PGY-6 (Cardiothoracic Anesthesia)

My Perioperative Transesophageal Echocardiography (TEE) Image Acquisition Sequence

According to the guidelines from the American Society of Echocardiography (ASE) and Society of Cardiovascular Anesthesiologists (SCA), a comprehensive transesophageal echocardiographic (TEE) examination consists of 28 views. In practice, many of these views are difficult to obtain or irrelevant to the task at hand; however, if I’m inserting a TEE probe (an invasive procedure), I’m trying to get the most information as quickly as possible.

During my cardiothoracic anesthesiology fellowship, I tried obtaining images in many sequences to accomplish these goals. Keep in mind that things are very fast-paced in the operating room, and as a cardiac anesthesiologist, I’m often trying to do balance many other tasks while doing the TEE. Furthermore, prepping the patient, electrocautery, and other artifacts are factors that I must work around. With that said, here’s the general approach I use to perform a perioperative TEE (abbreviations at the bottom of the post).

Midesophageal (ME) Views

I’ll start my exam with a global overview by adjusting the beam focus to the LV apex and panning through 5 chamber -> 4 chamber -> 3D full volume of the LV -> MV commissural view -> 2 chamber -> long axis. This sequence allows me to quickly look for regional wall motion abnormalities, obvious valvular issues like calcification or leaflet malcoaptation, atrial/ventricular chamber size, clots, thrombi, effusions, etc.

ME four chamber
ME MV commissural
ME long axis

Left-Sided Heart Structures

Next I’ll look at left-sided cardiac structures. I go through the aforementioned sequence backwards with “color compare” (or a similar mode) to simultaneously display the structure of interest with and without CFD. I’m constantly adjusting my gain and focus to optimize the image. This allows me to look more closely at valve morphology, regurgitant jets, regional pathologies, and velocities across various structures (MV inflow, velocity within the LAA, velocity within the pulmonary veins, etc.)

Long axis view – mitral valve focus
Long axis view – aortic valve focus. A “Live 3D” view lets me orient the omniplane and probe depth in a way that more accurately slices down the center of the LVOT and aortic root. Then I obtain measurements of the AV annulus, sinuses of Valsalva, sinotubular junction (STJ), and ascending aorta.
Mid-commissural view. I often use this view or the 2 chamber view to obtain PV velocities and assess the LAA. For MV repair/replacement, I’ll also determine how close the LCx artery is to the annulus.
4 chamber view – mitral valve focus. Of note, I’ll withdraw the probe till I almost lose the MV at the lateral commissure (A1-P1 scallops). Then I’ll slowly advance the probe towards the medial commissure (A3-P3 scallops). I’ll also obtain mitral inflow velocities, tissue doppler the medial and lateral aspects of the MV annulus (e’ and a’) as well as the lateral annulus of the tricuspid valve to approximate the right ventricular (RV) S’.

Right-Sided Heart Structures

Now that I’m back at the midesophageal 4 chamber view, I’ll turn my attention to right-sided cardiac structures. I’ll either start with regular 2D and CFD separately or in a color compare mode on the TV as I pan through the 4 chamber view -> RV inflow-outflow, and modified bicaval views. In the RV inflow-outflow view, I also look at the AV and PV.

Four chamber view – TV focus
RV inflow-outflow – TV focus. Sometimes this is a good place to doppler TR velocities. I’ll also measure the TV annulus diameter here in addition to the four chamber view.
RV inflow-outflow – PV focus. I use this view to guide pulmonary artery (PA) catheter placement.
AV in short axis. I’ll use this view to determine the location/severity of regurgitant jets, the morphology of the aortic valve (fused cusps, bicuspid, calcific stenosis, etc.) and the flow down the left main and right coronary arteries
AV in short and long axis. I’ll obtain this view by X-plane (“bi-plane”) down the AV in short axis. If shot correctly, I should only see the right coronary cusp on the long axis view. These views help me further localize pathology.
Modified bicaval view. I often doppler the TR jet here since the ultrasound beam tends to line up better.
Bicaval view. I’ll use this wire to confirm my central line wire is indeed in the right place at the beginning of the surgery and to grossly assess the SVC, IVC, CS, and IAS.
Bicaval view – interatrial septum in focus. I’ll decrease my Nyquist limit to look for low velocity flow across the IAS suggestive of an ASD or PFO.

Transgastric Views

Next I’ll dive into the stomach (transgastric views) with some left tilt and anteflexion of the TEE probe.

From the bicaval view, I track the IVC down into the liver and PWD the hepatic veins. With some left rotation and anteflexion of the TEE probe, I’l acquire the following transgastric views: basal short axis -> mid-papillary short axis -> two chamber/long axis -> apical short axis -> RV basal -> deep transgastric

Transgastric basal. Another way to look at the mitral valve and basal region wall motion.
Transgastric mid-papillary. Both papillary muscles are visible. I use this view to assess mid-ventricular wall motion and cavity volumes. It’s important to also pay attention to the RV and interventricular septal motion.
Transgastric long axis. Allows assessment of the sub-MV apparatus (papillary muscles, chordae. vegetations, etc.)
Deep transgastric. Excellent for doppler signals from the AV and LVOT as the ultrasound beam tends to be in line with blood flow.

Then I’ll rotate the probe to the left, decrease the depth, and focus on the descending thoracic aorta. I’ll biplane through the center of the aorta while scanning upwards noting areas of atheroma, the left subclavian takeoff, and abnormalities within the aortic arch.

Descending thoracic aorta in short/long axis. This view is important to look for dissections, atheromas, and reversal of flow indicative of AV insufficiency.

Now that I’ve landed in the upper esophagus, I’ll get a view of the pulmonary artery and ascending aorta orthogonal to each other.


I’m constantly tweaking things in my workflow as I become more proficient at perioperative TEE. If you have any suggestions, please feel free to leave them below!

Abbreviations: color-flow doppler (CFD), continuous-wave doppler (CWD), pulsed-wave doppler (PWD), aortic valve (AV), mitral valve (MV), tricuspid valve (TV), pulmonic valve (PV), right atrium (RA), right ventricle (RV), left atrium (LA), left ventricle (LV), left ventricular outflow tract (LVOT), sinotubular junction (STJ), left main coronary artery (LM), left anterior descending coronary artery (LAD), left circumflex coronary artery (LCx), right coronary artery (RCA), mitral regurgitation (MR), tricuspid regurgitation (TR), aortic insufficiency (AI), aortic stenosis (AS), coronary sinus (CS), interatrial septum (IAS), interventricular septum (IVS), superior vena cava (SVC), inferior vena cava (IVC), left atrial appendage (LAA)

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