Transesophageal echocardiography (TEE): Difference between revisions

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'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; Eli V. Gelfand, M.D.; Anne B. Riley, M.D.
'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; Eli V. Gelfand, M.D.; Anne B. Riley, M.D. {{AE}} {{SHA}}


==Overview==
== Overview ==
A specialized probe containing an ultrasound transducer at its tip is passed into the patient's [[esophagus]]. This allows image and Doppler evaluation which can be recorded.  This is known as a transesophageal echocardiogram, or TEE (TOE in the United Kingdom). The advantage of TEE over TTE is usually clearer images, especially of structures that are difficult to view transthoracicly (through the chest wall). The explanation for this is the heart rests directly upon the esophagus leaving only millimeters in distance that the ultrasound beam has to travel. This reduces the attenuation (weakening) of the ultrasound signal, generating a stronger return signal, ultimately enhancing image and Doppler quality. Comparatively, transthoracic ultrasound must first traverse skin, fat, ribs and lungs before reflecting off the heart and back to the probe before an image can be created.  All these structures, and the distance the beam must travel, attenuate the ultrasound signal, degrading image and Doppler quality.
Transesophageal echocardiogram, or TEE is a type of [[echocardiogram]] that uses a endoscopic probe with an [[ultrasound]] transducer to assess, visualize and take images of cardiac structures and great vessels.


In adults, several structures can be evaluated and imaged better with the TEE, including the [[aorta]], pulmonary artery, valves of the heart, both atria, atrial septum, left atrial appendage, and coronary arteries.  While TTE can be performed quickly, easily and without pain to the patient, TEE requires a fasting patient, a team of medical personel, takes longer to perform, is uncomfortable for the patient and has some risks associated with the procedure (esophageal perforation--1 in 10,000, and adverse reactions to the medication).  
== Procedure ==
TEE is performed by passing a probe with an ultrasound transducer into the [[esophagus]], resulting in clear visualization and high-quality images of posterior cardiac structures, thoracic [[aorta]], [[pulmonary veins]] and [[left coronary artery]].<ref name="pmid8065188" /> This is because of the proximity of the esophagus and these structures which reduces the attenuation of ultrasound signal, whereas in transthoracic echocardiogram (TTE), ultrasound signal passes through the chest wall and lungs resulting in degraded image quality.


Before inserting the probe, conscious [[sedation]] is induced with the patient to ease the discomfort of the individual and to decrease the [[gag reflex]], thus making the ultrasound probe easier to pass into the esophagus. Conscious sedation is a light [[sedation]] usually using the medications midazolam (a [[benzodiazepine]] with sedating, amnesiac qualities) and fentanyl. Sometimes a local anesthetic spray is used for the back of the throat, such a xylocaine and/or a jelly/lubricant anesthetic for the esophagus. Children are [[anesthesia|anesthetized]]. Unlike the TTE, the TEE is considered an invasive procedure and is thus performed by physicians in the U.S., not sonographers.
TEE performance requires trained physicians and personnel.<ref name="pmid8065188" />


To insert the TEE probe, the probe is placed in the patient’s mouth through a bite block (to protect the $30,000 TEE probe), and then passed down the patient's throat when they swallow, preventing inadvertent placement into the [[trachea]]. Although the placement of the pinky-wide transducer is uncomfortable, there are very few complications with gagging from the patient once the transducer is in the correct location.
=== Preparation, '''Sedation and Anesthesia'''  ===


== Historical Aspect ==
* Patients must abstain from all oral intake of food or water for at least 4 hours before TEE procedure.<ref name="pmid8065188">{{cite journal| author=Khandheria BK, Seward JB, Tajik AJ| title=Transesophageal echocardiography. | journal=Mayo Clin Proc | year= 1994 | volume= 69 | issue= 9 | pages= 856-63 | pmid=8065188 | doi=10.1016/s0025-6196(12)61788-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8065188  }} </ref>
* Patient medical history must be checked for contraindications and medication allergies.<ref name="pmid8065188" /><ref name="pmid23998692">{{cite journal| author=Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM | display-authors=etal| title=Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. | journal=J Am Soc Echocardiogr | year= 2013 | volume= 26 | issue= 9 | pages= 921-64 | pmid=23998692 | doi=10.1016/j.echo.2013.07.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23998692  }} </ref>
* Dentures must be removed.<ref name="pmid8065188" /> 
* Intravenous access is required in all patients.<ref name="pmid23998692" /><ref name="pmid8065188" />
* Oxygen delivery and suction devices, endotracheal tubes, and laryngoscopes should be available (in case of respiratory complications).<ref name="pmid23998692" />
*[[Methylene blue]] (in case of [[methemoglobinemia]] caused by the topical use of [[benzocaine]]), [[flumazenil]] (reversal agent for [[Benzodiazepine|benzodiazepines]]), and [[naloxone]] (reversal agent for [[Opioid|opioids]]) should be available.<ref name="pmid23998692" /> 
* Continuous monitoring of the patients's hemodynamic stability, vital signs (heart rate, blood pressure, respiratory rate) and oxygen saturation should be assessed during TEE performance.<ref name="pmid23998692" />
*Topical anesthesia of the oropharynx is acheived by a local anesthetic (benzocaine or [[lidocaine]]), <ref name="pmid8065188" /><ref name="pmid23998692" /> which will reduce the gag reflex and eliminate laryngospasm.<ref name="pmid8065188" />
* For sedation, benzodiazepines (midozolam is the best choice) are most commonly used.<ref name="pmid23998692" />
*Opioids ([[fentanyl]] and [[meperidine]] are the most commonly used) are used as additional sedatives to decrease the discomfort of TEE procedure.<ref name="pmid23998692" />
* A bite block is placed in the patient’s mouth (after topical anesthesia and before sedation). <ref name="pmid23998692" />
* The procedure is performed with the patient being in the left lateral decubitus position.<ref name="pmid8065188" /><ref name="pmid23998692" />
* Patients in the intensive care unit or in the operating room are placed in the supine position.<ref name="pmid8065188" /><ref name="pmid23998692" />
*Patients undergoing surgery with TEE are generally anesthetized and intubated.<ref name="pmid23998692" />
*Most pediatric patients are generally anesthetized and intubated. <ref name="pmid1344706">{{cite journal| author=Fyfe DA, Ritter SB, Snider AR, Silverman NH, Stevenson JG, Sorensen G | display-authors=etal| title=Guidelines for transesophageal echocardiography in children. | journal=J Am Soc Echocardiogr | year= 1992 | volume= 5 | issue= 6 | pages= 640-4 | pmid=1344706 | doi=10.1016/s0894-7317(14)80332-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1344706  }} </ref>


* 1971(2)
== Tomography of Transesophageal echocardiography (TEE) ==
* 1976
* 1977
* 1980(1)
* 1982
* 1990(1)
* 2007(1)
* Recently


== Procedure ==
* M-mode echocardiography
* 2D echocardiography  
* 3D echocardiography
*[[Doppler echocardiography]]
 
== Standard Views of Transesophageal echocardiography (TEE) ==
<br />
<br />
== Prophylaxis ==
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! colspan="5" style="background: #4479BA; text-align: center;" | {{fontcolor|#000|'''Standard Views of Transesophageal echocardiography (TEE)
(Modified table from "Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists")<ref name="pmid23998692" />'''}}
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''View'''
| colspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#000|'''Imaging Plane'''}}|
|style="padding: 5px 5px; background: #4479BA;" align="center"  |'''Aquisition Protocol'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''Structures Imaged'''
|-
| rowspan="15" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#000|'''Midesophageal (ME)'''}}
|style="padding: 5px 5px; background: #4479BA;" align="center"|'''1'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME five-chamber view'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-10 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
*[[Aortic valve]]
* Left ventricle outflow tract (LVOT) 
*[[Left atrium]]/[[Right atrium]]
*[[Left ventricle]]/[[Right ventricle]]/[[Interventricular septum|Interventricular septum (IVS)]]
*[[Mitral valve]] (A2A1-P1)
*[[Tricuspid valve]]
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''2'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME four-chamber view'''
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-10 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Left atrium/Right atrium
* Interatrial septum (IAS)
* Left ventricle/Right ventricle/interventricular septum (IVS)
* Mitral valve (A3A2-P2P1)
* Tricuspid valve
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''3'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Mitral Commissural View'''
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 50-70 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Left atrium
* Coronary Sinus
* Left ventricle
* Mitral valve (P3-A3A2A1-P1)
* Papilliray muscles
*[[Chordae tendineae|Chordae tendinae]]
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''4'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Two-Chamber View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 80-100 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Left atrium
* Coronary Sinus
* Left atrial appendage
* Left ventricle
* Mitral valve (P3-A32A1)
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''5'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Long Axis (LAX) View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~120-140 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Left atrium
* Left ventricle
*Left ventricle outflow tract (LVOT)
*Right ventricle outflow tract (RVOT)
*Mitral valve (P2-A2)
*Aortic valve
*Proximal ascending aorta
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''6'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME AV LAX View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 120-140
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Left atrium
*Left ventricle outflow tract (LVOT)
*Right ventricle outflow tract (RVOT)
*Mitral valve (A2-P2)
*Aortic valve
*Proximal ascending aorta
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''7'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Ascending Aorta LAX View'''
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 90-110 degrees
* '''Level:''' Upper-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Mid-ascending aorta
* Right [[pulmonary artery]]
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''8'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Ascending Aorta Short Axis (SAX) View'''
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-30 degrees
* '''Level:''' Upper-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Mid-ascending aorta (SAX)
* Main/bifurcation pulmonary artery
* Superior vena cava
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''9'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Right Pulmonary Vein View'''
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-30 degrees
* '''Level:''' Upper-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Mid-ascending aorta
*[[Superior vena cava]]
* Right [[pulmonary veins]]
|-
|style="padding: 5px 5px; background: #4479BA;" align="center"|'''10'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME AV SAX View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 25-45 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Aortic valve
* Right atrium
* Left atrium
* Superior IAS
* RVOT
*[[Pulmonary valve]]
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''11'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME RV Inflow-Outflow View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 50-70 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Aortic valve
* Right atrium
* Left atrium
* Superior IAS
* Tricuspid valve
* RVOT
* Pulmonary valve
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''12'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Modified Bicaval TV View''' 
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 50-70 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Right atrium
* Left atrium
* Mid-IAS
* Tricuspid valve
* Superior vena cava
*[[Inferior vena cava]]/coronary sinus
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''13'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Bicaval View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 90-110 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Left atrium
* Right atrium/appendage
* IAS
* Superior vena cava
* Inferior vena cava
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''14'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME Right and Left Pulmonary Vein View'''
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 90-110 degrees
* '''Level:''' Upper-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Pulmonary vein (upper and lower)
* Pulmonary artery
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''15'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''ME LA Appendage View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 90-110 degrees
* '''Level:''' Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Left atrial appendage
* Left upper pulmonary vein
|-
| rowspan="9" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#000|'''Transgastric (TG)''' }}
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''16'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''TG Basal SAX View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-20 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Left ventricular (base)
* Right ventricular (base)
* Mitral valve (SAX)
* Tricuspid valve (short-axis)
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''17'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''TG Midpapillary SAX View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-20 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Left ventricular (mid)
* Papillary muscles
* Right ventricular (mid)
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''18'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''TG Apical SAX View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-20 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Left ventricular (apex)
* Right ventricular (apex)
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''19'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''TG RV Basal View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-20 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Left ventricular (mid)
* Right ventricular (mid)
* RVOT
* Tricuspid valve (SAX)
* Pulmonary valve
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''20'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''TG RV Inflow-Outflow View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-20 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Right atrium
* Right ventricular
* RVOT
* Pulmonary valve
* Tricuspid valve
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''21'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''Deep TG Five-Chamber''' 
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-20 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Left ventircule
* LVOT
* Right ventricle
* Aortic valve
* Aortic root
* Mitral valve
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''22'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''TG Two-Chamber View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 90-110 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Left ventricle
* Left atrium/appendage
* Mitral valve
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''23'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''TG RV Inflow View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 90-110 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Right ventricle
* Right atrium
* Tricuspid valve
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''24'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''TG LAX View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:'''  ~ 120-140 degrees
* '''Level:''' Transgastric
|style="padding: 5px 5px; background: #DCDCDC;|
* Left ventircule
* LVOT
* Right ventricle
* Aortic valve
* Aortic root
* Mitral valve
|-
| rowspan="4" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#000|'''Aortic'''}}
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''25'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''Descending Aorta SAX''' '''View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-10 degrees
* '''Level:''' Transgastric to Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
*[[Descending aorta]]
* Left thorax
* Hemiazygous and [[Azygos vein|Azygous veins]]
* Intercoastal arteries
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''26'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''Descending Aorta LAX View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 90-100 degrees
* '''Level:''' Transgastric to Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Descending aorta
* Left thorax
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''27'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''UE Aortic Arch to LAX View'''  
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 0-10 degrees
* '''Level:''' Upper-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
*[[Aortic arch]]
* Innominate vein
* Mediastinal tissue
|-
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''28'''
|style="padding: 5px 5px; background: #4479BA;" align="center" |'''UE Aortic Arch SAX View''' 
|style="padding: 5px 5px; background: #DCDCDC;|
* '''Transducer Angle:''' ~ 70-80 degrees
* '''Level:''' Transgastric to Mid-esophageal
|style="padding: 5px 5px; background: #DCDCDC;|
* Aortic arch
* Innominate vein
* Pulmanory artery
* Pulmonary valve
* Mediastinal tissue
|}


== Clinical Applications ==
== Clinical Applications ==
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Indications for Transesophageal echocardiography (TEE)
(Modified table from "Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography")<ref name="pmid20418689">{{cite journal| author=American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography| title=Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. | journal=Anesthesiology | year= 2010 | volume= 112 | issue= 5 | pages= 1084-96 | pmid=20418689 | doi=10.1097/ALN.0b013e3181c51e90 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20418689  }} </ref>'''}}
|-
|style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Cardiac and Thoracic Aortic Surgery'''}}
|style="padding: 5px 5px; background: #DCDCDC;" |
*All cardiac and thoracic aortic surgery
or


* inoperative procedures ( Cardiac and aorta) (5, other))
*Valve repair or [[Valve replacement|replacement]] ( aortic, mitral, other)  
*Trnasplant surgery (lung and liver) (5,other)
*Coronary artery bypass grafting (CABG) surgery with or without normal ventricular function, off-pump CABG  
* intensive care unit/ critically ill/ ER(5other)
*Redo cardiac surgery  
* interventional laboratory/transcatheter procedures
*Congenital heart surgery with or without cardiopulmonary bypass  
* outpatient
*Ascending or decending thoracic aortic surgery   
*<s>aortic pathology, (5,otehr)</s>
*[[Hypertrophic cardiomyopathy]] surgery  
* <s>cardiac valve dysfunction,</s>
*Resection of [[Cardiac mass causes|cardiac mass]]  
*<s>percutaneous noncoronary cardiac interventions,</s>
*Ventricular remodeling surgery  
*<s>infective endocarditis,</s>
*Open surgery for [[Cardiac arrhythmia|dysrhythmias]]  
* <s>atrial fibrillation or flutter,</s>
*[[Endocarditis]] surgery  
*<s>embolic events.</s>  
*[[Heart transplantation]]
*Pericardiectomy  
*Open pericardial surgery  
*Ventricular assist device  
*Endoscopically assisted surgery  
*Cannulae positioning
|-
|style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Transcatheter intracardiac procedures'''}}
|style="padding: 5px 5px; background: #DCDCDC;" |
*When general anesthesia is provided and intracardiac ultrasound is not used
*Septal defect closure
*Atrial appendage obliteration  
*Valve replacement and repair  
*Dysrhythmia treatment
|-
|style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Noncardiac Surgery'''}}
|style="padding: 5px 5px; background: #DCDCDC;" |
*Known or suspected cardiovascular pathology that might result in hemodynamic, pulmonary or neurologic compromise  
*Unexplained persistent [[hypotension]] or hypoxemia   
*Anticipation of life-threatening hypotension
*Open abdominal or endovascular aortic procedures
*Orthopedic surgery  
*Transplant (liver,lung) 
*Neurosurgery in the sitting position  
*Percutaneous cardiovascular interventions    
*Major Trauma (abdominal or thoracic)
|-
|style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Critical Care'''}}
|style="padding: 5px 5px; background: #DCDCDC;" |
*Diagnostic information expected to alter management cannot be obtained by TTE or other modalities in a timely manner
*Unexplained persistent hypotension or hypoxemia
|}


== Contraindications ==
== Contraindications ==
Relative contraindications:(3)
Contraindications include:<ref name="pmid20418689" /><ref name="pmid1999032" /><ref name="pmid16153515" /><ref name="pmid1760179" /><ref name="pmid23998692">{{cite journal| author=Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM | display-authors=etal| title=Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. | journal=J Am Soc Echocardiogr | year= 2013 | volume= 26 | issue= 9 | pages= 921-64 | pmid=23998692 | doi=10.1016/j.echo.2013.07.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23998692  }} </ref><ref name="pmid20864313">{{cite journal| author=Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK| title=Safety of transesophageal echocardiography. | journal=J Am Soc Echocardiogr | year= 2010 | volume= 23 | issue= 11 | pages= 1115-27; quiz 1220-1 | pmid=20864313 | doi=10.1016/j.echo.2010.08.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20864313  }} </ref>


* Esophageal varices
* Perforated viscus
* Gastric varices,
* Esophegeal stricture, tumor, perforation, laceration, diverticulum, varices
* Tumors
*Mallory-Weiss tears <ref name="pmid16153515" />
* Strictures
* Active upper gastrointestinal (GI) bleeding
* Mallory-Weiss tears  
* Large descending [[aortic aneurysm]]<ref name="pmid20418689" />, thoracic aortic aneurysm<ref name="pmid11323333" />
* Medication use, such as steroids and bisphosphonates
 
*[[Zenker's diverticulum|Zenker diverticulum]]<ref name="pmid20418689" />
*Prior [[esophagectomy]] or esophagogastrectomy<ref name="pmid20418689" />
 
* Prior GI surgery
* Resent upper GI bleeding
*[[Barrett's esophagus]]
*[[Dysphagia]]
* Restricted neck mobility (severe cervical arthritis, atlantoaxial joint disease)
* Prior radiation to neck and chest
* Symptomatic [[Hiatus hernia|hiatal hernia]]
* Active [[esophagitis]] or active [[peptic ulcer]] disease
*[[Coagulopathy]], [[thrombocytopenia]]


== Complications ==
== Complications ==


* Majority of the complications are caused by injury or trauma<ref name="pmid11323333" />
* Majority of the complications are caused by injury or trauma<ref name="pmid11323333">{{cite journal| author=Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK| title=The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. | journal=Anesth Analg | year= 2001 | volume= 92 | issue= 5 | pages= 1126-30 | pmid=11323333 | doi=10.1097/00000539-200105000-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11323333  }} </ref>
*Dental injury (eg. loosened tooth) <ref name="pmid11323333">{{cite journal| author=Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK| title=The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. | journal=Anesth Analg | year= 2001 | volume= 92 | issue= 5 | pages= 1126-30 | pmid=11323333 | doi=10.1097/00000539-200105000-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11323333  }} </ref><ref name="pmid20418689" />
*Dental injury (eg. loosened tooth) <ref name="pmid11323333">{{cite journal| author=Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK| title=The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. | journal=Anesth Analg | year= 2001 | volume= 92 | issue= 5 | pages= 1126-30 | pmid=11323333 | doi=10.1097/00000539-200105000-00009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11323333  }} </ref> <ref name="pmid20418689">{{cite journal| author=American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography| title=Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. | journal=Anesthesiology | year= 2010 | volume= 112 | issue= 5 | pages= 1084-96 | pmid=20418689 | doi=10.1097/ALN.0b013e3181c51e90 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20418689  }} </ref>
*Tongue necrosis (caused by prolonged placement of TEE probe)<ref name="pmid16932012" />
*Tongue necrosis (caused by prolonged placement of TEE probe)<ref name="pmid16932012">{{cite journal| author=Sriram K, Khorasani A, Mbekeani KE, Patel S| title=Tongue necrosis and cleft after prolonged transesophageal echocardiography probe placement. | journal=Anesthesiology | year= 2006 | volume= 105 | issue= 3 | pages= 635 | pmid=16932012 | doi=10.1097/00000542-200609000-00043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16932012  }} </ref>
*Sore throat<ref name="pmid8065188" />
*Sore throat<ref name="pmid8065188" />
*Odynophagia<ref name="pmid11323333" /><ref name="pmid16153515" />
*[[Odynophagia]]<ref name="pmid11323333" /><ref name="pmid16153515" />
*Dysphagia<ref name="pmid11323333" /><ref name="pmid20418689" />
*Dysphagia<ref name="pmid11323333" /><ref name="pmid20418689" />
*Profound gag<ref name="pmid8065188" />
*Profound gag<ref name="pmid8065188" />
*<s>'''Aspiration'''</s>
*Laryngeal palsy<ref name="pmid20418689" />
*Laryngeal palsy<ref name="pmid20418689" />
*Hoarsness<ref name="pmid8065188" />
*Hoarsness<ref name="pmid8065188" />
*Methemoglobinemia (caused by the topical use of benzocaine in the preparation of TEE procedure)<ref name="pmid16517334" />
*Methemoglobinemia (caused by the topical use of benzocaine in the preparation of TEE procedure)<ref name="pmid16517334">{{cite journal| author=Jacka MJ, Kruger M, Glick N| title=Methemoglobinemia after transesophageal echocardiography: a life-threatening complication. | journal=J Clin Anesth | year= 2006 | volume= 18 | issue= 1 | pages= 52-4 | pmid=16517334 | doi=10.1016/j.jclinane.2005.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16517334  }} </ref>
*Hypoxia<ref name="pmid1999032" /><ref name="pmid1622623" /><ref name="pmid8065188" /><ref name="pmid16153515" />
*Hypoxia<ref name="pmid1999032" /><ref name="pmid1622623" /><ref name="pmid8065188" /><ref name="pmid16153515" />
*Laryngospasm<ref name="pmid1622623" /><ref name="pmid8065188" />
*Laryngospasm<ref name="pmid1622623" /><ref name="pmid8065188" />
*Bronchospasm<ref name="pmid1999032" /><ref name="pmid1760179" />
*Bronchospasm<ref name="pmid1999032" /><ref name="pmid1760179">{{cite journal| author=Chan KL, Cohen GI, Sochowski RA, Baird MG| title=Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations. | journal=J Am Soc Echocardiogr | year= 1991 | volume= 4 | issue= 6 | pages= 577-82 | pmid=1760179 | doi=10.1016/s0894-7317(14)80216-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1760179  }} </ref>
*Airway obstruction<ref name="pmid10359925" /><ref name="pmid12198035" /><ref name="pmid10794340" />
*Airway obstruction<ref name="pmid10359925">{{cite journal| author=Stevenson JG| title=Incidence of complications in pediatric transesophageal echocardiography: experience in 1650 cases. | journal=J Am Soc Echocardiogr | year= 1999 | volume= 12 | issue= 6 | pages= 527-32 | pmid=10359925 | doi=10.1016/s0894-7317(99)70090-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10359925  }} </ref><ref name="pmid12198035">{{cite journal| author=Arima H, Sobue K, Tanaka S, Morishima T, Ando H, Katsuya H| title=Airway obstruction associated with transesophageal echocardiography in a patient with a giant aortic pseudoaneurysm. | journal=Anesth Analg | year= 2002 | volume= 95 | issue= 3 | pages= 558-60, table of contents | pmid=12198035 | doi=10.1097/00000539-200209000-00010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12198035  }} </ref><ref name="pmid10794340">{{cite journal| author=Nakao S, Eguchi T, Ikeda S, Nagata A, Nishizawa N, Shingu K| title=Airway obstruction by a transesophageal echocardiography probe in an adult patient with a dissecting aneurysm of the ascending aorta and arch. | journal=J Cardiothorac Vasc Anesth | year= 2000 | volume= 14 | issue= 2 | pages= 186-7 | pmid=10794340 | doi=10.1016/s1053-0770(00)90016-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10794340  }} </ref>
 
*Accidental tracheal intubation<ref name="pmid1760179" /><ref name="pmid10359925" />
*Accidental tracheal intubation<ref name="pmid1760179" /><ref name="pmid10359925" />
*Endotracheal tube malposition<ref name="pmid11323333" />
*Endotracheal tube malposition<ref name="pmid11323333" />
*[[Congestive heart failure]]<ref name="pmid1622623" /><ref name="pmid8065188" />
*Dysrhythmias (eg. [[atrial fibrillation]], [[supraventricular tachycardia]], [[atrioventricular block]], [[Premature ventricular contraction|premature ventricular beats]], nonsustained [[ventricular tachycardia]], ventricular tachycardia)<ref name="pmid1760179" /><ref name="pmid1999032" /><ref name="pmid1622623" /><ref name="pmid8065188" />
*Transient hypotention or hypertension<ref name="pmid1622623" /><ref name="pmid8065188" />
*Transient changes in heart rate<ref name="pmid3400617">{{cite journal| author=Geibel A, Kasper W, Behroz A, Przewolka U, Meinertz T, Just H| title=Risk of transesophageal echocardiography in awake patients with cardiac diseases. | journal=Am J Cardiol | year= 1988 | volume= 62 | issue= 4 | pages= 337-9 | pmid=3400617 | doi=10.1016/0002-9149(88)90244-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3400617  }} </ref>
*Oroharyngeal,hypopharyngeal, esohageal or gastric abrasion<ref name="pmid11323333" /> or perforation <ref name="pmid15868517">{{cite journal| author=Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC, Yusoff IF| title=Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients. | journal=J Cardiothorac Vasc Anesth | year= 2005 | volume= 19 | issue= 2 | pages= 141-5 | pmid=15868517 | doi=10.1053/j.jvca.2005.01.020 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15868517  }} </ref><ref name="pmid1999032" /><ref name="pmid11323333" /><ref name="pmid1760179" /><ref name="pmid16153515" /><ref name="pmid20418689" />
*Oroharyngeal,hypopharyngeal, esohageal or gastric abrasion<ref name="pmid11323333" /> or perforation <ref name="pmid15868517">{{cite journal| author=Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC, Yusoff IF| title=Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients. | journal=J Cardiothorac Vasc Anesth | year= 2005 | volume= 19 | issue= 2 | pages= 141-5 | pmid=15868517 | doi=10.1053/j.jvca.2005.01.020 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15868517  }} </ref><ref name="pmid1999032" /><ref name="pmid11323333" /><ref name="pmid1760179" /><ref name="pmid16153515" /><ref name="pmid20418689" />
*Hemorrhage  
*[[Bleeding|Hemorrhage]]
**Upper GI bleeding<ref name="pmid1999032" /><ref name="pmid16153515" /><ref name="pmid11323333" />,
**Upper GI bleeding<ref name="pmid1999032" /><ref name="pmid16153515" /><ref name="pmid11323333" />
**Hemoptysis<ref name="pmid16153515" /><ref name="pmid1999032" />
**[[Hemoptysis]]<ref name="pmid16153515" /><ref name="pmid1999032" />
**Blood-tinged sputum<ref name="pmid1622623" /><ref name="pmid8065188" />,
**Blood-tinged sputum<ref name="pmid1622623" /><ref name="pmid8065188" />
**Cardiac tamponade (due to rupture of aortic dissection or aortic anuerysm)<ref name="pmid9250927" /><ref name="pmid11442947" /><ref name="pmid2063804" />,
**[[Cardiac tamponade]] (due to rupture of [[aortic dissection]] or aortic aneurysm)<ref name="pmid9250927">{{cite journal| author=Kim CM, Yu SC, Hong SJ| title=Cardiac tamponade during transesophageal echocardiography in the patient of circumferential aortic dissection. | journal=J Korean Med Sci | year= 1997 | volume= 12 | issue= 3 | pages= 266-8 | pmid=9250927 | doi=10.3346/jkms.1997.12.3.266 | pmc=3054279 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9250927  }} </ref> <ref name="pmid11442947">{{cite journal| author=Dalby Kristensen S, Ramlov Ivarsen H, Egeblad H| title=Rupture of Aortic Dissection During Attempted Transesophageal Echocardiography. | journal=Echocardiography | year= 1996 | volume= 13 | issue= 4 | pages= 405-406 | pmid=11442947 | doi=10.1111/j.1540-8175.1996.tb00912.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11442947  }} </ref><ref name="pmid2063804">{{cite journal| author=Silvey SV, Stoughton TL, Pearl W, Collazo WA, Belbel RJ| title=Rupture of the outer partition of aortic dissection during transesophageal echocardiography. | journal=Am J Cardiol | year= 1991 | volume= 68 | issue= 2 | pages= 286-7 | pmid=2063804 | doi=10.1016/0002-9149(91)90769-h | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2063804 }} </ref>
**Splenic rupture<ref name="pmid9636915" />
**[[Splenic rupture]]<ref name="pmid9636915">{{cite journal| author=Chow MS, Taylor MA, Hanson CW| title=Splenic laceration associated with transesophageal echocardiography. | journal=J Cardiothorac Vasc Anesth | year= 1998 | volume= 12 | issue= 3 | pages= 314-6 | pmid=9636915 | doi=10.1016/s1053-0770(98)90013-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9636915  }} </ref>
*Hematoma<ref name="pmid20418689" /><ref name="pmid16153515" />
*[[Hematoma]]<ref name="pmid20418689" /><ref name="pmid16153515" />
*Dysrhythmias (eg. atrial fibrillation, supraventricular tachycardia, atrioventricular block, premature ventricular beats, nonsustained ventricular tachycardia, ventricular tachycardia)<ref name="pmid1760179">{{cite journal| author=Chan KL, Cohen GI, Sochowski RA, Baird MG| title=Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations. | journal=J Am Soc Echocardiogr | year= 1991 | volume= 4 | issue= 6 | pages= 577-82 | pmid=1760179 | doi=10.1016/s0894-7317(14)80216-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1760179 }} </ref><ref name="pmid1999032" /><ref name="pmid1622623" /><ref name="pmid8065188" />
*Pressure necrosis (in patients with severe [[atherosclerosis]])<ref name="pmid8712461">{{cite journal| author=Kharasch ED, Sivarajan M| title=Gastroesophageal perforation after intraoperative transesophageal echocardiography. | journal=Anesthesiology | year= 1996 | volume= 85 | issue= 2 | pages= 426-8 | pmid=8712461 | doi=10.1097/00000542-199608000-00027 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712461  }} </ref>
*Transient hypotention or hypertension<ref name="pmid1622623" /><ref name="pmid8065188" />
*Transient changes in heart rate
*Congestive heart failure<ref name="pmid1622623" /><ref name="pmid8065188" />
*Pressure necrosis (in patients with severe atherosclerosis)<ref name="pmid8712461" />
*Death(rare)<ref name="pmid16153515">{{cite journal| author=Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP | display-authors=etal| title=Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations. | journal=J Am Soc Echocardiogr | year= 2005 | volume= 18 | issue= 9 | pages= 925-9 | pmid=16153515 | doi=10.1016/j.echo.2005.01.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16153515  }} </ref><ref name="pmid1999032">{{cite journal| author=Daniel WG, Erbel R, Kasper W, Visser CA, Engberding R, Sutherland GR | display-authors=etal| title=Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. | journal=Circulation | year= 1991 | volume= 83 | issue= 3 | pages= 817-21 | pmid=1999032 | doi=10.1161/01.cir.83.3.817 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1999032  }} </ref><ref name="pmid1622623">{{cite journal| author=Seward JB, Khandheria BK, Oh JK, Freeman WK, Tajik AJ| title=Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications. | journal=J Am Soc Echocardiogr | year= 1992 | volume= 5 | issue= 3 | pages= 288-305 | pmid=1622623 | doi=10.1016/s0894-7317(14)80352-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1622623  }} </ref><ref name="pmid8065188">{{cite journal| author=Khandheria BK, Seward JB, Tajik AJ| title=Transesophageal echocardiography. | journal=Mayo Clin Proc | year= 1994 | volume= 69 | issue= 9 | pages= 856-63 | pmid=8065188 | doi=10.1016/s0025-6196(12)61788-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8065188  }} </ref>
*Death(rare)<ref name="pmid16153515">{{cite journal| author=Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP | display-authors=etal| title=Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations. | journal=J Am Soc Echocardiogr | year= 2005 | volume= 18 | issue= 9 | pages= 925-9 | pmid=16153515 | doi=10.1016/j.echo.2005.01.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16153515  }} </ref><ref name="pmid1999032">{{cite journal| author=Daniel WG, Erbel R, Kasper W, Visser CA, Engberding R, Sutherland GR | display-authors=etal| title=Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. | journal=Circulation | year= 1991 | volume= 83 | issue= 3 | pages= 817-21 | pmid=1999032 | doi=10.1161/01.cir.83.3.817 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1999032  }} </ref><ref name="pmid1622623">{{cite journal| author=Seward JB, Khandheria BK, Oh JK, Freeman WK, Tajik AJ| title=Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications. | journal=J Am Soc Echocardiogr | year= 1992 | volume= 5 | issue= 3 | pages= 288-305 | pmid=1622623 | doi=10.1016/s0894-7317(14)80352-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1622623  }} </ref><ref name="pmid8065188">{{cite journal| author=Khandheria BK, Seward JB, Tajik AJ| title=Transesophageal echocardiography. | journal=Mayo Clin Proc | year= 1994 | volume= 69 | issue= 9 | pages= 856-63 | pmid=8065188 | doi=10.1016/s0025-6196(12)61788-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8065188  }} </ref>


<ref name="pmid8712461">{{cite journal| author=Kharasch ED, Sivarajan M| title=Gastroesophageal perforation after intraoperative transesophageal echocardiography. | journal=Anesthesiology | year= 1996 | volume= 85 | issue= 2 | pages= 426-8 | pmid=8712461 | doi=10.1097/00000542-199608000-00027 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8712461  }} </ref>
== Advantages and Disadvantages of Transesophageal echocardiography (TEE) ==
 
<br />
<ref name="pmid16932012">{{cite journal| author=Sriram K, Khorasani A, Mbekeani KE, Patel S| title=Tongue necrosis and cleft after prolonged transesophageal echocardiography probe placement. | journal=Anesthesiology | year= 2006 | volume= 105 | issue= 3 | pages= 635 | pmid=16932012 | doi=10.1097/00000542-200609000-00043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16932012  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
 
|+
 
! colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Advantages and Disadvantages of Transesophageal echocardiography (TEE)'''}}
 
|-
 
|style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Advantages'''}}
 
|style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Disadvantages'''}}
<ref name="pmid9250927">{{cite journal| author=Kim CM, Yu SC, Hong SJ| title=Cardiac tamponade during transesophageal echocardiography in the patient of circumferential aortic dissection. | journal=J Korean Med Sci | year= 1997 | volume= 12 | issue= 3 | pages= 266-8 | pmid=9250927 | doi=10.3346/jkms.1997.12.3.266 | pmc=3054279 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9250927  }} </ref>
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" |
<ref name="pmid11442947">{{cite journal| author=Dalby Kristensen S, Ramlov Ivarsen H, Egeblad H| title=Rupture of Aortic Dissection During Attempted Transesophageal Echocardiography. | journal=Echocardiography | year= 1996 | volume= 13 | issue= 4 | pages= 405-406 | pmid=11442947 | doi=10.1111/j.1540-8175.1996.tb00912.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11442947  }} </ref>
* High-quality imaging<ref name="pmid1622623">{{cite journal| author=Seward JB, Khandheria BK, Oh JK, Freeman WK, Tajik AJ| title=Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications. | journal=J Am Soc Echocardiogr | year= 1992 | volume= 5 | issue= 3 | pages= 288-305 | pmid=1622623 | doi=10.1016/s0894-7317(14)80352-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1622623 }} </ref><ref name="pmid8065188">{{cite journal| author=Khandheria BK, Seward JB, Tajik AJ| title=Transesophageal echocardiography. | journal=Mayo Clin Proc | year= 1994 | volume= 69 | issue= 9 | pages= 856-63 | pmid=8065188 | doi=10.1016/s0025-6196(12)61788-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8065188 }} </ref>
 
* Continuous imaging<ref name="pmid20864313">{{cite journal| author=Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK| title=Safety of transesophageal echocardiography. | journal=J Am Soc Echocardiogr | year= 2010 | volume= 23 | issue= 11 | pages= 1115-27; quiz 1220-1 | pmid=20864313 | doi=10.1016/j.echo.2010.08.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20864313 }} </ref>
<ref name="pmid9636915">{{cite journal| author=Chow MS, Taylor MA, Hanson CW| title=Splenic laceration associated with transesophageal echocardiography. | journal=J Cardiothorac Vasc Anesth | year= 1998 | volume= 12 | issue= 3 | pages= 314-6 | pmid=9636915 | doi=10.1016/s1053-0770(98)90013-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9636915  }} </ref>
| style="padding: 5px 5px; background: #DCDCDC;" |  
 
* Invasive procedure
<ref name="pmid20418689">{{cite journal| author=American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography| title=Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. | journal=Anesthesiology | year= 2010 | volume= 112 | issue= 5 | pages= 1084-96 | pmid=20418689 | doi=10.1097/ALN.0b013e3181c51e90 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20418689  }} </ref>
* Risk of complications
 
* Requires patient fasting
<ref name="pmid2063804">{{cite journal| author=Silvey SV, Stoughton TL, Pearl W, Collazo WA, Belbel RJ| title=Rupture of the outer partition of aortic dissection during transesophageal echocardiography. | journal=Am J Cardiol | year= 1991 | volume= 68 | issue= 2 | pages= 286-7 | pmid=2063804 | doi=10.1016/0002-9149(91)90769-h | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2063804  }} </ref>
* Requires patient sedation or anesthesia
 
|}
<ref name="pmid10359925">{{cite journal| author=Stevenson JG| title=Incidence of complications in pediatric transesophageal echocardiography: experience in 1650 cases. | journal=J Am Soc Echocardiogr | year= 1999 | volume= 12 | issue= 6 | pages= 527-32 | pmid=10359925 | doi=10.1016/s0894-7317(99)70090-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10359925  }} </ref>
 
 
 
<ref name="pmid16517334">{{cite journal| author=Jacka MJ, Kruger M, Glick N| title=Methemoglobinemia after transesophageal echocardiography: a life-threatening complication. | journal=J Clin Anesth | year= 2006 | volume= 18 | issue= 1 | pages= 52-4 | pmid=16517334 | doi=10.1016/j.jclinane.2005.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16517334  }} </ref>
 
<ref name="pmid10794340">{{cite journal| author=Nakao S, Eguchi T, Ikeda S, Nagata A, Nishizawa N, Shingu K| title=Airway obstruction by a transesophageal echocardiography probe in an adult patient with a dissecting aneurysm of the ascending aorta and arch. | journal=J Cardiothorac Vasc Anesth | year= 2000 | volume= 14 | issue= 2 | pages= 186-7 | pmid=10794340 | doi=10.1016/s1053-0770(00)90016-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10794340 }} </ref>
 
<ref name="pmid12198035">{{cite journal| author=Arima H, Sobue K, Tanaka S, Morishima T, Ando H, Katsuya H| title=Airway obstruction associated with transesophageal echocardiography in a patient with a giant aortic pseudoaneurysm. | journal=Anesth Analg | year= 2002 | volume= 95 | issue= 3 | pages= 558-60, table of contents | pmid=12198035 | doi=10.1097/00000539-200209000-00010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12198035  }} </ref>
 
<s><ref name="pmid10527219">{{cite journal| author=Kawahito S, Kitahata H, Kimura H, Tanaka K, Oshita S| title=Recurrent laryngeal nerve palsy after cardiovascular surgery: relationship to the placement of a transesophageal echocardiographic probe. | journal=J Cardiothorac Vasc Anesth | year= 1999 | volume= 13 | issue= 5 | pages= 528-31 | pmid=10527219 | doi=10.1016/s1053-0770(99)90002-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10527219 }} </ref></s>
 
==Advantages==
Combined with [[Transthoracic echocardiography|Transthoracic echocardiography (TTE)]], a TEE before cardiac surgery can<ref name="pmid15637497">{{cite journal| author=Ayres NA, Miller-Hance W, Fyfe DA, Stevenson JG, Sahn DJ, Young LT et al.| title=Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease: report from the task force of the Pediatric Council of the American Society of Echocardiography. | journal=J Am Soc Echocardiogr | year= 2005 | volume= 18 | issue= 1 | pages= 91-8 | pmid=15637497 | doi=10.1016/j.echo.2004.11.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15637497 }} </ref>:
 
* Confirm or exclude previous TTE findings
* Assess the immediate preoperative hemodynamics
* Assess [[ventricular function]] of the patient
* Facilitate placement of central venous catheters
* Assist with selection of [[anesthetic]] agents
* Be used as an [[inotropic]] support in identifying [[ventricular systolic]] size and function
 
After surgery but before closure, a TEE can<ref name="pmid15637497">{{cite journal| author=Ayres NA, Miller-Hance W, Fyfe DA, Stevenson JG, Sahn DJ, Young LT et al.| title=Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease: report from the task force of the Pediatric Council of the American Society of Echocardiography. | journal=J Am Soc Echocardiogr | year= 2005 | volume= 18 | issue= 1 | pages= 91-8 | pmid=15637497 | doi=10.1016/j.echo.2004.11.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15637497  }} </ref>:
* Improve overall outcome
:* Assist in determining whether the level of repair is acceptable
:* Detect and diagnose significant disease remaining to be treated
:* Assess cardiac function
:* Assess the presence of intracardiac air
:* Diagnosis [[arrhythmias|abnormal cardiac rhythms]]
:* Monitor ventricular function and loading
:* Provides a better imaging view for determination of appropriate timing and the hemodynamic effect of sternal closure
:* Assist in monitoring inotropic drugs
 
In noncardiac procedures, TEE can:
* Enhance monitoring of [[myocardium|myocardial function]]
* Enhance monitoring of volume status
 
==Disadvantages==
Constraints for testing include:
* Limited potential for optimal [[Doppler]] alignment
* Limited time to perform a complete study
* Suboptimal ambient lighting
 
==Standard views of Transesophageal echocardiography (TEE)==
===1. Esophageal Position===
====Four-Chamber Plane====
#Location: high trans-esophageal position, probe posterior to the left atrium at 0 degrees rotation, angle transducer toward the left ventricular apex
#View
##Lateral wall and inferior segments of left ventricle. Apparent apex may be a more proximal segment of anterior wall
##Anterior and posterior mitral valve leaflets
##Assess the size, shape, systolic function of the RV by turning the probe towards the patient's right
 
====Two-Chamber Plane====
#Location: with LV apex in center of image in four chamber view, rotate probe 60 degrees
#View
##Inferior and anterior LV walls
##Rotation to 90 degrees shows LA appendage
 
====Long-Axis Left Ventricular Plane====
#Location: with high trans-esophageal positioning, posterior to left atrium, rotate image plane 120 degrees
#View
##Proximal ascending aorta, sinuses of Valsalva, right and non coronary leaflets of the aortic valve, anterior and posterior mitral valve leaflets
##Good view for evaluating ascending aortic dissection, subaortic membrane, supracristal VSD, sinus of Valsalva aneurysm, aortic valve vegetations and abscess formation
 
====Short-Axis Plane====
#Location: withdraw the probe to the level of the aortic valve and rotate the image plane to between 30 and 45 degrees
#View
##Visualization of detailed aortic anatomy including 3 leaflets and sinuses of valsalva and the origin of the L main coronary artery
##Interatrial septum and fossa ovalis are well seen
 
===2. Gastric Position===
====Short-Axis Plane====
#Location: with probe in tip of the stomach, flex the scope superiorly
#View
##Global LV systolic function and global LV function can be evaluated
##May obtain a view of the mitral valve by withdrawing the transducer towards the esophagus
 
====Two-Chamber Plane====
#Location: in the transgastric position, rotate the image plane to the 90 degree position, then turn the probe towards the patient's right
#View
##Right atrium, tricuspid valve, right ventricle
##Can occasionally see RVOT and pulmonic valve
 
===3. Transgastric Apical Position===
 
====Four-Chamber Plane====
#Location: from transgastric short axis view, transducer is advanced further into the fungus
#View: apical four chamber, allows for doppler interrogation of LV outflow tract and valve
 
====Long-Axis Plane====
#Location: from transgastric apical four chamber plane, rotate the image to 120 degrees
#View: LVOT, allows doppler of the LVOT and aortic velocities
 
==Descending Thoracic Aorta==
#By rotating proble from the transesophageal or transgastric position until the image is directed just left of the patients spine, can visualize a short axis view of the thorasic aorta
#Useful for evaluation of aortic dissection, aneurysms and atheromas
 
==Examples==
[http://www.youtube.com/watch?v=TyyWnaNoyB0 TEE Pericardial Effusion]
 
==Resources==
* [http://www.SeeMyHeart.org SeeMyHeart Patient Information on Echocardiograms (Heart Ultrasounds)]
* [http://www.asecho.org American Society of Echocardiography]
* [http://www.ptca.org/imaging/stress_test.html Stress Test with Echocardiography]
* [http://heartcenter.seattlechildrens.org/what_to_expect/echocardiogram.asp Echocardiography information]
* [http://know-heart-diseases.com Coronary heart disease and echocardiography]
* [http://www.echocardiology.org Echocardiography Resources & Simple echocardiography tutorials]
* [http://www.manbit.com/ERS/ERSindex.asp Atlas of Echocardiography]
* [http://www2.umdnj.edu/~shindler/index.html E-chocardiography: Internet Journal of Cardiac Ultrasound]
* [http://www.echobasics.de Basic introduction to echocardiography]
* [http://www.mitral.com/echocardiography.shtml Basic information about echocardiography]
* [http://www.medical.philips.com/main/products/ultrasound/products/technology/live_3d.html 3D Echocardiography]
* [http://pie.med.utoronto.ca/TEE Perioperative Interactive Education VIRTUAL TEE]


==References==
==References==

Latest revision as of 19:36, 11 July 2020

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Eli V. Gelfand, M.D.; Anne B. Riley, M.D. Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD[2]

Overview

Transesophageal echocardiogram, or TEE is a type of echocardiogram that uses a endoscopic probe with an ultrasound transducer to assess, visualize and take images of cardiac structures and great vessels.

Procedure

TEE is performed by passing a probe with an ultrasound transducer into the esophagus, resulting in clear visualization and high-quality images of posterior cardiac structures, thoracic aorta, pulmonary veins and left coronary artery.[1] This is because of the proximity of the esophagus and these structures which reduces the attenuation of ultrasound signal, whereas in transthoracic echocardiogram (TTE), ultrasound signal passes through the chest wall and lungs resulting in degraded image quality.

TEE performance requires trained physicians and personnel.[1]

Preparation, Sedation and Anesthesia

  • Patients must abstain from all oral intake of food or water for at least 4 hours before TEE procedure.[1]
  • Patient medical history must be checked for contraindications and medication allergies.[1][2]
  • Dentures must be removed.[1] 
  • Intravenous access is required in all patients.[2][1]
  • Oxygen delivery and suction devices, endotracheal tubes, and laryngoscopes should be available (in case of respiratory complications).[2]
  • Methylene blue (in case of methemoglobinemia caused by the topical use of benzocaine), flumazenil (reversal agent for benzodiazepines), and naloxone (reversal agent for opioids) should be available.[2] 
  • Continuous monitoring of the patients's hemodynamic stability, vital signs (heart rate, blood pressure, respiratory rate) and oxygen saturation should be assessed during TEE performance.[2]
  • Topical anesthesia of the oropharynx is acheived by a local anesthetic (benzocaine or lidocaine), [1][2] which will reduce the gag reflex and eliminate laryngospasm.[1]
  • For sedation, benzodiazepines (midozolam is the best choice) are most commonly used.[2]
  • Opioids (fentanyl and meperidine are the most commonly used) are used as additional sedatives to decrease the discomfort of TEE procedure.[2]
  • A bite block is placed in the patient’s mouth (after topical anesthesia and before sedation). [2]
  • The procedure is performed with the patient being in the left lateral decubitus position.[1][2]
  • Patients in the intensive care unit or in the operating room are placed in the supine position.[1][2]
  • Patients undergoing surgery with TEE are generally anesthetized and intubated.[2]
  • Most pediatric patients are generally anesthetized and intubated. [3]

Tomography of Transesophageal echocardiography (TEE)

Standard Views of Transesophageal echocardiography (TEE)


Standard Views of Transesophageal echocardiography (TEE)

(Modified table from "Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists")[2]

View Imaging Plane| Aquisition Protocol Structures Imaged
Midesophageal (ME) 1 ME five-chamber view  
  • Transducer Angle: ~ 0-10 degrees
  • Level: Mid-esophageal
2 ME four-chamber view
  • Transducer Angle: ~ 0-10 degrees
  • Level: Mid-esophageal
  • Left atrium/Right atrium
  • Interatrial septum (IAS)
  • Left ventricle/Right ventricle/interventricular septum (IVS)
  • Mitral valve (A3A2-P2P1)
  • Tricuspid valve
3 ME Mitral Commissural View
  • Transducer Angle: ~ 50-70 degrees
  • Level: Mid-esophageal
  • Left atrium
  • Coronary Sinus
  • Left ventricle
  • Mitral valve (P3-A3A2A1-P1)
  • Papilliray muscles
  • Chordae tendinae
4 ME Two-Chamber View  
  • Transducer Angle: ~ 80-100 degrees
  • Level: Mid-esophageal
  • Left atrium
  • Coronary Sinus
  • Left atrial appendage
  • Left ventricle
  • Mitral valve (P3-A32A1)
5 ME Long Axis (LAX) View  
  • Transducer Angle: ~120-140 degrees
  • Level: Mid-esophageal
  • Left atrium
  • Left ventricle
  • Left ventricle outflow tract (LVOT)
  • Right ventricle outflow tract (RVOT)
  • Mitral valve (P2-A2)
  • Aortic valve
  • Proximal ascending aorta
6 ME AV LAX View  
  • Transducer Angle: ~ 120-140
  • Level: Mid-esophageal
  • Left atrium
  • Left ventricle outflow tract (LVOT)
  • Right ventricle outflow tract (RVOT)
  • Mitral valve (A2-P2)
  • Aortic valve
  • Proximal ascending aorta
7 ME Ascending Aorta LAX View
  • Transducer Angle: ~ 90-110 degrees
  • Level: Upper-esophageal
8 ME Ascending Aorta Short Axis (SAX) View
  • Transducer Angle: ~ 0-30 degrees
  • Level: Upper-esophageal
  • Mid-ascending aorta (SAX)
  • Main/bifurcation pulmonary artery
  • Superior vena cava
9 ME Right Pulmonary Vein View
  • Transducer Angle: ~ 0-30 degrees
  • Level: Upper-esophageal
10 ME AV SAX View  
  • Transducer Angle: ~ 25-45 degrees
  • Level: Mid-esophageal
11 ME RV Inflow-Outflow View  
  • Transducer Angle: ~ 50-70 degrees
  • Level: Mid-esophageal
  • Aortic valve
  • Right atrium
  • Left atrium
  • Superior IAS
  • Tricuspid valve
  • RVOT
  • Pulmonary valve
12 ME Modified Bicaval TV View 
  • Transducer Angle: ~ 50-70 degrees
  • Level: Mid-esophageal
  • Right atrium
  • Left atrium
  • Mid-IAS
  • Tricuspid valve
  • Superior vena cava
  • Inferior vena cava/coronary sinus
13 ME Bicaval View  
  • Transducer Angle: ~ 90-110 degrees
  • Level: Mid-esophageal
  • Left atrium
  • Right atrium/appendage
  • IAS
  • Superior vena cava
  • Inferior vena cava
14 ME Right and Left Pulmonary Vein View
  • Transducer Angle: ~ 90-110 degrees
  • Level: Upper-esophageal
  • Pulmonary vein (upper and lower)
  • Pulmonary artery
15 ME LA Appendage View  
  • Transducer Angle: ~ 90-110 degrees
  • Level: Mid-esophageal
  • Left atrial appendage
  • Left upper pulmonary vein
Transgastric (TG)  16 TG Basal SAX View  
  • Transducer Angle: ~ 0-20 degrees
  • Level: Transgastric
  • Left ventricular (base)
  • Right ventricular (base)
  • Mitral valve (SAX)
  • Tricuspid valve (short-axis)
17 TG Midpapillary SAX View  
  • Transducer Angle: ~ 0-20 degrees
  • Level: Transgastric
  • Left ventricular (mid)
  • Papillary muscles
  • Right ventricular (mid)
18 TG Apical SAX View  
  • Transducer Angle: ~ 0-20 degrees
  • Level: Transgastric
  • Left ventricular (apex)
  • Right ventricular (apex)
19 TG RV Basal View  
  • Transducer Angle: ~ 0-20 degrees
  • Level: Transgastric
  • Left ventricular (mid)
  • Right ventricular (mid)
  • RVOT
  • Tricuspid valve (SAX)
  • Pulmonary valve
20 TG RV Inflow-Outflow View  
  • Transducer Angle: ~ 0-20 degrees
  • Level: Transgastric
  • Right atrium
  • Right ventricular
  • RVOT
  • Pulmonary valve
  • Tricuspid valve
21 Deep TG Five-Chamber 
  • Transducer Angle: ~ 0-20 degrees
  • Level: Transgastric
  • Left ventircule
  • LVOT
  • Right ventricle
  • Aortic valve
  • Aortic root
  • Mitral valve
22 TG Two-Chamber View  
  • Transducer Angle: ~ 90-110 degrees
  • Level: Transgastric
  • Left ventricle
  • Left atrium/appendage
  • Mitral valve
23 TG RV Inflow View  
  • Transducer Angle: ~ 90-110 degrees
  • Level: Transgastric
  • Right ventricle
  • Right atrium
  • Tricuspid valve
24 TG LAX View  
  • Transducer Angle: ~ 120-140 degrees
  • Level: Transgastric
  • Left ventircule
  • LVOT
  • Right ventricle
  • Aortic valve
  • Aortic root
  • Mitral valve
Aortic 25 Descending Aorta SAX View  
  • Transducer Angle: ~ 0-10 degrees
  • Level: Transgastric to Mid-esophageal
26 Descending Aorta LAX View  
  • Transducer Angle: ~ 90-100 degrees
  • Level: Transgastric to Mid-esophageal
  • Descending aorta
  • Left thorax
27 UE Aortic Arch to LAX View  
  • Transducer Angle: ~ 0-10 degrees
  • Level: Upper-esophageal
28 UE Aortic Arch SAX View 
  • Transducer Angle: ~ 70-80 degrees
  • Level: Transgastric to Mid-esophageal
  • Aortic arch
  • Innominate vein
  • Pulmanory artery
  • Pulmonary valve
  • Mediastinal tissue

Clinical Applications

Indications for Transesophageal echocardiography (TEE)

(Modified table from "Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography")[4]

Cardiac and Thoracic Aortic Surgery
  • All cardiac and thoracic aortic surgery

or

  • Valve repair or replacement ( aortic, mitral, other)  
  • Coronary artery bypass grafting (CABG) surgery with or without normal ventricular function, off-pump CABG  
  • Redo cardiac surgery  
  • Congenital heart surgery with or without cardiopulmonary bypass  
  • Ascending or decending thoracic aortic surgery   
  • Hypertrophic cardiomyopathy surgery  
  • Resection of cardiac mass  
  • Ventricular remodeling surgery  
  • Open surgery for dysrhythmias  
  • Endocarditis surgery  
  • Heart transplantation
  • Pericardiectomy  
  • Open pericardial surgery  
  • Ventricular assist device  
  • Endoscopically assisted surgery  
  • Cannulae positioning
Transcatheter intracardiac procedures
  • When general anesthesia is provided and intracardiac ultrasound is not used
  • Septal defect closure
  • Atrial appendage obliteration  
  • Valve replacement and repair  
  • Dysrhythmia treatment
Noncardiac Surgery
  • Known or suspected cardiovascular pathology that might result in hemodynamic, pulmonary or neurologic compromise  
  • Unexplained persistent hypotension or hypoxemia   
  • Anticipation of life-threatening hypotension
  • Open abdominal or endovascular aortic procedures
  • Orthopedic surgery  
  • Transplant (liver,lung) 
  • Neurosurgery in the sitting position  
  • Percutaneous cardiovascular interventions    
  • Major Trauma (abdominal or thoracic)
Critical Care
  • Diagnostic information expected to alter management cannot be obtained by TTE or other modalities in a timely manner
  • Unexplained persistent hypotension or hypoxemia

Contraindications

Contraindications include:[4][5][6][7][2][8]

  • Perforated viscus
  • Esophegeal stricture, tumor, perforation, laceration, diverticulum, varices
  • Mallory-Weiss tears [6]
  • Active upper gastrointestinal (GI) bleeding
  • Large descending aortic aneurysm[4], thoracic aortic aneurysm[9]

Complications

  • Majority of the complications are caused by injury or trauma[9]
  • Dental injury (eg. loosened tooth) [9] [4]
  • Tongue necrosis (caused by prolonged placement of TEE probe)[10]
  • Sore throat[1]
  • Odynophagia[9][6]
  • Dysphagia[9][4]
  • Profound gag[1]
  • Laryngeal palsy[4]
  • Hoarsness[1]
  • Methemoglobinemia (caused by the topical use of benzocaine in the preparation of TEE procedure)[11]
  • Hypoxia[5][12][1][6]
  • Laryngospasm[12][1]
  • Bronchospasm[5][7]
  • Airway obstruction[13][14][15]

Advantages and Disadvantages of Transesophageal echocardiography (TEE)


Advantages and Disadvantages of Transesophageal echocardiography (TEE)
Advantages Disadvantages
  • Invasive procedure
  • Risk of complications
  • Requires patient fasting
  • Requires patient sedation or anesthesia

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 Khandheria BK, Seward JB, Tajik AJ (1994). "Transesophageal echocardiography". Mayo Clin Proc. 69 (9): 856–63. doi:10.1016/s0025-6196(12)61788-1. PMID 8065188.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM; et al. (2013). "Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists". J Am Soc Echocardiogr. 26 (9): 921–64. doi:10.1016/j.echo.2013.07.009. PMID 23998692.
  3. ↑ Fyfe DA, Ritter SB, Snider AR, Silverman NH, Stevenson JG, Sorensen G; et al. (1992). "Guidelines for transesophageal echocardiography in children". J Am Soc Echocardiogr. 5 (6): 640–4. doi:10.1016/s0894-7317(14)80332-5. PMID 1344706.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography (2010). "Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography". Anesthesiology. 112 (5): 1084–96. doi:10.1097/ALN.0b013e3181c51e90. PMID 20418689.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Daniel WG, Erbel R, Kasper W, Visser CA, Engberding R, Sutherland GR; et al. (1991). "Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations". Circulation. 83 (3): 817–21. doi:10.1161/01.cir.83.3.817. PMID 1999032.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP; et al. (2005). "Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations". J Am Soc Echocardiogr. 18 (9): 925–9. doi:10.1016/j.echo.2005.01.034. PMID 16153515.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Chan KL, Cohen GI, Sochowski RA, Baird MG (1991). "Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations". J Am Soc Echocardiogr. 4 (6): 577–82. doi:10.1016/s0894-7317(14)80216-2. PMID 1760179.
  8. ↑ 8.0 8.1 Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK (2010). "Safety of transesophageal echocardiography". J Am Soc Echocardiogr. 23 (11): 1115–27, quiz 1220-1. doi:10.1016/j.echo.2010.08.013. PMID 20864313.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK (2001). "The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients". Anesth Analg. 92 (5): 1126–30. doi:10.1097/00000539-200105000-00009. PMID 11323333.
  10. ↑ Sriram K, Khorasani A, Mbekeani KE, Patel S (2006). "Tongue necrosis and cleft after prolonged transesophageal echocardiography probe placement". Anesthesiology. 105 (3): 635. doi:10.1097/00000542-200609000-00043. PMID 16932012.
  11. ↑ Jacka MJ, Kruger M, Glick N (2006). "Methemoglobinemia after transesophageal echocardiography: a life-threatening complication". J Clin Anesth. 18 (1): 52–4. doi:10.1016/j.jclinane.2005.04.008. PMID 16517334.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Seward JB, Khandheria BK, Oh JK, Freeman WK, Tajik AJ (1992). "Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications". J Am Soc Echocardiogr. 5 (3): 288–305. doi:10.1016/s0894-7317(14)80352-0. PMID 1622623.
  13. ↑ 13.0 13.1 Stevenson JG (1999). "Incidence of complications in pediatric transesophageal echocardiography: experience in 1650 cases". J Am Soc Echocardiogr. 12 (6): 527–32. doi:10.1016/s0894-7317(99)70090-8. PMID 10359925.
  14. ↑ Arima H, Sobue K, Tanaka S, Morishima T, Ando H, Katsuya H (2002). "Airway obstruction associated with transesophageal echocardiography in a patient with a giant aortic pseudoaneurysm". Anesth Analg. 95 (3): 558–60, table of contents. doi:10.1097/00000539-200209000-00010. PMID 12198035.
  15. ↑ Nakao S, Eguchi T, Ikeda S, Nagata A, Nishizawa N, Shingu K (2000). "Airway obstruction by a transesophageal echocardiography probe in an adult patient with a dissecting aneurysm of the ascending aorta and arch". J Cardiothorac Vasc Anesth. 14 (2): 186–7. doi:10.1016/s1053-0770(00)90016-8. PMID 10794340.
  16. ↑ Geibel A, Kasper W, Behroz A, Przewolka U, Meinertz T, Just H (1988). "Risk of transesophageal echocardiography in awake patients with cardiac diseases". Am J Cardiol. 62 (4): 337–9. doi:10.1016/0002-9149(88)90244-5. PMID 3400617.
  17. ↑ Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC, Yusoff IF (2005). "Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients". J Cardiothorac Vasc Anesth. 19 (2): 141–5. doi:10.1053/j.jvca.2005.01.020. PMID 15868517.
  18. ↑ Kim CM, Yu SC, Hong SJ (1997). "Cardiac tamponade during transesophageal echocardiography in the patient of circumferential aortic dissection". J Korean Med Sci. 12 (3): 266–8. doi:10.3346/jkms.1997.12.3.266. PMC 3054279. PMID 9250927.
  19. ↑ Dalby Kristensen S, Ramlov Ivarsen H, Egeblad H (1996). "Rupture of Aortic Dissection During Attempted Transesophageal Echocardiography". Echocardiography. 13 (4): 405–406. doi:10.1111/j.1540-8175.1996.tb00912.x. PMID 11442947.
  20. ↑ Silvey SV, Stoughton TL, Pearl W, Collazo WA, Belbel RJ (1991). "Rupture of the outer partition of aortic dissection during transesophageal echocardiography". Am J Cardiol. 68 (2): 286–7. doi:10.1016/0002-9149(91)90769-h. PMID 2063804.
  21. ↑ Chow MS, Taylor MA, Hanson CW (1998). "Splenic laceration associated with transesophageal echocardiography". J Cardiothorac Vasc Anesth. 12 (3): 314–6. doi:10.1016/s1053-0770(98)90013-1. PMID 9636915.
  22. ↑ Kharasch ED, Sivarajan M (1996). "Gastroesophageal perforation after intraoperative transesophageal echocardiography". Anesthesiology. 85 (2): 426–8. doi:10.1097/00000542-199608000-00027. PMID 8712461.


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