Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Transesophageal echocardiography in the evaluation of aortic valve disease

Elyse Foster, MD
Section Editor
Warren J Manning, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Echocardiography is the procedure of choice for the evaluation of valvular heart disease. Because of enhanced resolution and unobstructed visualization, transesophageal echocardiography (TEE) may provide further detail not obvious on transthoracic echocardiography (TTE). TEE also has a growing role in transcatheter aortic valve implantation (TAVI).

This topic will discuss TEE evaluation of the aortic valve. Transthoracic echocardiographic (TTE) evaluation of the aortic valve is discussed separately. (See "Echocardiographic evaluation of the aortic valve".)


To characterize the aortic valve using TEE, the valve should be imaged in short- and long-axis views.

Short-axis view — The short-axis of the aortic valve can generally be visualized in a plane between 30 to 60˚ from the transverse (0˚) using a multiplane transducer [1]. In the short axis view, inspection should include identification of the number of aortic cusps, the presence and extent of calcification, fusion, leaflet perforation, malcoaptation, or vegetation. Adjustment of the imaging plane to a view that clearly demonstrates the coaptation of the leaflets provides another view for regurgitant jet assessment. Direct planimetry of the stenotic systolic orifice from this view is accurate to a level that equals, and may exceed, that of the standard continuity equation as applied to Doppler TTE. (See 'Aortic stenosis' below.)

Long-axis view — In the long axis view, typically at 110 to 140˚ from transverse (0˚) [1], the right and non-coronary cusps are visualized and the presence of any vegetations or leaflet prolapse is usually evident and regurgitant jet width can be ascertained. In the long axis, the ascending aorta should be viewed from the valve to the right pulmonary artery. This view of the left ventricular outflow tract is usually optimal for excluding subvalvular lesions (eg, subvalvular membrane), measuring regurgitant jet width and for examining associated pathology of the aortic valve, aortic root, and ascending aorta (eg, aorto-annular ectasia, type I aortic dissection, and Marfan's syndrome).

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: May 24, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999; 12:884.
  2. le Polain de Waroux JB, Pouleur AC, Goffinet C, et al. Functional anatomy of aortic regurgitation: accuracy, prediction of surgical repairability, and outcome implications of transesophageal echocardiography. Circulation 2007; 116:I264.
  3. Keane MG, Wiegers SE, Plappert T, et al. Bicuspid aortic valves are associated with aortic dilatation out of proportion to coexistent valvular lesions. Circulation 2000; 102:III35.
  4. Fedak PW, de Sa MP, Verma S, et al. Vascular matrix remodeling in patients with bicuspid aortic valve malformations: implications for aortic dilatation. J Thorac Cardiovasc Surg 2003; 126:797.
  5. Michelena HI, Khanna AD, Mahoney D, et al. Incidence of aortic complications in patients with bicuspid aortic valves. JAMA 2011; 306:1104.
  6. Movsowitz HD, Levine RA, Hilgenberg AD, Isselbacher EM. Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair. J Am Coll Cardiol 2000; 36:884.
  7. Thompson KA, Shiota T, Tolstrup K, et al. Utility of three-dimensional transesophageal echocardiography in the diagnosis of valvular perforations. Am J Cardiol 2011; 107:100.
  8. Roldan CA, Tolstrup K, Macias L, et al. Libman-Sacks Endocarditis: Detection, Characterization, and Clinical Correlates by Three-Dimensional Transesophageal Echocardiography. J Am Soc Echocardiogr 2015; 28:770.
  9. Stoddard MF, Arce J, Liddell NE, et al. Two-dimensional transesophageal echocardiographic determination of aortic valve area in adults with aortic stenosis. Am Heart J 1991; 122:1415.
  10. Klass O, Walker MJ, Olszewski ME, et al. Quantification of aortic valve area at 256-slice computed tomography: comparison with transesophageal echocardiography and cardiac catheterization in subjects with high-grade aortic valve stenosis prior to percutaneous valve replacement. Eur J Radiol 2011; 80:151.
  11. Saura D, de la Morena G, Flores-Blanco PJ, et al. Aortic valve stenosis planimetry by means of three-dimensional transesophageal echocardiography in the real clinical setting: feasibility, reliability and systematic deviations. Echocardiography 2015; 32:508.
  12. Teague SM, Heinsimer JA, Anderson JL, et al. Quantification of aortic regurgitation utilizing continuous wave Doppler ultrasound. J Am Coll Cardiol 1986; 8:592.
  13. Touche T, Prasquier R, Nitenberg A, et al. Assessment and follow-up of patients with aortic regurgitation by an updated Doppler echocardiographic measurement of the regurgitant fraction in the aortic arch. Circulation 1985; 72:819.
  14. Perry GJ, Helmcke F, Nanda NC, et al. Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol 1987; 9:952.
  15. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:777.
  16. Willett DL, Hall SA, Jessen ME, et al. Assessment of aortic regurgitation by transesophageal color Doppler imaging of the vena contracta: validation against an intraoperative aortic flow probe. J Am Coll Cardiol 2001; 37:1450.
  17. Sutton DC, Kluger R, Ahmed SU, et al. Flow reversal in the descending aorta: a guide to intraoperative assessment of aortic regurgitation with transesophageal echocardiography. J Thorac Cardiovasc Surg 1994; 108:576.
  18. Van Dyck MJ, Watremez C, Boodhwani M, et al. Transesophageal echocardiographic evaluation during aortic valve repair surgery. Anesth Analg 2010; 111:59.
  19. Michelena HI, Abel MD, Suri RM, et al. Intraoperative echocardiography in valvular heart disease: an evidence-based appraisal. Mayo Clin Proc 2010; 85:646.
  20. Hahn RT, Gillam LD, Little SH. Echocardiographic imaging of procedural complications during self-expandable transcatheter aortic valve replacement. JACC Cardiovasc Imaging 2015; 8:319.