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

Now available:

Book purchase allows the individual to utilize the Inkling platform on tablets and smart-phones to view full text and videos.

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July 2017

July question: A fun question for the summer. Those of you with kids will be familiar with the "Fidget Spinner". I have rotated the spinner CLOCKWISE and acquired a video at 30 fps. At the same rotational speed (rpm) video was acquired at 240 fps. In Doppler echocardiography, what are the frames per second (fps) analogous to, and what phenomenon is being illustrated?

 

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June 2017

June question: A and B are MPRs of the same vave. The green plane appears to be intersecting the mitral valve in the A2-P2 postion of the valve in both. Only one is accurate; which one and why?

June answer: The correct response is A, and is explained by the phenomenon known as parallax, which results from the apparent displacement of a 2D plane from its actual position while traversing a 3D plane.

In Figure 1, the depiction of a gas tank meter offers a simple explanation; needle on the right is seen from the driver's side and indicates the tank is more than 3/4 full, but from the passenger’s side (left), it falsely indicates that the tank is only 3/4 full; in the latter example, parallax is present.

In Figure 2A, parallax has been eliminated by adjusting the commissural and long axis planes in slice mode so that only the lines are present indicating true intersection of A2 and P2. In 2B, parallax is present so that the plane is actually intersecting A1 and P1.

The article by Zimmerman (Circ Cardiovasc Imaging 2014; 7:132-41) offers an excellent review.

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May 2017

May question: This patient underwent diagnostic cath for suspected CAD. The cath was negative but shortly after the patient experienced severe SOB. What’s the diagnosis?

May answer: The 2D and 3D image and videos show what appears to be avulsion of the noncoronary cusp with aortic insufficiency. One has to be careful about “mid-leaflet perforation of the aortic valve” seen in 3D as there is frequently dropout; however in the image one can see an avulsed portion of the leaflet. Because it was acute AR, the patient was very symptomatic and was operated on urgently.

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April 2017

April question: This patient’s preop TEE is shown in Video 1, and aortic annular measurements shown in figure 1. The surgeon places a 23mm Trifecta® valve. Post bypass TEE is shown in videos 2 and 3, and a multiplanar reconstruction shown in Video 4. What do you tell the surgeon?

April answer: In the post implantation video, there was a large eccentric jet of AR (see April answer 1). The valve was explanted and found to be distorted (see April answer 2).  A smaller size valve was uneventfully placed.

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March 2017

March question: This 70 year old male presented with fevers, rigors and shortness of breath of 3 weeks duration. Judging by what you seen in the first 2 videos, what is the significance of the findings in video 3 and image 1?

March answer: As seen in videos 1 and 2, the patient has a bicuspid aortic valve, endocarditis, aortic root abscess, and severe AR. In video 3, there appears to be diastolic MR, which is a sign of severely elevated LVEDP. In March answer figure 1, the white arrow indicates flow from LV to LA, and the green arrow shows that the heart is still in diastole.  In the March answer figure 2, the CW Doppler through the mitral valve shows diastolic inflow (white arrow), and the commencement of MR (red arrow) before the end of diastole.

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February 2017

February question: This patient was being worked up for hemolysis. TEE is shown. What is the problem and where is it located? Any other investigations warranted?

February answer: In February answer 1, the white arrow indicates the perivalvular jet which in this long axis view is posterior. In February answer 2, multiplanar reconstruction of the jet allows measurement of the defect size (black arrow). The white arrow indicates intravalvular regurgitation. In January answer 3, an occluder has been placed postero-medially.

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January 2017

January question: What congenital abnormality is seen in this patient? What is the significance of what the arrow in the spectral Doppler is pointing to? The second video is a cardiac MRI resembling a trans-gastric short axis.

January answer:This patient had a double chamber right ventricle-essentially 2RV “chambers” separated by a muscular narrowing in the RVOT
History: angina, dyspnea, dizziness, syncope
PE: harsh systolic ejection murmur at left sternal border
EKG: right ventricular hypertrophy
Diagnosis: TTE, TEE and cardiac MRI.

Associated Abnormalities

VSD (~ 75%)
Valvular pulmonary stenosis
Tetrology of Fallot
Double-outlet RV
Subaortic obstruction
Persistent left SVC

Surgery

• Indications
Symptomatic patient
Peak gradient > 50 mmHg

• Usually repaired in childhood or adolescence
• Approach
Right transatrial
Right transatrial-pulmonary
Right ventriculotomy

Our patient’s operative procedure: Resection of right ventricular outflow muscle and enlargement, reconstruction of the distal main pulmonary artery, the anterior one third of the pulmonic valve annulus, and the right ventricular outflow tract with CorMatrix oval patch. The postoperative gradient was small. (Images and discussion courtesy of Peter Von Homeyer an Srdjan Jelacic.) In the postoperative video, the small jet at the inter-ventricular septum was thought to be an anomalous coronary artery.

• See Prior Months' TEEs