Transesophageal echocardiography (TEE)

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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. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 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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