A systematic approach to performing a comprehensive transesophageal echocardiogram. A call to order
© Kothavale et al; licensee BioMed Central Ltd. 2009
Received: 29 December 2008
Accepted: 13 May 2009
Published: 13 May 2009
While the order for a clinical transthoracic examination is fairly standardized, there is considerable variability between laboratories and even among physicians in the same laboratory with regard to the order for transesophageal echocardiograms (TEE). A systematic approach is desirable for more efficient use of physician and patient time, avoidance of inadvertent omission of important views, and to facilitate study review.
We propose a standardized approach to TEE data acquisition in which cardiac structures are systematically identified and characterized at sequential positions and imaging planes to facilitate organized, efficient and comprehensive assessment.
Our approach to TEE study begins in the mid-esophagus with the imaging plane at 0°. Based on the specific indication for the TEE, a cardiac structure (e.g., mitral valve, left atrial appendage, or interatrial septum) is chosen as the primary focal point for a comprehensive, multiplane analysis. This structure is assessed in 20° – 30° increments as the imaging plane is advanced from 0° to 165°. Using the aortic valve as a reference point, pertinent cardiac structures are then assessed as the imaging plane is reduced to 135°, to 90°, to 40 – 60° and then back to 0°. The probe is then advanced into the stomach to obtain transgastric images at 0°, 90°, and 120°. Finally, the thoracic aorta and pulmonary artery are assessed as the probe is withdrawn from the body. Using this method, an organized and comprehensive TEE can be performed in 10 – 15 minutes.
A standardized and systematic TEE approach is described for efficient and comprehensive TEE study.
Transesophageal echocardiography (TEE) is a moderately invasive technique used to image the heart and great vessels by placing an ultrasound probe into the patient's esophagus and stomach. Compared to transthoracic echocardiography (TTE), the distance between the ultrasound transducer and the heart is diminished with minimal intervening air or body structures, enabling the use of higher frequency probes that yield improved spatial resolution. TEE technology has evolved significantly since 1974 when the first rigid M-mode device was described by Frazin . Subsequent advancements in TEE technology have led to monoplane, followed by bi-plane, and now smaller, flexible, high frequency multiplane probes capable of two dimensional, M-mode, and Doppler imaging. This remarkable progress has allowed TEE to become a routine imaging modality for the diagnosis and management of a wide range of cardiovascular diseases and performed in the ambulatory, intensive care, and operative room settings. This advancement from monoplane to multiplane imaging has also increased the complexity of the TEE examination. An early description of a systematic multiplane examination for patients under conscious sedation was published by Seward et al. in 1993 . Later, in 2001, Shanewise reported a comprehensive method of performing an intraoperative TEE . These papers as well as current echocardiography textbooks [4, 5] and Society recommendations [6, 7] are based on sequentially imaging specific anatomical structures, but they provide limited guidance for a specific "order" for a study that would provide a comprehensive assessment of a patient. A common recommendation by all of these authors is to begin the TEE examination by focusing on the structure of primary interest so that the main objective is achieved if the study is terminated prematurely due to hemodynamic instability or other disruption [4–8]. A systematic method of TEE image acquisition is important, just as an orderly approach to a TTE exam (parasternal long axis, followed by parasternal short axis, apical four chamber, apical five chamber, apical two chamber, apical three chamber, subcostal, and suprasternal views) facilitates effective use of sonographer and patient time, avoids inadvertent omission of important views, and also facilitates subsequent review. These issues are especially pertinent for a moderately invasive procedure such as TEE. In this report, we present an example of an organized approach for clinical TEE in which the cardiac structures are systematically identified at specified sequential multiplane transducer angle positions to facilitate organized assessment. Using this method, a comprehensive TEE can be performed in 10 – 15 minutes.
A comprehensive review of the indications and morbidity for TEE is beyond the scope of this paper, and the reader is referred elsewhere for discussions of these topics [9–12]. In preparation for performing a TEE, it is important to review the indication for the study as well as the patient's medical history as this clinical information is crucial to the TEE exam.
A Structured Comprehensive TEE Examination
Summary of TEE Examination
TEE probe distance from incisors
~35–40 cm (mid esophagus)
LV, MV; RA, TV; LVOT, AV, IAS; LA, LAA
20–30° Incremental to 165°
Crystal rotation about area of interest
e.g., MV, LAA, IAS
LV long axis
MV, AV, ascending Ao
Anterior/clockwise probe rotation
TV, RA, RAA, IAS, SVC; RUPV, RLPV
MV, LV, LA
Clockwise/anterior probe rotation
PV, RVOT; TV, RA, RAA; IVC, IAS, SVC; RUPV, RLPV
AV, TV, IAS; LAA
~40 cm (distal esophagus)
Passing through GE junction
RAA, CS, TV
~45 cm (gastric)
LV short axis
RA, TV, RV, PV
~45–50 cm with graded 2–3 cm withdrawal
(if plaque seen)
Aortic arch, PA, PV
Our approach to a comprehensive TEE study begins in the mid-esophagus, approximately 35 centimeters (cm) beyond the patient's incisors with the imaging plane at 0°. Based on the indication for the TEE, a cardiac structure such as the aortic valve, mitral valve, left atrial appendage, or interatrial septum is chosen for initial analysis. This structure is assessed at increasing (20° – 30°) image plane increments as the imaging plane is advanced to 165°. Using the aortic valve as a reference point prior to adjusting transducer crystal angles, pertinent cardiac structures are then assessed as the transducer crystal angle is then reduced to 135°, 90°, 50 – 60° and back to 0°. The probe is then advanced into the stomach, approximately 40 – 50 cm beyond the incisors, to obtain transgastric images at 0°, 90°, and 120°. Finally, the thoracic aorta and pulmonary artery are assessed as the probe is withdrawn from the body.
The TEE probe can be manipulated in multiple ways. The following terms are used here to describe probe manipulation:
1) Advance the probe = push the transducer tip forward towards the stomach
2) Withdraw the probe = pull the probe backward towards the oropharynx
3) Anteflex (flex) = turn the large wheel anteriorly (clockwise)
4) Retroflex (extend) = turn the large wheel posteriorly (counterclockwise)
5) Turn clockwise = turn the control handle clockwise (tip of the probe turns anteriorly)
6) Turn counterclockwise = turn the control handle counterclockwise (tip of the probe turns posteriorly)
Imaging Plane Advancement 0 – 165 Degrees
135° Imaging plane
90° Imaging plane
40 – 60° Imaging plane
Imaging plane 0° – Passing Through the Gastroesophageal Junction
Thoracic Aorta and Pulmonary Artery
Agitated saline contrast is often performed during TEE in patients with suspected paradoxical embolism due to a patent foramen ovale . For these patients, we usually interrogate the interatrial septum from 0–180° to identify the best orientation to visualize the thinnest portion of the interatrial septum/fossa ovalis. The 90° orientation is often best, but this can vary. Saline is administered at rest, followed by injections with cough and post-Valsalva release. Except for cases of suspected persistence of a left sided superior vena cava, our preference is to inject agitated saline from the right arm so as to avoid potential obstruction to venous flow related to the patient's left lateral decubitus position.
In this manuscript, we present an organized guide to the performance of a comprehensive TEE examinationThough not intended to be exclusive, the examination outlined in this manuscript is functionally efficient for both the operator and subsequent image review. Our presentation is distinct from other reports that have described the structures seen in various views/esophageal positions [4–6, 11, 14] but without an organized approach to performing the TEE.
While not considered exclusive, we hope our approach provides for a more comprehensive assessment of structures related to the specific TEE indication while also providing structure/organization to the image acquisition so as to reduce the likelihood of accidentally omitting any views, which is important for a moderately invasive procedure in which it would be strongly desireable to not to have to repeat the procedure. While we recognize that a focused or abbreviated protocol may be preferred in specific situations (hemodynamic instability; follow-up of atrial appendage thrombus), we believe that a comprehensive TEE should be performed on the vast majority of patients so as to provide a complete assessment of all of the structures of the heart as well as specific views of the thoracic aorta and main pulmonary artery. Using the approach described here, an organized and comprehensive TEE examination can be completed in 10 – 15 minutes.
An organized guide to the performance of a comprehensive TEE examination is advocated and presented. Such an approach will likely reduce the likelihood of inadvertently omitting a view/structure and also assist in image review.
left atrial appendage
left upper pulmonary vein
left ventricular outflow tract
right atrial appendage
- Frazin L, Talano JV, Stephanides L, Loeb HS, Kopel L, Gunnar RM: Esophageal echocardiography. Circulation. 1976, 54: 102-8.View ArticlePubMedGoogle Scholar
- Seward JB, Khandheria BK, Freeman WK, Oh JK, Enriquez-Sarano M, Miller FA, et al: Multiplane transesophageal echocardiography: image orientation, examination technique, anatomic correlations, and clinical applications. Mayo Clin Proc. 1993, 68: 523-51.View ArticlePubMedGoogle Scholar
- Shanewise JS: Performing a complete transesophageal echocardiographic examination. Anesthesiol Clin North America. 2001, 19: 727-67. viiiView ArticlePubMedGoogle Scholar
- Feigenbaum H, Armstrong WF, Ryan T: Echocardiography. 2005, Philadelphia: Lippincott Williams and Wilkins, SixthGoogle Scholar
- Otto C: Textbook of Clinical Echocardiography. 2004, Philadelphia: W.B. Saunders Company, 94-ThirdGoogle Scholar
- Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, et al: ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr. 1999, 12: 884-900. 10.1016/S0894-7317(99)70199-9.View ArticlePubMedGoogle Scholar
- Flachskampf FA, Decoodt P, Fraser AG, Daniel WG, Roelandt JRTC: Guidelines from the Working Group. Recommendations for performing transesophageal echocardiography. Eur J Echocardiogr. 2001, 2: 8-21.View ArticlePubMedGoogle Scholar
- Stewart WJ: Willie Sutton and the completeness and priorities of the ideal transoesophageal echo study in the year 2001. Eur J Echocardiogr. 2001, 2: 6-7.View ArticlePubMedGoogle Scholar
- Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP, et al: Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations. J Am Soc Echocardiogr. 2005, 18: 925-9. 10.1016/j.echo.2005.01.034.View ArticlePubMedGoogle Scholar
- Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK: The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg. 2001, 92: 1126-30. 10.1097/00000539-200105000-00009.View ArticlePubMedGoogle Scholar
- Oh JK, Seward JB, Tajik AJ: The Echo Manual. 1999, Philadelphia: Lippincott Williams & Wilkins, SecondGoogle Scholar
- Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al: ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography–summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). J Am Coll Cardiol. 2003, 42: 954-70. 10.1016/S0735-1097(03)01065-9.View ArticlePubMedGoogle Scholar
- Foster GP, Isselbacher EM, Rose GA, Torchiana DF, Akins CW, Picard MH: Accurate localization of mitral regurgitant defects using multiplane transesophageal echocardiography. Ann Thorac Surg. 1998, 65: 1025-31. 10.1016/S0003-4975(98)00084-8.View ArticlePubMedGoogle Scholar
- Konstadt S, Shernan SK, Oka Y: Clinical Transesophageal Echocardiography. 2003, Philadelphia: Lippincott Williams & Wilkins, SecondGoogle Scholar
- Pearson AC, Labovitz AJ, Tatineni S, Comez CR: Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol. 1991, 17: 66-72.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/9/18/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.