5/7/2021

Normal TEE Examination:

Applications, Pitfalls, Probe Insertion & Manipulation, Risks & Complications

Renuka Jain MD, FACC, FASE

Director of Structural and Interventional Echocardiography
Clinical Associate Adjunct Professor
University of Wisconsin School of Medicine and Public Health
Aurora St. Luke’s Medical Center, Milwaukee, WI

Disclosures None

Off label use None

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Historical Perspective

1976 1981 1989 1992

M-mode TEE 2D phased array Biplane TEE Multiplane TEE
matrix

Two-Dimensional Multi-frequency, Biplane TEE with

TEE Multiplane TEE CV Doppler
1977 1988 1991

Evolution of TEE

• Transducer Design Improvements:

Fixed Rigid Scope FLEXIBLE ENDOSCOPE

• Transducer Array Improvements:

Monoplane Biplane MULTIPLANE

MULTIPLANE:
• Single crystal array that may be rotated in 180-degree arc
• Use the sternum as the reference for degree marker
• Continuum of images along the arc

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TEE TRANSDUCER

• Transducer at distal end

(Diameter = 9-12 mm)

• Controls on the proximal end (handle)

• Distance from Tip of Transducer to

Incisors:
30-40 cm – Esophagus
40-50 – Gastric

VALUE OF TEE

• Advantages:
✓Excellent image quality (increased frequency)
✓Portable – ICU, bedside, OR, ER
✓Resolution of structures 1-2 mm (TTE > 3 mm)

• Disadvantages:
✓Invasive procedure with risk
✓Does not replace TTE
✓Less helpful with anterior structures
✓Constrained by esophagus and stomach

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TEE Indications: Four Main Categories

Evaluation of cardiac structures when Detailed evaluation of left atrial appendage, aorta,
prosthetic valves, paravalvular spaces for abscess
TTE is nondiagnostic or would be or leaks; chest wall injuries; poor imaging windows
inadequate on TTE

All open-heart procedures involving valves and

thoracic aorta; some coronary artery bypass
Intraoperative guidance surgeries; noncardiac surgery if knowledge of
cardiovascular structures is needed.

Ventilated patients with possible cardiovascular

Critically ill patients pathology that will impact ICU management

Transcatheter valve procedures, left atrial

appendage occlusion, atrial or ventricular septal
Transcatheter procedure guidance defect closures.

Table 12.1, ASE Textbook of Echocardiography, 3rd Edition, 2021.

Key Indications:

• Cardiac Source of Embolus

• Valve Anatomy particularly MITRAL and Prosthetic
• Left Atrial Appendage
• Aortic Dissection – ALMOST entire aorta
• Critically Ill Patients
• Intraoperative Guidance
• Endocarditis
• Transcatheter Procedure Guidance

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TOP TEE INDICATIONS at Aurora St. Luke’s

Bacteremia
Valvular Disorder

Source of Embolus

STRUCTURAL CASES

Atrial Fibrillation

Appropriate Use of TEE

• Endocarditis suspicion with moderate-to-high pre-test probability
• Cardiac Source of Embolus
• Evaluation of posterior structures
• Acute Aortic Syndromes
• Critically Ill Patients suspected acute cardiac conditions
• Suspected severe native valve disease not seen adequately on TTE
• Prosthetic valve dysfunction
• Intra-operative or Transcatheter guidance
• Non-diagnostic TTE images
• Re-evaluation of prior TEE findings when management would change
• Evaluation of valvular structures for planned interventions

Douglas PS et. al. JASE (2011): 24: 229-267; Doherty JU et. al, JACC (2017) 70: 1647-1672)

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Inappropriate Use of TEE

• Routine use if TTE is nondiagnostic

• Re-evaluation of prior TEE findings without change in management

• Suspected endocarditis in low probability patients

• Evaluation for source of embolism when source is already known

• Evaluation of mild or moderate valve disease

• Hypotension/hemodynamic instability

• Assessment of volume status in critically ill patients

Douglas PS et. al. JASE (2011): 24: 229-267; Doherty JU et. al, JACC (2017) 70: 1647-1672)

Contraindications to TEE.
Absolute Contraindications Relative Contraindications
Esophageal related: esophageal tumor, stricture, Barrett esophagus
fistula, diverticulum, or perforation including History of dysphagia (may require
Schatzki’s ring gastroenterology consultation)
Active upper GI bleed Active esophagitis
High grade esophageal varices
Perforated bowel or bowel obstruction
Active peptic ulcer disease
Neck immobility (severe cervical arthritis,
Unstable cervical spine
atlantoaxial joint disease)
Uncooperative patient Severe hiatal hernia

Recent GI surgery:
esophagectomy, bariatric surgery
Recent oropharyngeal surgery
Severe coagulopathy or thrombocytopenia
Prior neck or chest radiation
Prior GI surgery
Esophageal diverticulum
Loose teeth (may require dental consultation)

Table 12.2, ASE Textbook of Echocardiography, 3rd Edition, 2021.

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TEE Preparation: Patient Preparation

Fasting State – NPO for 6 hours
Rule-out contraindications
Peripheral IV access
(COVID-testing)
Assess oropharynx – dentures, loose-teeth
Assessment of Sedation Risk for Conscious Sedation
Level of alertness
Mallampati Score
ASA risk stratification

TEE Preparation: LAB

Staff trained in moderate sedation and ACLS
Supplies:
Supplemental Oxygen
Oral suctioning equipment
ACLS Equipment and staff
Monitoring:
Noninvasive blood pressure
Heart rate “Bite Block” – protects
Oxygen saturation teeth and transducer

End-tidal CO2 (if available)

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Medications
for Sedation

MODERATE SEDATION
purposeful response to verbal/tactile stimulation; no intervention needed
on airway; spontaneous ventilation; hemodynamics usually stable.

Medications for Reversal

• Naloxone – reversal for opiods

0.4 mg starting doses
Escalate and repeat every 2-3 min

• Flumazenil – reversal for benzodiazepenes

0.2 mg starting disease
Repeat every 2-3 min, max = 1 mg

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Methelhemoglobinemia Toxicity

• Occurs with benzocaine products

• Incidence: very low (0.15%)
• Symptoms: low O2 sat, cyanosis, arrhythmia
• Pathophysiology:
• Benzocaine oxidizes Fe2+ → Fe3+
• Fe3+ in RBCs can no longer carry oxygen
• Treatment:
• methylene blue, 1 to 2 mg/kg of a 1% solution, over 5 min
• Exchange transfusion or dialysis

Novaro et al. JASE 2003; 16:170-5.

POST-PROCEDURE Monitoring for all TEE

• 2 Hour Observation after Moderate Sedation

• Maintain NPO 1 hour - topical anesthesia will wear off
• No driving for 24 hours
• Review symptoms of complications:
hoarseness / sore throat
dysphagia
chest pain / dyspnea
• Additional observation if required reversal agents

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TEE can be performed throughout hospital

• ICU – Ventilated and Sedated Patients

Topical anesthesia
Titrate sedation depending on existing sedation level
Can consider removing OGT or nasal gastric tube

• Hybrid Cath Lab / Operating Room

Jaw thrust can facilitate esophageal intubation

Transesophageal Echo: Instrumentation

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ANGULATION ROTATION TILT

TURN
POSITION

TEE
CONTROLS

Figure 12.1, ASE Textbook of Echocardiography, 3rd Edition, 2021.

ROTATION of transducer
“degrees”

Hahn et. al, ASE Guidelines on TEE. JASE 2013

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Recommended TEE Views

• Upper Esophageal
• Mid Esophageal
• Deep Esophageal (if required)
• Transgastric
• Deep Transgastric
• Extracardiac Anatomy
• IVC, SVC
• Pulmonary Veins
• Pulmonary Artery
• Thoracic aorta

UPPER ESOPHAGEL VIEW

RPA

• SVC as it enters
SVC
right atrium
Aorta • Main Pulmonary
MPA
Artery (MPA) and
its branching
• Ascending Aorta

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Esophageal 4-Chamber View

Mitral Valve
Anatomy

Modified from JASE 1999;12:884-900.

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Mitral Valve

Modified from JASE 1999;12:884-900.

Mitral Valve in 2D TEE A3,A2

P2,P1

0-10o
P3 – A3,A2,A1 - P1

50-70o

P3

A3,A2,A1

P2 A2

80-100o
120-140o
Modified from JASE 1999;12:884-900.

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Mitral Valve in 3D TEE

Modified from JASE 1999;12:884-900.

3D TEE – FULL VOLUME

TEMPORAL Resolution = Frame rate

SPATIAL Resolution = Scanning Density

Spatial Temporal
Resolution Resolution

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3D TEE – ZOOM

Only use portion of the FULL VOLUME

with REGION OF INTEREST

3D TEE – MITRAL VALVE

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Re-orient to
view from LA

Rotate to AV at
12:00 position

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Normal mitral valve

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Restricted and tethered

posterior leaflet

Restricted and tethered

posterior leaflet – 3D COLOR

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Large P2 mitral valve flail

with ruptured chord

Normal bioprosthetic mitral

valve replacement

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Large Mitral Valve Vegetation on

anterior leaflet and dehiscence of
prosthetic annuloplasty ring

3D TEE introduces new Types of Artifacts

DROP-OUT
As a result of calcification or other
structures that cause shadowing, there is
appearance of a “hole” when it is actually 3-
D shadowing (aka “drop-out”)

STITCH ARTIFACT
Attempt to increase temporal
resolution by stitching smaller
volumes together of same structure
in different cardiac cycles.
As a result of different beats, there is
translational motion and the various
smaller volumes do not align.

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Aortic Valve
LA

LA
NCC
LCC

NCC
RCC
RA

RCC

• Mid-esophageal view LV

• 45-60o: Short-Axis
• 120-135o: Long-Axis

LEFT CORONARY ARTERY

LA

LCX
LA

Aortic Valve
LM

LV

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RIGHT CORONARY ARTERY

LA

LA

Aorta
Aorta
LV

LV
RCA
RCA

RV

Aorta
• Aortic Root and Ascending Aorta:
mid-esophageal
120-140o
Withdraw slightly LA
• Distal Ascending Aorta
obscured by air from trachea Proximal

• Thoracic Aorta Aortic

Ascending
Aorta
Root
mid-esophageal
0o short-axis, 90o long axis LV
Turn probe away from heart
• Aortic Arch
high-esophageal
0-40o long-axis, 90o short-axis
Anteflex

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Acute Aortic Syndromes

Aortic
Dissection • Where does dissection start?
• Are coronary arteries involved?
• Is aortic valve involved?
• Which is true and false lumen?
• Are there fenestrations?
• Are Great Vessels involved?
• Is there a pericardial effusion

Dissection Flap Begins at

ST junction: no
involvement of aortic root

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Thoracic Aorta Dissection

Flap: Fenestration

Penetrating Ulcer / Intramural Hematoma

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Aortic Arch Atheroma

Very Mobile Atheroma
Atheroma

Interatrial Septum and BICAVAL View

LA
CS
• Mid-esophageal SVC
view IVC
• 90-110o
• Turn Transducer RA
rightward/medial

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Interatrial Septum Aneurysm

• Interatrial septal aneurysm 15 LA

mm in both directions, 10 mm in
one direction.

• Provoke using maneuvers to

transiently increase right atrial
pressure

• Agitated Saline Contrast study

RA
• 7-10 beat capture

Clot in Transit Through Patent Foramen Ovale

LA

RA

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Left Atrial Appendage

• Mid-Esophageal View
• 0-135o
• Adjacent to Aortic Valve,
turn leftward and anteflex.
May need to withdraw
slightly.
• Must Assess LAA from 0-
135 degrees to visualize all
LOBES

LAA emptying Velocity < 20 cm/sec is

associated with thrombus

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Left Atrial Appendage

Differentiate:
No Thrombus
Spontaneous Echo Contrast
Sludge
Thrombus

Left Atrial Appendage

Differentiate:
No Thrombus
Spontaneous Echo Contrast
Sludge
Thrombus

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Left Atrial Appendage

Differentiate:
No Thrombus
Spontaneous Echo Contrast
Sludge
Thrombus

Left Atrial Appendage

Differentiate:
No Thrombus
Spontaneous Echo Contrast
?Sludge/Early Thrombus
?Thrombus

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Ultrasound Enhancing Agents very useful in LAA

Differentiate:
No Thrombus
Spontaneous Echo Contrast
Sludge
Thrombus

Pulmonary Veins
LUPV and LLPV RUPV and RLPV
• Mid-esophageal, 90-110o • Mid-esophageal view, 40-60o
• Turn leftward, anteflex • 40-60 degrees, turn rightward
• LUPV adjacent to LAA • RUPV adjacent to SVC-RA jxn

LLPV RLPV

LUPV
RUPV

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Pulmonary
Veins can also
be seen in 3D

LUPV and LLPV

TransGastric Advancement

Hilberath JN, Safety of TEE. JASE, 2010 Nov; 23(11): 1115-27.

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Transgastric Short and

Long Axis
• Left Ventricle – Advance transducer into
gastrum. Anteflexion of transducer → short-
axis view of ventricle at 0o.
• MV Apparatus - Rotate array to 90-100o
degrees for long-axis view.
• Right Ventricle – Turn transducer rightward to
view right ventricle from 0-120o to view RV and
RV inflow and outflow tracts

TV

LV

AV
Deep Transgastric
LA
Views
• Advance transducer deeper into gastrum, and
then significant anteflexion, 0-120o
• “Mimic” TTE Apical Views
• Best views in TEE for:
LV LVOT/AV velocities alignment
Tricuspid valve anatomy (short-axis)
LA LV Apex
AV

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TEE Doppler Assessment

• Transducer position is opposite of TTE

• Can Consider inverting Doppler spectral display

to mimic TTE appearance

• Easy to align mitral valve velocities parallel to

blood flow, more difficult with aortic valve.

Pitfalls of TEE
• Separating: normal from abnormal from artifact
• Esophagus and Stomach provide anatomic constraints
Ascending Aorta
Aligning Aortic/LVOT velocities
Air can limit visualization

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Normal Structures: Right Atrium

Catheters/Pacemaker Leads

Right Atrial
Appendage Crista Terminalis Eustachian Valve/Chiari Network

Normal Structures: Left Atrium and Appendage

“Coumadin”
Ridge – “Q-tip”

Transverse Sinus

Left Circumflex

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Orogastric/Nasogastric Tubes

Initial Image After OG Tube Removed

Complications of TEE
• Complications of Sedation
Hypotension
Hypoxia
Decreased responsiveness → hypercapnia, aspiration
Methehemoglobinema (benzocaine products)

• Complications of TEE procedure

Thermal Injury
Trauma

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Risks and Complications of TEE.

COMPLICATIONS INCIDENCE FOR DIAGNOSTIC TEE
Mortality < 0.01%-0.02%
Major bleeding < 0.01%
Major morbidity 0.2%
Esophageal perforation < 0.01%
Dysphagia 1.8%
Hoarseness 12%
Bronchospasm 0.06%-0.07%
Laryngospasm 0.14%
Minor pharyngeal bleeding 0.01%-0.2%
Dental injury 0.1%
Lip injury 13%
Heart failure 0.05%
Arrhythmia 0.06%-0.3%

Table 12.3, ASE Textbook of Echocardiography, 3rd Edition, 2021.

TEE INSERTION
COMPLICATIONS:
OROPHARYNX

Hilberath JN, Safety of TEE. JASE, 2010 Nov; 23(11): 1115-27.

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TEE PROCEDURE
COMPLICATIONS:
multiple sites

Hilberath JN, Safety of TEE. JASE, 2010 Nov; 23(11): 1115-27.

COVID-19 PANDEMIC
• TEE is an “aerosolizing” procedure:
• “AIRBORNE PRECAUTIONS”
• TEE only when appropriate
• N95 or PAPR
• Full PPE: gown, gloves, head and shoe covers
• Essential personnel only
• Did not downgrade PPE if pre-procedure
COVID PCR was negative

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COVID-19 PANDEMIC

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Conclusions:

• TEE is generally SAFE

• Critical Thinking of TEE - know
indication for procedure
• Learning Curve
• Recognition of normal from
abnormal from artifact
• Recognition of TEE limitations

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