PERFORMANCE OF

TRANSESOPHAGEAL
ECHOCARDIOGRAPHY,
BASIC PRINCIPLES AND VIEWS
Dr.K.G.Monisha
Ass.Prof
FAHS
INTRODUCTION

● Transesophageal echocardiography (TEE) is an important

cardiac imaging modality with unique advantages over
conventional transthoracic echocardiography (TTE).
● TEE generally provides excellent quality images , especially of the
structures situated posteriorly, such as atria, pulmonary veins,
mitral valve, left atrial appendage (LAA),etc.
● TEE is routinely utilized for better delineation of pathologies
related to these structures.
● TEE is the most suited imaging modality for use in the operating
rooms and cardiac catheterization laboratories for guiding
cardiac surgical or interventional procedures.
● TEE requires specific skillset for obtaining diagnostic quality
images as the probe manipulation and echoanatomic
orientation are vastly different from TEE.
● TEE is a semi invasive test and is associated with patient
discomfort as well as a small risk for minor and major
complications.
● TEE is required to gain competency in performing this test
successfully,smoothly, safely, and with minimum patient
discomfort.
TRANSESOPHAGEAL
ECHOCARDIOGRAPHY PROBE
HARDWARE :

● A TEE probe is a modified

flexible gastroscope with
remotely controlled ultrasound
transducer at the distal tip.
● DISTAL TIP (transducer lens) : It has a
round face plate behind which reside the
acoustic lens and an artery of packed
piezoelectric crystals (Two
dimensional(2D)TEE -128 crystals, three
dimensional (3D) TEE - 2,500 crystals),
resting on the backing material. The
distal tip portion of the probe can be
remotely flexed in anteroposterior & side
by side direction by two control knobs at
the handle.
● FLEXIBLE SHAFT : It contains the cables
carrying electrical impulses and mechanical
commands, encased in a synthetic housing
providing electrical and water insulation.

● HANDLE (controls housing) : This is the

fusiform and bulky part of the TEE probe
with one large wheel (to control
anteroposterior flexion of the tip).
The handle also has two closely spaced
buttons for “Forward” or “Backward”
electronic rotation of imaging plane from 0
to 180 degree.

•CABLE AND THE CONNECTOR : They

connect the TEE probe to the probe
connector socket present on the
echocardiography machine.
INDICATIONS FOR PERFORMING TEE :

● TEE has several advantages over TEE and other

cardiovascular imaging modalities.
● TEE can utilize high frequency ultrasound beam (5-8MHz) to
generate high resolution images with high signal to noise ratio
and with least reverberation or shadowing artifacts.
● TEE can achieve 360 degree scanning via electronic plane
rotation due to least acoustic impedance from soft tissue
around probe.
INDICATIONS FOR PERFORMING TEE :

● TEE invariably yields high diagnostic quality images of posterior

cardiac structures such as left atrium, right atrium, opening of
the pulmonary and systemic veins into atria, interatrial septum,
atrial appendages, aortic root, descending thoracic aorta and
arch, right pulmonary artery , etc..
● TEE is also the imaging modality of choice for cardiac surgery
or catheter interventions .
THE COMMON INDICATIONS FOR PERFORMING TEE :

● Nondiagnostic TEE due to poor echo windows

● Critical information is required about posterior cardiac
structures
● Patients with clinical suspicion of infective endocarditis,
especially when TEE is negative.
● TEE is pick up early paravalvular abscesses, valve
perforations, prosthetic valve dehiscence or other structural
damage caused by the infection.
THE COMMON INDICATIONS FOR PERFORMING TEE :

● Patient with atrial fibrillation (AF) who are scheduled to undergo

electrical cardioversion or radiofrequency(RF) ablation.
● FOR THE REGURGITANT LESIONS : In mitral or aortic valve
regurgitation, TEE provides incremental information about
mechanism of regurgitation and feasibility of repair.
● FOR STENOTIC LESIONS : In mitral stenosis, TEE is a sensitive
technique to diagnose LAA clot before balloon mitral valvulotomy
or in the presence of a cardioembolic even.
● For Aortic stenosis, TEE may useful for diagnosis of subaortic
membrane, direct planimetry of aortic valve and accurate
measurement of left ventricular outflow tract (LVOT) diameter or
cross sectional area and the size of aortic sinuses or ascending
aorta.
● In prosthetic valve dysfunction, for better visualization of
thrombus, pannus, paravalvular regurgitation etc..
● TEE is essential to exclude cardiac sources of embolism.
● To assess suitability for device closure in adult patients ostium
secundum atrial septal defect (ASD).
● For better delineation of intracardiac masses.
● For guiding various structural heart disease interventions in the
cardiac catheterization laboratory.
Contraindications :

DEFINITE CONTRAINDICATIONS : RELATIVE CONTRAINDICATION:

• Recent oropharyngeal or esophageal • Loose teeth or gum injury.

surgery. • Agitated and uncooperative or delirious
• Obstructive pathology of pharynx or patient.
esophagus such as neoplasm or • Inability to open mouth widely.
strictures.
• History of radiation to head, neck,
•Suspected esophageal perforation or mediastinum.
traumatic injury.
• History of Barrett’s esophagus.
•Diverticulum of esophagus
• Hiatus hernia
•Active bleeding from esophageal ulcer
(or) varices. • History of odynophagia or dysphagia.
 Complications

MAJOR COMPLICATIONS:

• Lung aspiration

• Tooth (native or implanted) dislocation and displacement into airway.

• Pharyngeal hematoma causing upper airway compromise.

• Laryngeal injury due to probe entering the trachea.

• Esophageal perforation or Mallory Weiss tear.

• Mediastinitis due to unsuspected perforation at cricopharyngeal junction or in

the esophagus.

•Bleeding from upper gastroesophageal ulcer or varices.

 Complications

MINOR COMPLICATIONS:

• Mucosal laceration with streaky bleeding while coughing or spitting

• Dysphagia, odynophagia • Dental injury

• Sore throat

• Vomiting

• Bronchospasm, laryngospasm

• Transient ventricular arrhythmia

• Heart failure

• Dislodgement of endotracheal tube in patients on mechanical ventilation

Technical aspects of tee probe :

IMAGING PLANE :
1) HORIZONTAL PLANES

The horizontally oriented imaging planes are displayed on the monitor in

such a way that the left sided and right sided cardiac structures are shown
on the right hand and left hand side of imaging display, respectively.
2) VERTICAL PLANES
The vertical oriented imaging planes are displayed on the monitor in
such a way that the cranial and caudal structures are shown on the
right hand and left hand side of imaging display, respectively.
PROBE MANIPULATION:
TEE probe can be manipulated

ADVANCING AND WITHDRAWING THE PROBE (IN and OUT motion):The TEE
probe can be gently “advanced” or “pushed in ” or can be gradually “withdrawn” or
“pulled outward”.

CLOCKWISE AND ANTICLOCKWISE TORQUE :

❏ The TEE probe can be gently and gradually rotated (torqued) either clockwise or
anticlockwise (assuming the patient’s face to represent the clock face).
❏ The clockwise torque of the TEE probe turns the imaging plane toward right
sided cardiac structures while the anticlockwise torque turns the imaging plane
toward the left sided structures.
ELECTRONIC ROTATION OF THE IMAGING PLANE :
The plane rotates by each degree unit, in anticlockwise direction (when viewed from the
front of the chest), starting from 0 degree (horizontal or axial plane) all the way through 30
to 60 degree (short axis SAX plane),90 degree (vertical or sagittal plane), 120 to 135
degree (long axis plane) to 180 degree (horizontal, mirror image).

FLEXION OF THE DISTAL TIP :

The distal end of the TEE probe can be flexed Antero posteriorly or side by side(leftward
and rightward) by two separate wheel like knobs situated on the control handle.
ANTEFLEXION :
❏ Anterior flexion of the TEE probe bends the tip forward, tilting the transducer lens
cranially.
❏ This maneuver is particularly useful for obtaining outflow tract view, from transgastric
SAX views.
❏ This outflow tract view allows parallel alignment of the doppler beam with the blood
flow and is ideal for measuring gradients.
RETROFLEXION :

❏ Retroflexion of the TEE probe bends the tip backward and tilts the transducer lens
caudally.
❏ This maneuver is particularly used for imaging lv apex in the midesophageal(ME) four
chamber view.
❏ In the lower esophageal view, the inferior vena cava(IVC) margin of ASD.
 Transesophageal echocardiography windows

1) MIDESOPHAGEAL WINDOW :

This is useful for detailed evaluation of the following

structures - LA cavity, LAA, Interatrial septum, all the
four pulmonary veins, multiplanar imaging of mitral
valve apparatus, multiplanar imaging of aortic valve and
aortic root, left ventricle in all the three long axis view,
RV inflow and outflow tract, RA cavity, in- flow portions
of SVC and IVC, tricuspid valve, ascending aorta up to
the level of posterior crossing of right pulmonary artery.
2) LOWER ESOPHAGEAL WINDOW :

This view is useful for following structures-additional evaluation of the tricuspid

valve(especially for acquisition of 3D dataset of the tricuspid valve), evaluation of the
coronary sinus , visualization of upper hepatic portion of IVC and hepatic vein tributary, IVC
margin of the ASD, Eustachian valve, distal part of descending thoracic aorta, and the
evaluation of pleural spaces for any effusion.

3) TRANSGASTRIC WINDOW :

❏ This window provides three SAX images of the left ventricle from base to apex.
❏ These SAX images are helpful in wall motion analysis of all the 16 segments of the left
ventricle
4) UPPER ESOPHAGEAL WINDOW :

The upper esophageal view is useful for detailed evaluation of following structures-
main pulmonary artery, SVC, right superior pulmonary vein, descending thoracic aorta,
entire arch of aorta, origins of the arch branches.
THE APPROXIMATE DISTANCE OF TEE PROBE TIPFROM THE INCISORS FOR
DIFFERENT TEE WINDOWS IS AS FOLLOWS :

• Upper esophageal window: 20-22 cm

• Midesophageal window: 28-30 cm

• Lower esophageal (gastroesophageal junction) window: 38-40 cm

• Deep transgastric (fundus) window: 42-45 cm

THANK YOU