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 2012

June Question: This patient had a prosthetic mitral valve placed. The 2 videos show post CPB clips, and the image is CW through the jet.

  1. What kind of valve is it?
  2. Where is the MR seen-in or outside the sewing ring?
  3. What part of the sewing ring is it related to ie anterior,posterior, etc.
  4. How severe is it?

Video 1 - June 2012 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - June 2012 - Tee of the Month
Video '2'   (click to enlarge)

Image 1- June 2012 - Tee of the Month
Image '1'   (click to enlarge)


June Answer: This is a bileaflet mechanical valve that is seen to be rocking immediately post CPB, a sure sign that there is dehiscence. The color Doppler jet is outside the valve, and is in the vicinity of where the anterior commissure once was. The density of the CW signal attests to the severity of the MR. The 3D color Doppler (june answer.jpg) shows a large jet near where the anterior commissure once was. The surgeon returned to CPB, found the dehiscence in the predicted area and successfully repaired it.

Answer Image - June 2012 - Tee of the Month
Answer Image '2'   (click to enlarge)



May 2012

May Question: This 46 year old male presented for mitral valve repair/replacement. His prebypass TEE is shown in videos 1,2 and 3; Video 3 is obtained by ante-flexing the probe from its position in Video 2. Following repair which involved resection of part of a leaflet and ring annuloplasy, the video 4 is obtained. What would you tell the surgeon?


Video 1 - May 2012 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - May 2012 - Tee of the Month
Video '2'   (click to enlarge)

Video 3- May 2012 - Tee of the Month
Video '3'   (click to enlarge)

Video 4- May 2012 - Tee of the Month
Video '4'   (click to enlarge)


May Answer: In the first video, a bicaval image is displayed which shows unequivocal P3 prolapse. P2 prolapse is seen on the midesophageal long axis in the 2nd video. With the probe flexed, as indicated by the arrows in the image,P1 is seen without prolapse. The post repair video shows a small but unusual jet which appears to come through the leaflet and move directly anterior, It was found on reinspection to be arising from a breakdown in the posterior leaflet repair stitch.

Image 1- May 2012 - Tee of the Month answer
Im age '1'   (click to enlarge)



April 2012

April Question:  This 52 year old woman from Samoa presented with a long history of progressive shortness of breath. Describe what the likely diagnosis is, what is seen in each Video, and what the image tells us.


Video 1 - April 2012 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - April 2012 - Tee of the Month
Video '2'   (click to enlarge)

Image 1- April 2012 - Tee of the Month
Image '1'   (click to enlarge)


April Answer: This patient has rheumatic heart disease. Video 1 reveals severe biatrial enlargement. There is mitral stenosis, and the still image shows a pressure half time of 463 msec which when plugged unto the equation 220/PHT gives a mitral valve area of 0.48 cm2. There is a caveat-the patient is in atrial fibrillation, so 5-10 beats should be analyzed and averaged. This equation is not valid in acute changes, because it the validity depends on a stable transvalvular gradient and relative atrial and ventricular compliances.

Video 2 shows extensive left atrial thrombus.

There is also rheumatic tricuspid valve involvement, with TR and TS.

A double valve replacement was performed.


March 2012

March Question:  Following an uncomplicated mitral procedure, cardiogenic shock developed. By looking at the video and the 2 Doppler images, describe what is going on. (NB the CVP is 38mmHg).


Video 1 - March 2012 - Tee of the Month
Video 1 (click to enlarge)

Doppler image 2 - March 2012 - Tee of the Month
Doppler image 1 (click to enlarge)

Doppler image 2 - March 2012 - Tee of the Month
Doppler image 2 (click to enlarge)


March Answer:  Following mitral repair surgery in which P2 excision with ring annuloplasty followed by tricuspid annuloplasty was performed, severe RV dysfunction of no obvious etiology occurred. Despite the annuloplasty, severe TR ensued. The pressure gradient between the RA and RV was only 5mmHg because the severe tricuspid incompetence resulted in a virtually common right sided chamber. The clues to the severity of the TR are the early peaking, dense, and triangular shaped TR jet, and the systolic reversal in the hepatic vein. The mitral repair looks abnormal because of the severe underfilling of the LV secondary to the RV failure. An RVAD was urgently placed, which over the next month was weaned. No obvious cause for the RV failure was discovered.



February 2012

February Question:  Videos 1 through 4 show clips from a 50 year old patient who presented for tandem heart LV assist device placement following a large myocardial infarction. The following day he returned to the OR because of severe hemodynamic instability, and clips 5 and 6 were obtained. Explain what the clips show, and the etiology of the patients deterioration.


Video 1 - February 2012 - Tee of the Month
Video 1 (click to enlarge)

Video 2 - February 2012 - Tee of the Month
Video 2 (click to enlarge)


Video 3 - February 2012 - Tee of the Month
Video 3 (click to enlarge)

Video 4 - February 2012 - Tee of the Month
Video 4 (click to enlarge)


Video 5 - February 2012 - Tee of the Month
Video 5 (click to enlarge)

Video 6 - February 2012 - Tee of the Month
Video 6 (click to enlarge)

February Answer:  As can be seen in clips 1 through 4, both ventricles are severely dysfunctional. The Tandem takes blood from the LA and pumps it to the aorta. Later, as seen in clips 5&6, stagnation occurred because of underlying LV dysfunction, compounded by diminishment of trans mitral flow secondary to successful Tandem drainage. Despite anticoagulation, thrombus formed in the LVOT, and across the aortic valve. He was taken to the OR where the clot was removed and a HEARTMATE II placed.



January 2012

January Question:  This patient with long standing cystic fibrosis and pulmonary hypertension underwent double lung transplant with cardiopulmonary bypass. Separation from CPB is accomplished with the aid of milrinone. The patient is hypotensive with a low cardiac index, so epinephrine is started, but no improvement is seen. TEE is performed and 3 clips are shown. What is the diagnosis?


Video 1 - January 2012 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - January 2012 - Tee of the Month
Video '2'   (click to enlarge)

Video 3 - January 2012 - Tee of the Month
Video '3'   (click to enlarge)


January Answer:  After the new lung, the hypertrophied RV faces the lowest pulmonary vascular resistance it has seen in a long time, a setup for RVOT obstruction. This is demonstrated in the RV inflow-outflow view, and the transgastric RV view with and without colour. With the cessation of inotropes, the initiation of vasoconstrictors, and volume, the situation resolved.