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

You might also like to visit the Canadian Society of Echocardiography-Cardiomath Echo Calculator

For those with smartphones or iPads I recommend the following apps as excellent reference guides. The first is from the University of Toronto (same folks who brought you the Virtual TEE website) and the next 3 are from the American Society of Echocardiography

TEE Standard Views on Apple iPad App icon

iTunes Preview

Echo AUC App icon

American Society of Echocardiography
Echo AUC

iTunes Preview

ASA Pocket Guidelines App icon

American Society of Echocardiography
ASE Pocket Guidelines

iTunes Preview

iASE App icon

American Society of Echocardiography
iASE

iTunes Preview


December 2013

December Question:  In the first clip, is this mitral valve in the anatomic or antianatomic position? In the second clip, A) is this a normally functioning prosthesis, and B) how do you explain the discrepant appearances of the top 2 quadrants?


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

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

December answer: This valve is in the antianatomic position. We know this because of the orientation of the leaflets; they are 90 degrees out of sync with where the native leaflets would lie. The video "anatomic" will highlight this difference.

I use the second video to make a point that is often unappreciated. In the lower right, we see the green line cuts symmetrically through the valve; this is represented in the top left quadrant where nice symmetric leaflet movement is demonstrated. This view is necessary to " make the call". In the top right quadrant, it appears as if only one leaflet is moving, but as seen in the lower right, this is merely because the prosthetic valve is not symmetrically cut by the red line.

If the valve is anatomically placed, the angle of interrogation should be around 120 degrees (MELAX); just like the native valve. If antianatomically placed, it should approximate the bicommisural view.

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


November 2013

November Question: These 2 videos were taken closely in time, in the same patient. What is the difference, and how might you account for it?


Video 1- November 2013 - Tee of the Month
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Video 2- November 2013 - Tee of the Month
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November answer: The change implies that the first injection was a false negative. The possible reasons include washout of SVC contrast by IVC flow, diversion of SVC contrast to the tricuspid valve by the Eustacian valve, and high left atrial pressure preventing contrast from crossing from the RA to the LA. Doing a Valsalva maneuver is the most common method used to overcome the high LAP. In the ventilated patient, a positive pressure hold of about 30cm H2O is applied; the contrast is then injected and the pressure is released. If there is suspicion that a false negative still exists, injecting the contrast below the diaphragm may get around the diversion by the tricuspid valve.


October 2013

October Question: This patient presented with numbness in the left hand. What do the 3 clips and 1 still from the TEE reveal?
(Images courtesy of T. A. Bowdle, MD)


Image 1 - October 2013 - Tee of the Month
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Video 2- October 2013 - Tee of the Month
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Video 3- October 2013 - Tee of the Month
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Video 4- October 2013 - Tee of the Month
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October Answer: The 4 views are high esophageal views of the aortic arch. The still image 1 shows what appears to be some sort of catheter in the aortic arch, which is visualized in the long axis at 0 degrees. Video 2 is again of the arch, but now seen in short axis at 89 degrees. In video 3 the catheter is seen in close proximity to the origin of the left subclavian artery, and finally video 4 shows some material (likely thrombus) associated with it.

This was a misplaced central line. We know this is not an artifact because of the complex nature of the image, and its striking similarity to a catheter. More importantly it does not have the appearance of an artifact; certainly not a reverberation, nor a side lobe, nor a beam width artifact, nor a range ambiguity artifact. It is appropriate to compare this situation to the saying: "If it looks like a duck and walks like a duck, it probably is a duck."


September 2013

September Question: This patient had a mitral valve repair 10 years previously and now presents with symptoms of increasing MR. What do you see in the 4 TEE clips? The 3D clips have been presented in standard orientation; ie surgeons view. (Images courtesy of Peter Von Homeyer, MD)


Image 1 - September 2013 - Tee of the Month
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Image 2- September 2013 - Tee of the Month
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Image 3- September 2013 - Tee of the Month
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Image 4- September 2013 - Tee of the Month
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September Answer: The top 2 clips show what appears to be a mitral ring with an unusual gap posterior to it, and a jet of MR through the gap. The bottom left clip is a 3D TEE from the LA perspective with a round defect posterior to the annuloplasty ring. The bottom right clip is the the mitral valve from the ventricular perspective which shows the defect as well. Either the ring has dehisced from the native annulus, or the defect is the result of breakdown of repair stitches, and subsequent dilation of the LA and "stretching" of the defect. The patient had actually been anesthetized for MV replacement, but on viewing the intraoperative TEE, the surgeon decided to seek an interventional cardiology opinion. The procedure was aborted and a planned device closure has been arranged.


August 2013

August Question: This patient had MR. Assuming the measurements have been made correctly, how would you assess the degree of MR?


Image 1 - August 2013 - Tee of the Month
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Image 2- August 2013 - Tee of the Month
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Image 3- August 2013 - Tee of the Month
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Image 4- August 2013 - Tee of the Month
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August Answer: If we calculate the stroke volumes through the mitral valve and then the aortic valve, we can assess the degree of MR. Images 1 and 2 reveal a mitral valve area of 7.3 cm2, and the VTI of mitral inflow is 10.2 cm, yielding a stroke volume through the mitral valve of 75ml. Images 3 and 4 reveal an LVOT area of 4.4 cm2, and the VTI of aortic outflow of 10.9 cm, yielding a stroke volume through the aortic valve of 48ml. The regurgitant volume is 27 ml and a regurgitant fraction of 75-48/75, or 0.36: overall mild in severity. 1. AMERICAN SOCIETY OF ECHOCARDIOGRAPHY REPORT Recommendations for Evaluation of the Severity of Native Valvular Regurgitation with Two-dimensional and Doppler Echocardiography. J Am Soc Echocardiogr 2003;16:777-802. 2. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. European Journal of Echocardiography (2010)11, 307–332


July 2013

July Question: Video 1 shows the aortic arch and below it the pulmonic valve and PA in a high esophageal view. In video 2 the probe is advanced slightly and rotated to the left. In video 3, CD is applied to video 2. Video 4 is a four chamber view. Image 1 is a PW Doppler interrogation of the color jet in video 3, and image 2 is a CW Doppler of the TR jet.

What is the patient's condition, and what is seen?


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

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

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

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

Image 1 - July 2013 - Tee of the Month
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Image2 - July 2013 - Tee of the Month
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July Answer: the images are indicative of an uncorrected PDA (Patent ductus arteriosus). This adult presented with abdominal pain. The PA is enlarged, there is systolic right to left flow, and diastolic left to right flow: I suspect the flow reversed in diastole, is because there was significant PR as seen in the TTE parasternal short axis view (July answer). Elevated right-sided pressures are evident from the 4-chamber view as well as the CW of the TR jet.

answer video 1 - July 2013 - Tee of the Month
Answer Video '1'   (click to enlarge)

answer Image 1  - July 2013 - Tee of the Month
Answer Image '1'   (click to enlarge)