Transesophageal echocardiography (TEE)

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Eli V. Gelfand, M.D.; Anne B. Riley, M.D.


A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. This is known as a transesophageal echocardiogram, or TEE (TOE in the United Kingdom). The advantage of TEE over TTE is usually clearer images, especially of structures that are difficult to view transthoracicly (through the chest wall). The explanation for this is the heart rests directly upon the esophagus leaving only millimeters in distance that the ultrasound beam has to travel. This reduces the attenuation (weakening) of the ultrasound signal, generating a stronger return signal, ultimately enhancing image and Doppler quality. Comparatively, transthoracic ultrasound must first traverse skin, fat, ribs and lungs before reflecting off the heart and back to the probe before an image can be created. All these structures, and the distance the beam must travel, attenuate the ultrasound signal, degrading image and Doppler quality.

In adults, several structures can be evaluated and imaged better with the TEE, including the aorta, pulmonary artery, valves of the heart, both atria, atrial septum, left atrial appendage, and coronary arteries. While TTE can be performed quickly, easily and without pain to the patient, TEE requires a fasting patient, a team of medical personel, takes longer to perform, is uncomfortable for the patient and has some risks associated with the procedure (esophageal perforation--1 in 10,000, and adverse reactions to the medication).

Before inserting the probe, conscious sedation is induced with the patient to ease the discomfort of the individual and to decrease the gag reflex, thus making the ultrasound probe easier to pass into the esophagus. Conscious sedation is a light sedation usually using the medications midazolam (a benzodiazepine with sedating, amnesiac qualities) and fentanyl. Sometimes a local anesthetic spray is used for the back of the throat, such a xylocaine and/or a jelly/lubricant anesthetic for the esophagus. Children are anesthetized. Unlike the TTE, the TEE is considered an invasive procedure and is thus performed by physicians in the U.S., not sonographers.

To insert the TEE probe, the probe is placed in the patient’s mouth through a bite block (to protect the $30,000 TEE probe), and then passed down the patient's throat when they swallow, preventing inadvertent placement into the trachea. Although the placement of the pinky-wide transducer is uncomfortable, there are very few complications with gagging from the patient once the transducer is in the correct location.

Historical Aspect

  • 1971(2)
  • 1976
  • 1977
  • 1980(1)
  • 1982
  • 1990(1)
  • 2007(1)
  • Recently



Clinical Applications

TEE Procedure Indications[1]
Cardiac and Thoracic Aortic Surgery
  • All cardiac and thoracic aortic surgery


  • Valve repair or replacement ( aortic, mitral, other)  
  • Coronary artery bypass grafting (CABG) surgery with or without normal ventricular function, off-pump CABG  
  • Redo cardiac surgery  
  • Congenital heart surgery with or without cardiopulmonary bypass  
  • Ascending or decending thoracic aortic surgery   
  • Hypertrophic cardiomyopathy surgery  
  • Resection of cardiac mass  
  • Ventricular remodeling surgery  
  • Open surgery for dysrhythmias  
  • Endocarditis surgery  
  • Heart transplant
  • Pericardiectomy  
  • Open pericardial surgery  
  • Ventricular assist device  
  • Endoscopically assisted surgery  
  • Cannulae positioning
Transcatheter intracardiac procedures
  • When general anesthesia is provided and intracardiac ultrasound is not used
  • Septal defect closure
  • Atrial appendage obliteration  
  • Valve replacement and repair  
  • Dysrhythmia treatment
Noncardiac Surgery
  • Known or suspected cardiovascular pathology that might result in hemodynamic, pulmonary or neurologic compromise  
  • Unexplained persistent hypotension or hypoxemia   
  • Anticipation of life-threatening hypotension
  • Open abdominal or endovascular aortic procedures
  • Orthopedic surgery  
  • Transplant (liver,lung) 
  • Neurosurgery in the sitting position  
  • Percutaneous cardiovascular interventions    
  • Major Trauma (abdominal or thoracic)
Critical Care
  • Diagnostic information expected to alter management cannot be obtained by TTE or other modalities in a timely manner
  •  Unexplained persistent hypotension or hypoxemia


Contraindications include:[1][2][3][4][5]

  • Perforated viscus
  • Esophegeal stricture, tumor, perforation, laceration, diverticulum, varices
  • Mallory-Weiss tears [3]
  • Active upper gastrointestinal (GI) bleeding
  • Large descending aortic aneurysm[1]
  • Zenker diverticulum[1]
  • Prior esophagectomy or esophagogastrectomy[1]
  • Prior GI surgery
  • Resent upper GI bleeding
  • Barrett's esophagus
  • Dysphagia
  • Restricted neck mobility (severe cervical arthritis, atlantoaxial joint disease)
  • Prior radiation to neck and chest
  • Symptomatic hiatal hernia
  • Active esophagitis or active peptic ulcer disease
  • Coagulopathy, thrombocytopenia


  • Majority of the complications are caused by injury or trauma[6]
  • Dental injury (eg. loosened tooth) [6] [1]
  • Tongue necrosis (caused by prolonged placement of TEE probe)[7]
  • Sore throat[8]
  • Odynophagia[6][3]
  • Dysphagia[6][1]
  • Profound gag[8]
  • Aspiration
  • Laryngeal palsy[1]
  • Hoarsness[8]
  • Methemoglobinemia (caused by the topical use of benzocaine in the preparation of TEE procedure)[9]
  • Hypoxia[2][10][8][3]
  • Laryngospasm[10][8]
  • Bronchospasm[2][4]
  • Airway obstruction[11][12][13]
  • Accidental tracheal intubation[4][11]
  • Endotracheal tube malposition[6]
  • Congestive heart failure[10][8]
  • Dysrhythmias (eg. atrial fibrillation, supraventricular tachycardia, atrioventricular block, premature ventricular beats, nonsustained ventricular tachycardia, ventricular tachycardia)[4][2][10][8]
  • Transient hypotention or hypertension[10][8]
  • Transient changes in heart rate[14]
  • Oroharyngeal,hypopharyngeal, esohageal or gastric abrasion[6] or perforation [15][2][6][4][3][1]
  • Hemorrhage
  • Hematoma[1][3]
  • Pressure necrosis (in patients with severe atherosclerosis)[20]
  • Death(rare)[3][2][10][8]


Combined with Transthoracic echocardiography (TTE), a TEE before cardiac surgery can[21]:

  • Confirm or exclude previous TTE findings
  • Assess the immediate preoperative hemodynamics
  • Assess ventricular function of the patient
  • Facilitate placement of central venous catheters
  • Assist with selection of anesthetic agents
  • Be used as an inotropic support in identifying ventricular systolic size and function

After surgery but before closure, a TEE can[21]:

  • Improve overall outcome
  • Assist in determining whether the level of repair is acceptable
  • Detect and diagnose significant disease remaining to be treated
  • Assess cardiac function
  • Assess the presence of intracardiac air
  • Diagnosis abnormal cardiac rhythms
  • Monitor ventricular function and loading
  • Provides a better imaging view for determination of appropriate timing and the hemodynamic effect of sternal closure
  • Assist in monitoring inotropic drugs

In noncardiac procedures, TEE can:


Constraints for testing include:

  • Limited potential for optimal Doppler alignment
  • Limited time to perform a complete study
  • Suboptimal ambient lighting

Standard views of Transesophageal echocardiography (TEE)

1. Esophageal Position

Four-Chamber Plane

  1. Location: high trans-esophageal position, probe posterior to the left atrium at 0 degrees rotation, angle transducer toward the left ventricular apex
  2. View
    1. Lateral wall and inferior segments of left ventricle. Apparent apex may be a more proximal segment of anterior wall
    2. Anterior and posterior mitral valve leaflets
    3. Assess the size, shape, systolic function of the RV by turning the probe towards the patient's right

Two-Chamber Plane

  1. Location: with LV apex in center of image in four chamber view, rotate probe 60 degrees
  2. View
    1. Inferior and anterior LV walls
    2. Rotation to 90 degrees shows LA appendage

Long-Axis Left Ventricular Plane

  1. Location: with high trans-esophageal positioning, posterior to left atrium, rotate image plane 120 degrees
  2. View
    1. Proximal ascending aorta, sinuses of Valsalva, right and non coronary leaflets of the aortic valve, anterior and posterior mitral valve leaflets
    2. Good view for evaluating ascending aortic dissection, subaortic membrane, supracristal VSD, sinus of Valsalva aneurysm, aortic valve vegetations and abscess formation

Short-Axis Plane

  1. Location: withdraw the probe to the level of the aortic valve and rotate the image plane to between 30 and 45 degrees
  2. View
    1. Visualization of detailed aortic anatomy including 3 leaflets and sinuses of valsalva and the origin of the L main coronary artery
    2. Interatrial septum and fossa ovalis are well seen

2. Gastric Position

Short-Axis Plane

  1. Location: with probe in tip of the stomach, flex the scope superiorly
  2. View
    1. Global LV systolic function and global LV function can be evaluated
    2. May obtain a view of the mitral valve by withdrawing the transducer towards the esophagus

Two-Chamber Plane

  1. Location: in the transgastric position, rotate the image plane to the 90 degree position, then turn the probe towards the patient's right
  2. View
    1. Right atrium, tricuspid valve, right ventricle
    2. Can occasionally see RVOT and pulmonic valve

3. Transgastric Apical Position

Four-Chamber Plane

  1. Location: from transgastric short axis view, transducer is advanced further into the fungus
  2. View: apical four chamber, allows for doppler interrogation of LV outflow tract and valve

Long-Axis Plane

  1. Location: from transgastric apical four chamber plane, rotate the image to 120 degrees
  2. View: LVOT, allows doppler of the LVOT and aortic velocities

Descending Thoracic Aorta

  1. By rotating proble from the transesophageal or transgastric position until the image is directed just left of the patients spine, can visualize a short axis view of the thorasic aorta
  2. Useful for evaluation of aortic dissection, aneurysms and atheromas


TEE Pericardial Effusion



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  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK (2001). "The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients". Anesth Analg. 92 (5): 1126–30. doi:10.1097/00000539-200105000-00009. PMID 11323333.
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  14. Geibel A, Kasper W, Behroz A, Przewolka U, Meinertz T, Just H (1988). "Risk of transesophageal echocardiography in awake patients with cardiac diseases". Am J Cardiol. 62 (4): 337–9. doi:10.1016/0002-9149(88)90244-5. PMID 3400617.
  15. Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC, Yusoff IF (2005). "Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients". J Cardiothorac Vasc Anesth. 19 (2): 141–5. doi:10.1053/j.jvca.2005.01.020. PMID 15868517.
  16. Kim CM, Yu SC, Hong SJ (1997). "Cardiac tamponade during transesophageal echocardiography in the patient of circumferential aortic dissection". J Korean Med Sci. 12 (3): 266–8. doi:10.3346/jkms.1997.12.3.266. PMC 3054279. PMID 9250927.
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  18. Silvey SV, Stoughton TL, Pearl W, Collazo WA, Belbel RJ (1991). "Rupture of the outer partition of aortic dissection during transesophageal echocardiography". Am J Cardiol. 68 (2): 286–7. doi:10.1016/0002-9149(91)90769-h. PMID 2063804.
  19. Chow MS, Taylor MA, Hanson CW (1998). "Splenic laceration associated with transesophageal echocardiography". J Cardiothorac Vasc Anesth. 12 (3): 314–6. doi:10.1016/s1053-0770(98)90013-1. PMID 9636915.
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