Trans-esophageal echocardiography (TEE) uses ultrasound to obtain high-quality images of the heart and surrounding structures. It involves inserting a probe with an ultrasound transducer at the tip through the mouth and esophagus. TEE provides clearer images than transthoracic echocardiography as the esophagus is directly behind the heart. A TEE exam involves systematically imaging the heart in various planes as the transducer is advanced and manipulated. Standard views include the mid-esophageal four-chamber, two-chamber, aortic, and RV inflow-outflow views. Real-time 3D TEE can provide en face views of structures.

1. TRANS-ESOPHAGEAL ECHOCARDIOGRAPHY

2. BASICS OF ULTRASOUND / ECHO
• Tissue insonated with sound above audible range,
>20000 Hz
• Most use 2.5-7.5 MHz
• Transducer composed of piezoelectric crystals

3. • Electrical signal applied to the crystal 
• Vibrate
• Sound 
• Absorption/reflection/refraction/scattering
• reflected ultrasound wave 
• crystal receive the reflected wave 
• convert it back to electrical signal

4. HOW IT FORMS THE IMAGE?
 v = f x λ
 Ultrasound travels at 1540 m/sec in blood and tissues
 Hence v constant
 As f increase, λ decrease
 v, f and λ known
 Find Time and Depth

5. • F more absorption more  resolution more
• λ less attenuation more  penetration less

6. HISTORY
 Side and Gosling (1971) - TEE for CwD of cardiac
flow and aortic arch flow
 Frazin et al (1976) - TEE M mode echo
 Hisanaga et al (1977) - Illustrated use of cross
sectional real time imaging
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7. • The modern era of TEE really began in 1982, with the
introduction of flexible probes with phased-array
transducers and manipulable tips, initially as a single,
horizontally oriented transducer (monoplane), next as
two orthogonally oriented transducers (biplane), and
then as adjustable transducers capable of rotating 180
within the tip of the probe (multiplane).
• Now, real-time three-dimensional (3D) images
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8. INTRODUCTION
 TEE uses sound waves to create high-quality moving
pictures of heart and its blood vessels
 Involves a flexible tube or probe with a transducer at
its tip
 Probe is guided down throat and esophagus
 More detailed pictures of heart as esophagus is directly
behind heart
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9. ADVANTAGES
 Transducer - 2- 3 mm from heart
 Closer to posterior structures - Better visualization of
LA, LAA, MV, LV, Aorta
 Far from surgical area - Intra-operative monitoring
 High resolution images : Absence of intervening lung
or bone tissue - Better signal to noise ratio and
decreased image depth, allows use of higher freq (5
and 7 MHz) transducers - enhances image quality.
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11. DISADVANTAGES
• Semi invasive procedure: chances of injury
• Needs special setup, technique, preparation,
instrumentation
• Needs orientation and expertise
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12. INDICATIONS
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13. INDICATIONS
• Assessment of prosthetic valves, infective endocarditis, native
valve disease
• Assessment of a suspected cardioembolic event
• Assessment of cardiac tumors
• Assessment of atrial septal abnormalities
• Assessment of aortic dissection, intramural hematomas
• Evaluation of CHD, CAD, pericardial disease
• Evaluation of critically ill patients
• Intraoperative monitoring
• Monitoring during interventional procedures
• Stress echocardiography
• Nondiagnostic TTE
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15. CONTRAINDICATIONS
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16. POSITIONING OF PATIENT, SONOGRAPHER,
NURSE AND PHYSICIAN FOR PERFORMING TEE

17. PRE-PROCEDURE
 4 - 6 hours fasting
 Written consent
 Intravenous line, oxygen, suction equipment
 Remove denture or devices
 Lidocaine hydrochloride spray for topical anesthesia
over pharynx and tongue, and diazepam 2-10mg,
midazolam 0.05mg/kg I.V. for light sedation.
 ECG must be monitored throughout
 Introduce the probe with some anteflexion through a
bite block
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18. • Consideration should be given to the use of telemetry in
addition to the standard monitors in patients with American
Society of Anesthesiologists status 3 or higher, because they
are higher risk for cardiac and pulmonary complications.
• Patients should have ‘‘nothing by mouth’’ for 1 hour until all
local anesthetic and sedation has metabolized, to decrease
the risk for aspiration.
• Patients should be counseled to call their physicians for
odynophagia or dysphagia that lasts >1 day because of the
low but real risk for soft tissue or esophageal injury from TEE.
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20. MODIFIED MALLAMPATI SCORING
• Class I: Soft palate, uvula, fauces, pillars visible.
• Class II: Soft palate, uvula, fauces visible.
• Class III: Soft palate, base of uvula visible.
• Class IV: Only hard palate visible.
• In obese patients and those with decreased neck mobility, if
the distance from the lower jaw to the hyoid
bone is less than three fingerbreadths, this is associated with
difficulty mask-ventilating and/or intubating the patient.
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21. ALDRETE SCORE
• Before the administration of sedation, a modified
Aldrete score should be calculated. Conscious
sedation is typically defined as a score of 9 or 10,
with a score of <9 defining oversedation.
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23.  Left lateral decubitus with head of bed elevated by 30 ͦ to
avoid aspiration (elective procedure) and supine position
(mechanically ventilated patients).
 Imaging surface of transducer faces tongue.
 Probe kept in central position to prevent entry into piriform
fossa.

24. • Gentle pressure and instruction to swallow.
• If resistance, withdraw and initiate new attempt.
• Bite guard always used to prevent involuntary
closure of mouth.
• If nausea wait for 10 – 15 seconds and then proceed
for imaging.

25. • Start with images from esophagus before gastric
views.
• GE sphincter reached when probe advanced 40cm
from incisor teeth.
• Descending thoracic and arch of aorta reserved for
the end of study as it causes gagging as probe is in
upper esophagus.

26. • Stridor or incessant cough indicates passage into
trachea also probe would not advance beyond 30 cm
and image quality will be poor.
• In intubated patients, introduce probe in supine
position and mandible pulled forward, if resistance at
25 – 30 cms deflate ET tube cuff.

27.  Routine antibiotic prophylaxis before TEE is not
advocated.
 Persistent resistance to advancing the instrument
mandates termination of TEE and endoscopy should
be performed before re-examination.
 After each TEE - Disinfect. Check for any damage,
ensure electrical safety
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28. CARE OF THE PROBE
• Enzymatic solution to remove secretions
• Gluteraldehyde for 20 mins
• Tap water dry for 20 mins

29. COMPLICATIONS
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30. MAJOR
 Death
 Esophageal rupture
 Laryngospasm or bronchospasm
 Congestive heart failure or pulmonary edema
 Sustained ventricular tachycardia
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31. MINOR
 Excessive retching or vomiting
 Sore throat
 Hoarseness
 Minor pharyngeal bleeding
 Non sustained or sustained supraventricular tachycardia
 Nonsustained ventricular tachycardia
 Bradycardia or heart block
 Transient hypotension
 Transient hypertension
 Angina
 Transient hypoxia
 Parotid swelling
 Tracheal intubation
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32. PROBE
 Modification of standard gastroscope, with transducers
in place of fibreoptics
 Conventional rotary controls with inner and outer dials
 Inner dial guides anteflexion and retroflexion
 Outer dial controls medial and lateral movement
 Multiplane probe has a lever control to guide rotation
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34.  Monoplane TEE - provides images in horizontal plane
only
 Biplane TEE - orthogonal longitudinal plane also
 Multiplane TEE transducer:
 single array of crystals, phased array transducers
with 64 - 256 piezoelectric elements
 that can be electronically and mechanically
rotated in an arc of 180°
 to produce a continuum of transverse and
longitudinal images from a single probe position
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35. STANDARD IMAGING PLANE LEVELS
(FROM THE INCISORS)
 Upper or high esophageal (25–28 cm)
 Mid-esophageal (29–33 cm)
 Transgastric (38–42 cm)
 Deep-transgastric (>42 cm)
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36.  A complete TEE exam usually takes 15–20 min.
 An abbreviated or problem-focused TEE study may
be appropriate in unstable or uncooperative patients
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37. Proceed systematically - from mid esophagus, 35 cms
from the incisors to gradually more distal esophagus,
fundus of the stomach after gentle advancement across
the cardia 40-50 cms from incisors and finally slow
withdrawal of the probe for complete scan of the
thoracic aorta from high esophageal views.
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38. TRANSDUCER MANIPULATION OPTIONS
• Advancement / withdrawal (for inferior or
superior structures respectively)
• Rotation (clockwise to view rightward
structures and counter- clockwise for leftward
structures)
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41. • Once we centre a cardiac structure in one image plane,
it will continue to remain there as the transducer is
rotated from 0-180°, facilitating the 3D assessment of
that particular structure

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45. PROCEDURE: BASIC VIEWS

46. • Guidelines developed by the ASE have described the
technical skills for acquiring 20 views in the
performance of a comprehensive intraoperative
multiplane transesophageal echocardiographic
examination.
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47. ME 5C: After initially passing the probe into the
esophagus, it is slowly advanced until the AV and LV
outflow tract come into view at a probe depth of about 30
cm. Slight transducer angle manipulation (10 rotation) will
allow image optimization of the AV and LV outflow tract.
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48. ME 4C: Position probe in mid-esophagus behind LA. Depth
30–35 cm, angle 0-10°. Image all 4 heart chambers.
Optimize LV apex by slight retroflexion of probe tip. Ensure
no part of AV or LVOT is seen. Aim to view entire LV.

49. ME 4C
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50. ME MITRAL COMMISURAL VIEW: From the ME four-
chamber view, rotating the transducer angle to between
50 and 70 will generate the ME mitral commissural view.
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51. ME 2C View: From ME 4C : keep probe tip still and MV in
the center, rotate omniplane angle forward to 80-100°, RA
+ RV disappear, LAA appears.

52. ME TWO-CHAMBER VIEW
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53. ME LAX (120°): Rotate omniplane angle forward to
120-130°. Imaging plane is directed through the LA to
image the aortic root in LAX and entire LV. The more
cephalad structures are lined up on the display right.

54. ME LAX VIEW
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55. ME AV LAX View: From the ME LAX view, slight withdrawal of the
probe while maintaining a transducer angle of 120 to 140 results in
the ME AV LAX view. Fine tuning by turning the probe to the right
(clockwise) may be needed.
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56. ME Asc A LAX (90°): Find the ME AV LAX (120°). Withdraw the probe
to bring the right pulmonary artery in view Decrease omniplane
angle slightly by 10-20° to make the aortic wall symmetric. Imaging
plane is directed through the right pulmonary artery to image the
proximal ascending aorta in LAX.

57. ME Asc A LAX (90°)
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58. ME Asc A SAX (0°): From ME AV LAX (110°) Withdraw probe (asc
aorta), Rotate the omniplane angle back to 0°

59. ME Asc A SAX (0°)
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62. ME AV SAX (30-45°)
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63. ME RVIO View (60-75°)
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64. • From the ME views and at a transducer angle of 0 to
20, the probe is straightened and advanced into the
stomach, frequently imaging the coronary sinus inflow
as well as the inferior vena cava and hepatic
vein before reaching the TG level.
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68. Cross-sectional views of the 11 views of the ASE Basic
examination.
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69. ASE & SCA recommend 20 views for a comprehensive TEE.

70. 3 DIMENSIONAL TEE
 Main advantages of Real-time three-dimensional
(RT3D) TEE during catheter-based interventions:
 Ability to visualize the entire lengths of
 Intracardiac catheters, including the tips of all catheters and
the balloons
 Devices they carry, along with a clear depiction of the
positions in relation to other cardiac structures
 To demonstrate certain structures in an ‘‘en face’’ view
 RT3D TEE is a powerful new imaging tool
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