Transesophageal Echocardiography
TEE provides higher-resolution imaging of posterior cardiac structures, valves, atrial appendages, interatrial septum, prosthetic valves, and thoracic aorta.
Common Indications¶
- Suspected endocarditis or prosthetic-valve infection
- LAA thrombus evaluation before cardioversion or ablation
- Embolic stroke evaluation
- Prosthetic-valve dysfunction
- Inadequate TTE assessment of valve disease
- Suspected aortic dissection
- Intracardiac mass or thrombus
- Guidance of structural heart procedures
- Evaluation of ASD, PFO, or other shunts
TEE should be performed when the expected findings may change management.
Before the Procedure¶
Confirm:
- Indication and prior imaging
- Informed consent
- Fasting status
- Dentures or removable oral devices
- Esophageal or gastric disease
- Prior esophageal surgery
- Dysphagia or gastrointestinal bleeding
- Sedation plan and monitoring
- IV access and resuscitation equipment
Avoid forceful advancement if resistance is encountered. A focused study may be appropriate when procedural risk, instability, or time constraints prevent a comprehensive examination.
Comprehensive Examination¶
Mid-Esophageal¶
| Structure | Principal views |
|---|---|
| Four chambers | 0° |
| Mitral valve | 0°, 60°, 90°, 120–150° |
| LAA | 0°, 45°, 90°, 135° |
| Aortic valve | SAX 30–60°; LAX 120–150° |
| Interatrial septum | 0° and bicaval 90–120° |
| Tricuspid valve | 0°, 60°, 90°, 120–150° |
| Pulmonic valve | 60–90° |
| Pulmonary veins | LUPV 60–90°; RUPV from bicaval view |
Angles are approximate. Anatomy should guide probe manipulation rather than rigid adherence to a number.
Transgastric¶
Obtain:
- LV short-axis views at basal, mid, and apical levels
- Transgastric two-chamber and long-axis views
- Deep transgastric LVOT and aortic-valve Doppler
- RV inflow, RVOT, and tricuspid-valve views when needed
The deep transgastric view commonly provides the best alignment for aortic-valve and LVOT Doppler.
Aorta¶
Survey the descending thoracic aorta in transverse and longitudinal planes while withdrawing the probe. Evaluate the aortic arch and visualized ascending aorta for:
- Plaque
- Mobile components
- Thrombus
- Intimal flap
- Intramural hematoma
- Ulceration
The distal ascending aorta may be obscured by the trachea and left main bronchus.
Targeted Assessments¶
Left Atrial Appendage¶
Image at 0°, 45°, 90°, and 135°.
Assess:
- Thrombus
- Spontaneous echo contrast
- Sludge
- LAA morphology
- Emptying velocity
Obtain PW Doppler approximately 1 cm inside the appendage. Velocity <40 cm/s indicates reduced mechanical function; <20 cm/s reflects marked stasis and greater thromboembolic risk.
Do not mistake pectinate muscles or the Coumadin ridge for thrombus.
Interatrial Septum¶
Evaluate in multiple planes with color Doppler. For agitated saline:
- Use the bicaval view
- Record the RA, IAS, and LA
- Perform an effective Valsalva when possible
- Confirm RA opacification and septal bowing
Early LA bubbles favor an intracardiac shunt; delayed appearance suggests intrapulmonary passage.
Mitral Valve¶
Define:
- Leaflet pathology
- Prolapse or flail segment
- Coaptation defect
- Regurgitant mechanism and severity
- Stenosis
- Vegetation
- Annular or subvalvular pathology
Three-dimensional imaging is particularly helpful for scallop localization and procedural planning.
Reporting¶
No thrombus is visualized in the left atrium or left atrial appendage. LAA emptying velocity is ___ cm/s.
Dense spontaneous echo contrast is present in the left atrium and LAA without a discrete thrombus.
Agitated saline demonstrates early right-to-left passage across the interatrial septum during Valsalva, consistent with a PFO.
TEE demonstrates a ___-cm mobile echodensity attached to the ___ surface of the ___ valve, concerning for vegetation in the appropriate clinical setting.
The thoracic aorta contains complex plaque measuring ___ mm with [ulceration/a mobile component].
Key Points¶
- Perform a systematic examination even when the indication is focused.
- Image the LAA in multiple planes before excluding thrombus.
- Use deep transgastric views for aligned aortic-valve Doppler.
- TEE does not completely visualize every portion of the ascending aorta.
- Document structures not evaluated because of technical or patient limitations.