My TEE report

Here is my TEE Report. I do not fully understand . Any help would be appreciated. It was sent to me by my Nurse educator today. No Doctor has explained anything to me but Dr. Natale was not there. All I know is I failed the TEE.
I would love a explanation about the mitral valve. This is where I see that I failed because of no A Waves which I think means its not emptying properly. I would like for a Physician to at least explain the diagnosis to me. This was a "costly" test.

My Nurse Educator is a fine person but she could not explain this to me either. I appreciate her sending me the report.




DATE OF STUDY: 12/08/2016
ORDERING PHYSICIAN: Andrea Natale, MD
PERFORMING PHYSICIAN: Hashim Khan, MD
PROCEDURES PERFORMED: Transesophageal echocardiogram with complete 2-dimensional imaging, spectral, and color flow Doppler imaging.
INDICATIONS: Paroxysmal atrial fibrillation, status post ablation. Left atrial appendage evaluation.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. After this, the patient was given a total of 3 mg of intravenous Versed and 75mcg of intravenous fentanyl for conscious sedation. Once adequate sedation was obtained, the transesophageal echocardiogram probe was inserted into the oropharynx and distally into the esophagus. Systematic 2-dimensional imaging, spectral, and color flow Doppler imaging was undertaken. Once all images were carefully reviewed, the probe was removed from the patient's body and he awoke without complications.
FINDINGS: 1. Left ventricle: Wall thickness is normal. Chamber size is normal. Systolic function is normal. Ejection fraction is visually estimated to be 55-60%.

2. Right ventricle: Wall thickness is normal. Chamber size is normal. Systolic function is normal.

3. Left atrium: Normal in size. Well visualized. No mass or thrombus. Left atrial appendage is well visualized.No mass or thrombus. There is color flow in and out of the left atrial appendage. Left atrial appendage emptying velocities of 50 - 60cm/sec.

4. Right atrium: Normal in size. Well visualized. No mass or thrombus.

5. Interatrial septum: Intact without any evidence of shunt of color flow mapping.

6. Aortic valve: Trileaflet valve, which is normal in structure and function. No stenosis or regurgitation.

7. Mitral Valve: Normal structure and function. There is trace mitral regurgitation. Pulse wave Doppler analysis of mitral inflow shows E waves only. Tall E waves ore noted. No A waves are seen.

8. Tricuspid valve: Well visualized. Normal structure and function. Trace tricuspid regurgitation.

9. Pulmonic valve: Well visualized.Normal structure and function. No stenosis or regurgitation.

10. Pericardium: Intact. No pericardial effusion is noted.

11. Aorta: The ascending aorta is normal in caliber.

COMPLICATIONS: None

CONCLUSIONS: 1. Normal left ventricular systolic function.

2. Normal left atrial appendage emptying velocities.

3. There is no evidence of A waves on mitral inflow.

Continue OAC



Edited 2 time(s). Last edit at 01/03/2017 10:40PM by smackman.

In a post on Dec. 14,2016 Shannon answered this question;

2. You must also have a consistently robust Doppler 'A-Wave' as measured at the Mitral valve inflow. Note the A-Wave is the positive inflection above the sine-waves horizontal zero line where the A-wave is all positive inflection above the zero line and the "E-Wave' is all of the negative inflection in the oscillating waveform below the sine-wave zero line. What you want to see in a consistently robust and not variable 'A-Wave' peak on each heart beat into the Mitral valve inflow indicated consistently good pumping action from the LAA blood flow through the Mitral valve inflow If one heart beat has a solid +6 on a scale of +10 and then the next beat is only +1 0r + 2 and then variable up and down from one heart beat to the next, that likely will not pass and I assume from our conversation today it is this criteria that you did not pass on this first TEE after your LAA isolation.


My question now is whether my A Waves will ever come back?

Your LAA emptying velocity is really good so I am not sure what the wave form means if anything. I would be curious to hear what Natale has to say. If you lost LAA contractility, the velocity would be a lot lower.

I wonder if these measurements can change over time, better or worse.

Quote
researcher
Your LAA emptying velocity is really good so I am not sure what the wave form means if anything. I would be curious to hear what Natale has to say. If you lost LAA contractility, the velocity would be a lot lower.

It has something to do with the blood flow going thru the LAA not completely emptying with no A wave. I talked to my nurse educator yesterday and she ask if I was having PVC's/ at the time of the TEE. I was having PVC's; the monitoring of the Heart showed it. I was having one every 10-15 seconds.I had taken Phenegren the night before which is a Antihistamine which causes me PVC's but I did not realize that Antihistamines at the time were causing me to have PVC"s.

The nurse educator said I could get it checked again in 6-12 months if I wanted to but it is a expensive procedure and a 800 mile round trip. If PVC's caused me not to have A Waves", I would have waited until they subsided then done the test. They knew I was having PVC's.

Anyway, I am in NSR and grateful for this. Maybe Shannon can explain in more detail when he has time.

Hi Smackman and researcher,

I think we should perhaps put this issue up as a 'sticky note' as we have discussed these three TEE parameters at 6 months post LAA isolation numerous times over the last few years and recently as well, and I do realize it is a lot to take in and fully understand.

The three parameters listed below must all be passed robustly before Dr Natale will give the go ahead to stop OAC drugs after the 6 month post LAA isolation TEE confirms that all 3 metrics are is good shape meters.

Post LAA Isolation 6 month TEE parameters that must be passed tin order possibly be able to stop OAC drugs (Assuming your systemic stroke/TIA risk factors that do not include LAA function nor anything directly regulated to AFIB/Flutter are:

1. LAA Emptying Velocity - the LAA emptying Velocity measured just inside the ostium (mouth) of the LAA must be >/= 40cm/sec

2. Doppler A-Wave into the Mitral Inflow - the doppler A-Wave of blood flow measured at the mitral valve inflow from the LAA outflow directly above and vertically perpendicular to the horizontal oriented mitral valve opening ... much show a Consistently Robust A-Wave amplitude beat by beat ... it is not okay to stop a blood thinner if the A-wave is largely absent or with an irregular A-wave amplitude that includes some mitral inflow measured A-wave heart beats that indicate less than robust and consistent mechanical function through the full LA/LAA through Mitral valve flow pattern with every heart beat

3. The Absence of any 'Smoke' or SEC (Spontaneous Echo Contrast) seen anywhere in the left atrium or left atrial appendage.

As noted previously last month here, and as discussed with Smackman a few days ago on the phone, the absence of A-wave detection into his mitral valve inflow is a deal breaker as far as stopping OAC goes at least from this first post LAA isolation TEE.

But with his robust LAA emptying velocity and no report of any Smoke at all in his LA or LAA, I told Smackman to strongly consider doing a repeat TEE at 6 more months to a year from now and see if there might be enough recovery of his A-Wave with a Consistent robust amplitude that might allow him to forgo OAC long term in any event, And it not then I recommend planning on an LAA closure when Medicare is paying for them more readily in the coming couple of years and he is comfortable with the rapidly evolving understanding and progress in this very important sub-field of cardiology and EP regarding LAA closure.

In the meantime, as I reassured Smack as well, his overall TEE was outstanding and really reason to rejoice! With no real LA dilation, no real issues at all to speak of with his LVEF nor any of his valves which all looked very good .. he has a super good TEE cardiac profile and is now in NSR as well, and in-spite of having Long standing Persistent AFIB when he first discovered this forum. The odds are still quite high that you will have the option to drop OAC drugs too not too far down the road, if not by passing this last Doppler A-Wave test on repeat TEE, then by opting for a solid LAA closure procedure at the right time for him.
some

Regarding your PVCs Smack, if you were having a lot during the actual procedure it may have caused a false negative on the A-Wave measure, but there would have been no way to know that up front. Also, every person has some degree of PAC/PVC and even when the PVCs do occur in large number during the brief TEE scan, you would still have to repeat the scan, in any event, at a later date when there was little to no PVC activity to rule, in or out, if those PVCs had a direct impact on your A-Wave consistency. So your are in for two TEEs any way you slice it.

I recommend most people who have LAA isolation to plan on two TEEs over the first year to year and a half after the LAA isolation, just to confirm for sure whatever the reading was in the first 6 month TEE is confirmed or improved over longer time. Unless perhaps, the person either hit the full 3 parameter test well out of the ballpark on the first test or totally failed such that there is almost not chance for a positive improvement going forward (like as was clear after the 6 month TEE in my case).

Just think too Smackman, had you not gotten your AFIB addressed properly and were still battling ongoing persistent/LSPAF there is no way on this green earth you would ever be free of both OAC drugs and free of AFIB! And with as good as your overall Echo profile looks now after all that you have been through, you are doing so very well indeed Cardio-wise.

Cheers!
Shannon

Thanks for the reply Shannon. I will say this; The Nurse and the "floor physician" both knew I was having a lot of PVC's before the procedure. I had the 12 lead Heart monitor hooked up to me for over a hour before the TEE was done. It was showing PVC's approx. every 15 seconds. The nurse and floor physician both knew this. My TEE was 1 hour late so my heart was monitored for a while. A "Buzzer" kept going off every time I had a PVC. The nurse or the Doctor finally turned off this buzzer.
Now, did they tell the Physician who did the TEE I was having bad PVC's? This I do not know. I had taken a Antihistamine (Phenergan) the night before. I found out later that Antihistamines trigger PVC's with me. I figured it out right at Christmas time.
Anyway, I am okay and did get a great report with that one exception as you explained to me. I will go back to Austin later this year and have the TEE ran again. My PVC's minimal now since I found the cause and stopped the Antihistamine. The Phenergan was prescribed because I have been having nausea issues and it worked well but the PVC's were really bad at times.
Thank you Shannon for all you do. Your knowledge and help is such a asset.
Smackman
aka David

P.S. Being out of AFIB is a Godsend and I owe this forum and Shannon for guiding me to the best for my condition.



Hi Smackman and researcher,

Regarding your PVCs Smack, if you were having a lot during the actual procedure it may have caused a false negative on the A-Wave measure, but there would have been no way to know that up front. Also, every person has some degree of PAC/PVC and even when the PVCs do occur in large number during the brief TEE scan, you would still have to repeat the scan, in any event, at a later date when there was little to no PVC activity to rule, in or out, if those PVCs had a direct impact on your A-Wave consistency. So your are in for two TEEs any way you slice it.



Cheers!
Shannon[/quote]



Edited 1 time(s). Last edit at 01/07/2017 04:16PM by smackman.