This document provides information about trans-esophageal echocardiography (TEE). It discusses the basics of ultrasound and how TEE forms images. The history and modern development of TEE is reviewed. Key advantages of TEE include its close proximity to the heart and ability to provide high-resolution images of posterior cardiac structures. Potential disadvantages and complications are also outlined. Standard imaging planes, views, and procedures for a TEE exam are described in detail.

1. TRANS-ESOPHAGEAL ECHOCARDIOGRAPHY

2. BASICS OF ULTRASOUND / ECHO
• Tissue insonated with sound above audible range,
>20000 Hz
• Most use 2.5-7.5 MHz
• Transducer composed of piezoelectric crystals

3. HOW IT FORMS THE IMAGE?
▪ v = f x λ
▪ Ultrasound travels at 1540 m/sec in blood and tissues
▪ Hence v constant
▪ As f increase, λ decrease
▪ v, f and λ known
▪ Find Time and Depth

4. HISTORY
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▪ Side and Gosling (1971) - TEE for CW of cardiac
flow and aortic arch flow
▪ Frazin et al (1976) - TEE M mode echo
▪ Hisanaga et al (1977) - Illustrated use of cross
sectional real time imaging

5. • The modern era of TEE really began in 1982
• flexible probes with phased-array transducers
• manipulable tips
• monoplane, biplane, multiplane.
• Real time 3-D imaging
5

7. INTRODUCTION
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▪ TEE uses sound waves to create high-quality moving
pictures of heart and its blood vessels
▪ Involves a flexible tube or probe with a transducer at
its tip
▪ Probe is guided down throat and esophagus
▪ More detailed pictures of heart as esophagus is directly
behind heart

8. ADVANTAGES
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▪ Transducer - 2- 3 mm from heart
▪ Closer to posterior structures - Better visualization of
LA, LAA, MV, LV, Aorta
▪ Far from surgical area - Intra-operative monitoring
▪ High resolution images : Absence of intervening lung
or bone tissue

10. DISADVANTAGES
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• Semi invasive procedure: chances of injury
• Needs special setup, technique, preparation,
instrumentation
• Needs orientation and expertise

11. INDICATIONS
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• Assessment of prosthetic valves, infective endocarditis, native
valve disease
• Assessment of a suspected cardioembolic event
• Assessment of cardiac tumors
• Assessment of atrial septal abnormalities
• Assessment of aortic dissection, intramural hematomas
• Evaluation of CHD, CAD, pericardial disease
• Evaluation of critically ill patients
• Intraoperative monitoring
• Monitoring during interventional procedures
• Nondiagnostic TTE

12. CONTRAINDICATIONS
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13. POSITIONING OF PATIENT, SONOGRAPHER,
NURSE AND PHYSICIAN FOR PERFORMING TEE

14. PRE-PROCEDURE
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▪ 4 - 6 hours fasting
▪ Written consent
▪ Intravenous line, oxygen, suction equipment
▪ Remove denture or devices
▪ Lidocaine hydrochloride spray for topical anesthesia
over pharynx and tongue, and diazepam 2-10mg,
midazolam 0.05mg/kg I.V. for light sedation.
▪ ECG must be monitored throughout
▪ Introduce the probe with some anteflexion through a
bite block

15. • Patients should have ‘‘nothing by mouth’’ for 1 hour until all
local anesthetic and sedation has metabolized, to decrease
the risk for aspiration.
• Patients should be counseled to consult their physicians
for odynophagia or dysphagia that lasts >1 day because of
the low but real risk for soft tissue or esophageal injury from
TEE.
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16. ▪ Left lateral decubitus with head of bed elevated by 30 ͦ to
avoid aspiration (elective procedure) and supine position
(mechanically ventilated patients).
▪ Imaging surface of transducer faces tongue.
▪ Probe kept in central position to prevent entry into piriform
fossa.

17. • Gentle pressure and instruction to swallow.
• If resistance, withdraw and initiate new attempt.
• Bite guard always used to prevent involuntary
closure of mouth.
• If nausea wait for 10 – 15 seconds and then proceed
for imaging.

18. • Start with images from esophagus before gastric
views.
• GE sphincter reached when probe advanced 40cm
from incisor teeth.
• Descending thoracic and arch of aorta reserved for
the end of study as it causes gagging as probe is in
upper esophagus.

19. • Stridor or incessant cough indicates passage into
trachea also probe would not advance beyond 30 cm
and image quality will be poor.
• In intubated patients, introduce probe in supine
position and mandible pulled forward, if resistance at
25 – 30 cms deflate ET tube cuff.

20. ▪ Routine antibiotic prophylaxis before TEE is not
advocated.
▪ Persistent resistance to advancing the instrument
mandates termination of TEE and endoscopy should
be performed before re-examination.
▪ After each TEE - Disinfect. Check for any damage,
ensure electrical safety
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21. CARE OF THE PROBE
• Enzymatic solution to remove secretions
• Tap water dry for 20 mins
• Gluteraldehyde for 20 - 45 mins

24. MINOR
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▪ Excessive retching or vomiting
▪ Sore throat
▪ Hoarseness
▪ Minor pharyngeal bleeding
▪ Non sustained or sustained supraventricular tachycardia
▪ Nonsustained ventricular tachycardia
▪ Bradycardia or heart block
▪ Transient hypotension
▪ Transient hypertension
▪ Angina
▪ Transient hypoxia
▪ Parotid swelling
▪ Tracheal intubation

25. MAJOR
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▪ Death
▪ Esophageal rupture
▪ Laryngospasm or bronchospasm
▪ Congestive heart failure or pulmonary edema
▪ Sustained ventricular tachycardia

26. COMPLICATIONS
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27. PROBE
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▪ Modification of standard gastroscope, with transducers in
place of fibreoptics
▪ Conventionalrotary controls with inner and outer dials
▪ Inner dial guides anteflexion and retroflexion
▪ Outer dial controls medial and lateralmovement

28. ▪ Monoplane TEE - provides images in horizontal plane
only
▪ Biplane TEE - orthogonal longitudinal plane also
▪ Multiplane TEE transducer:
▪ single array of crystals, phased array transducers
with 64 - 256 piezoelectric elements
▪ that can be electronically and mechanically
rotated in an arc of 180°
▪ to produce a continuum of transverse and
longitudinal images from a single probe position
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29. STANDARDIMAGING PLANE LEVELS
(FROM THE INCISORS)
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▪ Upper or high esophageal (25–28 cm)
▪ Mid-esophageal (29–33 cm)
▪ Transgastric (38–42 cm)
▪ Deep-transgastric (>42 cm)

30. ▪ A complete TEE exam usually takes 15–20 min.
▪ An abbreviated or problem-focused TEE study may
be appropriate in unstable or uncooperative patients
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31. Proceed systematically -
1. From mid esophagus, 35 cms from the incisors to
gradually more distal esophagus
2. Fundus of the stomach after gentle advancement across
the cardia 40-50 cms from incisors
3. Finally slow withdrawal of the probe for complete
scan of the thoracic aorta from high esophageal views.
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32. TRANSDUCER MANIPULATION OPTIONS
• Advancement / withdrawal (for inferior or
superior structures respectively)
• Rotation (clockwise to view rightward
structures and counter- clockwise for leftward
structures)
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34. 40
Orientation Description and features of the view
0 degree Transverse plane to the probe long axis Horizontal to the plane of the body Oblique to cardiac short axis
45 degree Short axis view of cardiac basal structures like aortic valve
90 degree Longitudinal plane (parallel to the probe long axis) Sagittal (vertical) to the plane of the body Oblique
to the cardiac long axis Parallel to ascending aorta
135 degree Long axis view of cardiac structures (LV and LVOT)
180 degree Mirror image of 0 degree transverse plane

35. • Once we centre a cardiac structure in one image plane,
it will continue to remain there as the transducer is
rotated from 0-180°, facilitating the 3D assessment of
that particular structure

36. 36

37. 37

38. 38

39. PROCEDURE:BASIC VIEWS

40. • Guidelines developed by the ASE have described the
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technical skills for acquiring 20 views in the
of a comprehensive intraoperative
transesophageal echocardiographic
performance
multiplane
examination.

41. Cross-sectional views of the 11 views of the ASE Basic
examination.

42. ASE & SCA recommend 20 views for a comprehensive TEE.

43. ME 4C: Position probe in mid-esophagus behind LA. Depth
30–35 cm, angle 0-10°. Image all 4 heart chambers.
Optimize LV apex by slight retroflexion of probe tip. Ensure
no part of AV or LVOT is seen. Aim to view entire LV.

44. ME 4C view (0°)
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45. ME 2C View: From ME 4C : keep probe tip still and MV in
the center, rotate omniplane angle forward to 80-100°, RA
+ RV disappear, LAA appears.

46. ME 2C view (90°)
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48. ME LAX (120°): Rotate omniplane angle forward to
120-130°. Imaging plane is directed through the LA to
image the aortic root in LAX and entire LV. The more
cephalad structures are lined up on the display right.

49. ME LAX VIEW (120°)
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50. ME Asc A LAX (90°): Find the ME AV LAX (120°). Withdraw the probeto
bring the right pulmonary artery in view Decrease omniplaneangle
slightly by 10-20° to make the aortic wall symmetric. Imagingplane is
directed through the right pulmonary artery to image theproximal
ascending aorta in LAX.

51. ME Asc A LAX (90°)
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52. ME Asc A SAX (0°): From ME AV LAX (120°) Withdraw probe (asc
aorta), Rotatethe omniplane angle back to 0°

53. ME Asc A SAX (0°)
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54. ME AV SAX View: From the ME A4Cview,slight withdrawal of theprobe wh

55. ME AV SAX (30°)

56. ME RVinflow-outflowView: Fromthe ME AVSAXview,slightly adjusting the

57. ME RVinflow -outflow View (60°)

58. ME Bicaval View : Fromthe ME RVinflow-outflow view,slightly adjusting
the angle to 90 - 110 degree isneeded.

59. ME Bicaval View

60. • From the ME views and at a transducer angle of 0 to 20,
the probe is straightened and advanced into the
stomach, frequently imaging the coronary sinus inflow as
well as IVC, HV before reaching the TG level.

61. TG Mid SAX : Reach the TG level and slightly ante-flex the tip of the
probe. Angle maintained at 0 degree. The papillary muscles must come
into view.

62. TG Mid SAX (0°)

63. Descending Aorta SAX : Withdraw (in neutral position) slightly from TG level to reach
the ME-TG junction and slightly ante-flex the tip of the probe. Angle maintained at 0
degree. Easy to obtain. Slight leftward rotation is advised for fine tuning

64. Descending Aorta SAX (0°)

65. Descending Aorta LAX : In the same position of DA SAX change the
angle from 0 degree to 90 degree.

66. Descending Aorta LAX (90°)