Anesthesiology & Pain Medicine >> Education >> TEE of the Month >> 2009 January – June

Transesophageal Echocardiogram of the Month

TEE pictures furnished by Dr. Donald Oxorn, UW Anesthesiologist

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June 2009

Question: What abnormality(s) are demonstrated in the clip?


June Tee

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.

June Answer


May 2009

Question: Identify the various Doppler velocities, and by examining the clip, the clinical context in which they are occurring.

May 2009 Tee Question

May 2009 Question detail

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)


May 2009 Answer, Fig. 1

2009_05_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.


May 2009 answer, Fig. 2

2009_05_answer Fig. 2



April 2009

Question: (Remember this is April 1st!) What does this clip show (April gif), and what continent is this parasite endemic to?
Image 1

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!

April 2009 Tee Answer


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?

Clip 1
March 2009 Clip #1
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Image 1
March 2009 Image 1

Clip 2
March 2009 Clip #2
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Image 2
March 2009 Image 2

Clip 3
March 2009 Clip #3
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Clip 4
March 2009 Clip #4
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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 1

March Answer 2

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)

Clip 1
February 2009 Clip #1
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Image 1
February 2009 Image 1

Clip 2
February 2009 Clip #2
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Image 2
February 2009 Image 2

Holiday Clip
Happy Valentine's Day Clip
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Answer 1
February 2009 Answer 1

Images courtesy of Dr. Ben Sherman


January 2009

Question: With the videoclip in mind, explain the 2 Doppler tracings.

Clip 1
January 2009 Clip
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Image 1
January 2009 Image 1

Image 2
January 2009 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:

  1. Carefully examine the 2D image to see what structures the Doppler beam intersects, especially important with CW.
  2. 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.
  3. 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.