Transesophageal echocardiography (TEE) provides high-quality ultrasound images of the heart by utilizing the proximity of the esophagus, enabling detailed assessment of cardiac conditions such as thrombi and valve diseases. The procedure involves proper patient preparation, real-time monitoring, and specific imaging techniques to visualize various heart structures, with minimal risks and contraindications. TEE is particularly safe for critically ill patients and is essential for intraoperative monitoring and diagnosis of cardiac anomalies.

1. TRANSESOPHAGEAL ECHO
ABHISHEK KUMAR TIWARI
DM CARDIO RESIDENT, CMCH
COIMBATORE

2. TEE is an alternative method to obtain ultrasound
images of the heart. The imaging can be performed at
the bedside, but with a higher-frequency transducer
and from a position that is posterior and closer to the
heart than can be achieved with TTE.

3. Why TEE is successful?
1)The close proximity of the esophagus to the posterior
wall of the heart.
2)The closeness and absence of intervening tissues, such
as bone or lung, allow the use of highfrequency
transducers and ensure high-quality imaging.

4. 3) The ability to position the transducer in the
esophagus or stomach for extended periods provides
an opportunity to monitor the heart over time, such
as during cardiac surgery.
4) The technique has proven to be extremely safe and
well tolerated so that it can be performed in critically
ill patients and very small infants.

5. UNIQUE DATA FROM TRANSESOPHAGEAL
ECHOCARDIOGRAPHY
Atrial thrombi/masses
Left atrial appendage clot
 Left atrial appendage spontaneous contrast
 Clot in body of left atrium
 Right atrial thrombus
 Thrombus/mass on pacemaker wire or indwelling
catheter

6. A) Transesophageal echocardiogram shows new thrombus
formation in the left atrium (arrow) . B) Left atrial thrombus was
not seen in transthoracic echocardiogram

7. Mitral valve
 Precise mechanism of mitral regurgitation
 Refined suitability for valvotomy in severe mitral
stenosis
 Define eccentric jets
Function of prosthetic valves
Paravalvar regurgitation

8. Two dimensional color Doppler image showing the mitral
bioprosthetic valve (yellow arrow) and a turbulent jet of mitral
paravalvular regurgitation (PVL, dashed red arrow). The para
valvular origin of the jet is clearly depicted (M)

9. Aorta
Detection/characterization of dissection
Detection of atheroma

10. Transesophageal echocardiography in the mid-esophageal
view, showing a linear dissection flap in the non-coronary
sinus of Valsalva LA, Left atrium

11. Aortic trauma/transection

12. Short axis view of descending aorta showing the location
of the aortic transection.

13. Chambers
 Refinement of patent foramen ovale characteristics

14. Transesophageal echocardiography. A patent foramen ovale
(PFO) with a left-to-right shunt is shown at the level of the
interatrial septum.

15. Online monitoring
Intraoperative left ventricular size/function
Monitoring interventional procedures
Atrial septostomy
Balloon valvotomy
Pulmonary vein/left atrial interventions
Percutaneous aortic and mitral valve replacement
or repair

16. Atrial septostomy. An image of an atrial septal puncture is shown using
TEE. Using a specialized catheter and fluoroscopy, an atrial septal
puncture is made in the region of the fossa ovalis and balloon dilation
is performed. The catheter (*asterix) can be seen traversing the
septum from the right atrium into the left atrium.

17. Endocarditis
Detect aortic abscess
Identify smaller vegetations
Detect valve perforation
Detect endocarditis of prosthetic valves

18. Mitral prosthetic valve endocarditis with prosthetic obstruction
(transoesophageal echocardiography). (A) Large vegetation
prolapsing into the mitral mechanical prosthetic valve (arrow). (B)
Central regurgitation associated with the absence of the
physiological regurgitant jets (arrow).

19. PREPARATION OF THE PATIENT
 First, Informed consent should be obtained.
The patient should fast for at least 4 to 6 hours before
undergoing TEE.
Any history of dysphagia or other forms of esophageal
abnormalities should be sought and evaluated.

20. All patients should have IV access and both
supplemental O2 and suction should be available.
 Before intubation, the use of a topical anesthetic to
numb the posterior pharynx is recommended.
Either lidocaine or Cetacaine is typically used for this
purpose

21. Although safe, rare cases of toxic methemoglobinemia
have been reported and should be considered whenever
significant O2 desaturation complicates the procedure.
Rx of this condition is IV methylene blue, usually given in a
dose of 1 mg/kg as a 1% solution over 5 minutes.
Conscious sedation, for pain prevention, and as an
anxiolytic

22.  The combination of midazolam and fentanyl is popular
in many laboratories.
Bacteremia induced by upper endoscopy during TEE is
very rare.
The routine use of antibiotic prophylaxis has generally
been abandoned.

23. THE PROCEDURE
The head of the bed is elevated approximately 30 degrees
to improve comfort and help avoid aspiration.
If the patient has dentures, these should be removed,
and in most patients, a bite block is placed

25. . After the probe has been lubricated with surgical jelly,
it is introduced into the oropharynx and gradually
advanced while the patient is urged to “swallow” to
facilitate intubation.
Once the probe has passed into the esophagus, a
completeexamination can usually be performed in 10 to
30 minutes

26. Special attention should be paid to the patient BP, heart
rate and rhythm, and O2 saturation.
Suctioning of the oropharynx is often required, and
additional intravenous medications may be needed to
maintain the proper level of conscious sedation and
comfort.

27.  Early TEE transducers were capable of imaging from only
in the transverse orientation and were called MONOPLANE
DEVICES.
The 2ND -generation instruments has BIPLANE capability
and are able to record images in both the transverse and
longitudinal orientations

29. All current-generation transesophageal
echocardiographic transducers have multiplane
capability

31. The image is rotated, either electronically or
mechanically, around a 180-degree arc to yield an infinite
number of possible imaging planes.
The availability of multiplane imaging effectively
provides a 360-degree “panoramic” reconstruction of the
heart and great vessels.

32. The probes operate at multiple frequencies, typically 3.5
to 7.0 MHz.
Pediatric probes are smaller in diameter (5 to 7 mm) and
operate at higher frequencies (5 to 10 MHz).
Transesophageal probes capable of realtime 3D imaging
have also been developed.

33. TRANSESOPHAGEAL ECHOCARDIOGRAPHIC VIEWS
 TEE does not lend itself to standardization of views as
readily as TTE.
The targeted nature of the test, together with the
constraints imposed by the esophagus and its relation to
the heart, limit our ability to define and describe standard
views using this modality.

34. TERMINOLOGY USED TO DESCRIBE THE MANIPULATION OF THE
PROBE AND TRANSDUCER DURING IMAGE ACQUISITION.

35. A useful starting point is the four-chamber view, which
is recorded with-
The transducer positioned immediately superior and
posterior to the left atrium and flexed in a way to provide
a long-axis plane through all 4 chambers

37. By adjusting the degree of flexion, variations on the
four-chamber views are recorded

39. The transthoracic four-chamber view places the left
ventricular apex in the near field and is ideally suited to
detect apical thrombi.
In contrast, the transesophageal four-chamber view
places the left atrium in the near field and is ideally suited
for assessing left atrial and mitral valve pathology.

40. By anteflexing the probe tip, the long-axis orientation
can be gradually converted into a more short-axis view
for the evaluation of the left ventricular outflow tract
and aortic valve

42. By gently flexing and relaxing the probe, the aortic root,
aortic valve, and LVOT can be thoroughly assessed

43. Four of the short-axis views that can be obtained with
the
horizontal probe in the upper esophagus.

44. By rotating the array angle from 0 degrees (transverse) to
approximately 90 degrees, a two-chamber view can be
obtained

46. Further angle rotation, to approximately 135 degrees,
will approximate a left ventricular long-axis view
This plane is closely aligned to the long axis of the heart
and provides an excellent assessment of the aortic valve
and aortic root.

48. Rotation of the probe clockwise will sweep the imaging
plane toward the right heart, eventually recording the
bicaval view in which the right atrium, and IVC & SVC are
visualized.
This view also provides assessment of the atrial septum
and is helpful to interrogate the superior portion of the
atrial septum for sinus venosus defects.

50. By slight angulation, the right atrial appendage can also be
examined from
this approach

52. Because the appendage is often
multilobed and varies considerably in size and shape, it
should be assessed
from multiple angles to ensure complete interrogation

53. 5 views of the LAA are recorded at
various angles of rotation of the scan
plane. Note how the appearance of the
appendage varies in the different views.
The relationship of the appendage to the
left upper pulmonary vein (*) is also
demonstrated.

54. By
withdrawing the probe slightly and adjusting to a more
horizontal plane
(approximately 0 degrees), the bifurcation of the main
pulmonary artery can
be visualized adjacent to the ascending aorta

56. The thoracic aorta, IS uniquely suited to TEE inspection,
lies in close proximity to the esophagus and on the
opposite side from the heart.
With the array angle at 0 degrees, the transducer itself
is rotated 180 degrees to view the aorta in short axis.
Beginning distally, gradual withdrawal of the transducer
will follow the descending aorta in a retrograde manner
up toward the arch

57. The descending aorta is recorded in a series of short-axis views at
various levels by withdrawing the transducer from the level of the
diaphragm to the distal arch (panels A–D).

58. At the level of the aortic arch, the origin of the branch
vessels can be recorded

60. Then, by rotating the transducer and gradually
advancing the probe further into the esophagus, a portion
of the AA can be recorded.
Because of the interposition of the trachea, some
portion of the ascending aorta will not be seen.
These series of views provide an excellent opportunity
to detect aortic aneurysm, dissection, and atherosclerosis.

61. To record the left pulmonary veins, the transducer angle
is adjusted to approximately 100 degrees and the
transducer is rotated to the far leftward plane
(counterclockwise rotation of the probe).
Color flow imaging can be used to assist in locating the
mouth of the veins.
The two left veins drain into the left atrium in close
proximity to each other, and the left upper pulmonary
vein is often recorded adjacent to the left atrial
appendage

63. To record the right pulmonary veins, adjust the
transducer angle from 50 to 60 degrees and rotate the
probe to the patient’s far right.
Again, the two veins appear to originate together,
sometimes as a bifurcation.

64. The transducer can also be advanced into the patient’s
stomach to provide a family of views
Beginning from the transverse plane (0 degrees), extreme
anteflexion and gradual withdrawal of the probe will bring
the transducer in contact with the superior portion of the
stomach, with the ultrasound beam directed upward
toward the heart.

65. A series of short-axis views of the ventricles can then be
recorded by sequential anteflexion and retroflexion to
visualize the various levels of short-axis planes

67. By increasing the array angle to a more vertical plane, a
long-axis view is recorded, often providing excellent
visualization of the LVOT and aortic valve.

68. RISKS AND CONTRAINDICATIONS FOR TRANSESOPHAGEAL
ECHOCARDIOGRAPHY
Topical anesthesia
Allergic reactions
Toxic methemoglobinemia

69. Conscious sedation
Respiratory compromise/hypoxia
Hypotension
Paradoxical hypertension
Paradoxical agitation
Idiosyncratic reactions

70. Probe insertion: immediate
Oral trauma
Dental trauma
Esophageal perforation
Vagal reaction

71. Probe insertion: delayed
Aspiration
Tachycardia
Paroxysmal supraventricular
tachycardia
Ventricular tachycardia

72. Contradictions
Absolute
Recent esophageal trauma/surgery
Recent esophageal bleed
Relative
Poorly cooperative patient
Remote esophageal procedures

79. TEE may also cause bleeding (0.02% to 1.0%) from direct
abrasion of the mucosa, esophageal varices, or tumor.

80. The overall risk for major adverse events with TEE is
0.2% to 0.5% in the nonsurgical setting, and the overall
mortality rate is exceedingly low (0.0004%).

81. THANK YOU

82. 1) Feigenbaum’s echocardiography EIGHTH EDITION
2) BRAUNWALD’S HEART DISEASE
3) Textbook of Clinical Echocardiography, 6th Edition