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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December 2012

December Question: What structure in indicated by the arrow ? (Image courtesy of Dr. Andy Bowdle)


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


December Answer: Although somewhat ambiguous, most would describe the structure as the Eustachian Valve, or valve of the inferior vena cava. Its purpose in embryo is to direct oxygenated blood from the placenta and via the IVC, towards the foramen ovalve, where it gains entrance to the left atrium. The Chiari network is a filamentous right atrial structure which is also an embryonic remnant and has no known purpose in adult life.


November 2012

November Question: Video clips and stills are presented from a patient who presented for surgery.

  1. What is the likely diagnosis?
  2. What procedure(s) would be indicated?

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

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

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

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


November Answer: This patient had a connective tissue disorder, specifically Marfan's syndrome. As seen in the. video clips there is only mild AR , with normally appearing leaflets. The stills show a grossly enlarged aortic root with tapering in the ascending aorta. The decision was made to excise the aorta that was dilated including the sinuses, reimplant the coronaries, and, resuspend the native aortic valve leaflets inside a Dacron graft. This is the so called "David Procedure" named for Dr. Tirone David of Toronto. As seen in the post procedure videos, the leaflets coapt nicely and there is no AR.

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

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


October 2012

October Question: what is seen in the 2 videos and the 2 stills from this 40-year-old patient with increasing dyspnea on exertion?


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

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

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

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


October Answer: This 18 year old woman underwent a balloon valvuloplasty of her pulmonic valve at 4 months of age. She subsequently developed pulmonic regurgitation, and presented for valve replacement.

Videos 1 and 2 show the pulmonic valve from a high esophageal position. The leaflets are thickened with rolled up edges. A jet of pulmonic regurgitation is seen. The first still image demonstrates a steep deceleration slope, and the second still image shows a vena contracta of 0.7 cm, both indicative of severe PR. A tissue prosthesis was placed, and the patient made an uneventful recovery.


September 2012

September Question: 1) What is the diagnosis? 2) What are some of the classic echo stigmata seen in the 3 video clips? 3) What is the finding in the still and what would lead to inaccuracy in its interpretation? 4) The patient complains of a hoarse voice—how might that be related to the findings in the TEE?


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

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

Video 2 - September 2012 - Tee of the Month
Video '3'   (click to enlarge)

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


September Answer: this patient demonstrates the echocardiographic findings of rheumatic mitral stenosis, as illustrated in the image:

  1. Top left; the orange arrow indicates the enlarged left atrium, the red arrow indicates the stiff and immobile posterior leaflet, the yellow arrow a thickened chord attached to the anterior leaflet, and the white arrow indicates the thickened anterior leaflet, which in real time resembles a "hockey stick."
  2. Top right; the blue arrow indicates aliased mitral inflow at an aliasing velocity of 61cm/sec.
  3. Bottom right; the purple arrow indicates the deceleration slope and pressure half time of 307msec, which using the constant 220 yields a mitral valve area of 0.7 cm2. This value of 220 depends on stable transvalvular net compliance and pressure gradients, so that with an ASD, or post balloon valvuloplasty, the calculation would be inaccurate. Significant aortic regurgitation would cause rapid increase in LV pressure, causing the valve area calculation to be erroneously high.
  4. Bottom left; the green arrow indicates a thrombus in the left atrial appendage, and in real time "smoke" is seen in the left atrium. The hoarse voice is characteristic of Ortner' syndrome (Ortner's Syndrome N Engl J Med 2011; 365:939), in which the enlarged left atrium compresses the recurrent laryngeal nerve. (Congratulations to Dr. Sergio Baratta of Argentina).


August 2012

August Question: this patient had a Bentall procedure 3 days prior, and now has the following TEE; what is the diagnosis and presumptive aetiology? What is the structure(s)indicated by the arrow in the still frame?

Images courtesy of Dr. Efthimios Anagnostou, Thessaloniki, Greece.


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

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

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


August Answer: The diagnosis is a dehiscence of the graft from the area of the aorto-mitral curtain. There does not appear to significant aortic regurgitation. As it is so early on in the postop course, infection is less likely the aetiology, and it is probably related to suture dehiscence. The structure indicated by the arrow is the bifurcation of the left main coronary artery into the circumflex and the LAD. (See image '2'.)



July 2012

July Question: In this video and image, what is the structure (α) and what is the color Doppler signal (β)?


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

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



July Answer: This is a transgastric view with the probe turned to the patient's right. The images demonstrate a massive right coronary sinus of Valsalva aneurysm, which is protruding into the right ventricular outflow tract, causing acceleration of flow. The aneurysm is unruptured, and demonstrates spontaneous contrast but no thrombus.

The color signal indicated by beta is a mirror image artifact; in fact the signal is outside the heart! The attached image (July_answer.) shows how the pericardial surface acts as a strong reflector. The white arrow is the path the Doppler takes as it is reflected, but the ultrasound machine "thinks" it is following the red arrow, so that the signal also appears in the mirrored location.

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