ECHO - TEE

Question 1

What LAA emptying velocities are associated with stroke in patients with A-Fib?

Answer 1

< 20 cm / s

Question 2

What are low LAA emptying velocities (< 20 cm/s) associations?

Answer 2

• severe spontaneous echocardiographic contrast
  
  • poor prognosis with increased mortality
• appendage thrombus
• cardioembolic events

Question 3

What is the sensitivity of TEE for acute ascending aortic dissection?

Answer 3

> 95% sensitivity

• also highly specific
• intimal flaps are easily visualized when present in the proximal ascending aorta, distal arch and descending thoracic aorta
• sensitivity and specificity verified with comparison to CTA and MRA

Question 4

In the mid-esophageal TEE short axis view of the aortic valve, which cusp is:

• adjacent to the interatrial septum
• most anteriorly located

***in normal trileaflet valves

Answer 4

• adjacent to interatrial septum –> non-coronary
• most anteriorly located –> right coronary

Question 5

What view is best to aid in TEE guided transseptal puncture (either anteriorly or posteriorly)?

Answer 5

Short-axis view at the level of the aortic valve (at the level of the aortic root)

• correct placement of the needle for transseptal puncture is paramount for the safety of the procedure
• to avoid aortic puncture, the needle has to be manipulated posteriorly to the aorta

Question 6

What are the appropriate techniques for probe insertion?

• Control wheels
• Examination of probe
• Patient position
• Neck position

Answer 6

• Control wheels –> unlocked
  
  • ​knobs should never be locked to diminish the possibility of pharyngeal or esophageal injury
• Examination of probe –> inspected for damage before insertion and a live sector image should be on the screen
  
  • helps to confirm normal probe function
• Patient position –> left lateral decubitus position
• Neck position –> anterior flexion of the neck

Question 7

What are the TV leaflets and radial length size?

Answer 7

• Anterior –> longest radial length
• Septal –> shortest radial length
• Posterior

**Ratio anterior-septal-posterior –> 1 : 1 : 0.75

Question 8

What is the longest and most apically positioned cardiac valve?

Answer 8

Tricuspid valve

Question 9

What views are utilized in assessment of the TV?

Answer 9

• ME4C
  
  • septal and anterior leaflets are typically visible
• ME inflow-outflow view
• ME modified bicaval TV view
  
  • may be the most useful for color flow Doppler and spectral Doppler
• TG RV basal view
• TG RV inflow-outflow view
• TG RV inflow view
  
  • TG views allow posterior leaflet to be seen in near field
• TG (deep) LAX views (0 degrees)
  
  • maximal anteflexion +/- rigth flexion

Question 10

Why is it difficult to visualize TR jets on TEE?

What can be done to improve visualization?

Answer 10

• Regurgitant jets are typically not coaxial with the US beam
• Explore in other angles
  • 70-100 degree views are often best for continuous wave Doppler interrogation
  • 150 degree view (in patients with normal sized aorta) –> TR jet size assessment

Question 11

What is the best TEE view for assessing aortic valvular gradients?

Answer 11

Deep TG view at 0 degrees with anteflexion

• objective is alignment of the aortic valve and proximal ascending aorta as prallel as possible witht he continuous wave Doppler cursor
• 90-100 degrees –> probe slowly pulled back keeping the aneflexion and the tip adjusted with the lateral knob
• also important in patients with HOCM

Question 12

What is the significance of spontaneous echo contrast (smoke) in the LAA?

Answer 12

highly associated with previous stroke or peripheral embolism in patients with A-fib

• increased risk of thromboembolic events

Question 13

Why is it important to anticoagulate patients when cardioverted in A-fib?

Answer 13

increased thromboembolic risk

• DCCV –> LAA stunning with increased severity of echocontrast immedately after the procedure
• case reports of patients, not anticoagulated, with no LAA thrombus on pre-cardioversion TEE who develop stroke after cardioversion

Question 14

What is the differential diagnosis for suspected aortic valve endocarditis?

Answer 14

• Lambl’s excresence
  
  • filamentous structures attached to the ventricular side of the valve
• Arantius nodules
  
  • present in the center of the free margin of each of the three cusps of the aortic valve
• Fibroelastomas
  
  • benign tumors often attached to the aortic side of the valve

Question 15

What are the absolute contraindications to TEE?

Answer 15

• Perforated viscus
• Esophageal
  
  • stricture
  • tumor
  • perforation, laceration
  • diverticulum
• Upper GI bleed (active)