Introduction to Transesophageal Echocardiography
Nakeisha L. Pierre, M.D
Tulane Department Anesthesiology
Look Familiar?!
IVC or SVC ?
Basic Principles of Ultrasound and
Doppler




Echocardiography creates images of the heart from reflected
sound waves
The ultrasound transducer records the time delay and
amplitude for each returning transmission
Speed in a medium is constant, so only the distance of the
structure from the probe alters the time to receive the
reflected wave
Timing the interval between transmissions and the time it
takes to receive reflected signals allows the ultrasound system
to precisely calculate the location of structures and construct
images
Basic Principles of Ultrasound and
Doppler




2-D echo is unable to visualize blood flow.. It’s
presented as just black on the display
Doppler ultrasonography overcomes this limitation
The Doppler system determines the velocity of blood
flow by assessing the change in frequency of the
ultrasound reflected from moving red blood cells
Directing the ultrasound at the flow of blood and
listening for those changes in frequency allows
Doppler echo to determine direction and speed of
blood flow
Basic Principles of Ultrasound and
Doppler


Frequency (cycles/s) is a
property exclusive to the
echo transducer/probe ( 210Hz)
Frequency determines
signal strength and imaging
resolution


Signal strength

Lower freq – stronger signal

Disadvantage is decreased
image resolution
Imaging resolution

Higher freq – better image
resolution

Disadvantage – decreased
penetration/weaker signal
Doppler Flow
Category I
Indications for Intra-Operative TEE








Acute, persistent life-threatening disturbances
Valve repair – particularly mitral valve
Aortic valve resuspension in dissection or aneurysm sx
Congenital heart surgery
Obstructive cardiomyopathy
Endocarditis
Thoracic Aortic Aneurysm
Pericardial Window
*conditions for which there is evidence and/or general agreement that a given procedure is
useful and effective*
Category II
Indications for Intra-Operative TEE











Increased risk for MI or unstable hemodynamics
Valve replacement
Myocardial aneurysm repair
Cardiac assist devices
Myocardial/intracardiac mass rsxn
Foreign body detection or removal
Pulmonary endareterctomy
Suspected cardiac trauma
Aortic atheromatous disease
Pericardial surgery
Cardiac or pulmonary transplantation
*Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness or
efficacy of procedure/treatment*
Contraindications to Intra-Operative TEE







Esophageal disease – stricture, diverticuli, varices,
tumor
Prior esophageal or stomach surgery
Perforated viscus
Difficulty passing the TEE probe
Anticoagulation
Thrombocytopenia
Facial or airway trauma
Anatomical Relationships


The esophagus provides an excellent window for visualizing detailed
echocardiographic images secondary to its close proximity to the heart
The esophagus extends from the posterior pharynx through the
mediastinum where it courses behind the trachea left main bronchus and
continues inferiorly where it becomes immediately adjacent to LA and LV
Esophagus
Comprehensive TEE Exam


20 views recommended by ASE task force
Goal during any exam is to visualize structure
and function of heart and not necessarily get
all 20 views
Comprehensive TEE Exam
Comprehensive TEE Exam

Views designated by

Echo window





Main anatomic structure



Upper esophageal (20-25cm)
Mid esophageal (30-40cm)
Transgastric (40-45cm)
Deep transgastric (45-50cm)
AV
RV
Imaging plane


Short axis/SAX
Long axis/LAX
Comprehensive TEE Exam



At a multiplane angle of 0 degrees
(the horizontal or transverse plane),
with the imaging plane directed
anteriorly from the esophagus
through the heart, the patient’s right
side appears in the left of the
display.
Rotating the multiplane angle
forward to 90 degrees (vertical or
sagittal plane) moves the left side of
the display inferiorly, toward the
supine patient’s feet.
Rotating the multiplane angle to 180
degrees places the patient’s left side
to left of the display, the mirror
image of 0 degrees.
Orientation of the Heart
Comprehensive TEE Exam
Advance
Withdraw
Retroflex
Flex
to Left
Flex to
Right
Anteflex
Mid.Ant line
rotation
ME Asc Aortic SAX
Angle: 10-30 degrees
Diagnostic Uses: aortic atherosclerosis, aortic dissection/ dilation, PA
pathology (emboli)
ME Asc Aortic LAX
Angle: 100 degrees
Diagnostic Uses: aortic atherosclerosis, aortic dissection, asc aortic dilation
Right Pulmonary A.
Ascending
Aorta
ME AV SAX
Angle:25-45 degrees
Diagnostic Uses: aortic stenosis, valve morphology
NCC
LCC
RCC
ME RV Inflow-Outflow
Angle: 50-70 degrees
Diagnostic Uses: PV disease, PA pathology, RVOT pathology
ME Bicaval
Angle: 105-120 degrees +/- rightward rotation
Diagnostic Uses: right atrial free wall, SVC, interatrial septum, IVC
Positive Bubble Study
ME AV LAX
Angle: 115-130degrees
Diagnostic Uses: AV pathology, aorta pathology, LVOT pathology
ME four chamber
Angle:0-10 degrees
Diagnostic Uses: ASD, chamber enlargement/dysfxn, LV regional wall motion
abnml,mitral dz, tricsupid dz, intracardiac
Lateral
Wall
Septal
Wall
Mitral Valve
ME Mitral Commissural
Angle: 60-75 degrees
Diagnostic Uses: localization of mitral valve pathology
P3
P1
A2
ME two chamber
Angle:80-100degrees
Diagnostic Uses: left atrial appendage mass/thrombus,LV apex pathology
LV systolic fxn/RWM
Coronary Sinus
A3A2A1
P3
ME LAX
Angle: 110-130 degrees
Diagnostic Uses: MV pathology, LVOT pathology, LV RWM abnml
A2
P2
Anteroseptal
Wall
Posterior Wall
TG Basal SAX
Angle: 0 degrees +/- anteflexion
Diagnostic Uses: LV systolic dysfunction, MV pathology
Posterior Leaflet
Anterior Leaflet
TG Mid(pap) SAX
Angle:0 degrees w/ anteflexion
Diagnostic Uses: hemodynamic instability, LV dilation/hypertrophy, LV
systolic function, LV RWM
Transgastric Two Chamber
Angle: 90 degrees
Diagnostic Uses: LV systolic dysfunction (ant/inf walls)
Inferior Wall
Inferior
(ant)
Anterior
Anterior Wall
TG LAX
Angle: 110-130 degrees +/- left rotation
Diagnostic Uses: LV systolic dysfunction, doppler AV
AV
TG RV Inflow
Angle: 110-130 degrees + right rotation
Diagnostic Uses: RV systolic fxn, tricuspid pathology
Tricuspid
Valve
RV
RA
Deep TG LAX
Angle: 0 degrees + anteflexion
Diagnostic Uses: AV pathology, LVOT pathology, doppler AV
Desc Aortic SAX
Angle: 0 degrees
Diagnostic Uses: aortic atherosclerosis, aortic dissection
Desc Aortic LAX
Angle: 90 degrees
Diagnostic Uses: aortic atherosclerosis, aortic dissection, IABP placement
UE Aortic Arch LAX
Angle: 0 degrees + rightward rotation
Diagnostic Uses: aortic atherosclerosis/dissection, measure distal asc aorta
Aortic Arch
UE Aortic Arch SAX
Angle: 90 degrees
Diagnostic Uses: aortic atherosclerosis/dissection
Pulmonary
Artery
Pulmonic
Valve
Aortic
Arch
References






Fleisher, et al. Intraoperative TEE. Philadelphia: Elsevier, 2008
Perrino, et al. A Practical Approach to Transesophageal Echo.
Philadelphia: Lippincott, 2008
Peak. Nuts and Bolts of Ultrasound Physics. Houston, 2006
Riedel. Guidelines for Performing a Comprehensive Intraoperative
Multiplane TEE exam. Houston, 2006
Shanewise, et al. ASE/SCA Intraoperative TEE Guidelines. Anethes
Analg 1999:89:870-84
Sidebotham. Practical Perioperative TEE. London: Butterworth
Heinmann, 2003