Transesophageal echocardiography

TRANSESOPHAGEAL ECHOCARDIOGRAPHY
NEERAJ VARYANI

 In 1987, TEE was introduced at Mayo Clinic
Rochester.
 Accounts for 5-10% of all echocardiography
studies.
 Semi-invasive procedure.
 Skillful physician and experienced sonographer
making it extremely safe and well tolerated.
 Spacious room which can accommodate a
stretcher, oxygen outlet and suction facilities, pulse
oximeter and medications. Ensure I.V. access.

 TEE probe (modified gastroesophageal endoscopy
probe with 3-7 MHz transducer at tip) should be
examined before use.
 Diameter of transducer tip in adults and pediatric
use are 9-14 mm and < 3 mm respectively.
 Anterior flexion should exceed 90%, and right and
left flexion should approach 90%.
 Contact the patient 12 hours, and to fast for at
least 4-6 hours before the procedure.
 Patient should be accompanied due to effect of
sedation.

PHOTO OF A TRANSDUCER AND CLOSE UP OF THE BODY OF A
TRANSDUCER

 Steering the imaging plane using pressure
sensitive switch.
 Manipulation of anterior-posterior and right-left
flexion by control knobs.

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

 Informed consent, explain transient abdominal
discomfort and gagging.
 Lidocaine hydrochloride spray for topical
anesthesia over pharynx and tongue, and
diazepam 2-10mg, midazolam 0.05mg/kg I.V. for
light sedation.
 Infective endocarditis prophylaxis not required.

o Left lateral decubitus with head of bed
elevated by ~30 ͦ to avoid aspiration
(elective procedure) and supine position
(mechanically ventilated patients).
o Remove dentures
o Patient’s head to be flexed
o Imaging surface of transducer faces tongue.
Probe kept in central position to prevent entry
into piriform fossa.

POSITIONING OF PATIENT,SONOGRAPHER
,NURSE AND PHYSICIAN FOR PERFORMING
TEE

 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.

 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.

 Stridor or incessant cough indicates passage into
trachea also probe would not advance beyond
30cm 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.

 IMAGE FORMAT
 No general agreement.
 Right sided structures are on the left and left sided
on the right.
 Apex of the imaging plane with artifact is at the top
of the screen.

 FOUR BASIC MANEUVERS
 Advancement and withdrawal : imaging views are
basal, four chamber, transgastric, and aortic views.
 Rotation from side to side: useful in longitudinal
imaging planes for continuity between vertically
aligned structures, SVC and arch vessels.

 BASAL VIEWS
 Probe: midesophagus
 Visualizes :Base of heart particularly AV.
 Relationship Of Two Great Arteries Till Pulmonary
Bifurcation.
 Proximal portions of left main and right coronary
artery.
 Left atrial appendage and left pulmonary veins.

Short-axis view of ascending aorta and main pulmonary artery (MPA), with bifurcation and
origin of right pulmonary artery (RPA), from the upper transoesophageal window.
F.A. Flachskampf et al. Eur J Echocardiogr 2010;11:557-
576
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2010. For permissions please email: journals.permissions@oxfordjournals.org

MID-ESOPHAGEAL AV SHORT AXIS VIEW

Transverse view of upper left atrium.
576

 Horizontal plane for 4 pulmonary veins.
 Right and left atrial appendages wrap around great
arteries anteriorly. Their corrugated endocardial
surface can be confused with small thrombi.
 150 ͦrightward plane for dilated and tortuous
ascending aorta.

Long-axis view of the ascending aorta.
576

 ATRIAL SEPTUM
 Longitudinal plane at 90-120 ͦfor fossa ovalis, SVC
to RA continuity , sinus venosus ASD, foramen
ovale at superior aspect of fossa ovalis and left-
right rotation for LVOT and RVOT.

Left and right atrium and atrial septum in longitudinal (sagittal) view.
576

PULMONARY BIFURCATION
o Withdrawal of probe and at 0 ͦ.
o Pulmonary valve (thinner) and artery are superior to
aortic valve.
o Entire right and very proximal left pulmonary artery
is visualized ( for proximal pulmonary emboli).

 FOUR CHAMBER VIEW
 Middle to low esophagus.
 Gentle retroflexion with withdrawal for left ventricle.
 For dilated and unfolded aorta rotate by 20-30 ͦ.
 Inferior septum and anterolateral wall of LV and
continuous sweep from 0-180 ͦ for LV global and
regional function.

Low transoesophageal view of right ventricle (RV), right atrium (RA), and tricuspid valve.
576

 Mitral valve
 Continuous sweep from 0-180 ͦfor scallops of
anterior and posterior leaflets at long axis view of
aortic valve and proximal ascending aorta at 120 ͦ.
 Papillary muscles and subvalvular chords
visualized ( better in transgastric view).
 Four chamber view ideal for MR assessment (
number of jets, direction and severity).

A MID ESOPHAGEAL, FOUR-CHAMBER VIEW SUPERIMPOSED WITH
COLOR FLOW DOPPLER SHOWING MITRAL REGURGITATION. THE
VENA CONTRACTA (VC) DEPICTS THE REGURGITANT ORIFICE.

 LVOT
o At 120-160 ͦ, opening and closing of AV and AR
assessment, also proximal ascending aorta on
slight withdrawal.
o Slight rotation to left for pulmonary valve and RVOT
and assessment of PR.

Transoesophageal long-axis view of the left ventricle.
576

 TRANSGASTRIC VIEWS
 Slight resistance and liver indicates probe in
stomach.
 Anterior flexion, leftward rotation and flexion.
 Extreme anterior flexion with advancement of probe
for 5 chamber view.

 LV
o Cross section view for intraoperative LV function
optimized by leftward rotation and leftward flexion.
o For LV apex gentle advancement with retroflexion.
o leftward rotation for LVOT and aortic valve
alignment for transaortic pressure gradient in AS.

Transgastric short-axis view of the left (LV) and right ventricle (RV).
576

DEEP TRANSGASTRIC TEE VIEWS OF THE LV OUTFLOW TRACT
AT 0° (UPPER PANEL) AND 120° (LOWER PANEL).

Transgastric two-chamber view.
576

 MV: transducer brought close to GE junction with
horizontal imaging with anterior flexion and leftward
flexion.
 Should be attempted in all patients with
myxomatous degeneration.
 Papillary muscles and chords.
 Coronary sinus: near GE junction and flexion knobs
in neutral position also by retroflexion in lower
esophagus.

Short-axis view of the open mitral valve from the transgastric position.
576

Transoesophageal two-chamber view.
576

TRANSGASTRIC MID-PAPILLARY SHORT AXIS VIEW. IN PANEL A THE SEPTAL AND
LATERAL WALL AREAS ARE POORLY DEFINED. IN PANEL B BOTH WALL REGIONS
ARE ADEQUATELY IMAGED BY INCREASING THE LATERAL GAIN.

 CS located posterior to LV at AV groove draining
into RA with TV to the right and anterior.
 Dilated CS indicates PLSVC which is the most
common cause which is visualized with leftward
rotation following CS.
 In esophageal views PLSVC is sandwiched
between LAA and LSPV.

 AORTIC VIEWS
 Descending thoracic aorta: in horizontal plane with
transducer rotated leftward and posterior followed
by slow withdrawal from diaphragm to aortic arch
with slight rotational adjustment.
 Dilated and tortuous aorta adjust imaging plane by
0-90 ͦ.

THE VARIOUS HORIZONTAL AND LONGITUDINAL VIEWS OF THE
AORTA THAT CAN BE OBTAINED WITH TEE

 Aortic Arch: longitudinal plane at 90 ͦ.
 Withdraw slightly for arch vessels( all 3 visualized in
one-third patients). Brachiocephalic artery being
most difficult due to rightward and anterior location
and interposing trachea.
 Proximal pulmonary artery seen in suspected PTE.

DOPPLER EXAMINATION
 No additional information over TTE.
 EXCEPT:
 LAA FLOW: imaged from midesophagus aortic
valve short axis view( 30 to 60 ͦ) or midesophagus
two chamber view(80 to 100 ͦ).
 In AF regular atrial contraction wave is absent.
 In atrial flutter velocity waves are regular and
greater due to slower atrial rate.

 Normal LAA velocity: contraction (60±14cm/s),filling
(52±13cm/s) and early diastolic filling(20±11cm/s).
 In AF with LAA velocity <20cm/s more likely have LA
thrombus and 2.6 fold greater risk of ischemic stroke
compared to patient’s with velocity > 20cm/s.
 Lower LAA velocity also seen in stroke patients in sinus
rhythm.
 LAA velocity may predict successful cardioversion of AF
and maintenance of sinus rhythm at 1 year.

(A) Left atrial appendage.
576

 PULMONARY VEIN FLOW:
 Evaluating
 LV diastolic function
 MR assessment
 Differentiating constrictive pericarditis from
restrictive cardiomyopathy
 Identifying pulmonary vein stenosis after RF
ablation for AF.

Left: left upper pulmonary vein (LUPV) imaged in an approximately longitudinal view.
576

INDICATIONS FOR TEE
 Nondiagnostic TTE
 Evaluation of native valve disease
 Evaluation of prosthetic valves
 Evaluation of suspected and definite IE
 Evaluation of suspected cardioembolic event(35%)
 Evaluation of cardiac tumors and masses
 Evaluation of a atrial septal abnormality
 Evaluation of acute aortic syndrome or aortic
disease

LEFT: TRANSESOPHAGEAL ECHOCARDIOGRAPHIC VIEW OF A PATIENT
WITH SEVERE MITRAL REGURGITATION DUE TO A FLAIL POSTERIOR
LEAFLET. THE ARROW POINTS TO THE PORTION OF THE POSTERIOR
LEAFLET THAT IS UNSUPPORTED AND MOVES INTO THE LEFT ATRIUM
DURING SYSTOLE. RIGHT: COLOR-FLOW IMAGING DEMONSTRATING A
LARGE MOSAIC JET OF MITRAL REGURGITATION DURING SYSTOLE.

TRANSESOPHAGEAL STILL-FRAME ECHOCARDIOGRAPHIC VIEW OF A PATIENT WITH A
DILATED AORTA, AORTIC DISSECTION, AND SEVERE AORTIC REGURGITATION. THE
ARROW POINTS TO THE INTIMAL FLAP THAT IS SEEN IN THE DILATED ASCENDING
AORTA. LEFT: THE LONG-AXIS APEX-DOWN VIEW OF THE BLACK-AND-WHITE TWO-
DIMENSIONAL IMAGE IN DIASTOLE. RIGHT: COLOR-FLOW IMAGING THAT
DEMONSTRATES A LARGE MOSAIC JET OF AORTIC REGURGITATION

A 3D ZOOM MODE IMAGE ROTATED TO DISPLAY THE SURGEONS
VIEW FROM THE LEFT ATRIUM ONTO THE MITRAL VALVE, WITH A
P2 PROLAPSE AND RUPTURED CHORDAE TENDINAE (RC)

 Atrial fibrillation ( TEE-guided strategy for “early”
cardioversion) (34%)
 Evaluation of naïve and surgically corrected
congenital heart disease
 Detection of coronary artery anomalies and
coronary artery disease
 Evaluation of postoperative cardiac tamponade and
pericardial disease
 Evaluation of the critically ill patient
 Intraoperative monitoring
 Guidance of interventional procedures

TRANSESOPHAGEAL STILL-FRAME ECHOCARDIOGRAPHIC
IMAGES OF A PATIENT WITH A LEFT ATRIAL MYXOMA. THERE IS A
LARGE ECHO-DENSE MASS IN THE LEFT ATRIUM, ATTACHED TO
THE ATRIAL SEPTUM. THE MASS MOVES ACROSS THE MITRAL
VALVE IN DIASTOLE

CONTRAINDICATIONS TO TEE
 ABSOLUTE
 Uncooperative patient
 Severe respiratory depression
 Tenuous cardiorespiratory status
 Esophageal obstruction (stricture, mass)
 Esophagectomy or esophagogastrectomy
 Tracheoesophageal fistula
 Perforated viscus
 Active upper gi bleed

 RELATIVE
 Esophageal diverticulum
 Esophageal varices
 Previous esophageal surgery
 History of dysphagia
 Recent upper gi bleed
 Severe cervical arthritis with restricted mobility
 Atlantoaxial joint disease with restricted mobility
 Severe Coagulopathy

PROCEDURAL COMPLICATIONS WITH TEE
 MAJOR
o Death
o Esophageal rupture/perforation
o Upper gi bleed
o Laryngospasm or bronchospasm
o Congestive heart failure or pulmonary edema
o Sustained ventricular tachycardia

 MINOR
o Excessive retching or vomiting
o Sore throat and Hoarseness
o Minor pharyngeal or lip bleeding
o Nonsustained or sustained supraventricular
tachycardia/atrial fibrillation, NSVT and Bradycardia
or heart block
o Transient hypotension or hypertension and Angina
o Transient hypoxia
o Tracheal intubation
o Dental injury

 1.9% failed esophageal intubation during TEE.
 Complications occur in 3.5% patients ,
predominantly minor.
 0.2-0.5% suffer major complication.
 < 0.01% TEE-related mortality.
 Recent review of 17 studies encompassing 42,355
patients identified only 4 TEE procedure deaths.
 Esophageal perforation and major upper GI
bleeding in 0.01% and 0.03% of TEE studies
respectively.
 Dental injuries in 0.03% patients.

 Minor sore throat may be present for 24 hrs after TEE.
 0.1% have persistent odynophagia requiring further
investigation and Laryngospasm in <0.02%.
 Topical anesthetic agents can cause acute toxic
methemoglobinemia, manifesting clinically in 0.115% of
TEE studies.
 Agents oxidizes hb and prevents oxygen delivery to
tissues -cyanosis, lethargy, tachycardia, dyspnea, and
death.
 Methylene blue is indicated if methemoglobin levels
>30%, or patient has cyanosis, CNS depression, or
cardiorespiratory compromise.
 Intraoperative TEE complication rate 2.4% (excluding
failed intubations).

Transesophageal echocardiography

Transesophageal echocardiography

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Transesophageal echocardiography

Similar to Transesophageal echocardiography (20)

More from Neeraj Varyani

More from Neeraj Varyani (7)

Recently uploaded

Recently uploaded (20)

Transesophageal echocardiography

Editor's Notes