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.
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.)
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.
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
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.
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)