II. Indication

  1. Suspected Pulmonary Embolism
    1. Patients too unstable to undergo CT PE study
    2. McConnell Sign (dilated RV, RV free wall akinesis, normal apical contractions)
  2. Aortic Dissection
    1. Aortic Dissection assessment (consider CT angiogram as alternative)
  3. Thoracic Aortic Aneurysm
  4. Valvular heart disease (including small valvular vegetations)
  5. Left atrial thrombus
  6. Cardiac Arrest
    1. Heart and Great Vessels are seen without chest wall or epigastric bowel gas obstruction
    2. May be monitored without interruption and not interfere with Resuscitation efforts
    3. Heart function and compression quality can be accurately monitored
    4. Distinguishes cardiac standstill (true PEA or Asystole) from ineffective contraction
    5. May identify Cardiac Tamponade, PE with RV strain, vascular rupture

III. Contraindications

  1. Severe esophageal stenosis
  2. Tracheoesophageal fistula
    1. More common in gastrostomy Feeding Tube

IV. Technique: Scope

  1. Assumes Conscious Sedation or Endotracheal Intubation
  2. TEE is inserted and steered in similar fashion to bronchoscope, Nasolaryngoscopy or endoscope
    1. Multiplane Ultrasound transducer lies in the scopes flat head
    2. Transducer direction is manipulated with thumb pad on scope handle
  3. Examiner hand positions
    1. Examiner holds scope with non-dominant hand by patients mouth to insert, secure or withdraw the tube
    2. Examiner uses dominant hand to hold the scope handle and manipulate the transducer direction
  4. Key Views (see below)
    1. Mid-Esophageal Four-Chamber View (MEFC View)
    2. Transgastric Mid-Papillary Short-Axis View (TGMPSA)

V. Imaging: Mid-Esophageal Four-Chamber View (MEFC View)

  1. Positioning
    1. Visualized on initial probe insertion
    2. Multiplane transducer angle set to 0 degrees (no rotation)
  2. Landmarks
    1. Four chamber view (only part of right atrium visualized)
    2. Mitral and tricuspid valves
    3. Interventricular septum and apex

VI. Imaging: Transgastric Mid-Papillary Short-Axis View (TGMPSA View)

  1. Positioning
    1. Scope inserted into Stomach, and then retro-flexed (or anteflexed) up toward the heart
    2. Scope is withdrawn in this J-tip position until the left ventricle comes into view
  2. Landmarks
    1. Coronary arteries
    2. Left ventricle (in cross section, appears as doughnut)
    3. Pericardium (and Pericardial Effusion)

VII. Imaging: Mid-Esophageal Long Axis View (MELA View)

  1. Positioning
    1. Scope at mid-esophagus depth
    2. Multiplane transducer rotation angle set to 120 degrees (toward LV outflow tract)
  2. Landmarks
    1. Left ventricular inflow via mitral valve
    2. Left ventricular outflow via aortic valve
    3. Proximal aorta (and Aortic Dissection or dilitation)

VIII. Imaging: Mid-Esophageal Bicaval View (MEBC View)

  1. Positioning
    1. Scope at mid-esophagus depth, rotated toward patient right (clockwise)
    2. Multiplane transducer rotation angle set similarly to MELA View (120 degrees) +/- 20 degrees
  2. Landmarks
    1. Right atrium with inflow from superior and inferior vena cava
    2. Interatrial septum and left atrium

IX. Efficacy

  1. Aortic Dissection
    1. Sensitivity: 97%
    2. Specificity: 75-90%

X. Advantage

  1. Sensitive for hemodynamically significant emboli
  2. Less invasive
  3. Fast
  4. Widely available

XI. Disadvantage

  1. Requires sedation
  2. Misses small Pulmonary Emboli (only 13% sensitive)
  3. Requires sedation and trained technician
  4. False Positives in the Cardiac Arrest setting
    1. For patients undergoing ROSC, confirm TEE findings

XII. References

  1. O'Rourke, Denson, Mendenhall, Fox (2018) Crit Dec Emerg Med 32(4): 19-25

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Echocardiography, Transesophageal (C0206054)

Definition (NCI) A cardiac ultrasound performed by passing a specialized probe containing a transducer into the patient's esophagus.
Definition (MSH) Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues using a transducer placed in the esophagus.
Concepts Diagnostic Procedure (T060)
MSH D017548
SnomedCT 175132007, 105376000
English Transesophageal Echocardiography, Transoesophag echocardiography, TEE, ECHOCARDIOGR TRANSESOPHAGEAL, Echocardiography, Transesophageal, TOE - Transoesoph echocardiogr, transesophageal Doppler study, transesophageal Doppler study (procedure), echocardiograms transesophageal, transesophageal echocardiogram, transesophageal echocardiography, echo transesophageal, echo transesophageal (procedure), Transoesophageal echocardiography (procedure), Transesophageal echocardiography, Transoesophageal echocardiography, TEE procedure, TOE - Transesophageal echocardiography, TOE - Transoesophageal echocardiography, Transesophageal echocardiography (procedure), Transesophageal echocardiogram, Transoesophageal echocardiogram
Dutch transoesofageaal echocardiogram, transoesofageale echocardiografie, Echocardiografie, transoesofagale, Transoesofagale echocardiografie
French Echocardiographie transoesophagienne, Echocardiogramme transoesophagien, Échocardiographie trans-oesophagienne, ETO (Échocardiographie Trans-Oesophagienne), Échocardiographie transoesophagienne
German Transoesophageale Echokardiographie, transaesophageale Echokardiographie, transoesophageales Echokardiogramm, Transoesophageales Echokardiogramm, Echokardiographie, transösophageale, Transösophageale Echokardiographie
Italian Ecocardiografia transesofagea, Ecocardiogramma transesofageo, Ecocardiografia trans-esofagea
Portuguese Ecocardiograma transesofágico, Ecocardiografia transesofágica, Ecocardiografia Transesofagiana
Spanish Ecocardiografía transesofágica, Ecocardiograma transesofágico, Ecocardiografía transesofágico, ecocardiografía transesofágica (procedimiento), ecocardiografía transesofágica, ecocardiograma transesofágico, Ecocardiografía Transesofágica
Japanese 経食道心エコー像, 経食道心エコー, ケイショクドウシンエコーゾウ, ケイショクドウシンエコー, 経食道心エコー図, 心エコー図-経食道
Swedish Ekokardiografi, transesofageal
Czech echokardiografie jícnová, echokardiografie transezofageální, Transezofageální echokardiografie, Transezofageální echokardiogram
Finnish Transesofageaalinen kaikukardiografia
Polish Echokardiografia przezprzełykowa
Hungarian Trans-oesophagealis echocardiogram, Transoesophagealis echocardiographia, Transoesophagealis echocardiogram
Norwegian Transøsofageal ekkokardiografi, Ekkokardiografi, transøsofageal