Transesophageal Echocardiography

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  • Whenever transthoracic images are nondiagnostic and improved image quality is needed for clinical decision making
  • Suspected acute aortic pathology including dissection/transsection
  • Perioperative and ICU evaluation of ventricular function and volume status
  • Guidance of percutaneous noncoronary cardiac interventions including but not limited to septal ablation, mitral valvuloplasty, patent foramen ovale (PVO)/atrial septal defect (ASD) closure, radiofrequency ablation
  • Severe mitral regurgitation to determine the mechanism of regurgitation and suitability of valve repair
  • Suspected prosthetic mitral valve dysfunction
  • Suspected endocarditis with a moderate or high pre-test probability (eg, bacteremia, especially staph bacteremia or fungemia)
  • Suspected complications of endocarditis (eg, abscess, fistula)
  • Persistent fever in patient with intracardiac device
  • Congenital heart disease, especially for evaluation of posterior structures (eg, atrial septum, pulmonary veins, atrial baffles)
  • Evaluation of patients with atrial fibrillation/flutter for detection of left atrial thrombus to facilitate clinical decision making with regard to anticoagulation and/or cardioversion and/or radiofrequency ablation
  • Evaluation for a cardiac source of embolus in adults with a neurologic event or for exclusion of interatrial shunting before a surgical procedure


  • Uncooperative patient
  • Severe respiratory depression or tenuous cardiopulmonary status
  • Recent esophageal or upper gastrointestinal (GI) surgery
  • Esophageal stricture, mass, or perforation
  • Active upper GI bleeding


  • Coagulopathy, thrombocytopenia
  • Atlantoaxial joint disease or severe cervical arthritis (causing restricted cervical mobility)
  • Previous esophageal surgery
  • Esophageal diverticulum or varices
  • Recent upper GI bleeding
  • History of dysphasia
  • Sleep apnea
  • Echocardiography system
  • Transesophageal echocardiography probe
  • Sterile ultrasound gel
  • Patient monitoring equipment (blood pressure, ECG, pulse oximeter)
  • Suction for oropharynx
  • Bite-block for probe insertion
  • Nasal oxygen
  • Medications for conscious sedation and IV line for medication administration
  • Local anesthetic and applicator for pharyngeal anesthesia
  • Masks, gowns, gloves for medical personnel (universal precautions)
  • Echocardiography can evaluate each of the cardiac chambers and each of the valves, including:
    • Right and left ventricles
    • Right and left atria
    • Mitral, tricuspid, pulmonic, and aortic valves
    • Inferior and superior vena cavae
    • Aortic arch including the proximal portion of the head and arm vessels
    • Portions of the abdominal aorta
  • The flexible tip of the TEE probe is manipulated by “wheels” into various positions with respect to the heart. The movements of the probe tip are described as:
    • Advance
    • Withdrawal
    • Turning
    • Flexion and extension
    • Rotation
  • By manipulation of the TEE probe through insertion, withdrawal, turning, flexion, extension, and plane rotation, 20 standard views of the heart and great vessels can be obtained.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Registered nurse monitors vital signs and clinical status for at least 30 minutes after last sedation dose or as required by institutional conscious sedation protocols.
  • At the end of the monitoring period, ensure patient can sit and stand without difficulty and remove monitoring equipment.
  • Instruct patient to avoid eating or drinking until normal sensation in pharynx returns, usually within 60 to 90 minutes after the procedure.
  • Instruct the patient to not drive until the next day and ensure the patient has a companion to accompany him or her home..
  • Instruct the patient to call if he or she has any concerns about throat discomfort or difficulty swallowing.

Rate of complications that require interruption of procedure is < 1%.

Risks of Esophageal Placement of the TEE probe

  • Dental trauma
  • Esophageal trauma or perforation
  • Bleeding
  • Aspiration
  • Dislodgement of endotracheal tube, especially on probe withdrawal
  • Displacement of nasogastric tubes
  • Inadvertent tracheal intubation of TEE probe with injury

Risks of Conscious Sedation

  • Hypotension
  • Respiratory depression (hypoxia, respiratory arrest)
  • Arrhythmias
  • Bronchospasm
  • Death (risk with TEE < 1 in 10,000)
  • Echocardiographic images and Doppler data are recorded in digital cine-loop format for later review.
  • The images are reviewed by the cardiologist, and a report is generated.
  • The following key elements are included in every report:
    • Clinical data
    • Measurements
    • Echo findings: The findings should include estimated pulmonary pressure and should describe the anatomy and function of the:
      • Left ventricle (size, hypertrophy, regional and global systolic function, diastolic function)
      • Right ventricle
      • Left atrium
      • Right atrium and atrial septum
      • Aortic valve
      • Mitral valve
      • Tricuspid valve
      • Pulmonic valve
      • Pericardium
  • Conclusions
  • When clinically appropriate, specific recommendations are made.
  • Serious unexpected findings are communicated promptly to the referring physician.
  • When data are not definitive, the findings are described along with a differential diagnosis to explain the findings.
  • Additional diagnostic approaches are recommended as appropriate.
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