

An appropriate first step would be which of the following, and explain WHY!

  1. Begin infusions of milrinone and volume
  2. Begin infusions of epinephrine and volume
  3. Begin an infusion of epinephrine alone
  4. Administer volume
  5. Administer atropine

Video 1 - March 2011 - Tee of the Month
Video 1 (click to enlarge)

Video 2 - March 2011 - Tee of the Month
Video 2 (click to enlarge)


Video 3 - March 2011 - Tee of the Month
Video 3 (click to enlarge)

Video 4 - March 2011 - Tee of the Month
Video 4 (click to enlarge)


Image 1 - March 2011 - Tee of the Month
Image 1 (click to enlarge)


March Answer:  Here is a pt with chronic pulmonary hypertension who is used to a high PVR but now has new lungs. The pulmonic valve looks normal but there is clear RVH. Both ventricles are empty. The DOPPLER is CW across the RVOT, the pulmonic valve, and proximal PA. The pulmonic valve and proximal PA are normal. The obstruction is in the very muscular RVOT, and results from hypovolemia, and a dramatic decrease in PVR in the new lungs post Tx. It is akin to HOCM and is treated with volume. Milrinone would exacerbate the situation.



February 2011

February Question:  This patient had an MVR for myxomatous disease, and the next day was noted to have a coarse midsystolic murmur at the base of the heart. What do the 2D TEE & colour Doppler show?


Video 1 - February 2011 - Tee of the Month
Video 1 (click to enlarge)

Video 2 - February 2011 - Tee of the Month
Video 2 (click to enlarge)



February Answer:  This patient had a tissue MVR, with preservation of the valvular apparatus. The hemodynamic conditions favored SAM and in fact the clips show SAM of the residual anterior leaflet of the MV, and color flow acceleration in the LVOT. Any condition which results in excessive anterior leaflet length predisposes the patient to outflow obstruction, be it a long posterior mitral leaflet moving the AML into the LVOT, a redundant anterior leaflet, or an undersized annuloplasty ring.

2 nice reviews are:



January 2011

January Question:  What is being demonstrated in the video clip? The most superior chamber is the left atrium.


Video 1 - January 2011 - Tee of the Month
Video 1 (click to enlarge)


January Answer:  The 2D and 3D images show an occluding device free floating in the left atrium. The occluder had been placed to close a paravalvular leak around the bileaflet mechanical mitral prosthesis & became dislodged. It was retrieved via a transseptal puncture, and another occluder placed to close the leak.