My Transesophageal Echocardiography (TEE) Sequence Of Views

As a cardiothoracic anesthesiologist and intensivist, transesophageal echocardiography (TEE) is a powerful cardiac imaging modality I perform in the OR during cardiac surgery and in the cardiovascular ICU when point-of-care ultrasound is not feasible or helpful due to poor image quality.

Before anything, I take a quick shot of the pathology in question to confirm the purpose of the exam, operation, etc. For example, if a patient has aortic valve endocarditis, I’ll glance at the aortic valve before proceeding with my full exam.

Next, for comprehensive TEE exams, I’ll gather 3D data sets (gated 6-beat full volumes if possible). If necessary, I’ll briefly pause mechanical ventilation to minimize stitch artifacts while gating the data sets.

The typical sequence of views I acquire during a routine TEE exam starts with left-heart structures. I’ll focus on acquiring the midesophageal (ME) 5-chamber, 4-chamber, mid-commissural, 2-chamber, and long-axis views as I keep the probe more-or-less stationary but increase the omniplane angle. This gives me an idea of overall left ventricular (LV) function.

ME 5-Chamber View
ME 4-Chamber View
ME Commissural View
ME 2-Chamber View
ME Long-Axis View

Next, I’ll decrease the depth and adjust my focus to the level of the aortic and mitral valves. As I reverse the sequence above, I’ll capture views with and without color-flow Doppler (CFD) assessing valvular function and pathologies. When I return to the ME 2-chamber view, I’ll interrogate the left pulmonary veins and left atrial appendage. I’ll end at the ME 4-chamber view and perform mitral valve inflow measurements, tissue Doppler imaging of the lateral and medial mitral annulus, and an inflow propagation velocity.

Then I’ll turn my attention to right-heart structures. I’ll start with a ME 4-chamber view with right-sided emphasis → ME right ventricular inflow-outflow (TR jet) → ME aortic-valve short-axis (biplane with/without color) → ME bicaval/modified bicaval view (TR jet, PFO, ASD).

ME Right Ventricular Inflow-Outflow View
ME Aortic Valve Short-Axis View (with concurrent X-plane)
ME Bicaval View
ME Modified Bicaval View

At this point, I’ll adjust the TEE probe to “penetration” mode and gently advance into the stomach to acquire transgastric (TG) views. Just like in the ME views, I’ll start with left heart structures followed by right heart structures.

TG Basal View
TG Mid-Papillary View
TG 2-Chamber View
Deep TG 5-Chamber View
TG RV Inflow
TG RV Inflow-Outflow
TG views of the tricuspid valve

I’ll then rotate the TEE probe to the patient’s left to assess the descending aorta with X-plane. As I withdraw the probe back towards the esophagus, I’m looking for dissection flaps, atheromas, etc. I’ll proceed to look at the aortic arch and ultimately advance the probe back down to the level of the ascending aorta.

Descending Aorta Short and Long Axis
Upper Esophageal Aortic Arch Long and Short Axis
ME Ascending Aorta Short and Long Axis
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