Transesophageal echocardiography: Indications, complications, and normal views
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
- Joseph P Kannam, MD
Joseph P Kannam, MD
- Assistant Professor of Medicine
- Harvard Medical School
Although transthoracic echocardiography (TTE) remains the cornerstone of diagnostic cardiac ultrasound, transesophageal echocardiography (TEE) is a valuable complementary tool. As compared with TTE, TEE offers superior visualization of posterior cardiac structures because of close proximity of the esophagus to the posteromedial heart with lack of intervening lung and bone. This proximity permits use of high-frequency imaging transducers that afford superior spatial resolution (image 1).
The first practical clinical use of TEE was described in 1976 when a modified rigid endoscopic probe with single M-mode crystal was used . Since that time, TEE technology has evolved rapidly with developments in flexible endoscopic probe technology, phased-array ultrasound systems, and crystal miniaturization and real time three-dimensional (3D) imaging. Current TEE probes allow for both two-dimensional (2D) and 3D imaging as well M-mode, spectral Doppler, and color Doppler. The versatility of these transducers permits improved penetration with lower frequency imaging and superior spatial resolution with higher frequency imaging. Additional developments have focused on further probe miniaturization and improvement of 3D echocardiography capability. (See "Echocardiography essentials: Physics and instrumentation".)
The indications, potential complications, and normal views associated with TEE will be reviewed here. The role for TEE in the evaluation of specific cardiac abnormalities is discussed in detail separately. (See "Transesophageal echocardiography in the evaluation of the left ventricle" and "Transesophageal echocardiography in the evaluation of aortic valve disease" and "Transesophageal echocardiography in the evaluation of mitral valve disease" and "Transesophageal echocardiography in traumatic rupture of the aortic isthmus".)
INDICATIONS FOR TEE
Both TTE and TEE have a variety of clinical indications and applications. In most patients, TEE provides superior image quality, particularly for posterior cardiac structures which are nearer to the esophagus and less well visualized on transthoracic echocardiography. Because of its moderately invasive nature, however, TEE is generally reserved for selected indications in which the potential benefits of making a diagnosis outweigh the risks associated with the procedure. For many clinical situations, a TTE study precedes the TEE as the TTE study may obviate or help guide the TEE.
How often TEE is used for a particular indication varies from institution to institution. However, TEE is most commonly performed to evaluate for a potential cardiac source of embolus, to assess valves for endocarditis, or to exclude left atrial appendage (LAA) thrombi in patients with atrial fibrillation . In a large series from the 1990s, the most common clinical indications for TEE were to evaluate for cardiac source of embolism, endocarditis, prosthetic heart valve dysfunction, native valvular disease, and aortic dissection or aneurysm . Thoracic magnetic resonance imaging and computed tomography have largely displaced TEE for assessment of aortic aneurysm/dissection. In current practice, TEE is also performed with many cardiac surgical procedures, especially those involving congenital or valve repairs, both to verify preoperative diagnosis and to monitor the success of repair . (See "Clinical manifestations and diagnosis of aortic dissection", section on 'Imaging'.)
- Frazin L, Talano JV, Stephanides L, et al. Esophageal echocardiography. Circulation 1976; 54:102.
- Oh JK, Seward JB, Tajik AJ. Transesophageal and Intracardiac Echocardiogrphy. In: The Echo Manual, 3rd edition, Lippincott Williams & Wilkins, 2007. p.29-30.
- Khandheria BK, Seward JB, Tajik AJ. Transesophageal echocardiography. Mayo Clin Proc 1994; 69:856.
- Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146.
- Otto CM. Clinical Indications and Quality Assurance. In: Textbook of Clinical Echocardiography, 4th edition, Saunders Elsevier, 2009. p.117-118.
- American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol 2011; 57:1126.
- Foster E, Schiller NB. The role of transesophageal echocardiography in critical care: UCSF experience. J Am Soc Echocardiogr 1992; 5:368.
- Quiñones MA, Douglas PS, Foster E, et al. ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. J Am Coll Cardiol 2003; 41:687.
- Daniel WG, Erbel R, Kasper W, et al. Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation 1991; 83:817.
- Ofili EO, Rich MW. Safety and usefulness of transesophageal echocardiography in persons aged greater than or equal to 70 years. Am J Cardiol 1990; 66:1279.
- Pearson AC, Castello R, Labovitz AJ. Safety and utility of transesophageal echocardiography in the critically ill patient. Am Heart J 1990; 119:1083.
- Min JK, Spencer KT, Furlong KT, et al. Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations. J Am Soc Echocardiogr 2005; 18:925.
- Spier BJ, Larue SJ, Teelin TC, et al. Review of complications in a series of patients with known gastro-esophageal varices undergoing transesophageal echocardiography. J Am Soc Echocardiogr 2009; 22:396.
- Suriani RJ, Cutrone A, Feierman D, Konstadt S. Intraoperative transesophageal echocardiography during liver transplantation. J Cardiothorac Vasc Anesth 1996; 10:699.
- Vedrinne JM, Duperret S, Bizollon T, et al. Comparison of transesophageal and transthoracic contrast echocardiography for detection of an intrapulmonary shunt in liver disease. Chest 1997; 111:1236.
- Saphir JR, Cooper JA, Kerbavez RJ, et al. Upper airway obstruction after transesophageal echocardiography. J Am Soc Echocardiogr 1997; 10:977.
- Moore TJ, Walsh CS, Cohen MR. Reported adverse event cases of methemoglobinemia associated with benzocaine products. Arch Intern Med 2004; 164:1192.
- Kane GC, Hoehn SM, Behrenbeck TR, Mulvagh SL. Benzocaine-induced methemoglobinemia based on the Mayo Clinic experience from 28 478 transesophageal echocardiograms: incidence, outcomes, and predisposing factors. Arch Intern Med 2007; 167:1977.
- Henry LR, Pizzini M, Delarso B, Ridge JA. Methemoglobinemia: early intraoperative detection by clinical observation. Laryngoscope 2004; 114:2025.
- Steckelberg JM, Khandheria BK, Anhalt JP, et al. Prospective evaluation of the risk of bacteremia associated with transesophageal echocardiography. Circulation 1991; 84:177.
- Wilson W, Taubert KA, Gewitz M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 115 published online April 19, 2007. www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1 (Accessed on May 04, 2007).
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002; 105:539.
- Zaroff JG, Picard MH. Transesophageal echocardiographic (TEE) evaluation of the mitral and tricuspid valves. Cardiol Clin 2000; 18:731.
- Chan SK, Kannam JP, Douglas PS, Manning WJ. Multiplane transesophageal echocardiographic assessment of left atrial appendage anatomy and function. Am J Cardiol 1995; 76:528.
- Pollick C, Taylor D. Assessment of left atrial appendage function by transesophageal echocardiography. Implications for the development of thrombus. Circulation 1991; 84:223.
- Subramaniam B, Riley MF, Panzica PJ, Manning WJ. Transesophageal echocardiographic assessment of right atrial appendage anatomy and function: comparison with the left atrial appendage and implications for local thrombus formation. J Am Soc Echocardiogr 2006; 19:429.
- Tanabe K, Yoshitomi H, Oyake N, et al. Effects of supine and lateral recumbent positions on pulmonary venous flow in healthy subjects evaluated by transesophageal Doppler echocardiography. J Am Coll Cardiol 1994; 24:1552.
- INDICATIONS FOR TEE
- TEE in critical care
- PATIENT PREPARATION
- SAFETY OF TEE EXAMINATION
- THE NORMAL HEART AND GREAT VESSELS
- Horizontal plane
- - Four-chamber view
- - Mitral valve
- - Left atrial appendage
- - Pulmonary veins
- - Pulmonary artery
- - Right and left atria
- - Aortic leaflets and aortic root
- Vertical plane
- Imaging at the gastroesophageal junction
- Gastric imaging
- Thoracic aorta