Dr. Awadhesh Kumar Sharma is a distinguished interventional cardiologist with extensive academic and professional credentials, including gold medals in his studies and multiple prestigious awards. He has performed over 10,000 invasive cardiac interventions and is actively involved in teaching and publishing in his field. Currently, he serves as an assistant professor at LPS Institute of Cardiology in Kanpur, focusing on both invasive and non-invasive cardiology techniques.

1. Awadhesh Sharma ,MD ,DM,FSCAI,FACC
LPS Institute of Cardiology
Kanpur

2. 
 Dr. Awadhesh Kumar Sharma is a young, diligent and dynamic interventional cardiologist. He
did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB
Medical College Jhansi. Then he did his superspecilization degree DM in Cardiology from
PGIMER & DR Ram Manohar Lohia Hospital New Delhi. He had excellent academic record with
Gold medal in MBBS, MD and first class in DM. He was also awarded chief ministers medal in
2009 for his academic excellence by former chief minister of UP Hon. Mayawati in 2009.He is
also receiver of GEMS international award. Recently he received best interventional cardiologist
award from central health minister Hon Ashwini Chaubey ji. He was also awarded with
prestigious fellowships of American College of Cardiology (FACC) and FSCAI. He had many
national & international publications. He had special interest in both invasive & non invasive
cardiology. He had performed more than 10000 invasive cardiac intervention procedures
successfully till date including coronary angiography, simple & complex angioplasty, peripheral
vessels angiography & angioplasty, carotid angiography & angioplasty, ASD, PDA device
closures, Mitral & pulmonary valvotomy. He is also in editorial board of many national &
international journal- Journal of clinical medicine & research (JCMR),Clinical cardiology update,
United Journal of Cardiology and Cardiovascular Medicine, EC Pulmonology and Respiratory
Medicine. He is also active member of reviewer board of many journals. He is active member of
many professional bodies including Indian Medical Association, Cardiological Society of India,
APVIC, ICC, API. He had worked as Intervention Cardiologist at RML Hospital, New Delhi(2011-
2014),NABH Accredited Grecian Hospital, Mohali (2014-2016). Currently he is working as
Assistant Professor of cardiology at Prestigious LPS Institute of Cardiology, GSVM Medical
college, Kanpur (UP),Centre of excellence under Govt of UP. He is actively involved in teaching
of 30 postgraduates (DM Cardiology) and 100 paramedical students.

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

4.  TEE- ultrasound diagnostic technique using an
esophageal window.
 TEE utilizes an electronically steered high-
frequency 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

5.  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

6.  Atrial fibrillation
 Suspected endocarditis
 Cardiac source of embolism
 Valvular heart disesase
 Prosthetic valve evaluation-Assessing the structural complications such
as myocardial abscess, fistulas, mycotic aneurysm, valvular
aneurysms or perforations, flail leaflets, or prosthetic valve dehiscence
 ASD assessment
 Assessment of acute aortic syndromes, and cardiac masses

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

9. 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

10.  Evaluate oropharynx for airway patency.
 Informed consent
 Establish peripheral IV with 3-way stopcock
 Topical anesthesia
 Lidocaine 2% viscous solution or spray

11.  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

19.  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.

20.  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.

21.  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).

25.  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

26.  0 Degree(transverse Plane)- Oblique view of upper esophageal
basal structures, the mid esophageal four chamber view or basal
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

27.  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)

33. With transducer array at 90 degrees, the plane is Sagittal to the
body and oblique to the long axis of the Heart.
1. Counterclockwise rotation of the probe-two chamber left
ventricular inflow view
2. Slight clockwise rotation of probe from first view, produce long axis
of right ventricular outflow tract(RVOT)

34. 3.Further clockwise rotation-Long axis view of proximal
ascending aorta.
4.Further clockwise rotation-Long axis view of the Vena
Cava and Atrial septum.

39.  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.

40.  Sequential rotation of multi plane transducer provides the primary
trans gastric 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- trans gastric view of the LVOT and aortic valve

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

45.  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 non leaflet 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 of leaflets), and papillary muscles (anterior: chordae attached to
lateral aspects of leaflets; posterior: chordae attached to medial aspects of leaflets).

55.  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.

56.  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

57.  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 cul-de- 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).

58.  In LAA/LA clot except type Ia- most of the interventionalist usually
defer PTMC.
 For LA/LAA clot assessment we image LAA in mid esophageal 0
degree and 90-110 degree.
 Second image is obtained by slightly withdrawing TEE probe till
visualization of aorta and image LAA in 0 degree and 90-110 degree
angle with slight counter clock wise probe rotation.

59.  Severe rheumatic MS specially with associated AF, dilated LA(>4.5
cm),dense spontaneous ECHO contrast and LAA emptying velocity
<25 cm/sec is associated with LAA/LA clot.
 AS per classification by Manjunath et al it is classified as follows-
1. Type Ia: LA appendage clot confined to appendage.
2. Type Ib: LA appendage clot protruding into LA cavity.
3. Type IIa: LA roof clot limited above the plane of fossa ovalis.
4. Type IIb: LA roof clot extending below the plane of fossa ovalis
5. Type III: Layered clot over the IAS
6. Type IV: Mobile clot which is attached to LA free wall or roof or IAS
7. Type V: Ball valve thrombus (free floating).

62. Type Ib Type Ib

63. Type Ib Type Ib

64. Type Ib LAA clot Type IV LAA Clot

68.  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.  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

77.  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.

78.  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

80.  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

82.  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 .

84.  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.

85.  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

88.  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 .

91.  Trans catheter closure of ASD is an effective alternative to surgery
in most patients with ostium secundum ASD.
 Factors that decide suitability for trans catheter 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 the procedure.

93.  The rims of a secundum ASD are labeled as -
1. Aortic or (anterosuperior),
2. Atrio ventricular (AV) Valve ,mitral or (inferoanterior),
3. Superior vena caval (SVC or posterosuperior),
4. Inferior vena caval (IVC or posteroinferior)
5. Posterior or superrior
6. Coronary sinus
By conventional definition, a margin 5 mm is considered to be
adequate.Deficient aortic rim (42.1%).

97. Bicaval view SVC & IVC Rims

98. Aortic rim (down) Posterior rim(UP)

100.  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.

101.  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.

102. THANK YOU