Abstract
The ability to identify imaging artifacts and normal anatomic variants commonly encountered during a TEE exam can be as important as identifying normal anatomy and function. Lack of knowledge regarding these anatomic structures and imaging artifacts can result in misdiagnoses and adverse effects for patients. Anatomic variants commonly encountered in a TEE exam include Lambl’s Excrescences, Eustachian Valve, Chiari Network, Moderator Band, Crista Terminalis, Nodules of Arantius, and the Coumadin Ridge. Imaging artifacts that result from the violation of the basic assumptions of ultrasound physics include Dropout, Acoustic Shadowing, Side Lobes, Reverberation, and Mirroring. The focus of this chapter will be the identification of the aforementioned anatomic variants/imaging artifacts and the general techniques the echocardiographer can utilize to distinguish them from pathology.
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Mid-esophageal four chamber view at end systole. Epicardial fat is present between the right ventricular lateral wall and the pericardium (MOV 1,760 KB)
Mid-esophageal bicaval view demonstrating a Eustachian valve at the junction of the inferior vena cava and RA. A pulmonary artery catheter, which is seen in cross section, is also directed towards the area of the tricuspid valve. RA right atrium (MOV 1,741 KB)
Mid-esophageal bicaval view. A thin, filamentous, and mobile Chiari network is present at the junction of the inferior vena cava and RA. RA right atrium (MOV 1,780 KB)
Mid-esophageal bicaval view demonstrating a prominent crista terminalis at the superior portion of the right atrium near the superior vena cava and right atrial junction. A pulmonary artery catheter is also visualized traversing the RA towards the tricuspid valve. RA right atrium (MOV 2,150 KB)
Mid-esophageal four chamber view at end diastole. A moderator band is seen connecting the interventricular septum to the anterior papillary muscle in the distal half of the ventricle. RA right atrium (MOV 1,770 KB)
Mid esophageal long axis view in diastole demonstrating Lambl’s excrescences present on the AV extending to the level of the sinotubular junction. See associated video online to observe the classic appearance and movement of these relatively small structures. AV aortic valve (MOV 1,762 KB)
a Mid-esophageal aortic valve short axis view with the probe slightly withdrawn demonstrating a papillary fibroelastoma attached to the aortic valve (MOV 1,585 KB)
b A zoomed in mid-esophageal AV long axis view of the same patient demonstrates the pedunculated mass attached near the coaptation line of the aortic valve. The pedunculated mass is consistent with a papillary fibroelastoma (MOV 1,687 KB)
Simultaneous mid-esophageal AV short axis and long axis views demonstrating Nodules of Arantius that are present on the center of all three AV cusps (MOV 2,013 KB)
Mid-esophageal commissural view (depth decreased). The Coumadin ridge separates the left upper pulmonary vein from the left atrial appendage (MOV 1,687 KB)
Transgastric midpapillary SAX view. Hypo or anechoic areas of the septal and lateral walls represent imaging dropout, common in the TG SAX view (MOV 1,347 KB)
Mid-esophageal AV SAX (modified angle of interrogation) in a patient with a bioprosthetic aortic valve replacement. The prosthetic aortic valve creates a shadowing artifact which obscures visualization of the RV. In addition, a ring down or comet tail artifact, which is generated by the closely spaced annular ring and ascending aorta, is also present. Acoustic shadowing and ring down artifacts can both result in inadequate imaging distal to the reflecting structure(s) (MOV 1,303 KB)
Midesophgeal four chamber view demonstrating side lobe artifacts and inappropriately high gain settings, result in echogenic artifacts in the RA near the interatrial septum and LA above the lateral mitral annulus (MOV 1,754 KB)
An upper esophageal view withdrawn from the ascending aortic views encountering tracheal rings. A reverberation artifact is generated by the tracheal rings, demonstrating repeating artifacts at evenly spaced intervals (MOV 1,363 KB)
Descending aortic view demonstrating mirroring artifacts that can occur in both two dimensional imaging and color flow Doppler imaging. A mirroring artifact of the true aorta is displayed here with CFD (MOV 1,632 KB)
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Cronin, B. (2016). Imaging Artifacts and Common Misdiagnoses. In: Maus, T., Nhieu, S., Herway, S. (eds) Essential Echocardiography. Springer, Cham. https://doi.org/10.1007/978-3-319-34124-8_12
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DOI: https://doi.org/10.1007/978-3-319-34124-8_12
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