1. Trans-esophageal & Intra-cardiac Echocardiography
Himal raj
Sr cardiology

2. HISTORY Side and Gosling (1971) - TEE for CwD of cardiac flow
Frazin et al (1976) - TEE M mode echo
Hisanaga et al (1977) - illustrated use of cross sectional real time imaging

3. introduction
TEE uses sound waves to create high-quality moving pictures of heart and its blood vessels
involves a flexible tube or probe with a transducer at its tip
probe is guided down throat and esophagus
more detailed pictures of heart as esophagus is directly behind heart

4. TEE: Types 3D pictures provide more details about Types of TEE :
Structure and function of heart and Its blood vessels
3D TEE helps to diagnose heart problems like:
Congenital heart disease
Heart valve disease and
To assist with heart surgery
Types of TEE :
2-Dimensional (2D)
3-Dimensional (3D)
Standard TEE pictures are 2D

5. Transesophageal Echocardiography (TEE)

6. tee

7. TEE: Advantages Transducer - 2- 3 mm from heart
Closer to posterior structures - Better visualization of LA, LAA, PV, MV, LV, Aorta
Far from surgical area - Intra-operative monitoring
High resolution images : [Absence of intervening lung or bone tissue - Better signal to noise ratio and decreased image depth – allows use of higher freq (5 and 7 MHz) transducers – enhances image quality]

8. TEE: DISADVANTAGES semi invasive procedure: chances of injury ;
needs special setup, technique, preparation, instrumentation
needs orientation and expertise

9. Indications -common
Assessment of prosthetic valves; infective endocarditis ; native valve disease
Assessment of a suspected cardioembolic event
Assessment of cardiac tumors
Assessment of atrial septal abnormalities
Assessment of aortic dissection, intramural hematomas
Evaluation of CHD; CAD ;pericardial disease
Evaluation of critically ill patients
Intraoperative monitoring
Monitoring during interventional procedures
Stress echocardiography
Nondiagnostic TTE

10. Contraindications ABSOLUTE Oesophageal stricture or obstruction
Suspected or known perforated viscus
Instability of cervical vertebrae
GI bleeding not evaluated
RELATIVE
Esophageal varices or diverticula
Cervical arthritis
Oropharyngeal distortion
Bleeding diathesis or over-anticoagulation

11. procedure 4- 6 hours fasting Written consent
Intravenous line ; oxygen ; suction equipment ; Remove denture or devices ; 2% lidocaine spray
ECG must be monitored throughout
Left lateral position
Introduce the probe with some anteflexion through a bite block

12. procedure
Routine antibiotic prophylaxis before TEE is not advocated [ risk of IE is extremely low].Recommended in high risk patients - prosthetic valves, multivalvular involvement or those with a past h/o IE]
Persistent resistance to advancing the instrument mandates termination of TEE and endoscopy should be performed before re-examination.
After each TEE - Disnfect ; Check for any damage - ensure electrical safety

13. complications Majority are minor.
Major complications [death, laryngospasm, sustained VT & CHF occur in ≈ 0.3% of patients]
Cardiac complications include SVT or AF, VT, bradycardia, transient hypotension or hypertension, angina ,CHF and pulmonary edema.

14. complications MAJOR Death Esophageal rupture
Laryngospasm or bronchospasm
Congestive heart failure or pulmonary edema
Sustained ventricular tachycardia

15. complications MINOR Excessive retching or vomiting Sore throat
Hoarseness
Minor pharyngeal bleeding
Blood tinged sputum
Non sustained or sustained supraventricular tachycardia
Atrial fibrillation
Nonsustained ventricular tachycardia
Bradycardia or heart block
Transient hypotension
Transient hypertension
Angina
Transient hypoxia
Parotid swelling
Tracheal intubation

16. TEE PROBE
Modification of standard gastroscope, with transducers in place of fibreoptics
Conventional rotary controls with inner and outer dials
Inner dial guides anteflexion and retroflexion
Outer dial controls medial and lateral movement
Multiplane probe has a lever control to guide rotation

17. Tee probe

18. TEE Transducer
TEE Transducer
Relation of TEE transducer with heart

19. TEE PROBE Monoplane TEE - provides images in horizontal plane only
Biplane TEE - orthogonal longitudinal plane also
Multiplane TEE transducer :
single array of crystals [phased array transducers with piezoelectric elements]
that can be electronically and mechanically rotated in an arc of 180 °
to produce a continuum of transverse and longitudinal images from a single probe position

20. Standard imaging plane levels (from the incisors)
upper or high esophageal (25–28 cm)
mid-esophageal (29–33 cm)
transgastric (38–42 cm)
deep-transgastric (>42 cm)

22. PROCEDURE
Proceed systematically - from mid esophagus [≈35 cms from the incisors] to gradually more distal esophagus, fundus of the stomach after gentle advancement across the cardia [≈40-50 cms from incisors] and finally slow withdrawal of the probe for complete scan of the thoracic aorta [from high esophageal views].

23. PROCEDURE A complete TEE exam usually takes 15–20 min.
An abbreviated or problem-focused TEE study may be appropriate in unstable or uncooperative patients

24. Transducer manipulation options
[1] Advancement/withdrawal (for inferior or superior structures respectively)
[2] Rotation (clockwise to view rightward structures and counter- clockwise for leftward structures)

25. Transducer manipulation options
[3] Anteflexion and retroflexion of the probe shaft (to view structures towards the heart base or towards the apex)
[4] Leftward and rightward flexion of the probe shaft (used infrequently with the advent of multiplane probes)

26. Transducer manipulation options
[5] Electronic image plane rotation (0–1800)

27. TEE PROBE ORIENTATION

28. By convention, in TEE, tip of 2D sector is displayed on top of screen and left-sided cardiac structures appear on right side of display.

29. BASIC VIEWS

30. Prior guidelines developed by the ASE and the SCA have described the technical skills for acquiring 20 views in the performance of a comprehensive intraoperative multiplane transesophageal echocardiographic examination
But current guidelines recommend that a basic PTE examination should focus on encompassing the 11 most relevant views.

31. Cross-sectional views of the 11 views of the ASE and SCA basic PTE examination.

32. ASE & SCA recommend 20 views for a comprehensive TEE.

33. Mid Esophagus 4C ( 0°)
Position probe in mid-esophagus behind LA. depth 14cm,
angle 0-10°. Image all 4 heart chambers. Optimize LV apex by slight retroflexion of probe tip. Ensure no part of AV or LVOT is seen. Aim to maximize TV diameter, and adjust depth to view entire LV.
Assess :chamber size; ventricular function; mitral valve disease; tricuspid valve disease; ASD; pericardial effusion

34. ME 4 CHAMBER VIEW

35. ME 2C ( 90° )
From ME 4C : keep probe tip still and MV in the center; rotate omniplane angle forward to °; RA + RV disappear,
LAA appears.Retroflex probe tip for true LV apex; adjust depth to see entire LV apex.
Assess : LAA mass/thrombus; LV size and function; MV disease (A1, A2 & P3 scallops); MV annulus measurement ‘

36. ME TWO-CHAMBER VIEW

37. ME LAX (120°)
Rotate omniplane angle forward to °
Imaging plane is directed thru the LA to image the aortic root in LAX and entire LV. The more cephalad structures are lined up on the display right.
The LV anteroseptal + inferolateral walls & MV segments, A2 and P2 are seen.
Assess : LV function, MV disease, AV and aortic root disease, IVS pathology.

38. ME LAX VIEW

39. ME Asc A LAX ( 90°)
Find the ME AV LAX (120°). Withdraw the probe to bring the right pulmonary artery in view Decrease omniplane angle slightly by 10-20° to make the aortic wall symmetric
Imaging plane is directed thru the right pulmonary artery to image the proximal ascending aorta in LAX.
For: aortic pathology, pericardial effusion, pulmonary embolus

40. ME Asc A LAX ( 90°)

41. ME Asc A SAX (0°)
From ME AV LAX (120°) OR from ME AV SAX (30°)…. Withdraw probe (asc aorta ), Rotate the omniplane angle back to 0°
Imaging plane is directed slightly above the aortic valve thru the RPA(seen in LAX), ascending aorta (seen in SAX) and SVC (SAX).
For : PA pathology, pulmonary embolus, ascending aorta pathology ,PDA, swan-ganz in SVC

42. ME Asc A SAX (0°)

43. ME AV SAX (30-45°)
From ME 4C (0°) withdraw cephalad to obtain the ME 5C(0°) [imaging plane is directed thru the LA and aligned parallel to the AV annulus] rotate to 30-45°; center aortic valve and aim to make 3 aortic valve cusps symmetric. Withdraw probe for coronary ostia.Advance probe for LVOT.
Assess : AV disease, OS ASD, LA size, coronary artery pathology

44. ME AV SAX (30-45°)

45. ME RVIO View (60-75°)
From ME AV SAX (30-60°) rotate omniplane angle to °
Optimize TV leaflets, open up RVOT,
Bring PV + main PA into view
For : P valve / PA / RVOT /TV pathology /VSD

46. ME RVIO View (60-75°)

47. ME BCV ( 90°)
From ME 2 C (90°), Turn entire probe right
Change angle or rotate probe slightly to image both IVC (left) and SVC (right) simultaneously
For : ASD (secundum, sinus venosus), atrial pathology, lines/wires,Venous cannula (SVC, IVC)

48. ME BCV ( 90°)

49. TG mid SAX (0°)
Advance probe until you see stomach (rugae) or liver. anteflex to contact stomach wall and inferior wall of heart .
center LV by turning probe R or L . image both papillary muscles .
imaging plane transversely thru the mid inferior wall of the LV with all 6 mid LV segments viewed at once from the stomach.
For: Left ventricle size, function, IVS motion, VSD, pericardial effusion

50. TG mid SAX (0°)

51. ME DA SAX (0°)
Insert the probe to the ME, sector depth 10-12cm, angle 0°;
Turn probe to left to find the aorta; put aorta in middle of display
Decrease depth to 5cm; advance + withdraw probe
Near field image of the circular aorta represents the right anterior wall of the aorta
For :Aortic pathology , Color flow reversal: AI severity, IABP position

52. ME DA SAX (0°)

53. ME DA LAX (90°)
From ME DA SAX…. Rotate to 900 … aortic walls appear in parallel
Distal aorta is to the display left and the proximal aorta to the display right

54. ME DA LAX (90°)

55. ME Mitral Commissural View (60°)
Find the ME 4C : keep the probe tip still and MV in the center;
rotate omniplane angle forward to 45-60°;RA,RV disappear, retroflex slightly for LV apex;
Imaging plane is directed thru the LA to image LA, MV and LV apex.
Assess : MV disease, LV function, LA pathology.

56. ME AV LAX (120°)
From ME AV SAX (30-60°), rotate to °
LVOT, AV, proximal ascending aorta line up.
Optimize aortic annulus and make sinuses of valsalva symmetric
Assess : MV disease, AV disease, aortic root dimensions & pathology, LVOT pathology, VSD

57. TG 2C (90° )
From mid TG SAX (0°) .. rotate omniplane angle to 90° Anteflex until LV is horizontal
Imaging plane ….Transversely thru the inferior wall of the LV and subvalvular structures of the mitral valve from the stomach.
For : LV function , mitral valve subvalvular pathology

58. TG Basal SAX(0°)
From TG mid SAX view … withdraw the probe until MV is seen in SAX … aim to see symmetric MV commissures
Views MV (with A3 & P3) that is parallel to the annulus
For : LV size, function ; VSD ; MV planimeter orifice area

59. TG LAX ( °)
From TG 2 chamber (90°) … rotate omniplane angle to °
Imaging plane is directed longitudinally thru the LV to image the aortic root in LAX.
For : MV pathology ,VSD, LV systolic function, Aortic valve: spectral and color doppler, LVOT: spectral and color doppler

60. Deep TG LAX (0°)
From mid or apical TG SAX view, anteflex and gently advance probe, hugging the stomach mucosa until the LV apex is seen at the top of the display
For: paravalvular leak prosthetic aortic valve ; AV gradient
spectral doppler ; LVOT gradient spectral doppler

61. TG RV inflow (90°)
From mid TG SAX (0°) turn probe right to put RV in center …
Rotate omniplane angle to 90°… anteflex until RV is horizontal
Imaging plane is directed longitudinally thru the posterior RV wall to reveal a long axis view of the RV, with the apex of the RV to the display left and the anterior free wall in the far field.
For : RV function; tricuspid subvalvular /TV pathology

62. UE Aortic Arch LAX (0°)
From ME(0°)… ME descending aorta SAX (0°) view… Withdraw probe until aorta changes into oval shape…
Turn probe slightly to the right
Imaging plane is directed thru the longitudinal axis of the transverse aortic arch. The circular shape of the DA changes to an oblong shape of the transverse aortic arch (0°)
For : aortic pathology

63. UE Aortic Arch SAX (60-90°)
From UE aortic arch LAX (0°) view…. Rotate the omniplane angle
to 60-90°…. Bring the pulmonic valve and pulmonary artery in view
Imaging plane is directed thru the transverse aortic arch in SAX and the pulmonary artery in LAX.
For : Aortic arch pathology, Pulmonic valve disease, PDA

66. 3 Dimensional TEE
Main advantages of Real-time three-dimensional (RT3D) TEE during catheter-based interventions:
Ability to visualize the entire lengths of
Intracardiac catheters, including the tips of all catheters and the balloons
Devices they carry, along with a clear depiction of the positions in relation to other cardiac structures
To demonstrate certain structures in an ‘‘en face’’ view
RT3D TEE is a powerful new imaging tool
May become the technique of choice and the standard of care for guidance of selected percutaneous catheter- based procedures
Gila Perk, et al. J Am Soc Echocardiogr 2009;22:865-82

67. INTRACARDIAC ECHOCARDIOGRAPHY

68. Intracardiac Echocardiography
An imaging technique that helps to guide percutaneous interventional procedures
Probe can be inserted under local anaesthesia
Principally used during closure of atrial septal abnormalities

69. Intracardiac Echocardiography

71. Intracardiac Echocardiography
The 1st generation ICEs were introduced in 1980s
They provided high resolution imaging
Tissue penetration limited due to high frequency of the transducers (20–40 MHz)
Anatomic intracardiac overviews not properly obtained
Recently the development of steerable phased array ultrasound catheter systems with low frequency and Doppler qualities has expanded the clinical use of ICE
M R M Jongbloed, et al. Heart July; 91(7): 981–990.

72. ICE: Advantages No radiation is needed
Not necessary to position a transducer in a sterile field as compared to TTE
Patient discomfort is less
Availability of direct online information on the position of catheters and devices
General anaesthesia not needed
The possibility of direct monitoring of acute procedure related complications such as:
Communication with the patient during the procedure possible as compared to TEE
Thrombus formation
Pericardial effusion etc
M R M Jongbloed, et al. Heart July; 91(7): 981–990.

73. ICE: Limitations Considerable shaft size (10 French)
Lack of additional catheter features, such as
Ports for guidewires
Therapeutic devices and pressure
The phased array catheters are expensive and for single use only
Phased array ICE provides only monoplane image sections
Difficult for operators to obtain the same views
No standard views for ICE are currently defined as compared to standard views for for TTE and TOE.
M R M Jongbloed, et al. Heart July; 91(7): 981–990.

74. ICE: Clinical Implications
Applications of intracardiac echocardiography (ICE) in interventional procedures
Evaluation of intracardiac thrombus
Transseptal puncture
Atrial septal defect/patent foramen ovale closure
Interventional electrophysiological procedures
Pulmonary vein ablation in patients with atrial fibrillation
Atrial flutter ablation
Ventricular tachycardia ablation
Other applications
Diagnosis/biopsy of intracardiac masses
Balloon mitral valvuloplasty
Atrial appendage occlusion
Visualisation of coronary sinus

75. Closure of an ASD under ICE guidance

76. ICE: Technical Requirements
Mechanical ultrasound tipped catheter:
Can be used for both
Intravascular
Intracardiac imaging
For intracardiac use
9 MHz single element transducer is incorporated in an 8 French catheter
A Piezoelectric crystal is rotated at 1800 rpm in the radial dimension perpendicular to the catheter shaft
Provides cross sectional images in a 360˚ radial plane
The ICE catheter needs to be filled with 3–5 ml sterile water before it is connected to the ultrasound machine
M R M Jongbloed, et al. Heart 2005;91:981–990.

77. ICE: Technical Requirements
Phased array ultrasound tipped catheter system uses
A 10 French ultrasound catheter
Positioned in the right atrium (RA) or right ventricle (RV) via a femoral approach
Through a 10 French introducer
Measurements of haemodynamic and physiologic variables can be made using Doppler imaging
Catheter is connected to an ultrasound system
M R M Jongbloed, et al. Heart 2005;91:981–990.

78. ICE Future Advances Higher resolution
Are more reproducible and more flexible than piezoelectric ceramic
They are extremely reproducible and can be made from masks like integrated circuits
Electrophysiology- Enabled Devices for Imaging and Therapy
Integration of ultrasound imaging with mapping technologies, fusion, and overlay images
Ziyad M. Hijazi, et al. Circulation. 2009;119:

79. REFERENCES
OTTO – The practice of clinical echocardiography – 4th edition
FEIGENBAUM’S Echocardiography – 7th edition
Basic perioperative TEE – A consensus statement of ASE and SCA – S.T Reeves – J Am Soc Echo 2013
Recommendations for TEE: update 2010 – Flachskampf - European Journal of Echocardiography 2010
TEE Multimedia Manual - André Y. Denault, Pierre Couture
TEE Study Guide and Practice Questions-Dr Andrew Roscoe
Virtual TEE Website – University of Toronto

80. mcqs
1)The number of most relevant views for a basic perioperative TEE examination according to current guidelines by ASE and SCA –
20 views
15 views
12 views
11 views

81. 2) In ME 2 chamber view , the omniplane angle is
135˚
120˚
90˚
60˚

82. 3) In ME LAX view, the omniplane angle is
45˚
60˚
90˚
120˚

83. 4) In desc aortic LAX view, the omniplane angle is0˚
60˚
90˚
120˚

84. 5)Principal use of ICE is in
Evaluation of intracardiac thrombus
Balloon mitral valvuloplasty
ASD closure
Pulmonary vein ablation