Mastering the most important TEE views

When performing transesophageal echo, there are a handful of important TEE views you need to master. In this video, Andrew Houghton, MD will teach you what they are and how they differ.

This video was taken from our TEE Essentials course, which comes with 10 CME credits. Get a free trial account and start the course today!

[00:00:00] Transesophageal echo views are often divided into mid-esophageal views, transgastric views, and aortic views. And these are obtained from a number of different probe positions. To begin with, the mid-esophageal views, as the name suggests, are obtained with the TEE probe in the mid-esophageal position. This is the most useful of all the probe positions and allows us to obtain most of the views

[00:00:30] that we want with the heart. The transgastric views are obtained with the TEE probe with the patient's stomach or in the case of the deep transgastric view with the probe inserted deeply into the stomach so that its tip is adjacent to the apex of the heart. The aortic views are obtained either with the TEE probe in the upper esophagus, to look principally at the aortic arch or with the TEE probe in the mid-esophageal

[00:01:00] position but turned for 180 degrees so that it faces posteriorly, and therefore, is able to view the descending thoracic aorta. In this lesson, we're going to look in a little more detail at each of these views. And let's begin with the mid-esophageal views. Now, according to recommendations of The American Society of Cardiology and The Society of Cardiovascular Anesthesiologists, there are 15 distinct mid-esophageal

[00:01:30] views. And these views were obtained and optimized using a variety of probe manipulations. Although the views are principally obtained at the mid-esophageal level, nevertheless, some withdrawal or advancement of the probe might be necessary just to optimize the image that we're obtaining. Similarly, it may be necessary to turn the TEE probe to the patient's right or to the patient's left, in order to sweep across the heart. We may need to adjust the position of the tip of the probe

[00:02:00] either by anti-flexing or retroflexing the tip or by flexing the tip to the right or to the left. Finally, we can also rotate the transducer imaging plane so that we can obtain different cuts or slices through the heart, at each different probe position. And then this way, we can obtain a wide variety of different views at the mid-esophageal level. This, for example, is a mid-esophageal four-chamber view that

[00:02:30] shows the left atrium, mitral valve, left ventricle, right atrium, tricuspid valve, and right ventricle. By manipulating the probe, as we outlined a moment ago but maintaining a probe in the approximate mid-esophageal position, we can change the view to obtain, for example, a short-axis view looking at the aortic valve en face. Many other views are also possible in the mid-esophageal position, allowing us to

[00:03:00] inspect and assess a wide range of cardiac structures. As well as the mid-esophageal views, there are also nine different transgastric views. Most of these transgastric views are obtained with the TEE probe, in what we might call the standard transgastric position. Where we're looking from the stomach, up through the patient's diaphragm, at the heart. The TEE probe is, here, on the image and so in the

[00:03:30] near field, we have the inferior surface of the heart, as seen in the diagram. And here, we have the anterior surface in the far field, again, as shown in the diagram. By adjusting the position of the TEE probe, i.e., by advancing or withdrawing it or by anti-flexing or retroflexing the tip as necessary, we can obtain different slices through the heart. Here, we have a basal short-axis view where we're seeing the mitral

[00:04:00] valve en face. It must be obtained by cutting through the heart, in this kind of imaging plane, shown in the diagram. By advancing the TEE probe, we can obtain cuts through the mid-left ventricle or indeed through the apical portion of the left ventricle. By adjusting our transducer imaging plane angle, we can also take cuts through the long-axis of the heart as well as the short-axis. And here, we have a left ventricular long-axis view

[00:04:30] showing the left ventricle, here, the mitral valve, and the left atrium. By advancing the TEE probe all the way to the cardiac apex, we can look back at the heart from what is called the deeper transgastric position. This gives us a very foreshortened view of the left ventricle but gives us a good alignment with the left ventricular outflow tract, for performing flow assessment in the LVOT and through

[00:05:00] the aortic valve. Finally, there are also four commonly recognized aortic views. Two of these views are obtained in the upper esophageal probe position, where we're looking primarily at the aortic arch. In this view, here, we're seeing the aortic arch in long-axis but by altering the transducer imaging plane angle, we can also look at the arch in short-axis. If we now advance the TEE

[00:05:30] probe back down towards the mid-esophageal position and this time, turn the probe for 180 degrees. We're now looking posteriorly at the descending thoracic aorta. And we can look at the descending aorta in short-axis view, with the transducer imaging plane angle of 0 degrees, as shown here or we can look at it in its long-axis view, with the transducer imaging plane angle of approximately 90 degrees.

[00:06:00] We'll look in more detail at each of these TEE views in the next few lessons.