This document provides guidelines for performing transesophageal echocardiography (TEE) in children and patients with congenital heart disease. TEE can be used intraoperatively to assess cannula position, facilitate deairing, and characterize rhythm disturbances. Post-operatively, TEE evaluates the adequacy of surgical repairs and assesses ventricular function. When used in cardiac catheterization, TEE aids in device placement and reduces fluoroscopy time. Risks of TEE include a 1-3% complication rate in pediatrics and potential swallowing difficulties, though long-term issues are rare. Probe size selection depends on patient weight and size.

1. Guidelines for Performing a
Comprehensive Transesophageal
Echocardiographic Examination in
Children and All Patients with
Congenital Heart Disease
ASE guidelines
standards
LUIS GERARDO RODRIGUEZ ORTEGA

3. • In the intraoperative setting, TEE can be used to assess cannula
position and venous drainage during cardiopulmonary bypass,
facilitate intra-cardiac deairing, and characterize rhythm disturbances.
• An important role of the post-intervention TEE is to evaluate the
adequacy of the surgical repair and assess ventricular function.
• Decisions to return to bypass, therefore, should consider not only the
TEE findings, but also clinical information, hemodynamics, and the
risk versus benefit of a re-intervention.

5. • TEE serves an important role in the cardiac catheterization laboratory:
• During placement of septal closure devices, TEE provides precise
identification of the location, geometry, and number of defects, allowing the
interventionalist to develop clear strategies for closure.
• TEE use during catheter-based procedures limits fluoroscopy time, decreases
contrast load, and improves the overall safety of the interventions.

8. Patient Selection and
Complications
• 1-3% complication rate in the pediatric age group
• When intraoperative TEE imaging is performed, the imaging probe
ideally should be inserted before placement of sterile drapes.
• The incidence of oropharyngeal dysphagia after TEE has been
estimated at 18% in children undergoing open heart procedures.
• Risk factors included age < 3 years, preoperative endotracheal intubation, longer
duration of endotracheal intubation, and interventions for leftsided obstructive lesions.

9. • Although a high incidence (64%) of abnormal findings (erythema,
edema, and hematoma; less frequently, mucosal erosion and
petechiae) were found by flexible endoscopy after TEE for pediatric
cardiac surgery, no long-term feeding or swallowing difficulties were
identified.
• Critically ill infants with total anomalous pulmonary venous anomalies
who might develop hypotension and hypoxemia from compression of
the pulmonary venous confluence by the imaging probe.

11. • TEE probe selection for infants and children relies primarily on two
factors: the weight of the patient and the size of the probe.