June 2004
Question: What is the diagnosis is this high esophageal view?

Answer: The images are of an adult PDA, best seen in the high esophageal 80-110 degree plane. There is continuous flow fron the aorta to PA as the aortic pressure always exceeds the PA. The pressure gradient was probably measured during an episode of arterial hypertension. Some suggested the diagnosis of ASD but the pressure gradient clearly rules that out.

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May 2004
Question: Describe what is seen in this intraoperative image in a patient who has lost the pulses in his lower extremities?

Answer: There is an intra-aortic balloon pump in the descending thoracic aorta in the presence of an aortic dissection-the etiology of the dissection was unclear. It is most likely in the true lumen; general evidence distinguishing true from false is color Doppler intraluminal flow, and systolic expansion of the true lumen. The true lumen is often though not invariably smaller. Color jets between the lumens does not guarantee the diagnosis as the jet may be an exit or re-entry jet.

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April 2004
Question: What is the echocardiographic diagnosis and what are the suggestive clues?

Answer: The image on the left is a transgastric and on the right is a midesophageal view of a patient who sustained a type "A" aortic dissection and developed tamponade. Along with the presence of a sizable pericardial effusion, there is RA and RV collapse and the times in the cardiac cycle when the chamber pressure is the least: end of diastole-beginning of systole for the RA and end of systole-beginning of diastole for the RV.

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March 2004
Question: What is this mass seen in the left atrium?

Answer: The mass is an inverted left atrial appendage (ILAA), which can occur de novo or appear after cardiac surgery. Risk factors thought to be associated with ILAA include the use of LV vent, the use of LA line, inversion of the LA during deairing procedures, and a long, thin atrial appendage with a narrow base. (Cohen AJ. Inverted left atrial appendage presenting as a left atrial mass after cardiac surgery. Ann Thorac Surg. 1999 May;67(5):1489-91) In our patient, after being discharged home following an aortic root replacement, she was readmitted with symptoms of a TIA, and was re-explored following echocardiographic demonstration of the left atrial "mass".

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February 2004
Question: This patient with a history of transposition of the great vessels received a heart transplant. What is the etiology of the turbulent flow in this high esophageal image?

Answer: The turbulent flow in this high esophageal image is the result of a relative stricture of the anastomosis between the native and transplanted pulmonary artery; this resulted because the patient's pulmonary artery was so large compared to the donor's. The gradient measured was high at 29 mmHg. This high essophageal image is usually suitable for PW and CW of the PA and RVOT. (see image-Feb answer.jpg)

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January 2004
Question: Describe the course of the flow indicated by the arrows on the left hand image. Once you have decided what it is, does it appear in any way abnormal?

Answer: The flow is in the left main coronary artery. The abnormality is the size of the orifice; this is in fact a coronary button that has been sewn into the aorta during a Bentall procedure, which is the insertion of a valved conduit-aortic valve and ascending aortic graft