European Journal of Echocardiography (2010) 11, 557–576 RECOMMENDATIONS

doi:10.1093/ejechocard/jeq057

Recommendations for transoesophageal

echocardiography: update 2010
F.A. Flachskampf 1*, L. Badano 2, W.G. Daniel 1, R.O. Feneck 3, K.F. Fox 4,
Alan G. Fraser 5, Agnes Pasquet 6, M. Pepi 7, L. Perez de Isla 8, and J.L. Zamorano 8 for
the European Association of Echocardiography; endorsed by the Echo Committee of
the European Association of Cardiothoracic Anaesthesiologists

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Document Reviewers: J.R.T.C. Roelandt a and L. Piérard b
1
Med.Klinik 2, University of Erlangen, Erlangen, Germany; 2Department of Cardiology, University of Padova, Padova, Italy; 3Department of Anaesthesia, St Thomas’ Hospital London,
London, UK; 4Imperial College, London, UK; 5Wales Heart Research Institute, School of Medicine, Cardiff University, Cardiff, UK; 6Cliniques Universitaires St Luc de Bruxelles,
Brussels, Belgium; 7Centro Cardiologico Monzino IRCCS Milan, Italy; 8University Clinic San Carlos, Madrid, Spain

a
Department of Cardiology, Thoraxcentre, Erasmus MC, Rotterdam, The Netherlands; and bDepartment of Cardiology, Université de Liège, Liège, Belgium

Received 29 March 2010; accepted after revision 2 April 2010

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations rep-
resent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European
Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing appli-
cations such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Transoesophageal echocardiography † Interventional cardiology † 3D echocardiography

Introduction Training and competence

Since its introduction in the 1980s, transoesophageal echocardio- In order to provide patients with a clinically useful TOE, the oper-
graphy (TOE) has become a standard and indispensable technique ator must be competent in the procedure, the environment and
in clinical practice. It should be available in every echocardiographic supporting team must be appropriately equipped and trained,
laboratory as well as in every centre performing cardiac surgery. and a programme of quality control should be in place to ensure
The present recommendations represent an update and extension the validity and reproducibility of the reports issued. Individual
of the recommendations published in 2001 by the Working Group competence requires acquisition of knowledge and practical skill
on Echocardiography of the European Society of Cardiology,1 the during a period of supervised training. Few data exist on the
precursor of the present European Association of Echocardiogra- amount of training required to achieve competency, but a
phy. Technology has evolved considerably, as multiplane TOE has number of organizations have specified the contents of a training
become standard and real-time three-dimensional TOE is now programme. Evidence of competency is established through com-
increasingly used. Large clinical experience has been gathered in pletion of a training programme, but specific accreditation in TOE
all typical indications, including the universal acceptance of TOE is being increasingly recognized. The joint European Association of
as an important intra-operative tool especially in valve repair.2 Echocardiography (EAE) and European Association of Cardio-
As stated in 2001, these recommendations are not intended as a thoracic Anaesthesiologists (EACTA) accreditation requires indi-
comprehensive review of the technique, which is available in viduals to train under a supervisor, to pass a multiple choice
many textbooks, but rather as a statement of current standards question exam testing theoretical knowledge and image interpret-
in indications, patient preparation and safety precautions, and per- ation, and to submit a log book of 125 procedures undertaken (75
formance of the procedure according to diagnostic requirements. if the applicant already holds transthoracic echo accreditation). The

* Corresponding author. Tel: +49 9131 853 5301, Email: frank.flachskampf@uk-erlangen.de

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org.
558 F.A. Flachskampf et al.

Table 1 Studies required to achieve competence/undertake accreditation of various organizations and their
re-accreditation requirements, together with web source

Organization Studies Exam Re-accreditation (studies/CME)

...............................................................................................................................................................................
EAE/EACTA accreditation, www.escardio.org 125 (75 if TTE accredited) Yes 50 studies/year and 30 h CME over 5 years
ACC/ASE guidance, http://www.asefiles.org/COCATS.pdf 125 (TOE) 150 (Intraop) N/A –
NBE TOE accreditation, www.echoboards.org 300 Yes After 10 years; .50 in 2 of last 3 years;
15 h CME in last 3 years
ACTA; BSE accreditation; www.bsecho.org 125 (75 if TTE accredited) Yes After 5 years; 40 studies/year and 15 h CME
over 5 years

ACTA, Association of Cardiothoracic Anaesthetists; ASE, American Society of Echocardiography; ACC, American College of Cardiology; BSE, British Society of Echocardiography;
CME, continuing medical education; EACTA, European Society of Cardiac Anaesthesiologists; EAE, European Association of Echocardiography; N/A, not applicable; NBE, National
Board of Echocardiography (USA); TTE, transthoracic echocardiography.

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

reports are graded by external examiners. Individual competence Risks and precautions
must be maintained by continuing practice and learning.3 EAE/
EACTA accreditation is valid for a period of 5 years and then Serious complications of TOE are very rare.7,8 A recent review
re-accreditation requires submission of evidence of continued listed four deaths attributed to the procedure in over 40 000
practice and learning on a 5-yearly basis. Table 1 lists the require- TOE examinations. Major complications included laryngospasm,
ments of different organizations for competence or accreditation arrhythmias including cardiac arrest, oesophageal perforation, and
together with the requirements for re-accreditation in TOE. haemorrhage from oesophageal tumour.8 For comparison, a
Minimum standards for a TOE echo laboratory have been estab- recent gastroenterological survey of over 100 000 cases of upper
lished by the EAE,4 with recommended minimum room sizes of gastrointestinal endosonographic procedures found a mortality of
20 m2, cleaning and sterilizing equipment, suction, oxygen supply, 0.01% and a perforation rate of 0.03%.9 Any true resistance to
resuscitation equipment with facilities to monitor ECG, blood introduction of the probe, which may occur due to entrapment
pressure, saturation, and recover patients after TOE. Room size of the probe tip in the piriform recess, an oesophageal diverticu-
may be less relevant in theatres or in intensive care units. lum, an oesophageal obstruction, e.g. a tumour, or due to hiatus
Quality control is an important criterion for accrediting TOE hernia, should be respected and the procedure aborted. Upper
laboratories. endoscopy should then be performed prior to a new attempt.
Note that oesophageal perforation may manifest in a delayed
fashion with fever, neck pain, and subcutaneous emphysema.
Death during or immediately after TOE has been reported in
patients with acute aortic dissection, where the putative mechan-
Indications ism was retching and an attending sharp surge in blood pressure.
In general, TOE is indicated whenever the transthoracic examin- Therefore, in the context of aortic dissection, blood pressure
ation is inconclusive and the potential new information is impor- must be tightly controlled during the procedure by administration
tant enough to warrant the very small risk and moderate of sedatives and/or titration of blood pressure. Anticoagulation or
discomfort of the procedure. Typically, this involves clinical ques- thrombocytopenia entail an enhanced bleeding risk but are not
tions about cardiovascular structures that are not seen well or absolute contraindications to TOE. Bradycardia or tachycardia
not seen at all from the transthoracic approach, such as the left may occur, especially during probe introduction. Sedation may
atrial appendage, the pulmonary veins, the atrial septum, or the lead to hypoxia and apnoea. If sedatives are used, after TOE
thoracic aorta, and also clinical questions where the best available patients should be allowed to recover in the recumbent position
image quality is of crucial importance, such as in infective endocar- under surveillance. Duration of effect depends on sedative type
ditis or the assessment of prosthetic valves.5,6 In patients who are and dose and for midazolam typically ranges between 20 and
extremely difficult to examine transthoracically (e.g. postoperative 80 min, although assessment of recovery should be individua-
and ventilated patients), this may include classic indications for lized.10,11 Rarely, methemoglobinaemia due to the topical anaes-
transthoracic echocardiography, such as the evaluation of left ven- thetic agents prilocaine and benzocaine, in particular, has been
tricular function. The principal indications are given in Table 2. Fur- observed.12 Endocarditis prophylaxis is not recommended for
thermore, an important field for TOE is intra-operative monitoring TOE; however, instrument cleaning and disinfection prescriptions
during cardiac surgery or peri-interventional imaging, e.g. in percu- must be observed carefully. Electrical current leakage may occur
taneous valve interventions or positioning of occluding devices for after damage to the probe, such as from the patient’s teeth; there-
atrial septal defects, patent foramen ovale, ventricular septal fore, the probe has to be inspected after each use for damage. Per-
defects and paraprosthetic leaks, or electrophysiological iodic leakage current tests are also recommended by the
procedures. manufacturers.
Recommendations for transoesophageal echocardiography 559

Table 2 Principal TOE indications: essential views and Patient preparation and
structures in specific clinical situations (reproduced, equipment
with permission, from Reference 1)
It is mandatory to ask every conscious patient in advance about
1) Search for a potential cardiovascular source of embolism swallowing problems and any history of oesophageal disease,
Left ventricular apex or aneurysm (transgastric and such as strictures, diverticula, tumours, or recent gastro-
low-transoesophageal two-chamber views) oesophageal surgery. A discussion with the patient about the
Aortic and mitral valve (look for vegetations, degenerative changes, or procedure, risks, and benefits, including implications of topical
tumours, e.g. fibroelastoma)
anaesthesia (oral intake should be avoided for 2 h after the
Ascending and descending aorta, aortic arch
examination) and sedation (e.g. unfitness for driving for at least
Left atrial appendage (including pulsed wave Doppler); note spontaneous
contrast
12 h), should precede the examination. Informed consent is man-
Left atrial body including atrial septum; note spontaneous contrast
datory in conscious patients and should be documented. At least
Fossa ovalis/foramen ovale/atrial septal defect/atrial septal aneurysm; a 4 h fast (preferably 6 h, with clear liquids allowed until 2 h
contrast + Valsalva prior to the examination) before TOE should be observed,
2) Infective endocarditis except in emergency situations; the possibility of diabetic gastro-

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Mitral valve in multiple cross-sections paresis should be kept in mind.
Aortic valve in long- and short-axis views; para-aortic tissue (in particular TOE should be performed with multiplane equipment. The ECG
short-axis views of aortic valve and aortic root) to rule out abscess must be monitored throughout the procedure. An intravenous line
Tricuspid valve in transgastric views, low oesophageal view, and right should be in place both for sedation and in the event of compli-
ventricular inflow-outflow view
cations, and a supply of oxygen as well as equipment for suction
Pacemaker, central intravenous lines, aortic grafts, Eustachian valve,
should be at hand, especially if sedation is used. Blood pressure
pulmonic valve in high-basal short-axis view of the right heart
(inflow–outflow view of the right ventricle) and oxygen saturation monitoring, including baseline values prior
3) Aortic dissection, aortic aneurysm to the examination, are desirable. Dental fixtures have to be
Ascending aorta in long- and short-axis views; note maximal diameter, removed, and a bite guard should be in place. Topical oropharyn-
flap, intramural haematoma, para-aortic fluid geal anaesthesia with an agent such as lidocaine is usually given.
Descending aorta in long- and short-axis views; note maximal diameter, Sedatives should be used sparingly, if needed, especially in frail
flap, intramural haematoma, para-aortic fluid or severely compromised patients. A typical dose in a stable
Aortic arch; note maximal diameter, flap, intramural haematoma, patient is 2 –4 mg of intravenous midazolam (0.075 mg/kg), but
para-aortic fluid
lower doses may be sufficient; other sedatives or analgesics such
Aortic valve (regurgitation—note mechanism, annular and aortic
diameters, number of cusps)
as fentanyl may be used instead. Whenever sedatives are used,
Relation of dissection membrane to coronary ostia availability of and experience with resuscitation equipment are
Pericardial effusion, pleural effusion mandatory. A benzodiazepine antagonist, e.g. flumazenil (0.3–
Entry/re-entry sites of dissection (use colour Doppler) 0.6 mg), must be available. The instrument tip has to be unlocked
Spontaneous contrast or thrombus formation in false lumen (use colour regarding flexion and extension during intubation of the oesopha-
Doppler to characterize flow/absence of flow in false lumen) gus. Awake patients are usually examined in the lateral decubitus
4) Mitral regurgitation (note systolic or mean blood pressure) position, to facilitate drainage of saliva, but introduction of the
Mitral anatomy (transgastric basal short-axis view, multiple lower instrument is sometimes easier with the patient sitting upright. In
transoesophageal views). Emphasis on detection of mechanism and ventilated patients, use of a laryngoscope can facilitate oesophageal
origin of regurgitation (detection and mapping of prolapse/flail to
intubation. After each examination, probes have to be disinfected,
leaflets and scallops, papillary muscle and chordal integrity,
vegetations, paraprosthetic leaks) inspected for damage, and checked for electrical safety according
Colour Doppler mapping of regurgitant jet with emphasis on jet width to manufacturer’s guidelines.
and proximal convergence zone
Left upper pulmonary, and, if eccentric jet present, also right upper
pulmonary venous pulsed Doppler Documentation
5) Prosthetic valve evaluation
Morphologic and/or Doppler evidence of obstruction (reduced opening/
Video recording or digital documentation of the examination is
mobility of cusps/disks/leaflets and elevated velocities by CW mandatory. A written report and a log of examinations, the use
Doppler) of echo contrast, adjunctive medication, and examiners must be
Morphologic and Doppler evidence of regurgitation, with mapping of the kept. In the report, it is desirable (especially with computerized
origin of regurgitation to specific sites (transprosthetic, report generation) to specify whether certain cardiac structures
paraprosthetic); presence of dehiscence/rocking of prosthesis
have or have not been studied. It is mandatory to note all side
Presence of morphologic changes in the prosthetic structure:
calcification, immobilization, rupture, or perforation of bioprosthesis
effects and complications.
leaflets; absence of occluder in mechanical prostheses
Presence of additional paraprosthetic structures (vegetation/
thrombus/pannus, suture material, strand, abscess, pseudoaneurysm, General course of the examination
fistula)
Unlike transthoracic echocardiography, TOE is uncomfortable for
the patient. Therefore, the duration of the examination must be
560 F.A. Flachskampf et al.

limited, and the procedure cannot be repeated frequently. The gastric fundus. Although any number of additional views may be
examiner should aim to ensure that necessary to better delineate pathological findings (e.g. vegetations,
thrombi, etc.), the italicized views are essential for a complete TOE
(1) the diagnostic goal is satisfied,
examination, and colour Doppler, pulsed, and continuous wave
(2) the structures not well visualized by transthoracic echo are
Doppler should be used as indicated.
thoroughly investigated (e.g. the left atrial appendage and the
aorta), and
(3) the study is complete. Lower transoesophageal views
Thus, depending on patient tolerance and circumstances, the With the imaging plane in the transverse position, immediately
examiner may restrict the examination to just one critical struc- above the diaphragm the orifice of the inferior vena cava, the
ture, such as scanning the left atrial appendage and left atrium to right atrium, and the tricuspid valve are visualized in a long-axis
rule out thrombi before the electrical cardioversion of atrial fibril- view (Figure 1). Adjacent to the septal tricuspid leaflet, the
lation. On the other hand, in the sedated or anaesthetized patient, orifice of the coronary sinus may be seen, which courses
a systematic and thorough approach, satisfying all three listed goals, upwards (towards the transducer). The anterior (or sometimes
will ensure maximal diagnostic benefit from the procedure. posterior) tricuspid leaflet is seen to the left, and the septal to

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Analogous to transthoracic echocardiography, TOE views are the right.
mainly defined by internal landmarks, not by specification of Slightly further up, a (foreshortened) transoesophageal four-
probe position and plane angulation. Where degrees of viewing chamber view is obtained (Figure 2). Sometimes a low degree of
plane are given, 08 denotes a transverse and 908 a vertical view, rotation (10 –208) is useful to exclude the aortic valve. The
with clockwise plane rotation when looking in the direction of probe should be straightened before withdrawal from the
the ultrasound beam. Plane rotation (or switching from transverse stomach to minimize foreshortening, as long as image quality is
to longitudinal in biplane probes), shaft rotation, anteflexion, retro- maintained. In the transoesophageal four-chamber view, the left
flexion, and sideward flexion of the tip, and finally probe advance- ventricle is on the right side of the sector and the right ventricle
ment and withdrawal are the manoeuvres available to the on the left. The left atrium is on top, and septal and lateral walls
examiner to change the view. Anteflexion flexes the tip mechani- of the left ventricle, as well as the right ventricular free wall, are
cally upwards anteriorly, thereby usually improving contact with seen. The anterior mitral leaflet is seen on the left and the posterior
the anterior gastric or oesophageal wall, and retroflexion flexes on the right side; the septal tricuspid leaflet is on the right side and
it upwards posteriorly, thereby often deteriorating transducer the anterior tricuspid leaflet on the left side. The transoesophageal
contact with the gastric or oesophageal wall. Sideward (lateral) two-chamber view (Figure 3) is obtained at 60–908, with the
flexion (to the right or left of the transducer face) can be used convex anterior wall to the right, the straight inferior wall to the
instead of plane rotation to fine tune views and improve contact left, and the apex in the far field. The posterior mitral leaflet is on
with oesophageal or gastric wall, but is less important with the the left side and the anterior leaflet on the right side. Frequently,
use of multiplane transducers. Probe shaft rotation is described the left atrial appendage is seen on the right side of the base of
as clockwise or counterclockwise as seen from the examiner’s
viewpoint looking down the shaft of the probe.
The following description is intended to outline a complete
examination. Pathological findings or special questions may
necessitate a more detailed examination of particular structures,
which is beyond the scope of this article.
The typical TOE examination comprises three major steps:

† the proper transoesophageal examination, which may be con-

ceptually divided into lower oesophageal views, mainly to
image the ventricles, and upper transoesophageal views,
mainly to image the valves, atria, and great vessels. However,
sharply defined transducer positions or windows do not exist,
since they vary individually and have to be adjusted for each
view. Often, upper and lower transoesophageal views can be
obtained from approximately the same transducer position by
flexing or extending the tip of the transducer, since the
optimal oesophageal window often is small.
† the transgastric examination
† the examination of the aorta.
Figure 1 Low transoesophageal view of right ventricle (RV),
The sequence of these elements may be chosen individually;
right atrium (RA), and tricuspid valve. This is a transoesophageal
many operators start with transoesophageal views, followed by four-chamber view modified by slight counterclockwise shaft
transgastric views, and finally visualize the descending aorta and rotation.
aortic arch pulling the instrument back from the position in the
Recommendations for transoesophageal echocardiography 561

the left ventricle (in the sector image). Further plane rotation brings chamber, and long-axis) are the essential oesophageal views for
into view the transoesophageal long-axis view of the left ventricle evaluating the left ventricle, including segmental wall motion
(Figure 4) at 120– 1508, with the anterior mitral leaflet, the abnormalities. The mitral valve can be studied in detail (after
aortic valve and ascending aorta, and the anteroseptal left ventricu- appropriate depth reduction) in the same views enumerated for
lar segments on the right side (from near to far field), and the pos- the left ventricle. The use of multiple transoesophageal cross-sections
terior mitral leaflet and posterior left ventricular wall on the left of the mitral valve, especially with a multiplane transducer, includ-
side. These three views of the left ventricle (four-chamber, two- ing spectral Doppler of transmitral flow and colour Doppler
mapping of the left atrium, allows mapping of mitral pathology
and regurgitant jet origin to leaflets and leaflet segments (scallops
in the posterior mitral leaflet). This is discussed in more detail in
the section on the mitral valve. Pulsed Doppler tracings of pulmon-
ary venous flow can be recorded from both the left and the right
upper pulmonary veins. Spontaneous echo contrast (‘smoke’) in

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Figure 2 Transoesophageal four-chamber view. LA, left atrium.

Figure 4 Transoesophageal long-axis view of the left ventricle.

Aoa, ascending aorta.

Figure 3 Transoesophageal two-chamber view. AW, anterior

wall; IW, inferior wall; LAA, left atrial appendage; CS, coronary Figure 5 Aortic valve short-axis view (ac, acoronary; lc, left
sinus. coronary; rc, right coronary cusp and sinus).
562 F.A. Flachskampf et al.

the left atrium and/or appendage should be noted. Since spon- the bottom (i.e. anteriorly). If the transducer is slightly withdrawn
taneous echo contrast is gain-dependent, it should be ensured from the aortic valve in a short-axis view, the coronary ostia can be
that gain levels are high enough not to miss it. identified by adjusting the plane individually, located at 2 o’clock
(left coronary ostium) and 6 o’clock (right coronary ostium) of the
circumference of the aortic root. The right coronary ostium is fre-
Upper transoesophageal views quently visualized more easily in the long-axis view of the aortic
valve. Colour Doppler mapping should be performed in both
Flexion of the tip or withdrawal of the probe will display the aortic
aortic valve views. Spectral Doppler assessment of aortic flow vel-
valve and both atria from an upper transoesophageal position.
ocities is better achieved in transgastric long-axis views due to
Short- and long-axis views of the aortic valve (Figures 5 and 6)
more coaxial beam alignment. The maximal visualizable extent of
should be obtained by looking for a circular aortic root in the
the ascending aorta (Figure 7) should be documented, which
short-axis views (at 40 –708) and a central closure of the two visu-
necessitates withdrawal of the probe to display the upper part of
alized aortic leaflets, as well as a maximal visualized length of the
the ascending aorta (displayed on the right sector side), with an
ascending aorta in the long-axis view (at 130 –1608). The short-axis
angle between 130 and 1608, especially where the ascending
view shows the left coronary cusp in the upper right third, the non-
aorta courses anteriorly of the right pulmonary artery. The right
coronary cusp in the upper left third, and the right coronary cusp

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

atrium, the tricuspid valve, inflow and outflow tract of the right
in the lower third (anteriorly), while the long-axis view has the
ventricle, the pulmonary valve, and the main pulmonary trunk
non-coronary aortic cusp on top and the right coronary cusp at
are seen in counterclockwise continuity, with the aortic valve in
the centre, in the short-axis view of the aortic valve (Figure 5).
This view (also called the right ventricular inflow– outflow view)
resembles an upside down parasternal aortic valve short-axis
view. Colour Doppler evaluation of the tricuspid and—less
satisfactorily—the pulmonary valve can be performed. If visualiza-
tion of the distal right ventricular outflow tract, the pulmonary
valve, and the proximal main pulmonary artery are of particular
interest, a plane rotation to a lower angle (100 –1308) or counter-
clockwise shaft rotation brings these structures into view.
From an upper transoesophageal window, the atrial septum with
the oval fossa should be visualized in at least two planes (trans-
verse and longitudinal or sagittal view). The transverse view of the
right atrium is usually a minor modification of the transoesophageal
four-chamber view with reduced depth. It shows the left atrium on
top, the atrial septum as approximately horizontal structure, and
the tricuspid valve to the right. Neither caval vein is seen in this
view. The longitudinal, sagittal, or bicaval view of the right atrium
(at 908; Figure 8) displays the orifices of the superior (right
sector side) and inferior caval veins (left sector side) and the
Figure 6 Aortic valve long-axis view (magnification). right atrial appendage; the tricuspid valve is not seen. This view
allows in particular the evaluation of atrial septal defects of

Figure 7 Long-axis view of the ascending aorta. (A) Proximal ascending aorta. (B) In the same patient, after retraction of the probe and adjust-
ment of the plane orientation, a long portion of the dilated ascending aorta is seen. RPA, right pulmonary artery.
Recommendations for transoesophageal echocardiography 563

secundum type, the foramen ovale, pacemaker leads, and intrave- spontaneous breathing and, importantly, on release of a Valsalva
nous lines. If patency of the foramen ovale is to be checked, manoeuvre.
echo contrast should be applied and monitored during Views of cranial structures of the heart and great vessels are
obtained by withdrawing and anteflecting the probe in the trans-
verse (08) plane from a position showing the mitral valve in the
centre of the sector. On the right side of the screen, the left
atrial appendage is seen (Figure 9); careful study of this structure
which varies in size, shape (e.g. presence and number of distinct
lobes), and orientation often requires additional plane rotation
between 0 and 908. Pulsed wave Doppler recording of appendage
flow is useful to assess the risk of thrombus formation. Further
withdrawal and anteflexion displays the left upper pulmonary vein
(Figure 10). Clockwise shaft rotation displays the short-axis view of
the ascending aorta, accompanied on the left side by the superior
vena cava (Figure 11), and on the right side by the main pulmonary

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

artery. The right pulmonary artery courses to the left side of the
sector posteriorly of the ascending aorta. The left pulmonary
artery is poorly seen and courses to the right side of the sector.
The orifice of the right upper pulmonary vein is seen at the junction
of right atrium and superior vena cava and posterior to the latter,
both in transverse and longitudinal views (Figure 12). This junction
is the location of the transthoracically often poorly visualized sinus
Figure 8 Left and right atrium and atrial septum in longitudinal
venosus atrial defects. In a longitudinal (908) view, the orifice of the
(sagittal) view. Note orifice of superior (SVC) and inferior vena
cava (IVC) and right atrial appendage (RAA). right upper pulmonary vein can be located between left atrium and
right pulmonary artery.

Figure 9 (A) Left atrial appendage. (B) Pulsed wave Doppler recording of emptying (upward) and filling (downward) velocities in atrial fibrilla-
tion. The velocities are quite high (.25 cm/s), indicating relatively low risk of thrombus generation. LUPV, left upper pulmonary vein.
(C ) Example of left atrial appendage with marked pectinate muscles (arrow). There is no thrombus.
564 F.A. Flachskampf et al.

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Figure 10 Left: left upper pulmonary vein (LUPV) imaged in an approximately longitudinal view. Right: pulsed Doppler recording of normal
pulmonary venous inflow from the left upper pulmonary vein. Positive (upward) velocities are directed into the left atrium. S, systolic wave; D,
diastolic wave; R, reverse wave.

Figure 12 Transverse view of upper left atrium. Colour

Figure 11 Short-axis view of ascending aorta and main pul- Doppler display of inflow from right upper pulmonary vein
monary artery (MPA), with bifurcation and origin of right pulmon- (RUPV, arrow). SVC, superior vena cava; AoA, ascedending aorta.
ary artery (RPA), from the upper transoesophageal window.

posterior, and inferior (closest to the transducer) left ventricular

walls are seen. In the left ventricular two-chamber view (at 908),
Transgastric views the inferior wall is seen in the near field of the sector and the
The transducer is positioned in the upper stomach (gastric fundus), anterior wall at the bottom of the sector. The apex, which often
enabling left ventricular short-axis and two-chamber views (Figures 13 is not well visualized, is to the left and the mitral valve to the
and 14). In the left ventricular short-axis view at the mid-papillary right of the sector. Wall motion abnormalities, thrombi, and path-
level (at 08), the anterolateral papillary muscle is seen at 5 ology of the subvalvular mitral apparatus, which is particularly well
o’clock and the posteromedial approximately between 11 and 2 displayed in the transgastric two-chamber view, should be noted.
o’clock. The free wall of the right ventricle is seen on the left The long-axis view of the left ventricle, with assessment of
sector side. Counterclockwise, the mid-segments of the septal, left ventricular outflow tract and aortic valve, is obtained at
anteroseptal, anterior (farthest from the transducer), lateral, 100–1208 and sometimes minor clockwise shaft rotation
Recommendations for transoesophageal echocardiography 565

(Figure 15). The aortic valve is seen in the far field. Elevated or withdrawing and anteflexing the instrument, and sometimes
reversed flow velocities in the outflow tract or through the aortic adding 10–208 of rotation. The origin of mitral regurgitation jets
valve should be documented. It is frequently difficult to achieve by colour Doppler, as well as flail or prolapsing portions, and sys-
this view, and the ascending aorta is not seen well. Additionally, or tolic anterior motion of the leaflets, can be detected in this view.
alternatively in case of difficulty in obtaining the long-axis view of Although this view is often not easy to obtain, it is very helpful
the left ventricle from the typical transgastric position, a deep trans- in assessing the origin of mitral regurgitant jets.
gastric long-axis view or five-chamber view (Figure 16), including the Additional views of the right heart, which are not routinely
aortic valve, can be obtained by advancing the probe further into obtained, but are important whenever right heart pathology has
the gastric fundus and using maximal anteflexion of the probe. to be evaluated, are generated by rotating the probe from the
Note that this view will display cardiac structures roughly like a transgastric left ventricular short-axis position to the right, posi-
transthoracic apical four-chamber view, i.e. upside down compared tioning the right ventricle in the centre of the sector, and steering
with the transoesophageal four-chamber view. Rotation to 60–908 the plane angulation first to 308, producing a short-axis view of
creates a modified transgastric apical long-axis view of the left ven- the tricuspid valve, with the posterior leaflet to the upper left, the
tricle. These views are particularly useful for the Doppler examin- septal leaflet to the upper right, and the large anterior leaflet in the
ation of the left ventricular outflow tract and aortic valve. lower half of valve cross-section. A right ventricular inflow view

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

A short-axis view of the mitral valve (Figure 17) is obtained further can be obtained by further rotation. At 908, a long axis of the
basally from the mid-papillary muscle short-axis view by slightly right ventricular inflow is seen, which is analogous to the left ven-
tricular two-chamber view in that the apex is to the left and the
right atrium to the right. Further rotation discloses the right ventri-
cular outflow tract, with the pulmonary valve located at the
bottom of the sector.

Aortic views
Unless aortic pathology is the primary indication for a study, the
thoracic aorta is usually examined at the end of the TOE after
the cardiac examination. Between the upper abdomen and the
aortic arch, the oesophagus and the descending aorta change
their anterior –posterior relationships (at the diaphragm the oeso-
phagus lies anterior to the aorta; at mid-thorax it is medially
located; at the aortic arch it is posterior). Therefore, the complete
length of the thoracic descending aorta should be scanned in the
short-axis view (supplemented by long-axis views) by gentle rotation
Figure 13 Transgastric short-axis view of the left (LV) and of the probe to maintain correct visualization of aortic walls along
right ventricle (RV). the entire course of the vessel (Figure 18). The take-off of the left
subclavian artery can usually be seen, and often part of the distal

Figure 14 Transgastric two-chamber view. The apex is to the left, and the left atrium to the right in the image. (A) Cross-section showing the
cavity of the left ventricle. (B) Slightly modified view intersecting both papillary muscles and chordal subvalvular apparatus. AW, anterior wall;
IW, inferior wall; AL, anterolateral papillary muscle; PM, posteromedial papillary muscle.
566 F.A. Flachskampf et al.

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Figure 15 Transgastric long-axis view of the left ventricle Figure 17 Short-axis view of the open mitral valve from the
(1178). AoA, ascending aorta.
transgastric position. AL, anterolateral; PM, posteromedial com-
missure. A1 – A3 and P1– P3 denominate the respective leaflet
scallops.

Assessment of the mitral valve

Anatomically, it is standard practice to divide each mitral leaflet
into three segments, defined by dividing the attachment of each
leaflet to the atrioventricular junction (annulus) into three equal
parts, and then by dropping perpendicular lines to the closure
line of the valve (Figure 19). The body of the anterior leaflet is a
single structure which is attached along approximately one-third
of the circumference of the annulus, between the fibrous trigones.
The ‘posterior’ leaflet occupies the lateral and inferior parts of the
left atrioventricular junction and is attached along approximately
two-thirds of the circumference of the mitral annulus. Usually,
the posterior leaflet has three scallops, but their size and also
the number of scallops can vary. It is difficult even with TOE to
identify the clefts between the scallops precisely, and so an echo-
cardiographic approximation of the site of disease to the lateral,
Figure 16 Deep transgastric long-axis view of the left ventri- middle, or medial thirds of the posterior mitral leaflet (P1, P2,
cle, with maximal anteflexion. RV, right ventricle. and P3, respectively) may not correspond exactly either with the
precise anatomy of the scallops or with the exact location of find-
ings on surgical inspection. 3D TOE provides en face views of the
arch and the supra-aortic branches can be visualized; probe shaft mitral valve as if seen by the surgeon after left atriotomy, which are
rotation may be useful to adjust the images. Clockwise rotation felt to be advantageous for communication with the surgeon due
and slight probe withdrawal at the junction of aortic arch and des- to their intuitive appeal; see corresponding section below.
cending aorta display the long axis of the aortic arch, with the Detailed echocardiographic assessment of the mitral valve leaf-
anterior aortic arch wall in the far field of the sector, and partially lets should be performed using 2D imaging planes that show the
the superior ascending aorta. At 908, a short axis of the aortic arch leaflet tips in a long-axis orientation. Because TOE provides a mul-
is obtained. By rotating the transducer and advancing further into titude of possible cross-sections through the mitral valve, a sys-
the oesophagus, the distal portion of the ascending aorta may be tematic reference framework is necessary for orientation. One
recorded. However, due to the interposition of the trachea or way to analyse the mitral anatomy is by rotating the orientation
left main bronchus, some portion of the arch or distal ascending of the image through 3608 (Figure 20). However, to show the
aorta will usually not be visualized. The location of findings in anatomy well and completely, this requires to position the probe
the descending aorta can be described either by the distance of so that the pivot around which all the imaging planes are rotated
the probe tip to incisors, or by the cardiac structures at the lies at the centre of the annulus. This requirement is often difficult
same distance. or impossible to fulfil with sufficient image quality. Therefore, plane
Recommendations for transoesophageal echocardiography 567

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Figure 18 Descending aorta: (A) short-axis view; (B) long-axis view. The aorta shows atherosclerotic lesions, some of which (arrow) have
superimposed mobile thrombus.

systole) and apposition (whether or not the leaflets are symmetri-

cally aligned opposite each other in systole).
In systole, the mitral annulus is not planar but saddle-shaped, with
high points that are anterior and posterior and low points that are
lateral and medial. Similar to transthoracic imaging, a transoesopha-
geal four-chamber view crosses through the low points of the
annulus and thus is more likely to display prolapse than are apical
two-chamber or long-axis images which cross the mitral annulus
at its high points. As in transthoracic imaging, mitral valve prolapse
should only be diagnosed confidently when the mitral leaflets
appear beyond the plane of the annulus in longitudinally orientated
images, i.e. long-axis views. When mitral regurgitation is provoked by
chronic dilatation of the left ventricle or during acute ischaemia,
increased traction and downwards and outwards displacement of
the subvalvar apparatus increase the distance between the bodies
Figure 19 Pathologic specimen of the closed mitral valve, seen
of the mitral leaflets and the plane of the annulus and reduce the
from the atrial side (‘surgeon’s view’). A1 –3 and P1– 3 designate
the leaflet scallops. The yellow triangles indicate the site of the
overlap of the tips of the leaflets (apposition of the rough zones).
fibrous trigones; the dotted black lines show the most common This is termed secondary, functional, or ischaemic mitral regurgita-
location of the fibrous mitral annulus. Opposite P2 the mitral tion. These changes can be quantified by measuring the ‘tenting’
annulus is usually composed only of ventricular myocardium. S, area or volume (by 2D or 3D echo, respectively), or simply by the
superior; I, inferior; L, left; R, right. Courtesy of JRTC Roelandt, distance between the coaptation point of the leaflets and the
Rotterdam, The Netherlands. plane of the annulus (the tenting height14,15). In this type of mitral
regurgitation, there are likely to be multiple regurgitant jets arising
along a large portion of the closure line. If no clear regurgitant
rotation alone often is not sufficient and should be supplemented pathology is identified and if the annulus and tenting height are
by systematically analysing parallel planes as depicted in Figure 20. normal, then alternative explanations such as a perforated leaflet
The classification of mechanisms of regurgitation that is most or a cleft should be considered.
commonly used by cardiac surgeons was developed by During TOE, the severity of mitral regurgitation should be
Carpentier13 (Table 3). It is based on the relative mobility of all graded using the same criteria recommended for transthoracic
the segments of both leaflets, compared with the mobility and imaging.16,17 When performing grading of residual regurgitation
position of the leaflets next to the anterolateral commissure compared with preoperative regurgitation in the operating room
taken as a reference point. However, this concept originally after bypass, it is important to ensure that left ventricular function
stems from surgical inspection while the patient is on cardio- and blood pressure have recovered, the Nyquist limit and gain set-
pulmonary bypass and when the heart is flaccid due to cardiople- tings for colour Doppler have been kept constant, and that frame
gia; for this reason, it is recommended that additionally the regional rates for colour Doppler are maximized. In the anaesthetised
pattern of closure of the mitral valve leaflets is described in terms patient with low blood pressure, the severity especially of func-
of coaptation (whether or not the leaflets touch each during tional mitral regurgitation is typically underestimated. Systolic
568 F.A. Flachskampf et al.

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Figure 20 Examination of the mitral valve. Screen depiction of relative position of mitral leaflets and segments/scallops in typical transoesopha-
geal cross-sections created by three different examination manoeuvres. Note that individual anatomy, especially scallop morphology, is variable,
and so is the relation of image plane orientation to individual anatomy; the schematic drawings should therefore be understood as approximations.
A1 – A3, anterior leaflet segments; P1– P3, posterior leaflet segments; Ao, aortic valve; LAA, left atrial appendage. (A) Examination by rotation of
imaging cross-section with fixed transducer position positioned at the level of the mitral valve centre. (B) Examination by flexion/withdrawal and
retroflexion/advancement of the transesophageal transducer, while rotation angle is fixed in a transverse orientation (08). (C) Examination by
probe shaft rotation (counterclockwise from plane A to C), while rotation angle is fixed in an orientation approximating the mitral closure line
(45 – 908). Note that the aortic valve is not imaged in these planes. Reproduced, with permission, from Foster et al.47

blood pressure should be recorded during any echocardiographic Percutaneous interventions in mitral regurgitation have opened
study of the severity of mitral regurgitation, whether before or a new field for TOE guidance and surveillance, which will possibly
during cardiac surgery. It is not necessary to perform pre-operative further benefit from 3D imagery. In the EVEREST I safety and feasi-
TOE in all patients before mitral valve surgery; if transthoracic bility trial, TOE was successfully used for this purpose as the
images are of sufficient quality for a detailed diagnosis to be primary imaging modality.18
made, then TOE can be postponed until the patient is anaesthe-
tized prior to surgery. Assessment of the aortic valve
Mitral prostheses should be assessed in a similar fashion to the
native mitral valve; here, it is often easy to use mainly systematic
and aortic root
plane rotation from a fixed viewing point in order to assess the pros- TOE is used for assessing the aortic valve in several frequent scen-
thesis and its circumference. This is particularly valuable to localize arios, including but not restricted to, endocarditis (Figure 21),
and quantify the size of paraprosthetic leaks. Occluder motion is improved characterization of stenotic or regurgitant lesions,
well assessed, thrombi or vegetations identified, and colour aortic prosthetic malfunction, preparation for aortic valve
Doppler as well as continuous wave Doppler examination for regur- surgery (especially if repair is contemplated), aortic interventions,
gitation or obstruction performed. However, structures on the ven- or in the context of dissection of the ascending aorta.
tricular side of the prosthetic ring or occluder may be masked by The main views to assess aortic valve and root morphology, which
shadowing. For 3D assessment see the corresponding section. are long- and short-axis views of these structures, have been
Recommendations for transoesophageal echocardiography 569

reviewed previously in this text. Doppler assessment by continuous guide the decision for repair of replacement of the aortic valve.
or pulsed wave Doppler can only be obtained with good alignment TOE assessment of the aortic valve must always take into
between ultrasound beam and flow direction using a deep transgas- account the characteristics of the aortic root. The aortic valve,
tric long-axis view (Figure 16). The normal aortic valve is composed aortic root, and left ventricular outflow tract should be inspected
of three cusps, surrounded by a dilatation of the aortic wall called the in short- and long-axis views. Subvalvar (Figure 22) or supravalvar
Sinus Valsalvae. Each of the cusps is named according to the coron- stenosis is visualized especially in the long-axis view. The normal
ary ostium in the corresponding sinus. Congenital abnormalities of aortic valve is very thin and may be difficult to image specially in
the aortic valves include the bicuspid valve, sometimes associated diastole in long-axis view. A bicuspid or stenotic valve may
with co-arctation of the aorta or with dilatation of the aortic root, display ‘doming’ in the long-axis view. Presence, location, and
and rarely the unicuspid or quadricuspid valve. Several types of severity of calcifications on the free margins of the leaflet bodies
bicuspid aortic valves may be distinguished according to the pres- can be evaluated best in the short-axis view. This view is also
ence and location of the raphe.19 used for the measurement of aortic valve orifice area by planime-
Although aortic valve replacement remains the most frequent try. To allow precise measurements, the cross-sectional plane
treatment for aortic valve stenosis, repair techniques are increas- must contain the smallest orifice of the valve and thus the probe
ingly used for the treatment of aortic regurgitation.20 Therefore, position and orientation must be adjusted to obtain the smallest

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

an accurate diagnosis of the mechanism of valve dysfunction is a valve orifice area at tips of the leaflets, which is of particular impor-
key point for determining the feasibility of the technique and tance in the doming valve. Use of biplane or 3D TOE may help
locate the right position for planimetry. A key point in considering
repair of the aortic valve is the mobility of the aortic leaflets.
Table 3 Carpentier classification and mechanisms of Restricted motion due to calcification suggests valve replacement
mitral regurgitation13 rather than repair. On the other hand, regurgitation due to exces-
Carpentier Definition Differential diagnosis
sive tissue motion, as in prolapse, is more amenable to repair. Pro-
classification lapse of aortic leaflets may be defined analogously to mitral valve
................................................................................ prolapse as diastolic displacement of an aortic leaflet (or part
Type 1 Normal leaflet Annular enlargement; thereof) towards the left ventricle beyond the plane of the
mobility perforated leaflet;
aortic annulus in diastole. The diagnosis is made in long-axis view
congenital cleft;
annular calcification but precise location requires frequently the use of short-axis
Type 2 Increased mobility Elongated cords; view and back-and-forth rotation between these two standard
(‘prolapse’); ruptured cords; views, particularly when pathology involves the ‘upper’ leaflet in
includes ‘flail excessive leaflet tissue long-axis view which may be the non-coronary or the left coronary
leaflet’ leaflet. Several kinds of prolapse exist (Figure 23):
Type 3 Restricted mobility; Thickened, rigid leaflets;
during diastole commissural fusion; † flail leaflet, when there is no more leaflet coaptation and the
(3A); during shortened or fused leaflet is ‘floating’ in the outflow tract, often with a ‘spoon’
systole (3B) tendinous cords;
appearance;
dilated left ventricle
with impaired function † prolapse proper of a leaflet, when the leaflet body is displaced
below the level of the annulus plane and thus coaptation
length is severely reduced allowing regurgitation during diastole;

Figure 21 Infective endocarditis of bioprosthesis in aortic position, with paraprosthetic abscess characterized by aortic wall thickening with
central zone of reduced reflectivity (arrows). (A) Long-axis view. (B) Short-axis view.
570 F.A. Flachskampf et al.

† partial leaflet prolapse, when only part of a leaflet is prolapsing; Colour Doppler localizes the origin and course of aortic regurgi-
frequently the leaflet is divided in two parts by a fibrous band, tant jets, e.g. a central jet due to central loss of coaptation, or a com-
and only the free margin portion prolapses. missural or eccentric jet due asymmetric leaflet restriction or a
leaflet prolapse. In the presence of a prolapse, colour Doppler
flow exhibits eccentric aortic regurgitation away from the prolapsing
leaflet, which may help identify the location of the prolapse
(Figure 23). Diastolic coaptation of the valve is well seen in the short-
axis view. Loss of central coaptation is associated with aortic insuf-
ficiency and usually the consequence of aortic root dilatation.
The aortic root, best assessed in long-axis views, is the proximal
part of the ascending aorta comprising the sinus of Valsalva located
above the valve and the sinotubular junction, which is the nar-
rowed portion just above the sinus of Valsalva making the junction
with the tubular part of the root (ascending aorta). Dilatation of
the aortic root frequently causes aortic regurgitation and is a

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

risk factor for aortic dissection. Several long-axis view diameter
measurements are helpful in characterizing the aortic root and
ascending aorta (Figures 24 and 25). Dilatation of the aortic root
can be located at the level of the sinus of Valsalva, the sinotubular
Figure 22 Subvalvular aortic stenosis due a subaortic mem-
junction or the tubular portion of the ascending aorta; precise
brane. Long-axis view.
location is important to guide the surgeon for the repair

Figure 23 Prolapse and flail of the aortic valve; long-axis views. (A) Flail leaflet. (B) Whole cusp prolapse. (C) Partial cusp prolapse, fibrous
band highlighted by arrow. (D) Colour Doppler corresponding to case C, showing eccentric regurgitant jet.
Recommendations for transoesophageal echocardiography 571

procedure. Dilatation of the aortic root is sometimes associated the aortic valve. Correct identification of the mechanism by TOE
with bicuspid aortic valve and Marfan’s disease, but most frequently may prevent unnecessary aortic valve replacement.
related to age or hypertension. Reference dimensions of the aortic Aortic valve prostheses are assessed in the same views as native
root have been published.21 aortic valves, and multiple views are necessary to minimize the
Aortic dissection can induce aortic regurgitation by several impact of acoustic shadowing. In mechanical valves, obstruction
mechanisms:22 dilatation of the ascending aorta, rupture of the may occur by thrombosis or pannus (fibroconnective tissue).
attachment of a cusp, or prolapse of the dissection flap through Restricted occluder motion may lead to both obstruction and regur-
gitation. However, it is not always possible to detect and quantify
restricted occluder motion in aortic prostheses by TOE.23 Degener-
ated bioprostheses may develop stenosis by thickened and immobi-
lized leaflets. While TOE provides good assessment of leaflet
morphology and mobility, gradients are often better obtained trans-
thoracically. By TOE, they can best be recorded in a transgastric
long-axis view or in a deep transgastric five-chamber or long-axis
view. Regurgitation in the presence of an aortic prosthesis can be

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

transprosthetic, paraprosthetic, or both. Short-axis views at the
level of the sewing ring allow best to differentiate transprosthetic
and paraprosthetic leakage. If a paraprosthetic leak is large (dehis-
cence), it may compromise the stability of the sewing ring, leading
to rocking of the whole prosthesis. For details of functional evalu-
ation of prosthetic valves see reference 6.
Prosthetic infective endocarditis is characterized by vegetations
Figure 24 Typical measurements of the aortic root apparatus. which in mechanical prostheses are usually attached to the pros-
ST, sinotubular. thetic ring, while in bioprostheses they may also arise from the leaf-
lets. An echo free space or localized aortic wall thickening next to

Figure 25 (A) Dilatation of the sinus of Valsalva. (B) Effacement of sinotubular junction. (C) Dilatation of the ascending aorta.
572 F.A. Flachskampf et al.

the prosthetic sewing ring is highly suspicious of an abscess

(Figure 21), typically in the region of the non-coronary sinus of
Valsalva.
An emerging application of TOE relates to interventional or trans-
catheter (transapical or transfemoral) aortic valve replacement.24,25
Before intervention, the aortic annulus diameter is of critical impor-
tance for selection of prosthetic size. Implantation can be TOE-
guided, although deployment of the prosthesis in most laboratories
relies more heavily on fluoroscopy. Immediately after deployment,
TOE is essential to evaluate aortic regurgitation, which if severe
and paraprosthetic may prompt re-insufflation of the deployment
balloon in the prosthesis in order to improve apposition of the pros-
thetic ring to the aortic wall.

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Three-dimensional (3D) TOE
Figure 26 3D transoesophageal en face view of the mitral
The recent advent of 3D imaging has considerably enhanced TOE
valve with a P2 prolapse, seen from a left atrial viewpoint (3D
by providing relatively high image quality and several unique views,
zoom). A2, anterior leaflet opposite to P2; AV, aortic valve
and by its capability to show intuitively understandable 3D images region.
to physicians not specialized in imaging. The one already commer-
cially available 3D TOE probe besides 3D imaging provides the
same modalities as a standard transoesophageal transducer (2D
imaging and all Doppler modalities). 3D imaging can be performed particularly in en face views (‘surgeon’s view’) with a viewpoint
in several modes: in the left atrium looking towards the left ventricular apex.
† Real-time, simultaneous biplane imaging (‘X-plane’), typically † Aortic valve disease.28 The best 2D view for launching the 3D acqui-
orthogonal, but plane orientations can be changed; includes sition is a long-axis view. The ‘zoom box’ should include the whole
colour Doppler. aortic valve, but should not include much of the ascending aorta. 3D
† Real-time (‘live’) 3D, where a real-time 3D data set is obtained TOE helps to planimeter the valvular orifice area in aortic stenosis
and displayed. The sector angle is lower than that of the typical and the regurgitant orifice area in aortic regurgitation.
2D sector and depends on the desired scan line density. † Prosthetic valves (Figure 28). One of its main advantages is the
† A zoom modality for real-time 3D. determination of location and extension of paraprosthetic
† A modality encompassing the classic full sector width (‘full leaks.28
volume’), but necessitating previous acquisition of several † Congenital heart disease.30 To obtain atrial septal images of the
heart cycles and therefore not fully ‘live’; this option can also atrial septum, bicaval or the best 2D cross-section showing
be used with colour Doppler. the defect should be used; the 3D acquisition should include
the whole atrial septum. Left and right upper pulmonary veins
3D frame rates are relatively low (25–28 per s in ‘full volume’, are well visualized using the 3D zoom.
higher for data sets recorded with a narrower sector angle). To † Guidance of percutaneous interventional procedures,26,27
obtain good quality, images should first be optimized in 2D especially closure of paraprosthetic leaks and atrial septal
mode, with special emphasis on gain (too much gain will loose defects, and interventional valvular procedures.
the 3D feel and too little gain will result in ‘holes’) and com-
pression (2D compression not too low, then adjust 3D com-
pression if necessary). For 3D zoom, after 2D optimization the Perioperative TOE
3D ‘zoom box’ should be adjusted to include the structure of
Perioperative TOE was introduced into clinical practice in the early
interest in the smallest volume possible in order to have a frame
1980s. The first reports were concerned with the assessment of left
rate as high as possible. For 3D ‘full volume’, after 2D optimization,
ventricular function and the detection of intra-operative air
it is recommended to switch to ‘live 3D’ mode to adjust 3D gain,
embolus.31 – 34 Since that time, there has been an exponential
volume size, and frame rate, followed by the full-volume 3D
growth in the use of TOE in surgical patients. The result is the
volume acquisition in a short breath hold. Similarly, for 3D
current situation where TOE skills are widespread among cardiac
colour Doppler imaging, colour Doppler gain, scale and wall
anaesthesiologists, and are developing among those anaesthesiologists
filter should first be optimized in 2D and live 3D before final 3D
and others involved in major surgery, particularly neurosurgery, liver
acquisition. The most frequent indications for 3D TOE are
transplantation, vascular surgery, trauma surgery, and in critical care.
† mitral valve disease,26 – 29 especially mitral regurgitation second- A growing body of articles and several guidelines, most recently the
ary to mitral valve prolapse (Figures 26 and 27). The main advan- Practice Guidelines for Perioperative Transoesophageal Echocardio-
tage of 3D TOE is the accurate identification of location and graphy update35 reflect the broad use of perioperative TOE by
extension of valve pathology (e.g. flail leaflet portions), anaesthesiologists.
Recommendations for transoesophageal echocardiography 573

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Figure 27 3D transoesophageal view of the jet of severe mitral regurgitation due to posterior mitral prolapse, seen from a left atrial per-
spective (‘full volume’, colour Doppler mode); LA, left atrium. (A) Diastolic frame, with open mitral valve. Note laminar blue inflow into the left
ventricle across the valve. (B) Early systolic frame with incipient formation of turbulent jet in the left atrium. (C) Mid-systolic frame. The
eccentric jet follows the concavity of the atrial wall. (D) Late systole: maximal size of colour Doppler representation of regurgitant jet.

In every surgical setting, the role of TOE is to confirm or further

define the preoperative diagnosis, exclude any new deterioration
or unsuspected pathology, facilitate the intra-operative manage-
ment of the patient, including where necessary to aid in surgical
planning, and to evaluate the results of surgery and provide infor-
mation for the postoperative care of the patient.

Cardiac surgery
Cardiac surgery represents the largest clinical arena for periopera-
tive TOE. Evidence for the indications for TOE has evolved over
time. The lack of randomized controlled trials and meta-analyses
has necessarily led to a cautious approach, most evident in the rec-
ommendations of the 2003 ACC/AHA guidelines.36 These stated a
Class I recommendation for TOE in a range of cardiac surgical con-
ditions including valve repair and complex valve replacement, most
congenital heart surgery, complex endocarditis, complex pericar-
dial drainage, aortic dissection, and intracardiac device placement.
They also recommended TOE as a Class I indication for the evalu-
ation of acute, persistent, and life-threatening haemodynamic dis-
turbances in the perioperative setting. However, a number of
Figure 28 3D transoesophageal view of bileaflet mitral pros-
thesis from the atrium; the discs are in the open position. LAA, other cardiac surgical procedures were identified as Class II indi-
left atrial appendage; AO, location of ascending aorta. cations, including surgical procedures in patients at increased risk
of myocardial ischaemia, myocardial infarction, or haemodynamic
574 F.A. Flachskampf et al.

disturbances. Arguably, this risk could be said to be relevant to all myocardial pump dysfunction, hypovolaemia, cardiac tamponade,
adult cardiac surgery patients, particularly in contemporary surgical aortic dissection, and intracardiac masses. Critical care patients
practice where both the age and clinical state of patients under- do not suffer from the same restrictions concerning contamination
going cardiac surgery represents a greater risk than in earlier of the operative field that are relevant to patients in the operating
years. In the light of this changing clinical environment, the continu- room, and therefore transthoracic imaging is a realistic alternative.
ing publication of evidence outlining the value of intra-operative Nonetheless, TOE should be performed in this setting if clinically
TOE for adult cardiac surgery, and the conclusion of the most relevant information is not obtainable by transthoracic
recent guidelines,35 we concur that TOE is reasonable for use in echocardiography.
all adult patients who are undergoing either cardiac surgery or
thoracic aortic surgical procedures under general anaesthesia. Provided that there is appropriate technology available, and that
Recent clinical developments have included the increased use of those charged with undertaking TOE have the knowledge and skills
catheter-based intracardiac procedures. Whereas septal defect appropriate to the task, it is therefore recommended that:
closure using occluder devices is already well established, trans- † TOE should be used in adult patients undergoing cardiac surgery
catheter valve procedures, particularly aortic valve replacement or surgery to the thoracic aorta under general anaesthesia, in
and mitral valve repair are novel procedures being undertaken particular, in valvular repair procedures.

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

with increasing frequency. Many centres perform these procedures † TOE may be used in patients undergoing specific types of major
with TOE monitoring, but the exact place for these procedures is surgery where its value has been repeatedly documented. These
still unclear. include neurosurgery at risk from venous thromboembolism,
liver transplantation, lung transplantation, and major vascular
Non-cardiac surgery surgery, including vascular trauma.
Although TOE was first utilized in non-cardiac surgery in 1983 for † TOE may be used in patients undergoing major non-cardiac
the detection of air embolism in neurosurgical patients, since then surgery in whom severe or life-threatening haemodynamic dis-
cardiac surgery has been the dominant clinical area of use. turbance is either present or threatened.
However, non-cardiac surgery has been increasingly identified as † TOE may be used in major non-cardiac surgery in patients who
a potentially valuable indication for TOE. In neurosurgery, TOE are at a high cardiac risk, including severe cardiac valve
may be recommended for the detection of venous air embo- disease, severe coronary heart disease, or heart failure.
lism.33,37 In liver transplantation, TOE may be recommended for † TOE may be used in the critical care patient in whom severe or
monitoring cardiac performance, and evaluating cardiac chamber life-threatening haemodynamic disturbance is present and unre-
volume and or compression.38,39 In vascular surgery, the sponsive to treatment, or in patients in whom new or ongoing
co-existence of coronary artery disease and high cardiovascular cardiac disease is suspected and who are not adequately
risk suggests that TOE may be recommended for monitoring and assessed by transthoracic imaging or other diagnostic tests.
evaluating left ventricular function as well.40 Numerous studies
Importantly, major complications of TOE, including oesophageal
and prior guidelines have established that TOE may be valuable
trauma, although rare, are more common among anaesthetised
in patients who have unexplained severe hypotension that is unre-
patients than in those undergoing the procedure under conscious
sponsive to standard treatment. Provided the expertise is available,
sedation.46
we recommend that TOE should be used in non-cardiac surgery
patients in this setting. These recommendations should also
apply to major vascular trauma.41,42 The recent guidelines of the Conclusion
European Society of Cardiology for perioperative cardiac manage- TOE, a minimal-risk, semi-invasive imaging procedure is nowadays
ment recommend TOE as a diagnostic and monitoring tool in an indispensable part of routine echocardiography. It provides
patients with unexplained haemodynamic deterioration or signs unique and well-documented diagnostic advantages in certain clini-
of myocardial ischaemia during or after non-cardiac surgery.43 cal scenarios where the image quality of transthoracic echocardio-
A number of studies have evaluated and supported the use of graphy is impaired (e.g. the ventilated patient or the patient in the
TOE in orthopaedic surgery (e.g. to detect fat embolism44,45). Fur- operating room), and routinely for a number of specific cardiovas-
thermore, many orthopaedic patients are frail and elderly and likely cular structures and clinical questions (e.g. valvular prosthetic heart
to have significant cardiovascular risk. Although TOE may be rec- disease, the presence of thrombi in the left atrial appendage, and
ommended in any patient with significant cardiac disease both for diseases of the thoracic aorta).
reasons of diagnosis and to monitor the effects of therapy, we do
not feel that the use of TOE should be recommended routinely for Conflict of interest: none declared.
patients undergoing orthopaedic procedures.
References
Critical care 1. Flachskampf FA, Decoodt P, Fraser AG, Daniel WG, Roelandt JRTC, for the Sub-
group on Transesophageal Echocardiography, Valvular Heart Disease, on behalf
The patient recovering from major surgery may experience pro- of the Working Group on Echocardiography of the European Society of Cardiol-
blems in the postoperative period. These may be ongoing from ogy. Recommendations for performing transesophageal echocardiography. Eur J
the intra-operative period, or new complications. TOE may be Echocardiogr 2001;2:8 –21.
2. Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB et al. ASE/
valuable in identifying or excluding a cardiovascular cause, including SCA guidelines for performing a comprehensive intraoperative multiplane trans-
valve lesions, endocarditis, and other consequences of sepsis, oesophageal echocardiography examination: recommendations of the American
Recommendations for transoesophageal echocardiography 575

Society of Echocardiography Council for Intraoperative Echocardiography and the 18. Silvestry FE, Rodriguez LL, Herrmann HC, Rohatgi S, Weiss SJ, Stewart WJ et al.
Society of Cardiovascular Anesthesiologists Task Force for Certification in Perio- Echocardiographic guidance and assessment of percutaneous repair for mitral
perative Transoesophageal Echocardiography. J Am Soc Echocardiogr 1999;12: regurgitation with the Evalve MitraClip: lessons learned from EVEREST I. J Am
884 –900. Soc Echocardiogr 2007;20:1131 – 40.
3. Popescu BA, Andrade MJ, Badano LP, Fox KF, Flachskampf FA, Lancellotti P et al. 19. Sievers H, Schmidtke C. A classification system for the bicuspid aortic valve from
European Association of Echocardiography recommendations for training, com- 304 surgical specimens. J Thorac Cardiovasc Surg 2007;133:1226 –33.
petence, and quality improvement in echocardiography. Eur J Echocardiogr 2009; 20. de Waroux JB, Pouleur AC, Goffinet C, Vancraeynest D, Van Dyck M, Robert A
10:893 –905. et al. Functional anatomy of aortic regurgitation: accuracy, prediction of surgical
4. Nihoyannopoulos P, Fox K, Fraser A, Pinto F, on behalf of the Laboratory. repairability, and outcome implications of transoesophageal echocardiography.
Accreditation Committee of the EAE laboratory standards and accreditation. Circulation 2007;116:I264– 9.
Eur J Echocardiogr 2007;8:79 –87. 21. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A et al. Diagnosis and
5. Habib G, Badano L, Tribouilloy C, Vilacosta I, Zamorano JL, Galderisi M et al., management of aortic dissection. Recommendations of the Task Force on Aortic
European Association of Echocardiography. Recommendations for the practice Dissection, European Society of Cardiology. Eur Heart J 2001;22:1642 – 81.
of echocardiography in infective endocarditis. Eur J Echocardiogr 2010;11:202 –19. 22. Movsovitz HD, Levine RA, Hilgenberg AD. Transesophageal echocardiographic
6. Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA description of the mechanisms of aortic regurgitation in acute type A aortic dis-
et al., American Society of Echocardiography’s Guidelines, Standards Committee, section: implications for aortic valve repair. J Am Coll Cardiol 2000;36:884 –90.
Task Force on Prosthetic Valves, American College of Cardiology Cardiovascular 23. Montorsi P, De Bernardi F, Muratori M, Cavoretto D, Pepi M. Role of cine-
Imaging Committee, Cardiac Imaging Committee of the American Heart fluoroscopy, transthoracic, and transesophageal echocardiography in patients
Association, European Association of Echocardiography, European Society of with suspected prosthetic heart valve thrombosis. Am J Cardiol 2000;85:58–64.
Cardiology, Japanese Society of Echocardiography, Canadian Society of 24. Moss R, Ivens E, Pasupati S, Humphries K, Thompson CR, Munt B et al. Role of

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010

Echocardiography, American College of Cardiology Foundation, American echocardiography in percutaneous aortic valve implantation. J Am Coll Cardiol
Heart Association, European Association of Echocardiography, European Imaging 2008;1:15–24.
Society of Cardiology, Japanese Society of Echocardiography, Canadian Society 25. Chin D. Echocardiography for transcatheter aortic valve implantation. Eur J Echo-
of Echocardiography. Recommendations for evaluation of prosthetic valves with cardiogr 2009;10:i21 –9.
echocardiography and doppler ultrasound: a report from the American Society 26. Pepi M, Tamborini G, Maltagliati A, Galli CA, Sisillo E, Salvi L et al. Head-to-head
of Echocardiography’s Guidelines and Standards Committee and the Task comparison of two- and three-dimensional transthoracic and transoesophageal
Force on Prosthetic Valves, developed in conjunction with the American echocardiography in the localization of mitral valve prolapse. J Am Coll Cardiol
College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging 2006;48:2524 – 30.
Committee of the American Heart Association, the European Association of 27. Garcı́a-Orta R, Moreno E, Vidal M, Ruiz-López F, Oyonarte JM, Lara J et al. Three-
Echocardiography, a registered branch of the European Society of Cardiology, dimensional versus two-dimensional transoesophageal echocardiography in mitral
the Japanese Society of Echocardiography and the Canadian Society of valve repair. J Am Soc Echocardiogr 2007;20:4 –12.
Echocardiography, endorsed by the American College of Cardiology Foundation, 28. Sugeng L, Shernan SK, Weinert L, Shook D, Raman J, Jeevanandam V et al. Real-
American Heart Association, European Association of Echocardiography, a time three-dimensional transoesophageal echocardiography in valve disease:
registered branch of the European Society of Cardiology, the Japanese Society comparison with surgical findings and evaluation of prosthetic valves. J Am Soc
of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr 2008;21:1347 – 54.
Echocardiogr 2009;22:975–1014. 29. Salcedo EE, Quaife RA, Seres T, Carroll JD. A framework for systematic charac-
7. Daniel WG, Mügge A. Transesophageal echocardiography. N Engl J Med 1995; terization of the mitral valve by real-time three-dimensional transesophageal
332:1268 –79. echocardiography. J Am Soc Echocardiogr 2009;22:1087 –99.
8. Côté G, Denault A. Transoesophageal echocardiography-related complications. 30. Miller AP, Nanda NC, Aaluri S, Mukhtar O, Nekkanti R, Thimmarayappa MV et al.
Can J Anaesth 2008;55:622 –47. Three-dimensional transoesophageal echocardiographic demonstration of ana-
9. Jenssen C, Faiss S, Nürnberg D. Complications of endoscopic ultrasound and tomical defects in AV septal defect patients presenting for reoperation. Echocar-
endoscopic ultrasound-guided interventions—results of a survey among diography 2003;20:105 –9.
German centers. Z Gastroenterol 2008;46:1177 –84. 31. Matsumoto M, Oka Y, Strom J, Frishman W, Kadish A, Becker RM et al. Appli-
10. Cohen LB, Delegge MH, Aisenberg J, Brill JV, Inadomi JM, Kochman ML et al., AGA cation of transoesophageal echocardiography to continuous intraoperative moni-
Institute. AGA Institute review of endoscopic sedation. Gastroenterology 2007;133: toring of left ventricular performance. Am J Cardiol 1980;46:95– 105.
675 –701. 32. Furuya H, Suzuki T, Okumura F, Kishi Y, Uefuji T. Detection of air embolism by
11. McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, con- transoesophageal echocardiography. Anesthesiology 1983;58:124 – 9.
trolled trials of moderate sedation for routine endoscopic procedures. Gastroint- 33. Cucchiara RF, Nugent M, Seward JB, Messick JM. Air embolism in upright neuro-
est Endosc 2008;67:910–23. surgical patients: detection and localization by two-dimensional transoesophageal
12. Novaro GM, Aronow HD, Militello MA, Garcia MJ, Sabik EM. Benzocaine induced echocardiography. Anesthesiology 1984;60:353 –5.
methemoglobinemia: experience from a high-volume transoesophageal echocar- 34. Roizen MF, Beaupre PN, Alpert RA, Kremer P, Cahalan MK, Shiller N et al. Moni-
diography laboratory. J Am Soc Echocardiogr 2003;16:170 –5. toring with two-dimensional transoesophageal echocardiography. Comparison of
13. Carpentier A. Cardiac valve surgery—the ‘French correction’. J Thorac Cardiovasc myocardial function in patients undergoing supraceliac, suprarenal-infraceliac, or
Surg 1983;86:323–37. infrarenal aortic occlusion. J Vasc Surg 1984;1:300 – 5.
14. Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik AJ. Determinants of the 35. Practice guidelines for perioperative transoesophageal echocardiography: An
degree of functional mitral regurgitation in patients with systolic left ventricular updated report by the American Society of Anesthesiologists and the Society
dysfunction: a quantitative clinical study. Circulation 2000;102:1400 –6. of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardio-
15. Sonne C, Sugeng L, Watanabe N, Weinert L, Saito K, Tsukiji M et al. Age and body graphy. Anesthesiology 2010;112. (Epub ahead of print).
surface area dependency of mitral valve and papillary apparatus parameters: 36. Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL
assessment by real-time three-dimensional echocardiography. Eur J Echocardiogr et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echo-
2009;10:287 –94. cardiography: summary article. A report of the American College of Cardiology/
16. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE
et al. American Society of Echocardiography: recommendations for evaluation Committee to Update the 1997 Guidelines for the Clinical Application of Echo-
of the severity of native valvular regurgitation with two-dimensional and cardiography). Circulation 2003;108:1146 –62.
Doppler echocardiography: A report from the American Society of Echocardio- 37. Fathi AR, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting
graphy’s Nomenclature and Standards Committee and The Task Force on position: a systematic review. Br J Anaesth 2009;102:588 –96.
Valvular Regurgitation, developed in conjunction with the American College of 38. Wax DB, Torres A, Scher C, Leibowitz AB. Transoesophageal echocardiography
Cardiology Echocardiography Committee, The Cardiac Imaging Committee, utilization in high-volume liver transplantation centers in the United States.
Council on Clinical Cardiology, The American Heart Association, and the J Cardiothorac Vasc Anesth 2008;22:811 –3.
European Society of Cardiology Working Group on Echocardiography. Eur J 39. Eimer MJ, Wright JM, Wang EC, Kulik L, Blei A, Flamm S et al. Frequency and significance
Echocardiogr 2003;4:237–61. of acute heart failure following liver transplantation. Am J Cardiol 2008;101:242–4.
17. Lancellotti P, Moura L, Pierard LA, Agricola E, Popescu B, Tribouilloy C et al., on 40. Mahmood F, Christie A, Matyal R. Transoesophageal echocardiography and non-
behalf of the European Association of Echocardiography. Recommendations for cardiac surgery. Semin Cardiothorac Vasc Anesth 2008;12:265 –89.
the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation. 41. Pepi M, Campodonico J, Galli C, Tamborini G, Barbier P, Doria E et al. Rapid diag-
Eur J Echocardiogr 2010;11:307 –32. nosis and management of thoracic aortic dissection and intramural haematoma: a
576 F.A. Flachskampf et al.

prospective study of advantages of multiplane vs. biplane transoesophageal echo- 44. Kato N, Nakanishi K, Yoshino S, Ogawa R. Abnormal echogenic findings detected
cardiography. Eur J Echocardiogr 2000;1:72–9. by transoesophageal echocardiography and cardiorespiratory impairment during
42. Smith MD, Cassidy JM, Souther S, Morris EJ, Sapin PM, Johnson SB et al. Transe- total knee arthroplasty with tourniquet. Anesthesiology 2002;97:1123 –8.
sophageal echocardiography in the diagnosis of traumatic rupture of the aorta. 45. Koessler MJ, Fabiani R, Hamer H, Pitto RP. The clinical relevance of
N Engl J Med 1995;332:356 –62. embolic events detected by transoesophageal echocardiography during
43. Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G et al., Task Force cemented total hip arthroplasty: a randomized clinical trial. Anesth Analg 2001;
for Preoperative Cardiac Risk Assessment, Perioperative Cardiac Management in 92:49 –55.
Non-cardiac Surgery, European Society of Cardiology, European Society of Anaes- 46. Feneck RO. Safety and complications of transoesophageal echocardiography. In:
thesiology. Guidelines for pre-operative cardiac risk assessment and perioperative Feneck RO, Kneeshaw J, Ranucci M (eds), Core Topics in Transoesophageal Echocar-
cardiac management in non-cardiac surgery: the Task Force for Preoperative diography. Cambridge University Press; 2009.
Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac 47. Foster GP, Isselbacher EM, Rose GA, Torchiana DF, Akins CW, Picard MH. Accu-
Surgery of the European Society of Cardiology (ESC) and endorsed by the Euro- rate localization of mitral regurgitant defects using multiplane transesophageal
pean Society of Anaesthesiology (ESA). Eur Heart J 2009;30:2769 –812. echocardiography. Ann Thorac Surg 1998;65:1025 –31.

Downloaded from ejechocard.oxfordjournals.org at ESC Member (EJE) on August 23, 2010