TRANS-ESOPHAGEAL &
INTRA-CARDIAC
ECHOCARDIOGRAPHY
HIMAL RAJ
SR CARDIOLOGY
HISTORY
 Side and Gosling (1971) - TEE for CwD of cardiac
flow
 Frazin et al (1976) - TEE M mode echo
 Hisanaga et al (1977) - illustrated use of cross
sectional real time imaging
2
INTRODUCTION
 TEE uses sound waves to create high-quality moving
pictures of heart and its blood vessels
 involves a flexible tube or probe with a transducer at its
tip
 probe is guided down throat and esophagus
 more detailed pictures of heart as esophagus is directly
behind heart
3
TEE: TYPES
•
Types of TEE :
1.
2.
•
•
2-Dimensional (2D)
•
3-Dimensional (3D)
Standard TEE pictures
are 2D
3D pictures provide more
details about
•
Structure and function of
heart and Its blood
vessels
3D TEE helps to diagnose
heart problems like:
•
•
•
Congenital heart disease
Heart valve disease and
To assist with heart
surgery
4
TRANSESOPHAGEAL
ECHOCARDIOGRAPHY (TEE)
5
TEE
6
TEE: ADVANTAGES
 Transducer - 2- 3 mm from heart
 Closer to posterior structures - Better visualization of
LA, LAA, PV, MV, LV, Aorta

Far from surgical area - Intra-operative monitoring
 High resolution images : [Absence of intervening lung or
bone tissue - Better signal to noise ratio and decreased
image depth – allows use of higher freq (5 and 7 MHz)
transducers – enhances image quality]
7
TEE: DISADVANTAGES
• semi invasive procedure: chances of injury ;
• needs special setup, technique, preparation,
instrumentation
•
needs orientation and expertise
8
INDICATIONS -COMMON
•
Assessment of prosthetic valves; infective endocarditis ;
native valve disease
•
•
•
•
•
•
•
•
•
•
Assessment of a suspected cardioembolic event
Assessment of cardiac tumors
Assessment of atrial septal abnormalities
Assessment of aortic dissection, intramural hematomas
Evaluation of CHD; CAD ;pericardial disease
Evaluation of critically ill patients
Intraoperative monitoring
Monitoring during interventional procedures
Stress echocardiography
Nondiagnostic TTE
9
CONTRAINDICATIONS
ABSOLUTE
 Oesophageal stricture or obstruction
 Suspected or known perforated viscus
 Instability of cervical vertebrae
 GI bleeding not evaluated
RELATIVE
 Esophageal varices or diverticula
 Cervical arthritis
 Oropharyngeal distortion
 Bleeding diathesis or over-anticoagulation
10
PROCEDURE
 4- 6 hours fasting
 Written consent
 Intravenous line ; oxygen ; suction equipment
;
Remove denture or devices ; 2% lidocaine spray
 ECG must be monitored throughout
 Left lateral position
 Introduce the probe with some anteflexion through
a bite block
11
PROCEDURE
 Routine antibiotic prophylaxis before TEE is not
advocated [ risk of IE is extremely
low].Recommended in high risk patients - prosthetic
valves, multivalvular involvement or those with a
past h/o IE]
 Persistent resistance to advancing the instrument
mandates termination of TEE and endoscopy
should be performed before re-examination.
 After each TEE - Disnfect ; Check for any damage ensure electrical safety
12
COMPLICATIONS
 Majority are minor.
 Major complications [death, laryngospasm,
sustained VT & CHF occur in ≈ 0.3% of patients]
 Cardiac complications include SVT or AF, VT,
bradycardia, transient hypotension or hypertension,
angina ,CHF and pulmonary edema.
13
COMPLICATIONS
MAJOR
 Death
 Esophageal rupture
 Laryngospasm or bronchospasm
 Congestive heart failure or pulmonary edema
 Sustained ventricular tachycardia
14
COMPLICATIONS
MINOR
 Excessive retching or
vomiting
 Sore throat
 Hoarseness
 Minor pharyngeal bleeding
 Blood tinged sputum
 Non sustained or sustained
supraventricular tachycardia
 Atrial fibrillation
 Nonsustained ventricular
tachycardia
 Bradycardia or heart block
 Transient hypotension
 Transient hypertension
 Angina
 Transient hypoxia
 Parotid swelling
15
 Tracheal intubation
TEE PROBE
 Modification of standard gastroscope, with
transducers in place of fibreoptics
 Conventional rotary controls with inner and outer
dials
 Inner dial guides anteflexion and retroflexion
 Outer dial controls medial and lateral movement
 Multiplane probe has a lever control to guide
rotation
16
TEE PROBE
17
TEE TRANSDUCER
TEE Transducer
Relation of TEE transducer with heart
18
TEE PROBE
 Monoplane TEE - provides images in horizontal
plane only
 Biplane TEE - orthogonal longitudinal plane also
 Multiplane TEE transducer :
 single array of crystals [phased array transducers with 64
-256 piezoelectric elements]
 that can be electronically and mechanically rotated in an
arc of 180 °
 to produce a continuum of transverse and longitudinal
images from a single probe position
19
STANDARD IMAGING PLANE LEVELS
(FROM THE INCISORS)
 upper or high esophageal (25–28 cm)
 mid-esophageal (29–33 cm)
 transgastric (38–42 cm)
 deep-transgastric (>42 cm)
20
21
PROCEDURE
Proceed systematically - from mid esophagus [≈35
cms from the incisors] to gradually more distal
esophagus, fundus of the stomach after gentle
advancement across the cardia [≈40-50 cms from
incisors] and finally slow withdrawal of the probe for
complete scan of the thoracic aorta [from high
esophageal views].
22
PROCEDURE
 A complete TEE exam usually takes 15–20 min.
 An abbreviated or problem-focused TEE study may
be appropriate in unstable or uncooperative
patients
23
TRANSDUCER MANIPULATION
OPTIONS
[1] Advancement/withdrawal (for inferior or superior
structures respectively)
[2] Rotation (clockwise to view rightward structures and
counter- clockwise for leftward structures)
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TRANSDUCER MANIPULATION OPTIONS
[3] Anteflexion and retroflexion of the probe shaft (to view
structures towards the heart base or towards the apex)
[4] Leftward and rightward flexion of the probe shaft (used
infrequently with the advent of multiplane probes)
25
TRANSDUCER MANIPULATION
OPTIONS
[5] Electronic image plane rotation (0–1800)
26
TEE PROBE ORIENTATION
27
• By convention, in TEE, tip of 2D sector is displayed
on top of screen and left-sided cardiac structures
appear on right side of display.
28
BASIC VIEWS
• Prior guidelines developed by the ASE and the SCA have
described the technical skills for acquiring 20 views in the
performance of a comprehensive intraoperative multiplane
transesophageal echocardiographic examination
• But current guidelines recommend that a basic PTE
examination should focus on encompassing the 11 most
relevant views.
30
CROSS-SECTIONAL VIEWS OF THE 11 VIEWS OF
THE ASE AND SCA BASIC PTE EXAMINATION.
31
ASE & SCA RECOMMEND 20 VIEWS FOR A COMPREHENSIVE TEE.
MID ESOPHAGUS 4C ( 0°)
Position probe in mid-esophagus behind LA. depth 14cm,
angle 0-10°. Image all 4 heart chambers. Optimize LV apex by
slight retroflexion of probe tip. Ensure no part of AV or LVOT is
seen. Aim to maximize TV diameter, and adjust depth to
view entire LV.
Assess :chamber size; ventricular function; mitral valve
disease; tricuspid valve disease; ASD; pericardial effusion
ME 4 CHAMBER VIEW
34
ME 2C ( 90° )
From ME 4C : keep probe tip still and MV in the center;
rotate omniplane angle forward to 80-100°; RA + RV disappear,
LAA appears.Retroflex probe tip for true LV apex; adjust depth
to see entire LV apex.
Assess : LAA mass/thrombus; LV size and function; MV
disease (A1, A2 & P3 scallops); MV annulus measurement
‘
ME TWO-CHAMBER VIEW
36
ME LAX (120°)
Rotate omniplane angle forward to 120-130°
Imaging plane is directed thru the LA to image the aortic root in
LAX and entire LV. The more cephalad structures are lined up
on the display right.
The LV anteroseptal + inferolateral walls & MV segments, A2
and P2 are seen.
Assess : LV function, MV disease, AV and aortic root
disease, IVS pathology.
ME LAX VIEW
38
ME ASC A LAX ( 90°)
Find the ME AV LAX (120°). Withdraw the probe to bring the
right pulmonary artery in view Decrease omniplane angle
slightly by 10-20° to make the aortic wall symmetric
Imaging plane is directed thru the right pulmonary artery to
image the proximal ascending aorta in LAX.
For: aortic pathology, pericardial effusion, pulmonary embolus
ME ASC A LAX ( 90°)
40
ME ASC A SAX (0°)
From ME AV LAX (120°) OR from ME AV SAX (30°)….
Withdraw probe (asc aorta ), Rotate the omniplane angle back
to 0°
Imaging plane is directed slightly above the aortic valve thru
the RPA(seen in LAX), ascending aorta (seen in SAX) and
SVC (SAX).
For : PA pathology, pulmonary embolus, ascending aorta
pathology ,PDA, swan-ganz in SVC
ME ASC A SAX (0°)
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ME AV SAX (30-45°)
From ME 4C (0°) withdraw cephalad to obtain the ME 5C(0°)
[imaging plane is directed thru the LA and aligned parallel to
the AV annulus] rotate to 30-45°; center aortic valve and aim to
make 3 aortic valve cusps symmetric. Withdraw probe for
coronary ostia.Advance probe for LVOT.
Assess : AV disease, OS ASD, LA size, coronary artery
pathology
ME AV SAX (30-45°)
44
ME RVIO VIEW (60-75°)
From ME AV SAX (30-60°) rotate omniplane angle to 60- 75°
Optimize TV leaflets, open up RVOT,
Bring PV + main PA into view
For : P valve / PA / RVOT /TV pathology /VSD
ME RVIO VIEW (60-75°)
46
ME BCV ( 90°)
From ME 2 C (90°), Turn entire probe right
Change angle or rotate probe slightly to image both IVC (left)
and SVC (right) simultaneously
For : ASD (secundum, sinus venosus), atrial pathology,
lines/wires,VENOUS CANNULA (SVC, IVC)
ME BCV ( 90°)
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TG MID SAX (0°)
Advance probe until you see stomach (rugae) or liver.
anteflex to contact stomach wall and inferior wall of heart .
center LV by turning probe R or L . image both papillary
muscles .
imaging plane transversely thru the mid inferior wall of the
LV with all 6 mid LV segments viewed at once from the
stomach.
For: Left ventricle size, function, IVS motion, VSD, pericardial
effusion
TG MID SAX (0°)
50
ME DA SAX (0°)
Insert the probe to the ME, sector depth 10-12cm, angle 0°;
Turn probe to left to find the aorta; put aorta in middle of display
Decrease depth to 5cm; advance + withdraw probe
Near field image of the circular aorta represents the right
anterior wall of the aorta
For :Aortic pathology , Color flow reversal: AI severity, IABP
position
ME DA SAX (0°)
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ME DA LAX (90°)
From ME DA SAX…. Rotate to 900 … aortic walls appear in
parallel
Distal aorta is to the display left and the proximal aorta to the
display right
ME DA LAX (90°)
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ME MITRAL COMMISSURAL VIEW (60°)
Find the ME 4C : keep the probe tip still and MV in the center;
rotate omniplane angle forward to 45-60°;RA,RV disappear,
retroflex slightly for LV apex;
Imaging plane is directed thru the LA to image LA, MV and LV
apex.
Assess : MV disease, LV function, LA pathology.
ME AV LAX (120°)
From ME AV SAX (30-60°), rotate to 120 -150°
LVOT, AV, proximal ascending aorta line up.
Optimize aortic annulus and make sinuses of valsalva
symmetric
Assess : MV disease, AV disease, aortic root dimensions &
pathology, LVOT pathology, VSD
TG 2C (90° )
From mid TG SAX (0°) .. rotate omniplane angle to 90°..
Anteflex until LV is horizontal
Imaging plane ….Transversely thru the inferior wall of the LV and
subvalvular structures of the mitral valve from the stomach.
For : LV function , mitral valve subvalvular pathology
TG BASAL SAX(0°)
From TG mid SAX view … withdraw the probe until MV is
seen in SAX … aim to see symmetric MV commissures
Views MV (with A3 & P3) that is parallel to the annulus
For : LV size, function ; VSD ; MV planimeter orifice area
TG LAX (110-120°)
From TG 2 chamber (90°) … rotate omniplane angle to 110-120°
Imaging plane is directed longitudinally thru the LV to image the
aortic root in LAX.
For : MV pathology ,VSD, LV systolic function, Aortic valve: spectral
and color doppler, LVOT: spectral and color doppler
DEEP TG LAX (0°)
From mid or apical TG SAX view, anteflex and gently advance
probe, hugging the stomach mucosa until the LV apex is seen at
the top of the display
For: paravalvular leak prosthetic aortic valve ; AV gradient
spectral doppler ; LVOT gradient spectral doppler
TG RV INFLOW (90°)
From mid TG SAX (0°) turn probe right to put RV in center …
Rotate omniplane angle to 90°… anteflex until RV is horizontal
Imaging plane is directed longitudinally thru the posterior RV wall
to reveal a long axis view of the RV, with the apex of the RV to the
display left and the anterior free wall in the far field.
For : RV function; tricuspid subvalvular /TV pathology
UE AORTIC ARCH LAX (0°)
From ME(0°)… ME descending aorta SAX (0°) view…
Withdraw probe until aorta changes into oval shape…
Turn probe slightly to the right
Imaging plane is directed thru the longitudinal axis of the
transverse aortic arch. The circular shape of the DA changes to an
oblong shape of the transverse aortic arch (0°)
For : aortic pathology
UE AORTIC ARCH SAX (60-90°)
From UE aortic arch LAX (0°) view…. Rotate the omniplane angle
to 60-90°…. Bring the pulmonic valve and pulmonary artery in
view
Imaging plane is directed thru the transverse aortic arch in SAX
and the pulmonary artery in LAX.
For : Aortic arch pathology, Pulmonic valve disease, PDA
64
3 DIMENSIONAL TEE
 Main advantages of Real-time three-dimensional (RT3D)
TEE during catheter-based interventions:
 Ability to visualize the entire lengths of
 Intracardiac catheters, including the tips of all catheters and the

balloons
Devices they carry, along with a clear depiction of the positions
in relation to other cardiac structures
 To demonstrate certain structures in an ‘‘en face’’ view
 RT3D TEE is a powerful new imaging tool
 May become the technique of choice and the standard
of care for guidance of selected percutaneous catheterbased procedures
66
Gila Perk, et al. J Am Soc Echocardiogr 2009;22:865-82
INTRACARDIAC
ECHOCARDIOGRAPHY
67
INTRACARDIAC
ECHOCARDIOGRAPHY
 An imaging technique that helps to guide
percutaneous interventional procedures
 Probe can be inserted under local anaesthesia
 Principally used during closure of atrial septal
abnormalities
68
INTRACARDIAC
ECHOCARDIOGRAPHY
69
70
INTRACARDIAC
ECHOCARDIOGRAPHY
• The 1st generation ICEs were introduced in 1980s
• They provided high resolution imaging
• Tissue penetration limited due to high frequency of the
transducers (20–40 MHz)
• Anatomic intracardiac overviews not properly obtained
• Recently the development of steerable phased
array ultrasound catheter systems with low
frequency and Doppler qualities has expanded the
clinical use of ICE
71
M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981–990.
ICE: ADVANTAGES
 No radiation is needed
 Patient discomfort is less
 General anaesthesia not
needed
 Communication with the
patient during the
procedure possible as
compared to TEE
 Not necessary to position a
transducer in a sterile field
M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981–990.
as compared to TTE
 Availability of direct online
information on the position
of catheters and devices
 The possibility of direct
monitoring of acute
procedure related
complications such as:
 Thrombus formation
 Pericardial effusion etc
72
ICE: LIMITATIONS
 Considerable shaft size (10 French)
 Lack of additional catheter features, such as
 Ports for guidewires
 Therapeutic devices and pressure
 The phased array catheters are expensive and for single use
only
 Phased array ICE provides only monoplane image sections
 Difficult for operators to obtain the same views
 No standard views for ICE are currently defined as compared
to standard views for for TTE and TOE.
73
M R M Jongbloed, et al. Heart. 2005 July; 91(7): 981–990.
ICE: CLINICAL IMPLICATIONS
 Applications of intracardiac echocardiography (ICE) in
interventional procedures
 Evaluation of intracardiac thrombus
 Transseptal puncture
 Atrial septal defect/patent foramen ovale closure
 Other applications
 Interventional
electrophysiological
procedures
 Pulmonary vein ablation


in patients with atrial
fibrillation
Atrial flutter ablation
Ventricular tachycardia
ablation
 Diagnosis/biopsy of
intracardiac masses
 Balloon mitral valvuloplasty
 Atrial appendage occlusion
 Visualisation of coronary
sinus
74
CLOSURE OF AN ASD UNDER
ICE GUIDANCE
75
ICE: TECHNICAL REQUIREMENTS
 Mechanical ultrasound tipped catheter:
 Can be used for both


Intravascular
Intracardiac imaging
 For intracardiac use
 9 MHz single element transducer is incorporated in an 8 French
catheter
 A Piezoelectric crystal is rotated at 1800 rpm in the radial
dimension perpendicular to the catheter shaft
 Provides cross sectional images in a 360˚ radial plane
 The ICE catheter needs to be filled with 3–5 ml sterile water
before it is connected to the ultrasound machine
76
M R M Jongbloed, et al. Heart 2005;91:981–990.
ICE: TECHNICAL
REQUIREMENTS
 Phased array ultrasound tipped catheter system
uses
 A 10 French ultrasound catheter
 Positioned in the right atrium (RA) or right ventricle (RV)
via a femoral approach
 Through a 10 French introducer
 Measurements of haemodynamic and physiologic
variables can be made using Doppler imaging
 Catheter is connected to an ultrasound system
77
M R M Jongbloed, et al. Heart 2005;91:981–990.
ICE FUTURE ADVANCES
 Higher resolution
 Are more reproducible
and more flexible than
piezoelectric ceramic
 They are extremely
reproducible and can be
made from masks like
integrated circuits
 ElectrophysiologyEnabled Devices for
Imaging and Therapy
 Integration of ultrasound
imaging with mapping
technologies, fusion,
and overlay images
78
Ziyad M. Hijazi, et al. Circulation. 2009;119:587-596
REFERENCES
 OTTO – The practice of clinical echocardiography – 4th edition
 FEIGENBAUM’S Echocardiography – 7th edition
 Basic perioperative TEE – A consensus statement of ASE and
SCA – S.T Reeves – J Am Soc Echo 2013
 Recommendations for TEE: update 2010 – Flachskampf European Journal of Echocardiography 2010
 TEE Multimedia Manual - André Y. Denault, Pierre Couture
 TEE Study Guide and Practice Questions-Dr Andrew Roscoe
 Virtual TEE Website – University of Toronto
79
MCQS
1)The number of most relevant views for a basic
perioperative TEE examination according to current
guidelines by ASE and SCA –
a)
b)
c)
d)
20 views
15 views
12 views
11 views
80
2) In ME 2 chamber view , the omniplane angle is
a) 135˚
b) 120˚
c) 90˚
d) 60˚
81
3) In ME LAX view, the omniplane angle is
a) 45˚
b) 60˚
c) 90˚
d) 120˚
82
4) In desc aortic LAX view, the omniplane angle is
a) 0˚
b) 60˚
c) 90˚
d) 120˚
83
5)Principal use of ICE is in
a) Evaluation of intracardiac thrombus
b) Balloon mitral valvuloplasty
c) ASD closure
d) Pulmonary vein ablation
84