June 2006
Question: What is the structure indicated by the asterisk in this mid esophageal 4 chamber view?

Answer: The structure is a hiatus hernia; there aren't too many structures behind the left atrium, and certainly none that resemble so closely the stomach and its lining as are often seen on transgastric imaging. Some respondents rejected the idea, and reasoned that the esophagus would offer a poor acoustic window; however, the hernia is filled with fluid regurgitated from the stomach. The CXR and CT scan certainly illustrate the hernia.

This report: Transesophageal Two-Dimensional Echocardiographic Identification of Hiatal Hernia from Echocardiography. Volume 22 Page 533  - July 2005, amplifies these points.

May 2006
Question: Frames A and B are both from the same patient-A is immediately postop and B is 6 months later. What surgery has been performed, and what has supervened?

Answer: The patient had a tissue aortic prosthesis inserted without complication, as demonstrated in the left hand panel. However, 6 months later he presented in CHF;the right hand panel shows a rocking aortic prosthesis, which inicates that part of the prosthetic annular attachment had come loose. In this situation, the most likely cause is endocarditis.

Video clip

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IMAGE COURTESY OF KRIS NATRAJAN MD

April 2006
Question: What are the identities of the 2 structures with question marks in this midesophageal long axis view, and what abnormalities are evident from the still and video clip?

Answer: Many respondents had trouble putting this image in context. ?1 is an aneurysmal ascending aorta that the patient was scheduled to have repaired, and ?2 is the right PA. It is an in between view that has element of a ME long axis, and a bicaval; the ascending aorta is so large, that it invades the long axis!

What is also present is a large ASD with right to left shunt, undiagnosed prior to intraoeprative TEE. The patient told me preoepratively that she had been told her SaO2 was low for a number of years!

Video clip

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Midesophageal long axis view

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March 2006
Question: This patient underwent a procedure because of severe MR due to mitral valve prolapse. The rest of the preop TEE was normal.

1. What was done to the mitral valve?
2. What new abnormality has appeared?
3. What is the likely cause of 2)?

Answer: This is a midesophageal aortic valve long axis view following MV replacement with a pericardial prosthesis-this appearance is typical-the 2 mitral leaflets are thin and look very similar. The small amount of central MR is normal. What is not normal is the new finding of significant aortic regurgitation, that has resulted from inadvertent plication of the NCC of the aortic valve. The close proximity of the MV & AV mandates that the AV be examined whenever surgery is done on the MV. The anatomy is nicely referenced in Bansal, R. et al Ann Thorac Surg. 1997 Sep;64(3):684-9.

Video clip

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February 2006
Question: In the figure, what is the structure indicated by the arrow, what abnormality is associated with it, and what is causing its positional change in the video clip?

Still image

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Video clip

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Answer: In this bicaval view, the redundant interatrial septum (IAS) is seen bowing to the right. (Figure). A Valsalva maneuver is performed, and over the next few frames, the septum moves towards the left atrium, signifying an increase in right atrial pressure. This is done to enhance the chances that during a bubble study, a PFO will be detected.

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January 2006
Question: In the still and the corresponding video clip, what structures are identified by letters A through D?

Still image

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Video clip

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Answer: The A,B,C,D structures are the left atrium, aortic valve, pulmonic valve, and a mirror image artifact of the RVOT and pulmonic valve. The structure indicated by the arrow (Figure 1 below), moves in synchrony with the cardiac cycle, which distinguishes it from the pericardium, and makes the diagnosis of mirror image artifact clear.

The etiology of mirror image artifacts is explained in several good references (JACC 1993; 21: 754-60 and J Ultrasound Medicine 1986; 5: 227-37), and involves excessive ultrasound reflection from a highly reflective surface. Our suspicion was confirmed by the appearance of colour Doppler in both the true RVOT and the mirror image, and when agitated saline was injected, it again appeared in both true and mirror image structures (Animation below). A still from the bubble study demonstrates the mirror effect (Figure 2 below, arrows).

Figure 1

Animation

Figure 2