Anesthesiology & Pain Medicine >> Education >> TEE of the Month

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


TEE Standard Views on Apple iPad App icon

iTunes Preview

Echo AUC App icon

American Society of Echocardiography
Echo AUC

iTunes Preview

ASA Pocket Guidelines App icon

American Society of Echocardiography
ASE Pocket Guidelines

iTunes Preview

iASE App icon

American Society of Echocardiography
iASE

iTunes Preview




December 2014

December Question: Considering the 3 videos, what is seen in the image and what is the likely cause? (Images courtesy of Andy Bowdle.)


Video 1 - Sep TEE of the Month
Image'1'   (click to enlarge)

Video 1 - Dec TEE of the Month
Video '1'   (click to enlarge)


Video 2 - Dec TEE of the Month
Video '2'   (click to enlarge)

Video 3 - Dec TEE of the Month
Video '3'   (click to enlarge)


December Answer: See graphic. Panel "A" shows moderate AR, Panel "B" shows PISA formation in a subvalvular position; both are 2D mid esophageal long axis views. Panel "C" is a 3D image and Panel "D" is a deep transgasric view, both showing a sub aortic membrane. The Doppler image from the December question is indicative of a fixed obstruction, very similar to the Doppler image that would have been seen in valvular aortic stenosis, and unlike the "ice pick" tracing seen in variable sub aortic obstruction.

Answer Image 1 - June 2014 - Tee of the Month
Answer Image '1'   (click to enlarge)



November 2014

November Question: In this image seen from the superior aspect of the heart, what is seen and what is the pathology?


Image 1 - Nov TEE of the Month
Video'1'   (click to enlarge)

November Answer: This patient is in this 3D TEE exhibiting classic features of rheumatic heart disease. The mitral valve (L) shows the classic "fish mouth" appearance. The tricuspid valve (R) also shows classic features of leaflet edge thickening, and what appears to be only 2 cusps, probably due to fusion. 



October 2014

October Question: This patient presented with severe prosthetic mitral stenosis as seen in the first video, and after her procedure, the appearance was that seen in the second video. What procedure was performed? (Hint-cardiopulmonary bypass was not used.)


Video 1 - Sep TEE of the Month
Video '1'   (click to enlarge)

Video 2 - Sep TEE of the Month
Video '2'   (click to enlarge)



October Answer: This is a relatively new procedure, the so-called "Valve in Valve" -- in which following a balloon valvuloplasty, a Melody Valve (similar to a transcatheter aortic valve prosthesis) is deployed inside the existing valve prosthesis. (See attached reference).

Answer Image 1 - June 2014 - Tee of the Month
Answer Image '1'   (click to enlarge)



September 2014

September Question: What pathology does this patient have (video 1), and what corrective procedure has been performed (video 2)?


Video 1 - Sep TEE of the Month
Video '1'   (click to enlarge)

Video 2 - Sep TEE of the Month
Video '2'   (click to enlarge)



September Answer: This patient as demonstrated in the first video, had a flail P2 segment along with generalized prolapse of the whole posterior leaflet. This was treated by an Alfieri Stitch between A2 and P2, and a ring annuloplasty. Some individuals mistook this for a mechanical valve, but the sewing ring is not circular. The appearance of a ‘strut” (September answer, arrow) is most likely a 3D artifact.

The Alfieri Stitch is the basis of the Mitraclip, which approximates anterior and posterior portions of the mitral leaflet, but does not allow for an annuloplasty ring.

Answer Image 1 - June 2014 - Tee of the Month
Answer Image '1'   (click to enlarge)



August 2014

August Question: This patient had a previous tissue aortic valve replacement. What complication(s) does he now present with?


Video 1 - Aug TEE of the Month
Video '1'   (click to enlarge)

Video 2 - Aug TEE of the Month
Video '2'   (click to enlarge)





August Answer: The patient has both prosthetic aortic valve regurgitation and a VSD with flow from the LVOT to the right ventricle.



July 2014

July Question: What is the rare abnormality seen in the video and image (images courtesy of Burkhard Mackensen)?


Image 1 - July 2014 - Tee of the Month
Image '1'   (click to enlarge)

Video 1 - July 2014 - Tee of the Month
Video '1'   (click to enlarge)



July Answer: This is a beautiful example of a quadricuspid aortic valve with central aortic regurgitation as imaged by G. Burkhard Mackensen. This is a rare congenital abnormality with a reported prevalence of between 0.01%–0.04%. Quadricuspid aortic stenosis is rare, but as in this case, thickened leaflets with significant aortic regurgitation is common.



June 2014

June Question: What is the structure indicated by the question marks?


Video 1 - June 2014 - Tee of the Month
Video '1'   (click to enlarge)

Video 2 - June 2014 - Tee of the Month
Video '2'   (click to enlarge)


Image 1 - June 2014 - Tee of the Month
Image '1'   (click to enlarge)

June Answer: The structure in question is a pseudoaneurysm of the mitral aortic intervalvular fibrosa, an area which is especially prone to complications following aortic valve endocarditis. In the current case, the patient had a previous tissue aortic valve replacement. It is likely that he subsequently developed endocarditis with pseudoaneurysm formation posterior to the aortic root. Color flow Doppler establishes to and fro movement form the LVOT to the pseudoaneurysm, and the absence of any communication with the left atrium. The asterix indicates the orifice of the pseudoaneurysm in the 3D image:

Answer Image 1 - June 2014 - Tee of the Month
Answer Image '1'   (click to enlarge)