CVOR DIAGNOSTIC INTRA-OPERATIVE PLACE LABEL HERE

TEE REPORT

Date: ______Time: ______
Anesthesiologist: ______Surgeon: ______
Surgical Procedure:______
Indication/Diagnosis:______

Coding:

*1-40042* FORM 1-40042 REV. 03/2013 WHITE: Medical Record CANARY: Anesthesia Page 1 of 1

CVOR DIAGNOSTIC INTRA-OPERATIVE PLACE LABEL HERE

TEE REPORT

Image Acquisition and Report 93312-26

CW or PW Doppler 93320-26

Color Doppler 93325-26

3-D Echo 76376-26-59

Monitoring Only 93318

*1-40042* FORM 1-40042 REV. 03/2013 WHITE: Medical Record CANARY: Anesthesia Page 1 of 1

CVOR DIAGNOSTIC INTRA-OPERATIVE PLACE LABEL HERE

TEE REPORT

2-D and Doppler Measurements:

Aortic Annulus ______mm Sinotubular Junction ______mm Mitral Annulus ______mm Tricuspid Annulus ______mm

Chamber / Size / Diameter
(cm) / Hypertrophy / Tumor / Thrombus / Device / Global Function / Ejection Fraction
LV / normal dilated / Yes No / Yes No / Yes No / NL mild hypokinesis mod. hypokinesis sev. Hypokinesis dyskinesis akinesis
RV / normal dilated / Yes No / Yes No / Yes No / NL mild hypokinesis mod. hypokinesis sev. Hypokinesis dyskinesis akinesis
RA / normal dilated / Yes No / Yes No / Yes No
LA / normal dilated / Yes No / Yes No / Yes No
Valves / Annulus / Peak Flow (cm/s ) / Stenosis / Area (cm2) / Gradient (mmHg) / Leaflet Morph / Leaflet Motion / Regurg. / Comments
Aortic
Valve / normal dilated
calcified bioprosthetic
mechanical / None Mild
Moderate Severe / peak
mean / normal calcified
vegetation bicuspid
thickened / normal prolapse
flail restricted
NCC RCC LCC / 0 1+
2+ 3+
4+
Mitral
Valve / normal dilated
calcified bioprosthetic
mechanical / None Mild
Moderate Severe / peak
mean / normal calcified
vegetation perforated
myxomat thickened / normal prolapse
flail tethered restricted
SAM Ant. P1 P2P3 / 0 1 +
2+ 3+
4+
Tricuspid
Valve / normal dilated
calcified bioprosthetic
mechanical / None Mild
Moderate Severe / normal calcified
vegetation perforated
myxomat thickened / normal prolapse
flail restricted / 0 1+
2+ 3+
4+

Interatrial Septum: Normal Aneurysm LIpomatous Hypertrophy PFO ASD (Primum Secundum Sinus Venosus AV Canal) Shunt: L to R R to L Bidirectional

Interventricular Septum: Normal Shift VSD (membranous muscular) Hypertrophy Shunt: L to R R to L

Pericardium: Normal Thickened Effusion: mild moderate severe tamponade

Aorta / Size / Diameter (cm) / Dissection / Plaque Thickness / Plaque Mobile
Ascending Aorta / normal dilated / Yes No / 0-3mm greater than
3mm / Yes No
Descending Aorta / normal dilated / Yes No / 0-3mm greater than
3mm / Yes No
Diastolic Function Analysis:
E: ______cm/s Decel Time: ______ms
A: ______cm/s E’: ______cm/s
E:A ratio ______E:E’ ratio ______
S: ______cm/s D: ______cm/s
a: ______cm/s a dur: ______ms / Systolic Function Analysis:
______
______
______
______
(1=normal 2 = mild hypokinesis 3= mod. hypokinesis 4 = sev.
Hypokinesis 5 - dyskinesis 6= akinesis)
(I=Inferior L =Lateral A=Anterior S= Septum)
Pre-Bypass Summary EF- (Ejection Fraction)= / Post- Bypass Summary: EF- (Ejection Fraction)=
Vasopressors: Epi Levo Milrinone Vasopressin
Pacing: A-Paced V-Paced AV Sequential None

Key: VSD= Ventricular Septal Defect, NL- Normal NCC= Non-coronary cusp LCC= Left coronary cusp RCC= Right coronary cusp Regurg= Regurgitation

SAM= Systolic anterior motion Ant= Anterior P1 P2 P3= P1P2P3 segments PFO= Patent foramen ovale

______

Date Time Physician SignaturePID Number

*1-40042* FORM 1-40042 REV. 03/2013 WHITE: Medical Record CANARY: Anesthesia Page 1 of 1