December 2006
Question: The patient had aortic valve endocarditis and had an aortic homograft placed 9 years prior to this admission. He currently presented with shortness of breath and pulmonary edema. In this midesophageal long axis view (left) with closeup (right), identify the pathology.

Answer: It is important to realize that just because a patient has a history of endocarditis, does not axiomatically mean that valve masses years later are necessarily vegetations. The aortic valve had no signs of infection, just senescent leaflet breakdown. The other lesion is a torn cord from the mitral, which was repaired at the time of AVR.

Novmeber 2006
Question: Using the still image and the real time clip, identify the 4 numbered structures.

Answer: This individual had previously undergone a replacement of his ascending aorta with prosthetic material. He later presented with shortness of breath, and TEE revealed pseudoaneurysm formation. The graft has dehised from the aortic root, with subsequent pseudoaneurysm formation. (1) is the entrance to the anterior pseudoaneurysm, and (2) is the entrance to another pseudoaneurysm posteriorly. (3) is the right ventricle, which has been displaced by the pseudoaneurysm, and (4) is debris on the side of the graft.

October 2006
Question: These are simultaneous clips of the distal aortic arch. Define what you see, and the clinical circumstances.

Answer: The TEE demonstrates the so called "Elephant Trunk" procedure. The patient had a type "A" dissection which was repaired; however, her arch and descending aorta enlarged to an unacceptable extent. Under deep hypothermic circulatory arrest, a graft was sewn to the ascending aorta, and the great vessels re-implanted. The distal end of the graft was left free floating in the descending aorta, where an intussuception had been created. At a later date, a descending graft was introduced through the femoral artery, and anastomosed interventionally to the free end of the "Elephant Trunk". In the angio, panel A shows dye being injected into the aortic root. It fills the elepjhant trunk. In panel B, the enodstent has been introduced from the groin, and deployed within the elephant trunk.

Question Image

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Answer Image

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September 2006
Question: What is the abnormality seen in these 2 images from the same study?

Answer: The images show an inferior wall aneurysm secondary to myocardial infarction. There is obvious dyskinesis in both clips. Aneurysms are classified as true or false- true aneurysms are lined by all 3 layers-endo, myo, and epicardium whereas false aneuryms are not. Typically the neck of a false aneurysm is smaller than the diameter, whereas the neck is broader in a true aneurysm. In the long axis, the aneurysm is unequivocally true.

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August 2006
Question: What is the structure peaking at you, as seen in real time and still image (arrow)? (Images courtesy of T. Andrew Bowdle, MD)

Answer: This is a mitral commissurotomy view, which shows, as in this case, P1, P3, and A2; in this instance however, there is a flail of P2 which is seen prolapsing behind A2. The 2 small densities are torn chords which subtend the flail segment.

Real time Image

Still Image

July 2006
Question: Put all 3 images together!

Answer: The 3 images show echocardiographic aspects of hypertrophic cardiomyopathy. The CW Doppler shows a peak gradient of 40mmHg, but the sawtooth pattern is very typical for the dynamic LVOT obstruction seen with hypertrophic cardiomyopathy. This is in contradistinction to the fixed obstruction seen with a sub aortic membrane; here the pattern resembles that of aortic stenosis, and is symmetric in its upstroke and downstroke (Answer #1).

The m mode shows a pattern seen in dynamic LVOT obstruction; the aortic valve cusps show an abnormal motion pattern, typically opening normally at the onset of ejection then fluttering to a semi-closed position, as the driving flow diminishes. This is compared to the normal m mode of an aortic valve in the absence of LVOT dynamic obstruction; there is no fluttering nor early closure. (Answer #2).

The loop shows the typical systolic anterior motion (SAM) of the anterior mitral leaflet.

Still Image #1

Still Image #2

Animation