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Transesophageal Echocardiogram of the Month

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

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June 2013

June Question: These three videos and one image are from a single procedure. Describe what was seen in each clip, and what procedure was done. The 3rd video is a 3D image looking from the dome of the LA (which has been cropped away) towards the mitral valve.


Video 1 - June 2013 - Tee of the Month
Video '1'   (click to enlarge)

Video 2- June 2013 - Tee of the Month
Video '2'   (click to enlarge)

Video 3- June 2013 - Tee of the Month
Video '3'   (click to enlarge)

Image- June 2013 - Tee of the Month
Image '1'   (click to enlarge)

June Answer: Video 1 and image 1 go together and show a patient with a total artificial heart (TAH). All that is left of the native heart are the 2 atria which are sewn on the TAH. Note the "mitral and tricuspid" valves which are tilting disc prosthesis. Video 2 is the patient after a heart transplant. The usual practice in our hospital is to anastomose the cavae individually; however, abnormal anatomy precluded this approach . Here the donor RA and LA were sewn onto the native atrial backwall which produces the appearance of a "double interatrial septum". Video 3 is a 3D image with the dome of the left atrium cut away; the anastomotic ring is seen, and through it the mitral valve.


May 2013

May Question: The 4 preoperative images are from a 30 year old woman who has had an aortic coarctation repaired, as well as an AVR with a root enlargement. What do the clips show and what is the likely syndrome?


Video 1 - May 2013 - Tee of the Month
Video '1'   (click to enlarge)

Video 2- May 2013 - Tee of the Month
Video '2'   (click to enlarge)

Video 3- May 2013 - Tee of the Month
Video '3'   (click to enlarge)

Video 4- May 2013 - Tee of the Month
Video '4'   (click to enlarge)

May Answer: This patient has "Shone's complex". As described in Dr. Shone's original paper (Am J Cardiol 1963; 11: 714-25), the complex involved a number of left sided obstructive lesions including parachute mitral valve, supravalvular ring of the left atrium, subaortic stenosis, and coarctation of the aorta. By history, the patient had a coarctation repair, as well as an AVR combined with a root enlargement. In the figure which corresponds to several of the videos, we see the supramitral ring, and the floppy chord which attaches to a single papillary muscle (which is typical). She underwent MVR.

Answer 1- May 2013 - Tee of the Month
Answer '1'   (click to enlarge)


April 2013

April Question: In images 1 and 2, which aortic cusps are indicated by the numbers 1 through 4?


Image 1 - April 2013 - Tee of the Month
Image '1'   (click to enlarge)

Image 2- April 2013 - Tee of the Month
Image '2'   (click to enlarge)

April Answer: Whereas with the midesophageal long axis 2D TEE it is often difficult to determine if the posterior cusp in the left or non, using 3D TEE it is feasible. In the top right hand frames of both images, the cusps the green plane intersects are displayed in the top left had frames. The answer is therefore: 1=LCC, 2=RCC, 3=NCC, 4=RCC.


March 2013

March Question: You are called STAT into the adjoining OR because the anesthetist in that room has just had a syncopal episode, and the surgeon needs an answer on how the TEE looks before he decannulates.

What procedure(s) have been performed, and what is seen? (Image courtesy of Srdjan Jelacic, MD.)


Video 1 - March 2013 - Tee of the Month
Video '1'   (click to enlarge)


March Answer: This patient has had an aortic valve replacement with a mechanical prosthesis, and a mitral valve repair with ring annuloplasty.

In the first image (March answer diastole), a small amount of normal regurgitation is seen (red arrow). In the second image (March answer systole), the green arrows show a small jet of central MR, and where it is arising from, the purple arrows indicate a jet that is arising outside the annuloplasty ring; either the ring has separated from the native annulus, or there has been a small area of A-V separation.

Answer 1- February 2013 - Tee of the Month
Answer '1'   (click to enlarge)

Answer 2- February 2013 - Tee of the Month
Answer '2'   (click to enlarge)


February 2013

February Question: with the videos and images in mind, please determine the Carpentier class of this patient's mitral regurgitation, and what evidence there is for the grade of the MR. Also identified the structures indicated by arrows in the second image.

The second image goes with video 5, and was obtained from video 4 in the following fashion-with the mitral valve seen in 3D, the image is rotated on its vertical axis, towards the examiner.


Video 1 - February 2013 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - February 2013 - Tee of the Month
Video '2'   (click to enlarge)

Video 3- February 2013 - Tee of the Month
Video '3'   (click to enlarge)

Video 4- February 2013 - Tee of the Month
Video '4'   (click to enlarge)

Video 5- February 2013 - Tee of the Month
Video '5'   (click to enlarge)

Image 1- February 2013 - Tee of the Month
Image '1'   (click to enlarge)

Image 2- February 2013 - Tee of the Month
Image '2'   (click to enlarge)


February Answer: this is a patient with a dilated cardiomyopathy. Most people responded that the clips indicated either type I or type III Carpentier class of MR (see Feb Answer 1 figure, from Carpentier's original paper). I believe that it is more in keeping with type III-restriction of the PML and a jet that is slightly posteriorly directed. The 3D clips show lack of central coaptation. (video 3 from the LV side, video 4 from the LA side.) We know the grade of MR is severe-the MR CW (image 1) is early peaking and triangular shaped. The structures are identified in the figure Feb Answer 2. This is the "surgeons view" of the mitral valve with slight angulation.

Answer 1- February 2013 - Tee of the Month
Answer '1'   (click to enlarge)

Answer 2- February 2013 - Tee of the Month
Answer '2'   (click to enlarge)



January 2013

January Question: This patient initially presented with severe SOB and a normal CXR, and subsequently developed a dense hemiplegia. Describe each image and put them all together.
From: "Massimiliano Meineri and Patricia Murphy-Masses and Devices" in Oxorn: Intraoperative Echocardiography, Elsevier 2011.)


Video 1 - January 2013 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - January 2013 - Tee of the Month
Video '2'   (click to enlarge)

Video 3- January 2013 - Tee of the Month
Video '3'   (click to enlarge)


January Answer: Video 1 shows what appears to a thrombus in right atrium. In video 2 a mass is seen in the right pulmonary artery, probably an embolus, causing shortness of breath. Video 3 shows the mass traversing the foramen ovale into the left atrium, and then presumably moving on to the brain causing a CVA.