The mid-esophageal four-chamber view in transesophageal echo (TEE)—the nuts and bolts

The mid-esophageal four-chamber view is one of the most important views in transesophageal echocardiography. In this video, cardiac imaging expert Andrew Houghton, MD will explain how to get it, how you can optimize it, and how to interpret it.

This video was taken from our CME accredited TEE Essentials course taught by Andrew Houghton, MD—Cardiac imaging specialist and head of cardiac imaging at Grantham & District Hospital.

Check out the course!

[00:00:00] In this lesson, we're going to learn how to obtain the mid-esophageal four-chamber view of the left ventricle. This view shows the left ventricle together with the mitral valve and left atrium and also the right ventricle tricuspid valve and right atrium. But our main focus is going to be on the left ventricle and on assessing its size, wall thickness, morphology, and function. This view is obtained at the mid-esophageal probe

[00:00:30] position, with the probe facing anteriorly, to obtain a cut through the left ventricle. And I'd suggest starting with a transducer imaging plane angle of 0 degrees, however, some fine-tuning is needed to obtain an on-access four-chamber view and I'll show you exactly how to obtain that. Now, when we start off with our view, initially, we tend to get to five-chamber view rather than the true four-chamber because we have as well as the

[00:01:00] two atria and two ventricles in the image, we also have the aortic root, aortic valve, and left ventricular outflow tract. And we want to eliminate these from the image to get to true four-chamber view. So, there are a number of maneuvers that we can make to optimize the image. And to begin with, I would suggest that we advance the probe very slightly and also that we retroflex the tip of the probe. This alters the angle of a cut that we're getting and

[00:01:30] helps to exclude the left ventricular outflow tract and aortic root from the view. So, a little bit of probe advancement and a little bit of retroflexion. Now, the problem with retroflexing the tip of the probe is that we start to lose contact with the anterior wall of the esophagus, so the image quality can start to deteriorate. And sometimes we have to accept to compromise between the amount of retroflexion that we can apply to optimize the image but without deteriorating the overall quality,

[00:02:00] by losing probe contact. So, here is the image that we've now obtained, by retroflexing the tip of the probe and advancing it a little and we can see that it is better. We've eliminated a large proportion of the left ventricular outflow tract and aortic root, but you can still see a little bit of that in the image, so there is one further adjustment that we can make. And what we can do is rotate the imaging plane forwards a little to increase the imaging plane angle to about 10 or 20 degrees.

[00:02:30] The exact amount will vary from one patient to the next but by increasing the angle by about 10 or 20 degrees, we will start to fully optimize the four-chamber view. And that's exactly what we're doing here. You can see, at the top right-hand corner of the image, that we're changing the angle of the transducer imaging plane to try and optimize the image. And as we do alter the angle by a few degrees, you can see how the aortic root and left ventricular outflow tract

[00:03:00] is disappearing from the image. So, by making an appropriate adjustment, you can normally fully optimize the image and obtain a true four-chamber view. In the four-chamber view, we can assess global left ventricular size and systolic function and we can also look at left ventricular wall thickness and we can look for any morphological abnormalities such as areas of hypertrophy, consistent of a hypertrophic cardiomyopathy. We can also assess

[00:03:30] regional wall motion in each of the myocardial segment, seen in this view. Those segments are the basal and mid-inferior septum, together with the apical septum and the basal and mid-anterolateral segments, together with the apical lateral segment. We can see that on the TEE image, here. We can see the basal and mid-inferoseptal segments and the apical septal segment, together with the basal and

[00:04:00] mid-anterolateral segments and the apical lateral segment.