Transesophageal echocardiography (TEE) is a crucial diagnostic tool that enhances cardiac imaging by providing high-resolution images via an esophageal window. It is particularly useful for evaluating various cardiac conditions, including atrial fibrillation, endocarditis, and valvular disease, owing to its superior anatomical proximity to cardiac structures compared to transthoracic echocardiography (TTE). The document details TEE's indications, preparation, technical aspects, potential risks, and specific applications in assessing the mitral valve and left atrial appendage.

1. TRANSESOPHAGEAL
ECHOCARDIOGRAPH
Y
Dr Awadhesh Sharma

2. INTRODUCTION
HISTORY
INDICATIONS AND CONTRAINDICATIONS
COMPLICATIONS
ANATOMICAL CONSIDERATIONS
PRIMARY VIEWS AND LONGITUDINAL VIEWS
TRANSGASTRIC MULTIPLANE VIEWS
USES IN VARIOUS CLINICAL SETTINGS

3. The term Trans esophageal echocardiography is used to
describe a constellation of ultrasound diagnostic
technique using an esophageal window.
TEE has become an important adjunct to the TTE
TEE utilizes an electronically steered high-frquency
ultrasound transducer (5-7MHz) mounted on an
endoscope
The higher resolution , coupled with anatomic proximity
of the transducer to the posterior cardiac structures,
delivers superior images quality when compared with
TTE, particularly of posterior cardiac structures
This include 2D-3D Echo. , M Mode , Colour flow
Doppler , Pulse Doppler and Continuous wave imaging.

4. In 1976, Frazin et al. described their initial experience with a single-
crystal ultrasound transducer attached to a coaxial cable that was
passed into the esophagus
Accurate positioning of this probe was difficult, and the device was not
used frequently
A major breakthrough in TEE came in the early 1980s, when phased-
array transducers connected to more flexible endoscopes were
introduced and made even smaller

5. After the initial monoplane probes that allowed scanning
in one (transverse) image plane, biplane probes were
developed.
The second (longitudinal) image plane improves
scanning, particularly of vertically oriented structures,
such as the superior vena cava, interatrial septum,
ascending aorta, atrial appendages, or the left ventricle
in the long-axis view.
At present, multiplane TEE probes have become
available, allowing stepwise study of an area of interest
by fine mechanical or electronic rotation of the scanning
plane through 180 degrees

6. INDICATIONS OF TEE
ATRIAL FIBRILLATION
SUSPECTED ENDOCARDITIS
CARDIAC SOURCE OF EMBOLISM
VALVULAR DISESASE,
are the most common indications of TEE,
TEE is also particularly usefull in assessment of acute aortic
syndromes, interatrial shunts, and cardiac masses
TEE is also important for assessing the structural
complications such as myocardial abscess, fistulas,
mycotic aneurysms, valvular aneurysms or
perforations, flail leaflets, or prosthetic valve
dehiscence

8. To assess adequacy of valve repair.
To assess Prosthetic Valve or Ring Regurgitation
To monitor LV function
To evaluate removal of air from the heart
To assess the adequacy of repair of congenital heart
disease

10. ACCF/ASE/ACEF/ASNC/SCAI/SCCT/SCMR 2007
Appropriateness Criteria For TEE as an Initial Study
Possibly appropriate as initial test
•Evaluation of suspected acute aortic pathology including
dissection/transaction
•Gudidance for percutaneous noncoronary cardiac intervention
including, but not limited to , septal ablation in patients with
hypertrophic cardiomyopathy, mitral valvuloplasty, PFO/ASD closure,
radiofrequency ablation
•To determine mechanism of regurgitation and determine suitability of
valve repair
•To Diagnose/manage endocarditis with a moderate or high pretest
probability (eg, bacteremia, especially staphylococcus aureus bactermia
or fungemia)
•Persistent fever in patient with intracardiac device
•Evaluation of patients with atrial fibrillation/flutter to facilitate clinical
decision making with re-gards to anticoagulation and/or cardioversion
and/or radiogrequency ablation
Inappropriate as initial test
•Evaluation of patients with atrial fibrillation/futter for left atrial
thrombus or spontaneous contrast when a decision has been made to
anticoagulate and not to perform cardioversion
Appropriateness unknown

11. TRANSESOPHAGEAL
ECHOCARDIOGRAPHY:
PREPROCEDURAL
PREPARATION
1. History
Evaluate for contraindications
Esophageal pathology
Dysphagia, odynophagia, recent esophageal bleeding
Evaluate for factors affecting intravenous conscious sedation
risk:
Poor ability to cooperate
Impaired ability to protect airway
Sleep apnea
Systemic illness
Nothing by mouth for 4–6 h

12. 2. Examination
Evaluate oropharynx for airway patentcy
3. Consider anesthesia consult for patients at increased risk
from conscious sedation
4. Informed consent
5. Establish peripheral IV with 3-way stopcock
6. Topical anesthesia
Lidocaine 2% viscous solution or spray

13. 7. Conscious sedation
Administered by nurse specifically trained in conscious
sedation in concert with a conscious sedation trained
physician
Commonly used agents:
Sedation: midazolam hydrochloride (versed): 1–6 mg IV
Reversal: flumazenil: 0.2–0.4 mg IV
Analgesia: fentanyl: 25–200 μg IV
Reversal: naloxone: up to 0.1 mg/kg IV

14. POTENTIAL RISKS OF TEE
Probe insertion
Dental trauma
Oropharyngeal trauma
Esophageal/gastric bleeding
Esophageal laceration/perforation
Vagal reaction
Conscious Sedation
Hypoventilation and hypoxia
Hypotension
Aspiration
Topical anesthetic
Methemoglobinemia (benzocaine)
Allergic reaction

22. ANATOMICAL
CONSIDERATIONS
From the level of T1 to T4, the esophagus has lung on
the left and right side, the trachea anteriorly and
vertebrae posteriorly, and so no image is obtained.
At the level of T4, the aortic arch is anterior to the
esophagus and (sometimes with the left brachiocephalic
vein and distal right pulmonary artery) can be visualized
with appropriate probe manipulation.
The superior vena cava is anterior and to the right at this
level but cannot be visualized due to the interposition of
the trachea.

23. ANATOMICAL
CONSIDERATIONS
From the level of T1 to T4, the esophagus has lung on
the left and right side, the trachea anteriorly and
vertebrae posteriorly, and so no image is obtained.
At the level of T4, the aortic arch is anterior to the
esophagus, and (sometimes with the left brachiocephalic
vein and distal right pulmonary artery) can be visualized
with appropriate probe manipulation.
The superior vena cava is anterior and to the right at this
level but cannot be visualized due to the interposition of
the trachea.

24. ANATOMICAL
CONSIDERATIONS
Between T4 and T8 ,the ascending aorta, superior vena
cava, pulmonary trunk, and right pulmonary artery lie
anterior to the esophagus and are usually the first
images seen as the probe is advanced without need for
further manipulation (upper esophageal window).
The left pulmonary artery is also anterior to the
esophagus at this level, but is obscured by the left main
bronchus.

25. ANATOMICAL
CONSIDERATIONS
From about the level of T8 to the level of T12 the left
atrium is immediately anterior to the esophagus, thus
allowing unimpeded visualization of all the intracardiac
structures (mid esophageal window).
Posterior to the esophagus from T4 to T12 is the
descending aorta; this is usually imaged at the end of the
study by complete rotation (clockwise or anticlockwise)
and subsequent slow withdrawal of the probe.
Below the diaphragm the stomach is directly inferior to
the ventricles and these can be visualized by flexing the
probe tip to bring it into apposition with the lesser
curvature of the stomach (transgastric window).

27. GENERAL PRINCIPLES
Although the most common transducer location and
multiplane angle are provided for each cross-sectional
image, final adjustment of the image is based on the
anatomic structures that are displayed.
It should be recognized that there is individual variation
in the anatomic relationship of the esophagus to the
heart; in some patients, the esophagus is adjacent to the
lateral portion of the atrioventricular groove, whereas in
others it is directly posterior to the left atrium (LA)
When possible, each structure is examined in multiple
imaging planes and from more than one transducer
position.

28. GENERAL PRINCIPLES
Structures closer to the probe, such as the aortic valve
(AV), are imaged best at a higher frequency, whereas
structures farther away from the probe, such as the
apical regions of the left ventricle (LV), are imaged best
at a lower frequency
The depth is adjusted so that the structure being
examined is centered in the display, and the focus is
moved to the area of interest
Overall image gain and dynamic range (compression) are
adjusted so that the blood in the chambers appears
nearly black and is distinct from the gray scales
representing tissue.

32. MAIN ECHOCARDIOGRAPHIC WINDOWS OF
STANDARD TEE
Upper Esophageal-approx. 20–30 from the incisors
Mid Esophageal-approx.30–40 from the incisors
Trans Gastric -approx.40–50 cm from the incisors

33. PRIMARY MULTIPLANE TEE
VIEWS
0 Degree(transverse Plane)- Oblique view of basal
structures. The Four chamber view or transgastric short
axis view can be obtained from this position by
reteroflexion and Anteflexion of transducer tip.
45 Degrees- Short axis view of the aortic valve

34. PRIMARY MULTIPLANE TEE
VIEWS
90 Degrees- Longitudinal transducer orientation, produce
images oblique to the long axis of the heart.
135 Degrees- True long axis of the LA and left ventricular
outflow tract(LVOT)

36. STAGE 1 OF THE STANDARD
TRANSESOPHAGEAL (TEE) EXAMINATION. (
MIDESOPHAGEAL FOUR-CHAMBER VIEW) AT 0
DEGREE).

37. MIDESOPHAGEAL MITRAL
BICOMMISSURAL VIEW

38. MIDESOPHAGEAL TWO-
CHAMBER VIEW

39. MIDESOPHAGEAL LONG-AXIS
VIEW.

40. LONGITUDINAL VIEWS
With transducer array at 90 degrees, the plane is
Sagittal to the Body and Oblique to the long axis of the
Heart.
1.Counterclockwise (Turn to left) rotation of the probe-
two chamber left ventricular inflow view
2.Slight rightward rotation of probe from first view,
produce long axis of right ventricular outflow tract(RVOT)

41. LONGITUDINAL VIEWS
3.Further right rotation-Long axis view of proximal
ascending aorta.
4.Further right rotation-Long axis view of the Vena Cavae
and Atrial septum.

43. STAGE 2 OF THE STANDARD TRANSESOPHAGEAL
ECHOCARDIOGRAPHY EXAMINATION, FOCUSING ON RV AND LV
INFLOW AND OUTFLOW. A, MIDESOPHAGEAL RV INFLOW-OUTFLOW
VIEW. B, MIDESOPHAGEAL BICAVAL VIEW. C, MIDESOPHAGEAL
ASCENDING AORTA IN LONG AXIS. D, MIDESOPHAGEAL AORTIC
VALVE IN LONG AXIS

45. STAGE 3 OF THE STANDARD TRANSESOPHAGEAL ECHOCARDIOGRAPHY
EXAMINATION, FOCUSING ON THE GREAT VESSELS. A, MIDESOPHAGEAL VIEW
OF THE ASCENDING AORTA IN SHORT AXIS. B, MIDESOPHAGEAL VIEW OF THE
AORTIC VALVE IN SHORT AXIS. C, UPPER ESOPHAGEAL VIEW OF THE AORTIC
ARCH IN LONG AXIS. D, DESCENDING THORACIC AORTA IN SHORT AXIS

46. TRANSGASTRIC VIEWS
With the transducer tip in fundus of the stomach (about 40-45cm
from the incisors)
The transducer array at 0 degree produces the short –axis view of LV
and RV.
Anteflexion or slight withdrawl of the tip of transducer optimizes the
basal short-axis view of the ventricles.
Retroflection of tip produces more apical short-axis view.

47. TRANSGASTRIC VIEWS
Sequential rotation of mutiplane transducer provides the
primary transgastric views of the LV
0 degree, short-axis view of LV and RV
70-90 degree- longitudinal two-chamber view of the LV
110-135 degree- transgastric view of the LVOT and
aortic valve

50. STAGE 4 OF THE STANDARD TRANSESOPHAGEAL ECHOCARDIOGRAPHY
EXAMINATION, FOCUSING ON TRANSGASTRIC VIEWS. A, TRANSGASTRIC
BASAL SHORT-AXIS VIEW OF THE LV AT THE LEVEL OF THE MITRAL VALVE. B,
TRANSGASTRIC SHORT-AXIS VIEW OF THE LV AT THE MIDPAPILLARY LEVEL. C,
TRANSGASTRIC TWO-CHAMBER VIEW. D, DEEP TRANSGASTRIC FIVE-CHAMBER
VIEW

51. MITRAL VALVE
The mitral valve is so named due to its appearance that
resembles a bishops’ miter.
Transesophageal echocardiography and the mitral valve
(that sits only 5–10 cm from the transducer with nothing
but blood between them)

52. THE MITRAL VALVE
The posterior leaflet has clefts that divide it into 3 scallops (P1, P2,
and P3);
The anterior leaflet has no such scallops, but is described as having
three regions that reflect those of the posterior leaflet (A1, A2, and
A3 respectively).
In addition to the points of apposition along the leaflets, there are
anterior (adjacent to A1/P1) and posterior (adjacent to A3/P3)
commissures.
The nonleaflet apparatus consists of the saddle-shaped mitral
annulus, the chordae tendinae (primary chordae attached to the free
edges of the leaflets, secondary and tertiary chordae attached to body

54. DIAGRAMMATIC REPRESENTATION OF THE RELATIONSHIP
BETWEEN EACH MID ESOPHAGEAL VIEW AND THE PARTS
OF THE MITRAL VALVE LEAFLETS SEEN.

55. MID ESOPHAGEAL 4 CHAMBERS VIEW AT
ZERO DEGREES WITH P2 AND A2 VISUALIZED.

56. MID ESOPHAGEAL 4 CHAMBERS VIEW AT 30°
WITH P1, A2, AND A3 VISUALIZE

57. MID ESOPHAGEAL COMMISSURAL VIEW WITH
P1, A2, P3, AND
BOTH COMMISSURES VISUALIZED

58. MID ESOPHAGEAL 2 CHAMBERS VIEW WITH
A1, A2, AND P3
VISUALIZED.

59. MID ESOPHAGEAL LONG AXIS VIEW WITH A2
AND P2 VISUALIZED

60. TRANSGASTRIC THE BASAL SHORT AXIS VIEW (VALVE CLOSED) WITH ALL 6
SCALLOPS AND BOTH COMMISSURES (ANTEROLATERAL [ALC] AND
POSTEROMEDIAL [PMC]) VISUALIZED.

61. TRANSGASTRIC THE BASAL SHORT AXIS VIEW
(VALVE OPEN) WITH ALL 6 SCALLOPS
VISUALIZED

62. It should be remembered that variations in the
orientation of the leaflets between individuals means that
nothing is absolute and the scallops seen in each image
plane may vary in different patients.
When describing which scallops are seen in each view,
the list starts with scallop furthest to the right of the
screen

63. THE LEFT ATRIUM
The fully developed human left atrium (LA) consists of
the true atrial septum, a superior smooth walled portion,
and an inferior trabeculated portion
The smooth walled portion is larger and originates
embryologically from the pulmonary veins that combine
to form a common pulmonary vein before becoming
integrated with the inferior portion of the left atrium.
The trabeculated portion of the adult LA is confined to
the appendage (LAA) and is all that remains is of the
primitive left atrium.

64. STANDARD IMAGE PLANES
The postero-superior wall of the LA is adjacent to the mid
esophagus, and all mid esophageal views image the left
atrial cavity by default.
There are therefore no specific left atrial views

65. LEFT ATRIAL APPENDAGE
Purpose of the left atrial appendage (LAA) is not fully
understood.
LAA acts as a capacitance chamber allowing
sudden changes in LA volume to be
accommodated without marked increases in
left atrial pressure (LAP)
The LAA acts as a culde- sac with a high
incidence of thrombus especially in the
presence of atrial fibrillation (AF).
The orifice of the neck of the appendage
curves around the lateral aspect of the LA
between the left upper pulmonary vein
(LUPV) (posteriorly) and the junction of the
LA and pulmonary trunk (anteriorly).

66. NORMAL LEFT ATRIAL APPENDAGE (LAA). THE LAA IS BEST VISUALIZED FROM THE
MIDESOPHAGEAL POSITION (A). IT IS A COMPLEX ANATOMIC STRUCTURE AND IS
MULTILOBED IN UP TO 80% OF THE GENERAL POPULATION. THE WALLS OF THE
APPENDAGE ARE LINED BY PECTINATE MUSCLES (B, ARROW). IN THE EVALUATION
FOR THROMBUS, THE APPENDAGE MUST BE METICULOUSLY EXAMINED IN
MULTIPLE PLANES IN ORDER TO ASSURE THAT ALL ASPECTS AND LOBES ARE
VISUALIZED. ONE APPROACH IS TO CENTER THE LAA IN THE IMAGING FIELD AT THE
0° POSITION AND SCAN THROUGH TO 180°, KEEPING THE APPENDAGE CENTERED
IN THE FIELD. TWO-DIMENSIONAL IMAGING OF THE APPENDAGE ALSO ALLOWS FOR
VISUAL ESTIMATION OF THE APPENDAGE SIZE AND CONTRACTILE FUNCTION

67. LEFT ATRIAL APPENDAGE (LAA) THROMBUS (ARROW). THE PRESENCE OF
LEFT ATRIAL (LA) OR LAA THROMBUS IS A CONTRAINDICATION TO
IMMEDIATE CARDIOVERSION . THE PRESENCE OF LA OR LAA THROMBUS IS
ASSOCIATED WITH A SIGNIFICANTLY INCREASED RISK OF STROKE
(RELATIVE RISK 2.7 IN THE STROKE PREVENTION IN ATRIAL FIBRILLATION III
[SPAF III] TEE SUBSTUDY . AT LEAST 3 WEEKS OF THERAPEUTIC
ANTICOAGULATION PRIOR TO, AND AT LEAST 4 WEEKS OF THERAPEUTIC
ANTICOAGULATION FOLLOWING, CARDIOVERSION IS RECOMMENDED
(CLASS IIA, LEVEL OF EVIDENCE C) IN THE 2006 AMERICAN COLLEGE OF
CARDIOLOGY (ACC) AND THE AMERICAN HEART ASSOCIATION (AHA)
GUIDELINES ON THE MANAGEMENT OF ATRIAL FIBRILLATION

68. DENSE SPONTANEOUS ECHOCONTRAST IN THE LEFT ATRIAL APPENDAGE (LAA)
(ARROW). SPONTANEOUS ECHOCONTRAST (SEC) IS DUE TO BACKSCATTER OF
ULTRASOUND FROM RED BLOOD CELL AGGREGATES OR LOW-VELOCITY BLOOD
FLOW. IT IS CHARACTERIZED BY A SWIRLING PATTERN OF INCREASED
ECHOGENICITY AT STANDARD SETTINGS, AND IS OFTEN IDENTIFIED IN THE LEFT
ATRIUM (LA). DATA REGARDING THE OPTIMAL MANAGEMENT OF PATIENTS WITH
ATRIAL FIBRILLATION AND DENSE SEC ARE LACKING. MULTIPLE STUDIES HAVE
DEMONSTRATED AN ASSOCIATION BETWEEN DENSE SEC AND STROKE RISK. IN
THE STROKE PREVENTION AND ATRIAL FIBRILLATION III (SPAF III)
TRANSESOPHAGEAL ECHOCARDIOGRAPHY SUBSTUDY, DENSE SEC WAS PRESENT
IN 89% OF PATIENTS WITH THROMBUS, AND 24% OF PATIENTS WITH DENSE SEC
HAD LAA THROMBUS . IN PUBLISHED STUDIES THAT REPORTED THE PRESENCE
OF SEC WITHOUT ASSOCIATED THROMBUS IN PATIENTS UNDERGOING
CARDIOVERSION, THE REPORTED INCIDENCE OF ADVERSE EVENTS IS
EXTREMELY LOW. ALTHOUGH THIS FINDING IS NOT AN ABSOLUTE
CONTRAINDICATION TO EARLY CARDIOVERSION, IT SHOULD PROMPT A
METICULOUS SEARCH FOR THROMBUS

69. NORMAL LEFT ATRIAL APPENDAGE (LAA) SPECTRAL PULSE WAVE DOPPLER
PATTERN. THE PULSE WAVE SAMPLE IS PLACED 1 CM INTO THE APPENDAGE FROM
ITS ORIFICE. NORMAL LAA DOPPLER FLOW PATTERN DEMONSTRATES A LATE
DIASTOLIC FLOW TOWARDS THE TRANSDUCER, REPRESENTING LAA EMPTYING
(HORIZONTAL ARROW). THIS SIGNAL OCCURS AFTER THE P WAVE ON THE SURFACE
ELECTROCARDIOGRAM, AND IT IS CONTEMPORANEOUS WITH THE MITRAL INFLOW A
WAVE. THE PEAK LAA EJECTION VELOCITY REFLECTS APPENDAGE CONTRACTILE
FUNCTION. LAA FILLING RESULTS IN A SIGNAL AWAY FROM THE TRANSDUCER IN
EARLY SYSTOLE (ARROWHEAD). FOLLOWING LAA FILLING THERE IS OFTEN A
VARIABLE NUMBER OF LOW AMPLITUDE INFLOW AND OUTFLOW SIGNALS TERMED
SYSTOLIC REFLECTION WAVES (VERTICLE ARROW).

70. LEFT ATRIAL APPENDAGE (LAA) PULSE WAVE DOPPLER PATTERNS IN ATRIAL
FIBRILLATION. SPECTRAL DOPPLER PATTERN DEMONSTRATES HIGH-
FREQUENCY ALTERNATING SAW-TOOTH APPEARING SIGNALS OF VARYING
VELOCITIES (A). VELOCITIES TEND TO BE LOWER DURING VENTRICULAR
SYSTOLE AND AT HIGHER VENTRICULAR RESPONSE RATES. MARKEDLY
DIMINISHED PEAK LAA EMPTYING VELOCITY (PLAAEV)

71. RREFLECTS MARKEDLY IMPAIRED APPENDAGE CONTRACTILITY. MULTIPLE
STUDIES HAVE FOUND AN ASSOCIATION BETWEEN LOW PEAK LAA
EMPTYING VELOCITY (< 20 CM/S) AND INCIDENCE OF STROKE IN PATIENTS
WITH ATRIAL FIBRILLATION. IN THE SPAF III TEE SUBSTUDY, PATIENTS WITH
LOW PLAAEV WERE MORE LIKELY TO HAVE THROMBUS (17% VS. 5%) . LIKE
DENSE SPONTANEOUS ECHOCONTRAST, LOW LAA VELOCITIES ARE A
MARKER OF POOR LAA FUNCTION.

72. RIGHT PULMONARY VIENS
Evaluation of the right sided veins is usually straight forward. From
the mid esophageal 4 chambers view the probe is rotated to the
right (with the image sector angle at 0–30° and depth at about 10 cm)
such that the inter-atrial septum is horizontal and in the centre of
the screen .
Color Doppler is added to the left side of the screen and the
probe is advanced slowly until 2 distinct pulmonary infows are seen ;
the more horizontal flow is from the RLPV and the more vertical fow is
from the RUPV.
The RUPV can also be seen by maintaining the probe depth,
rotating the image sector plane to the bicaval view at 80–120° , and
then manually rotating the probe clockwise/to the right .
This latter view of the RUPV is especially useful in patients’ with atrial
septal defects (ASD) when excluding anomalous pulmonary venous
drainage (most commonly the RUPV) and when assessing the distance
betweenthe rim of the ASD and the RUPV prior to considering
percutaneous closure.

73. MID ESOPHAGEAL 4 CHAMBERS VIEW WITH THE PROBE
ROTATED TO THE RIGHT,SO
THAT THE INTER-ATRIAL SEPTUM IS HORIZONTAL AND IN THE
CENTRE OF THE SCREEN

74. COLOR DOPPLER DEMONSTRATING TWO DISTINCT RIGHT
PULMONARY VEIN INFOWS (RED). THE MORE HORIZONTAL FLOW
IS FROM THE LOWER (RLPV) AND THE MORE VERTICAL FOW IS
FROM THE UPPER (RUPV) PULMONARY VEIN.

75. THE BICAVAL VIEW AT 124°.

76. THE BICAVAL VIEW WITH SUPERADDED MANUAL ROTATION OF
THE
PROBE CLOCKWISE/TO THE RIGHT. COLOR DOPPLER
DEMONSTRATING RIGHT UPPER
PULMONARY VEIN (RUPV) INFOW (RED)

77. LEFT PULMONARY VIENS
The left upper pulmonary vein (LUPV), which enters the
LA just lateral to the LAA from an anterior to posterior
trajectory, is identified by withdrawing slightly and
turning the probe to the left.
The left lower pulmonary vein (LLPV) is then identified
by turning slightly farther to the left and advancing 1 to
2 cm. The LLPV enters the LA just below the LUPV,
courses in a more lateral to medial direction, and is less
suitable for Doppler quantification of pulmonary venous
blood flow velocity being nearly perpendicular to the
ultrasound beam.
In some patients, the LUPV and LLPV join and enter the
LA as a single vessel

78. LEFT UPPER PULMONARY VEIN INFOW (LUPV)
SEEN IN THIS
VIEW TO THE RIGHT OF/LATERAL TO THE LEFT
ATRIAL APPENDAGE (LAA).

79. LEFT UPPER AND LOWER PULMONARY VEIN INFOW (RED CODED
BLOOD FOW). THE MORE VERTICAL FOW COMES FROM THE UPPER
(LUPV) AND
THE MORE HORIZONTAL FOW IS FROM THE LOWER (LLPV)
PULMONARY VEIN.

80. LEFT UPPER (LUPV) AND LOWER (LLPV) PULMONARY VEIN INFOW
(RED CODED BLOOD FOW). IN THIS VIEW THE FOW TO THE RIGHT OF
THE SCREEN IS FROM THE UPPER AND THE FLOW TO THE LEFT OF THE
SCREEN IS FROM THE LOWER PULMONARY VEIN.

81. THE AORTIC VALVE AND
AORTA
Valve Structure-
The valve itself consists of 3 cusps (right, left, and noncoronary)
attached to a fibrous annulus, and unlike the atrio-ventricular valves,
It does not have any anchoring supports (e.g., chordae tendinae) to
maintain the integrity. The integrity is dependant mainly on the annulus
geometry and the ratio of annulus: cusp area.
The annulus geometry is affected by the inter-ventricular septum and
proximal aortic root, and pathologies of either can alter the annular
shape and cause incompetence of the valve.
There is about 30% overlap of each cusp with its neighbour, and the
total cusp area must exceed the cross sectional area of the annulus in
order to maintain competency with a normal ratio being greater than
1.6:1;
Any pathology that decreases cusp area or increases annular area will
therefore lead to incompetence and regurgitation through the valve.

82. FIVE CHAMBERS VIEW
Starting in the mid esophagus (ME) and having briefly imaged the 4
chambers (4Ch) view the probe is withdrawn slightly to obtain the 5
chambers (5Ch) view;
The image sector depth is then reduced in order to visualize the valve
close up in 2D, and with color Doppler.
In this view the noncoronary cusp (NCC) or left coronary cusp (LCC) is
seen superiorly with the right coronary cusp (RCC) seen inferiorly

83. MID ESOPHAGEAL 5 CHAMBERS VIEW WITH THE NONCORONARY (N)
CUSP OR LEFT (L) CORONARY CUSP AT THE TOP AND THE RIGHT (R)
CORONARY CUSP AT THE BOTTOM.

84. SHORT AXIS VIEW
Maintaining this esophageal level the image plane angle
is slowly rotated between 40° and 80°, whilst gently
manually rotating the probe clockwise (to the right) to
obtain the AV short axis (SAX) view.
In order to remain spatially orientated it is best to
undertake these manipulations at a greater image sector
depth so as to have more landmarks to guide.
Once the AV SAX view is obtained the image sector
depth can be reduced once more for closer evaluation of
the valve.
The probe depth may need to be adjusted and some
degree of lateral flexion applied in order to get a perfect
“en face” view of the valve, and once achieved, it will
allow an exquisite view of all 3 cusps

85. MID ESOPHAGEAL AORTIC VALVE SHORT AXIS VIEW WITH REDUCED
IMAGE SECTOR DEPTH ALLOWING A CLOSE UP “EN FACE” VIEW OF THE
AORTIC VALVE. ALL 3 CUSPS ARE SEEN; NONCORONARY (N) TOP LEFT,
LEFT CORONARY (L) TOP RIGHT, AND RIGHT (R) CORONARY AT THE
AT THE BOTTOM

86. LONG AXIS VIEW
The third mid esophageal view recommended for AV
assessment is the (AV) long axis (LAX) view; this is
similar to the left ventricular LAX view but may require
further manipulation to ensure the appropriate cut
through the valve and proximal aortic root (i.e., with the
root being imaged in as close to horizontal projection as
possible).
Starting from the SAX view the image sector depth is
again increased to assist orientation.
The image plane angle is then rotated between 120° and
160° (although image may be acquired at angles 100–
120°) with or without some manual anticlockwise rotation
being applied. Then the sector depth is reduced to give a
close up of the valve and proximal root .

87. MID ESOPHAGEAL AORTIC VALVE LONG AXIS VIEW WITH ZOOMED IMAGE OF THE
AORTIC VALVE AND PROXIMAL AORTA. IN THIS VIEW, THE RIGHT (R) CORONARY CUSP
IS AT THE BOTTOM AND, DEPENDING ON THE ORIENTATION OF THE VALVE/AORTA
RELATIVE TO THE PROBE, THE NONCORONARY (N) OR THE LEFT (L) CORONARY CUSP
IS AT THE TOP

88. TRANSGASTRIC VIEWS
The most consistently attainable view is the TG LAX ; in
order to optimize visualization of the valve rotating the
probe to the right can be helpful.
The second transgastric view is the deep transgastric
view found at 0–40° by first obtaining the TG SAX view of
the LV and then advancing the probe. It should be noted
that it is not always possible to get the deep TG view and
patients’ tend to find it quite uncomfortable, so can be
ommited.

89. CORONARY OSTIA
The coronary ostia are well seen in the mid esophageal
AV short (left [LCA] and right [RCA]) and AV long (RCA)
axis views.
In the SAX view the left main stem (LMS) and proximal
portion of the anterior descending (LAD) and circumflex
(LCx) branches can be seen

90. THE LEFT
CORONARY OSTIUM (LCA) AND RIGHT CORONARY OSTIUM
(RCA) VISUALIZED

91. THE RCA IS SEEN IN THE SAX VIEW ALTHOUGH IT IS USUALLY BETTER SEEN IN THE
LAX VIEW MID ESOPHAGEAL AORTIC VALVE LONG AXIS VIEW WITH THE RIGHT
CORONARY ARTERY (RCA) VISUALIZED.

92. TEE AND ACUTE AORTIC
SYNDROME
Aortic dissection is a clinical emergency that is challenging to
diagnose.
TEE and CT angiography are the two most commonly employed imaging
modalities for aortic dissection.
Multiple studies have demonstrated the high sensitivity and specificity
of both modalities for diagnosing type A dissections.
The sensitivity and specificity of TEE have been reported as 90% to
100% and 94% respectively .
TEE offers the additional advantage of assessing for complications of
dissection including pericardial effusion, aortic insufficiency, and
regional LV wall motion abnormalities that suggest coronary
involvement.
One limitation of TEE is the inability to image the distal portion of the
ascending aorta and the proximal transverse aorta due to interposition
of the tracheal air column.
Intramural hematomas and penetrating atherosclerotic ulcers share
many risk factors, presenting features, and complications with classic
aortic dissection. A careful search for these entities should be

96. TRANSESOPHAGEAL
ECHOCARDIOGRAPHY FOR
DEVICE CLOSURE OF ATRIAL
SEPTAL DEFECTS
TRANSCATHETER CLOSURE IS AN EFFECTIVE
ALTERNATIVE TO SURGERY
In most patients with atrial septal defects (ASDs) of the
secundum type
Factors that decide suitability for
transcatheter closure include size of the
defect and presence of adequate tissue
rims around the defect.
Accurate imaging of the anatomic
features of the ASD is critical for case
selection, planning, and guidance during

97. ANATOMY OF THE ASD: NOMENCLATURE OF
THE RIMS/MARGINS
The rims of a secundum ASD are labeled as
1. Aortic (superoanterior),
2. Atrioventricular (AV).
3. Valve (mitral or inferoanterior),
4. Superior venacaval (SVC or superoposterior),
5. Inferior venacaval (IVC or inferoposterior), and
6. Posterior (from the posterior free wall of the atria).

98. By conventional definition, a margin 5 mm is considered to
be adequate
Podnar et al. (4) defined 10 morphological variations of
defects, the most common type being the defect with
Deficient aortic rim (42.1%).
The other variants includes central defects (24.2%),
Deficient inferoposterior rim (12.1%),
Perforated aneurysm of the septum (7.9%),
Multiple defects (7.3%),
Combined deficiency of mitral and aortic rims (4.1%),
deficient SVC rim (1%), and deficient coronary sinus rim
(1%).

99. FOR A COMPREHENSIVE EVALUATION OF THE ASD, TEE IS PERFORMED
IN 3 DIFFERENT PLANES: TRANSVERSE (0°), LONGITUDINAL (90°), AND AT
45°.

102. Diagnosis of Sinus Venosus Atrial Septal Defect With
Transesophageal Echocardiography
Roess D. Pascoe, MB, BS; Jae K. Oh, MD; Carole A. Warnes, MD;
Gordon K. Danielson, MD; A. Jamil Tajik, MD; James B. Seward, MD
the Division of Cardiovascular Diseases and Internal Medicine
(R.D.P., J.K.O., C.A.W., A.J.T., J.B.S.) and the Section of
Cardiovascular Surgery (G.K.D.), Mayo Clinic and Mayo
Foundation, Rochester, Minn.
Abstract
Background Sinus venosus atrial septal defect (SVD) is
underdiagnosed with transthoracic echocardiography because of
its posterior (far field) location. Transesophageal
echocardiography (TEE) should be ideally suited to diagnose
SVD, given the proximity of the transducer to the defect.

103. Methods and Results A retrospective study was
undertaken that used the medical history, echocardiographic
findings, and surgical data of patients identified from computer
records as having the diagnosis of SVD during the period in
which TEE has been in use (1987 to 1995). Twenty-five patients
(14 females and 11 males; median age, 45 years; range, 10 to
75 years) with SVD had TEE between 1987 and 1995. Prior
transthoracic echocardiography clearly defined the SVD in 3 of
these patients, and it was suspected in another 11 on the basis
of color-flow imaging. Ten patients had unexplained dilatation
of the right side of the heart, which prompted TEE examination.
SVD was visualized with TEE in all 25 patients and ranged in size
from 1 to 3 cm. Thirty-seven right-sided anomalous pulmonary
venous connections were identified in 23 patients. No left-sided
anomalous pulmonary venous connections were detected.
Anatomic confirmation was obtained in all 23 surgical patients.
No patient required preoperative cardiac catheterization for
diagnosis.
Conclusions TEE is accurate for the diagnosis of SVD and
should be undertaken in any patient with unexplained dilatation
of the right side of the heart. The associated pulmonary venous
abnormalities can be identified with TEE. Cardiac catheterization
for diagnostic purposes should not be required before surgical
correction.

104. Longitudinal scan of the atrial septum, which highlights sinus venosus
atrial septal defect (arrowhead) located in the superior fatty limbus of the
atrial septum (AS). The defect lies immediately inferior to the right
pulmonary artery (RPA), viewed in its short axis, and to the orifice of the
superior vena cava (SVC), viewed in its long axis. The SVC overrides the left
and right atria (LA, RA). The fossa ovalis (FO) portion of the atrial septum is
intact. Note the pathognomonic feature, ie, the absence of atrial septal

105. LONGITUDINAL SCAN DURING CONTRAST ECHOCARDIOGRAPHY THAT SHOWS SEQUENTIAL
FRAMES AFTER INTRAVENOUS INJECTION OF AGITATED NORMAL SALINE INTO THE RIGHT
ANTECUBITAL VEIN, WHICH HIGHLIGHTED TO-AND-FRO SHUNTING ACROSS THE SINUS VENOSUS
ATRIAL SEPTAL DEFECT WITH CHANGING ATRIAL PRESSURES DURING THE CARDIAC CYCLE. A,
CONTRAST AGENT FIRST APPEARS AS A BOLUS IN THE SUPERIOR VENA CAVA AT THE LEVEL OF
THE RIGHT PULMONARY ARTERY. B, CONTRAST AGENT ENTERS BOTH ATRIA SIMULTANEOUSLY. C,
NEGATIVE CONTRAST EFFECT WITH LEFT-TO-RIGHT SHUNTING ACROSS THE DEFECT. D, RIGHT-
TO-LEFT SHUNTING WITH OPACIFICATION OF BOTH ATRIA

107. In the European Multicenter Study, 10,419 attempted TEE
Insertion of the probe was unsuccessful in only 201
cases (1.9 percent);
Failure was due to a lack of cooperation by the patient or
to inexperience on the part of the operator in 98.5
percent of cases and to anatomical reasons
(tracheostoma or esophageal diverticulum) in 1.5
percent.

108. ENDOCARDITIS AND ITS
COMPLICATIONS
In a series of 80 patients who had 91 infected valves as confirmed by
surgery or autopsy, they identified vegetations by transthoracic
echocardiography in 58 percent and by TEE in 90 percent.
This series included 22 patients with infected prosthetic valves, for
which the diagnostic superiority of TEE was particularly striking.
Shively et al. reported that TEE had a sensitivity and specificity of 94
and 100 percent, respectively, for the detection of vegetations
In a prospective study of 118 patients with infective endocarditis, 44
patients had 46 abscess regions confirmed at surgery or autopsy. The
sensitivity and specificity of transthoracic echocardiography for the
detection of abscesses were 28 and 99 percent, respectively, as
compared with 87 and 95 percent for TEE

110. DETERMINING SOURCES OF
EMBOLISM
Approximately 15 percent of ischemic strokes are caused
by cardiogenic emboli
In a meta-analysis of nine studies that included 1469
patients who had cerebral ischemia, peripheral arterial
embolism, or nonvalvular atrial fibrillation or who were
candidates for mitral valvuloplasty, 183 patients had
thrombi in the left atrial appendage detected by TEE;
only two thrombi could also be visualized by
transthoracic echocardiography

111. SOME IMPORTANT TIPS
.
In order to remain spatially orientated it is best to
undertake these manipulations at a greater image sector
depth so as to have more landmarks to guide you.
When optimizing the image, whatever you do, do it
slowly; then, if the image looks worse do the opposite.
The ME 4Ch view is the easiest to obtain and recognize
and so can be used to orientate the operator. If you get
“lost” during a study, return to this view and start again.

112. CONCLUSION
TEE represents a valuable and generally safe diagnostic
and monitoring tool for the evaluation of cardiac
performance and structural heart disease and can
favorably influence clinical decision making.
Although complications associated with TEE probe
placement and manipulation can occur, these events are
rare.
Awareness of the possible complications, proper
identification, and careful assessment of patients is very
important.

113. CONCLUSION
Recent advances in echocardiographic instrumentation
have increased the diagnostic capabilities of TEE, but
have also increased the number of possible approaches
for performing a routine TEE examination
TEE and TTE compliment each other without being
competitive, and the transthoracic approach remains the
primary technique

114. THANK YOU