Features
www.uwanesthesiology.org/echoTransesophageal Echocardiogram of the Month
TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist
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January 2010
For better viewing, and the ability to alter the speed of the clip, drag the video to the desktop, and open with Quicktime or equivalent.
January Question: This patient had previously undergone aortic valve replacement for chronic AR, but developed progressive LV dilation and reduced systolic function. He now presents for LVAD placement.
1)What do the images of the mitral valve show?
2)What procedure would have to be done in conjunction with the LVAD placement?
Video 1
Video 2
Video 3
December 2009
December Question: What do each of the images show, and what is the underlying pathophysiology?
Video 1
Video 2
December Answer: Both video clips show enlarged right ventricles. In video 1, the septum is flat, and although the septal motion is paradoxical, the septum remains flat during the whole cardiac cycle giving the characteristic “D” shape. This indicates RV pressure overload; the patient in question had chronic pulmonary emboli. In video 2, although there is paradoxical septal motion, the septum retains its normal curvature, especially in systole. This indicates RV volume overload. In both video clips, there are prominent RV papillary muscles.
November 2009
November Question: A 45 year old male presents with severe backpain. Based on the figure and 3 video clips, what is the differential, what is your diagnosis and why.
Image 1
Video 1
Video 2
Video 3
November Answer: Any time an echoic space is present around a valve, especially the aortic, one must be suspicious of endocarditis with abscess formation. Although it is obvious that the patient has a bicuspid valve, there is no evidence whatsoever of endocarditis. Closer examination shows what appears to be an aortic ulcer in the non coronary cusp. Video #3 shows the resultant pericardial effusion. The patient was taken to the OR, where the diagnosis was confirmed (See image).
October 2009
October Question: This patient had a HeartMate II® implanted for an ischemic cardiomyopathy The HeartMate II® is a high-speed, axial flow, rotary blood pump, and as an axial flow device, produces no pulsatile action. The patient presented 6 weeks later with ventricular tachycardia. There was also evidence of significant hemolysis. The patient was cardioverted and a TEE was performed. Videos 1 and 2 show the inflow cannula from the left ventricle to the device. Images 1 and 2 are still frame during systole and diastole respectively, and image 3 is a pulse Doppler recording from the proximal end of the inflow cannula. Describe LVAD function and the interpretation of the videos and images.
Video 1
Video 2
Image 1
Image 2
Image 3
October Answer: This series of clips shows the TEE of a patient with a HeartMate II® left ventricular assist device. The non pulsatility of the design means that there should be continuos flow during the whole cardiac cycle. A slight pulsatility may be observed if the ventricle ejects a significant amout of blood through the inflow cannula. One instance where flow may be interrupted is if the LV is very underfilled; a "suction event" may occur in which the LV walls are literally sucked down on the inflow cannula (to the device) thereby occluding it.
In this case, the inflow cannula is misdirected toward the septum. During systole, the paradoxical motion of the septum opens the way for blood to flow into the device, but during diastole, the septum moves inward and occludes the orifice of the inflow cannula. This is obvious with colour Doppler, and the dropout of the pulse wave Doppler signal during diastole.
September 2009
Question: As an infant, this 26 year old patient had a Rastelli procedure for transposition of the great vessels with VSD and pulmonic stenosis. What is seen in each of the 2 video clips and corresponding still images? Calculate the pulmonary artery systolic pressure.
Image 1
Video 1
Image 2
Video 2
September Answer: Video 1 shows and extremely dilated right atrium and a hypertrophied right ventricle. Image 1 shows the CW through a jet of tricuspid regurgitation. According to the simplified Bernoulli's equation, and assuming the proximal velocity is small, the peak gradient across an orifice=4V2. In this case, this works out to 4 x (3.6 x 3.6) or 52.4 mmHg. If one then adds the CVP of 22, this means that the right ventricular systolic pressure is 72.4mmHg. It is usually assumed that this value is the same as the pulmonary artery systolic pressure, but not in this case where there is obstruction of the RV to PA conduit as seen in video 2 and figure 2. The peak systolic gradient from RV to PA is 54.5 making the the PA systolic pressure 72.4-54.5 or 18mmHg.
July/August 2009
Question: In video clips 1 and 2 a mass is evident on the mitral valve. What is the differential of the mass, and can one determine what portion of the mitral valve is involved? Video #3 is placed as reference.
Video 1
Video 2
Video 3
July/August Answer:
The mass was a myxoma, but it is impossible to know definitively if it was thrombus, tumor or vegetation-one might have suspicion, but as always, "clinical correlation is required".
In terms of localization,see the attached figure (July August answer) which I have modified to show the lesion. It was on P3,but so close to the posterior commissure that it is difficult to tell if A3 was involved. I neglected to mention that at zero degrees, the probe was retroflexed, so it was probably catching the lesion. I think the clincher was the bicommissural view, as if it was on A3, it probably would have dropped out of view in systole.
Leaflet involvement is perhaps easier if there is a colour jet involved; see November 2008 of my site.
June 2009
Question: What abnormality(s) are demonstrated in the clip?
June answer: As illustrated in the figure, there is a “windsock” marked with an asterisk, which is typical for a sinus of Valsalva aneurym. In this case, as illustrated with the colour flow, there is a jet from the aneurysm into the right atrium. Flow is continuous through the whole cardiac cycle, reflecting the pressure gradient form the aorta to the right atrium. As detailed in the following reference: Feldman:Aneurysms of the Sinuses of Valsalva, Cardiology 2006;106:73–81, these can either be congenital or acquired, and depending which sinus is involved, can rupture into a variety of chambers. The clinical sequelae also depend on the chambers involved.
May 2009
Question: Identify the various Doppler velocities, and by examining the clip, the clinical context in which they are occurring.
May answer: The patient is in atrial flutter, and the PW Doppler interrogation is of the left upper pulmonary vein (LUPV). Waves 2 and 3 are systole and diastole respectively. During diastasis, continuing flutter waves (4 and 5) in the presence of an open mitral valve generate some flow from the LUPV into the left atrium (LUPV red-May answer Fig. 1)
During left ventricular isovolumic contraction, the flutter wave meets a closed mitral valve, and flow is propogated down the pulmonary vein producing wave 1 (LUPV blue-Answer may#1). The aortic valve then opens, the left ventricle ejects, and we are back to wave 2.
This case emphasizes the point that interpreting a Doppler trace must be done with the ECG available.
April 2009
Question: (Remember this is April 1st!) What does this clip show (April gif), and what continent is this parasite endemic to?
April answer: The image is from a patient with aortic dissection, who developed a pleural effusion. The "parasite" is atelectatic lung, which is "consuming" fibrin debris from within the effusion!
March 2009
Question: Clips 1 and 2 show an RV inflow-outflow view with an abnormal jet; Image 1 shows the position of a CW cursor (white arrow) and image 2 shows the Doppler image. Clips 3 and 4 show a transgastric view at the same time. What is the pathologic process?
Image 1
Image 2
March answer: Clip #1 shows a tissue prosthetic aortic valve in place. Clip #2 shows Colour Doppler applied to the clip, with turbulent flow in both systole and diastole, and some diastolic flow appearing in the right ventricle. Clip #3 shows a transgastric long axis view, and the Colour Doppler applied in clip #4 shows a broad jet of diastolic regurgitant flow. The 2 figures show a CW cursor revealing what appears to be a double envelope appearing during systole.
This case represents a partially dehised aortic prosthesis with paravalvular regurgitaion, and systolic flow through the valve and paravalvular region, and then through a VSD that was probably iatrogenic. The image entitled March answer1 shows the paravalvular defect, and the image entitled March answer2 taken after valve explantation shows the interventricular septum with the VSD. The image entitled March answer3 (property Ed Gill, MD) is a 3D TEE; the asterisk most likely indicates a combination of the paravalvular leak and VSD.
March Answer 1
March Answer 2
February 2009
Question: This case involves an often undiagnosed anatomic abnormality.Clip 1 shows 2 structures, and Figure 1 shows the Doppler recording from one of them. Clip 2 shows the probe being withdrawn from the midesophageal depth, and rotated to the patient's LEFT. Figure 2 reveals a Doppler trace (Take note of the direction of the jet).
Bonus-the clip entitled Holiday Greetings is from a patient with advanced cardiac amyloid. The deposits have a predilection for the left atrium, and have involved the "coumadin ridge" to reveal an interesting pattern!
With the video clips in mind, explain the 2 Doppler tracings.
February answer: The case is an example of a right sided aortic arch. In clip #1 there is a structure seen to the right of the descending aorta, and Doppler interrogation of this structure reveals it to be a pulmonary vein; the descending aorta is on the right. In clip #2, the probe is withdrawn while visualizing the descending aorta, and the arch is seen to be right sided; Pulsed Doppler interrogation shows blood moving as demonstrated by the red arrow in the image “Answer 1”. This is opposite to the direction that one would normally expect. In the presence of normal situs, right sided aortic arch is uncommon, and is usually associated with other defects, especially those of right sided outflow. The patient in the current case had a repaired Tetralogy of Fallot. Other commonly associated lesions are pulmonary atresia with ventricular septal defect, and truncus arteriosus.
I am including 2 references-one from 1999 (Ann Thorac Surg 1999;67:1194 –202) and a historical reference sent to me by Greg Miller of Spokane, WA (Brit. Heart J 1966; 28: 722-39)
Image 1
Image 2
Answer 1
Images courtesy of Dr. Ben Sherman
January 2009
Question: With the videoclip in mind, explain the 2 Doppler tracings.
Image 1
Image 2
January answer: The clip suggests aortic stenosis. However, the peak and mean gradients are not very high.
This is the typical presentation of someone with aortic stenosis in the presence of low cardiac output. What is interesting is that the stepup from the LVOT to the aortic valve is almost 5 fold, so that AVA calculated using the continuity equation is quite small.
If there is still a question about the severity, some cardiologist will perform a dobutamine stress echo to see if the gradient increase with increased cardiac output.
When analyzing any Doppler trace, several basic principles apply:
- Carefully examine the 2D image to see what structures the Doppler beam intersects, especially important with CW.
- Examine the direction of the signal, the presence of aliasing,and the signal's shape and intensity. For example, the jet of dynamic outflow tract obstruction is usually dagger shaped, whereas valvular AS produces a parabolic shape as in the current case.
- Note the phase of the cardiac cycle and what portion of that phase the jet occupies ie MVP often produces a late peaking jet of MR.
November 2008
Question: What is seen in the 2 clips? Be specific.
Answer: The 4 chamber view shows the mitral apparatus. The aortic valve is not seen so the portions seen are probably A2 and P2. Medially and posteriorly, during systole, tissue is seen prolapsing into the atrium, and associated with a jet of MR suggestive of prolapse of a portion of the anterior mitral leaflet. Although is could be a vegetation, and i admit more views would have been helpful, it was a flail of A3. When eccentric jets occur, they usually imply excessive movement of leaflet tissue-if the jet is posterior, it is most likely due to anterior prolapse or posterior restriction (as is sometimes seen in ischemic MR) and vice versa.
October 2008
Question: Clip #1 is a series of cuts from base to mid-papillary level after coming off CPB following a procedure. Clip #2 shows a deep transgastric view taken at the same time. The first image shows a Doppler cursor placed in the same view as clip #2; the second image shows the CW trace at that time, and the third image shows the same CW cut after certain theraputic maneuvers have been undertaken. Describe what is seen in each instance.
Answer: Clip number 1 has 3 frames; on the left, a mitral annuloplasty ring is seen in short axis; in the middle, the ring is again seen, and during systole some unexpected tissue is seen; on the right is a midpapillary view showing LVH. Clip number 2 shows systolic anterior motion of the anterior mitral leaflet. Image 1 shows a cursor placed through the LVOT; image 2 shows the typical appearance of outflow tract obstruction, a so called "dagger-shapedappearance". This is secondary to underfilling, vasodilating, and increase inotropy. After fluid administration, vasoconstriction, and stopping the inotropes, we are left with a more uniform Doppler signal, which is consistent with an aortic valve prosthetic gradient from aortic valve replacement surgery several years back.
Clip 2
Image 1
Image 2
Image 3
September 2008
Question: What abnormality is demonstrated in this surface study?
Answer: This is a surface study of a newborn showing the ascending aorta, the arch, the great vessels, and the descending aorta. Under the aortic arch, the pulmonary artery is seen, Along with the colour Doppler jet indicating flow in the aorta and great vessels, there is continuous flow between the PA and the proximal descending aorta indicating a patent ductus arteriosus (PDA).
Surface Study
August 2008
Question: On the basis of the 6 videos and the two images, what abnormality did the patient have, and how was it corrected.
Answer: This patient had a D-transposition of the great arteries with a VSD and pulmonic stenosis, repaired by a Rastelli procedure.
Image 1 and video 1 show RVH secondary to the increased RV work. Video 2 shows parallel orientation of the aortic valve (anterior) and the pulmonic valve (posterior). It is also seen that the pulmonic valve is not opening-it has bee surgically obliterated so that the systemic ventricle stops pumping to the lungs. In figures 3a and 3b the VSD has been patched such that the systemic ventricle now pumps into the aorta.
To re-establish blood flow to the lungs, a valved conduit is placed from the RV to the PA as seen in videos 4a and 4b. The CW in image 4 shows a modest peak gradient of approximately 15mmHg.
Newer surgical techniques are now being used to correct this condition.
July 2008
Question: 4 cases of mitral regurgitation are presented. In only one of them is the MR made worse by decreased afterload. Which one?
Answer:
- Case 1 is a patient with an inferior wall MI as seen on the EKG. In animation “A”, the basal inferior wall is akinetic, and the papillary muscle does not contract; in fact in some views it looks ruptured. Animation “B” shows a retracted posterior mitral leaflet, with an eccentric jet of MR directed posteriorly. When the posterio papillary muscle was examined at surgery, its head was infracted, and scar tissue was seen on microscopic examination.
- Case 2 is a patient with MR secondary to rheumatic mitral stenosis.
- Case 3 (CORRECT) is a patient with systolic anterior motion of the anterior mitral leaflet, with outflow tract obstruction with turbulence of systolic flow, and eccentric MR. It is well none that the outflow tract obstruction worsens with vasodilation, as would the mitral deformation with subsequent worsening of MR. All other cases would show improvement of MR.
- Case 4 is a patient with a flail posterior mitral leaflet (P2).
Some respondents answered case 1, as they felt that lower BP would comprimise coronary perfusion, increase ischaemia, and worsen MR. The “Q” wave in the EKG, and the thin appearance of the inferior wall suggest that vasodilation would be unlikely to worsen MR; the decreased afterload and improved forward flow would augur well for decreased MR (and this was the case clinically).
Case #1 |
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