Well…not exactly. This modified bicaval view (you can actually see the SVC and IVC both, which is not that common) shows us a sliver of the tricuspid valve. The modified bicaval view can sometimes give you excellent alignment for spectral Doppler of the TV.

Well…not exactly, but I’m sure you were close. This is the left main coronary artery, coming off the left sinus of Valsalva. You can see the ostium in this case, pretty cool eh?

Better luck next time! This is a midesophageal aortic valve long axis, with color flow on the aortic valve. This is a nice example of normal, with appropriate color flow Doppler settings. There is no evidence of dynamic LVOT obstruction, aortic insufficiency, or aortic stenosis.

Drat! I’m sure you were close, just take another look and rethink your orientation.

Dang, you were so close!  I’m sure you’ll get it next time around. As you probably realize by now, this is a normal midesophageal LV 2 chamber image.  We see the LA at the top.  The arrow is indicating the opening of the left atrial appendage on the right side of the screen.  The 2 walls we see here are the anterior and the inferior.  The left atrial appendage is an anterior structure, and the anterior wall is generally ‘underneath’ it.  Opposite the LAA is the coronary sinus (on the left side of the LA.)  The coronary sinus is a posterior structure.  This may help you remember which wall is which is this view.

Whoops, you must have read that one wrong! This is a midesophageal four chamber, with the left atrium and LV directly under the transducer. Notice how, with the LV parallel to the probe, the right atrium and part of the RV are cut off. If you want to actually see all 4 chambers you will often need to rotate slightly to the right. This is a good view to assess chamber size, RV and LV function, and function of the mitral and tricuspid valves. In this image the arrow is pointing toward the mid segment of the inferoseptal wall. Every 4 chamber will include the inferoseptal and anterolateral walls.

Rats, you just barely missed this one I’m sure! This is a midesophageal 4 chamber with color flow on the mitral valve. This isn’t a perfect image, right? It isn’t a perfect world out there, and sometimes this is what it looks like. But from this image we feel pretty good about biventricular systolic function, that’s something. And the color flow here doesn’t look abnormal, no evidence of mitral stenosis or regurgitation.

Well…not exactly. Look at this bad boy again. See the LV at the top of the screen with the aortic valve and aorta heading into the distance? That’s the deep transgastric long axis. When it comes to the deep TG images you sometimes take what you can get. This isn’t perfect, but you have good alignment with the AV, so you’re good to go with spectral doppler.

Whoops! You probably realize by now that this is a midesophageal aortic valve short axis.  We see the left atrium at the top of the screen (under the transducer), which tell us that we’re in the mid esophagus, and we’re focused on the aortic valve.  The arrow is pointing at the right coronary cusp of the aortic valve.  Remember that the noncoronary cusp is always located adjacent to the interatrial septum and the right cusp is always by the right ventricle (you could say the left cusp is “left over” I guess.)

Oh, so close, but not exactly. This is a midesophageal aortic valve long axis. The left atrium is by the probe and we see the mitral and aortic valves well. In this view we assess the LVOT (looking for dynamic obstruction from the anterior mitral leaflet), the aortic valve, and the ascending aorta. In this clip the arrow is pointing to the anterior mitral leaflet (a structure which partly defines the left ventricular outflow tract.)

Rats, I was sure you knew this one! This is a midesophageal aortic valve long axis. Notice the left atrium at the top of the screen, and how we view the mitral valve, LVOT, aortic valve, and ascending aorta. In this view we’re seeing the right coronary cusp of the aortic valve. We can say with certainty that the right coronary cusp is seen anteriorly (review the aortic valve short axis imaging if this doesn’t make sense) though the other leaflet in this view could be either the non or the left coronary cusp.

Dang, you were so close. This is a sweet midesophageal 2 chamber, even if it is a little hard to see the inferior wall. The arrow here is pointing to the mid anterior segment of the LV. Every 2 chamber, every window, every modality will show inferior and anterior walls. The anterior wall of the LV will always be “under” the left atrial appendage.

Ahh, you were so close! This is a midesophageal 4 chamber, with the probe turned slightly to the right. For that reason the RV is in the 6 o’clock position, and the LV is in the 4 o’clock position. The Z is in the right atrium. The RV has normal function, as we can see from the vigorous (>1.6 cm) descent of the base of the lateral tricuspid annulus. We see the inferoseptal and some of the alterolateral wall of the LV in this view. This will be true from any window (TEE or TTE) – you will always see the inferoseptal and anterolateral walls in all true 4-chambers.

Dang, you missed it! I was sure you had it, maybe next time. Take a sec to reorient yourself (front vs. back of heart, location of the RV which defines the 2 septal segments, 3 anterior and 3 inferior segments.)

Nope, not quite. But this isn’t totally easy, so don’t feel too badly. We’re seeing a short axis of the LV at the basal level, right? We see the mitral valve/subvalvular apparatus. Since we’re looking at a TEE, we know the “apex” of the triangle is the back of the heart. So the commisure we’re seeing is the anterolateral commisure of the mitral valve (how do we name them again?) In case you’re interested, one of my favorite descriptions of mitral valve anatomy is found in Alain Carpentier’s textbook “Reconstructive Valve Surgery.” If you don’t have it already, that single chapter is worth the price.

Whoops, I’m sure you didn’t mean that. This is a nice example of a transgastric long axis. Consider the location of the probe with respect to the heart, the appearance of the image, and the multiplane angle when thinking about these questions. Often you’ll find better alignment with the aortic valve from the deep transgastric long axis, but sometimes the transgastric long axis will look like this – then you’re good to go with spectral doppler.

Not exactly. Take a moment to reorient yourself. This is a TEE, so the top of the screen is the back of the heart. Look at where the RV is. Our arrow is indicating one of the septal segments, this one nearer the back of the heart. We see papillary muscles, so this is the mid inferoseptal segment. There is normal global and regional function as well, for what its worth.

Try again and I’m sure you’ll get it. This ascending aorta short axis has the “Z” in the main pulmonary artery. The artifact in the ascending aorta (see how it crosses normal anatomic borders?) is likely from a catheter in the SVC.

Rats! Not quite. Perhaps you said pulmonic valve, which is pretty close. But I would have put the arrow a cm closer if I was showing you the valve rather than the PA.

Dang, I’m sure you’ll get this one next time. The AV long axis always shows the right coronary cusp anteriorly (in this case, bottom of the image.) Usually you see the non-coronary cusp as well, though it is possible to see the left and the right with a slight leftward rotation of the probe. You cannot cut across the non and left in the LAX.

Whoops, I fooled you! This is just a straightforward descending aorta short axis. You know that based on the appearance of the aorta in short axis with the multiplane at 0. This intima is nice and thin, no real atherosclerosis.

Bummer, I was sure you had this one! You would call this a midesophageal 4 chamber (even though you really don’t see much of the RA.) There is normal global and regional LV function and normal TAPSE (tricuspid annular plane systolic excursion) or “descent of the base.” The arrow is pointing to the basal anterolateral segment. Notice the circumflex coronary artery just above the arrow.

Try again, I’m sure you didn’t mean that.

Nope, not quite. Take another look and you’ll nail it next time. Remember that the anterior mitral leaflet will always be by the aortic valve. You’ll want to look at the mitral valve from this view in cases where you need to quantify the coaptation length of the mitral valve (generally when discussing appropriateness of MV repairs.)

Nope, that’s not quite right my friend. We’re seeing a normal descending aorta short axis here, zoomed in on the aorta. The arrow is pointing at the pleura of the left lung (the aorta’s in the left chest, correct?) You’ll be looking at this relationship if you’re worried about blood around the aorta from rupture (you’ll see an increased aorta-to-pleura distance.)

Rats! This is a midesophageal aortic valve short axis.  We see the left atrium at the top of the screen (under the transducer), which tell us that we’re in the mid esophagus, and we’re focused on the aortic valve. The arrow in this case is showing us the left coronary cusp of the aortic valve. Remember the right cusp is by the RV and the non coronary cusp is by the interatrial septum.

Dang, I really thought you had this one! Better luck next time. This is a midesophageal 4 chamber view, rotated slightly to the right to show all 4 chambers and to allow better focus on the tricuspid valve with color flow Doppler. We see normal color flow across the TV in this example, with no evidence of stenosis or regurgitation. Notice that there is essentially one frame, right at the beginning of systole, where a small wisp of flow appears at the coaptation of the valve. This is completely normal.

Not exactly, but I’m sure you were close. This is a straight ahead normal midesophageal (LA at the top of the screen) AV long axis. No problems here.

Take another look at that one, you’ll get it next time. The probe is in the stomach, the multiplane is at 90, and we see an excellent transgastric 2 chamber. That glob the arrow is on is clearly a papillary muscle, so it must be the…(remember how we name the paps?)

You were close, very close…This is a midesophageal RV inflow outflow view.  We see the LA at the top of the image, the AV in short axis, and the RA/TV/RV/PV/main PA.  The ZZ is in the main PA.  In this view we see normal size and function of the right ventricle, and no obvious abnormalities of the tricuspid or pulmonic valves.  The bright ‘structure’ we see on the RA side of the tricuspid valve and just past the pulmonic valve is a pulmonary artery catheter.  There is also a small pericardial effusion, seen between the PA and the left atrium.

Bzzztt! Try again and I’m sure you’ll get it. This is a transgastric RV inflow-outflow (see the PA catheter?) so we’re pointing at the pulmonic valve. This view can be good for spectral Doppler of the pulmonic valve in some cases.

Whoops, you must have mis-clicked by accident! This is a midesophageal 2 chamber with the arrow indicating the coronary sinus. The CS and left atrial appendage are good landmarks to pay attention to. Remember that the appendage is on the “front” of the heart, meaning it is anterior in the chest. As such it is next to the anterior wall of the LV. The coronary sinus lies in the posterior atrio-ventricular groove of the left heart, as such it is in the back of the heart and is associated with the inferior ventricular wall in this view.

Not exactly, this is basically a totally normal midesophageal 4 chamber with appropriate settings for color flow.

Sorry, this one’s a little tough. This beautiful clip is a nice, normal midesophageal long axis (sometimes called 3 chamber, with the LVOT/ascending aorta being a chamber.) We see normal global function, normal thickening of the anteroseptal and inferolateral walls, and an arrow showing us the apical anterior segment. What?! I thought we saw the anteroseptal wall here? Well…you do, but we don’t name 6 segments at the apex, only 4 (anterior, inferior, septal, lateral.) Its actually a little challenging to know exactly how to name the apical segments in this view, but we do what we can right?

Close, but no cigar!  This is the midesophageal aortic valve long axis.  The LA is at the top of the screen.  We’re evaluating primarily the LVOT, aortic valve, and root of the ascending aorta.  The aortic valve is nice and thin, with normal excursion.  There is no way this patient has aortic stenosis.  The arrow is pointing to the right coronary cusp of the aortic valve.  The RCC is always seen on the ‘bottom’ of the valve in this view.  The non-coronary cusp is generally seen ‘on top’, though occasionally it will be the left coronary cusp.  Reviewing the orientation of the cusps in short axis may help you see why this is the case.

Well, not exactly…remember that the non-coronary cusp is always by the interatrial septum and you’ll be on track.

Drat! You just missed it. This is a pretty typical midesophageal bicaval view, with the arrow pointing at the SVC. As is often the case, you can’t see the IVC as well. Don’t sweat that too much, it is actually not common to be able to image the SVC and IVC well at the same time (despite how the line drawings in texts may look!) You’ll look here (in the SVC) for your wire coming down if you’re doing a central line, and you’ll look for collapse of the SVC with positive pressure to indicate volume responsiveness.

Well…no. I would make this color flow Doppler box smaller, to focus on the valve of interest here. A box that is too large just wastes imaging power and decreases resolution. The Nyquist limit is set perfectly, between .5 and .6 m/s.

Try again! Remember that every long axis image shows the anteroseptal and inferolateral walls, and the basal segments are nearest the mitral valve. If you said inferolateral wall, you weren’t wrong but it wasn’t the best answer (I know, I’m a pain, but you have to pay attention in this game!)

Nope, you’re not quite right. Think about the anatomy of the aorta and pulmonary arteries again and be sure you understand this.

Dang, you were so close! This is a very nice midesophageal long axis. Notice how we see the mitral valve, the LV (including the LV apex), LVOT, and aortic valve. This is what you’re trying to make your long axis images look like. The arrow is indicating the posterior mitral leaflet. The anterior mitral leaflet is always by the aortic valve and appears longer in almost every view we make (though the surface areas of the valves is similar.)

Well…no, that’s not quite it. You’ll get it next time I’m sure. Look again at the appearance of the aorta and the multiplane. You’ve had to increase the multiplane to keep the aorta in short axis, that tells you we’re looking in the arch. Then, of course, you see a structure coming off the aorta which is almost guaranteed to be the left subclavian artery (the other vessels can be seen only rarely.) This view is one you’ll want to be facile with when you’re looking for: traumatic aortic injury, patent ductus arteriosus, and most commonly placement of intra-aortic balloon pumps.

I’m sure you just clicked that by accident…This is a transgastric short axis of the LV. We don’t see the mitral valve, so we know we’re not at the basal level. We can see a suggestion of papillary muscle, so we’re probably more or less at the midventricular level. The Z is indicating the mid anteroseptal segment (anteroseptal being the wall, mid being the location along the basal to apical axis.) The ventricle in this case is not dilated and has normal global and regional function. That’s good news, but don’t make the mistake of assuming that everything is OK because one view is encouraging. Many bad things could be hidden from view!

Not exactly. Take another look, I’m sure you’ll get it. When you make a 4 chamber view you often will not see all 4 chambers well. In fact, it is a reasonable practice to make 2 versions of the 4 chamber, one focused on the LV and one on the RV.

No, not quite. This is a little odd, but you will definitely see it so I don’t want you to be confused. The probe is in our patient’s stomach, which has a bunch of stuff in it and we can see the gastric rugae. I think I also saw a piece of hamburger float by!

Not quite..this is the anterior mitral leaflet in the midesophageal 2 chamber view. The “long” appearing mitral leaflet will basically always be the anterior, as well as being located…anteriorly (near the anterior wall and left atrial appendage.)

Dang, I’m sorry you missed this one. I’ll bet you get it next time. This is a midesophageal RV inflow outflow. Notice the left atrium at the top, the aortic valve in pseudo-short axis, and the excellent view we have of the RA/TV/RV/PV/PA. The arrow, of course, is pointing at the pulmonic valve.

Bzzzzt! Nope, try again and take a moment to orient yourself. This is a TEE, so where’s the back of the heart? What do we call the papillary muscles again? I don’t want you to say something silly and embarrass yourself.

Man, I really thought you had this one nailed! You’ll get it next time for sure.

Oops, your keyboard must be sticky! In this midesophageal 4 chamber we’re seeing the posterior mitral leaflet (PML.) It is called “posterior” but could more appropriately be called “postero-lateral” because the anterior and posterior leaflets are not in a true A-P orientation. In most views the PML will appear smaller in length than the AML, and the AML will always be near the aortic valve.