University of Utah Basic TEE Exam
Image Optimization
1.) Good ECG signal
2.) Patient information entered correctly
3.) Focus – just distal to structure of interest
4.) Gain – blood just black, random color just disappears
5.) Nyquist – set at 50-60 cm/s
6.) Review study to be sure images captured well
Midesophageal AV Short Axis: ~45°, depth ~8 cm
Goal: Rule out AS, evaluate structural abnormalities of AV
Center valve, advance/withdraw to see coaptation, multiplane for symmetrical cusps
Check bi/tri-leaflet, normal excursion and coaptation, sclerocalcific changes
Add ~90° to multiplane for next view
Midesophageal AV Long Axis: 130°-140°, depth ~8cm
Goal: Rule out AS, AI, type A dissection, dynamic LVOT obstruction
Keep LA-MV-LV “open” with rotation, find AV with multiplane
Rotate R/L until leaflet excursion is clear & central, sinuses symmetric
Check for normal coaptation, degree of calcification, normal Ao size
CFD to look for AI, Y-sign suggesting LVOT obstruction
Slight decrease in multiplane, slight right turn, increase depth for next view
Midesophageal Bicaval: 90°-110° with right turn, depth ~12 cm
Goal: Evaluate for ASD, SVC collapse, watch wire advancement; may not see IVC
Rotate to visualize fossa ovalis clearly;withdraw for SVC, advance for IVC/CS
CFD on fossa ovalis to look for ASD, scan through septum, don’t reduce Nyquist
Turn left and decrease multiplane for next view
Midesophageal RV Inflow/Outflow: 55°-75°, depth ~12 cm
Goal: Evaluate RV structure/function, TV, PV; follow PA catheter
Should see RA/RV/PV/PA simultaneously
CFD of PV (not TV)
Decrease multiplane, advance slightly, increase depth, don’t rotate for next view
Midesophageal RV-Focused 4 Chamber: 0-20°, depth 16 cm (to just see apex)
Goal: RV size and function, RA size, TR; normal TAPSE > 1.6 cm
CFD on TV, advance and withdraw slightly to scan valve
Rotate to the left, center LV in screen for next view
Midesophageal LV-Focused 4 Chamber: 0-20°, depth 16 cm (to just see apex)
Goal: LV inferoseptal and anterolateral wall, global LV function, LV/LA size, MR
Advance, retroflex, increase angle to eliminate LVOT and foreshortening
CFD on MV, advance and withdraw to scan valve
Position LV in center of screen, increase multiplane for next view
Prepared by Josh Zimmerman, MD, FASE
Images from Hahn, R. et. al, JASE ‘13
Midesophageal 2 Chamber: 80°-90°, depth ~16 cm
Goal: Assess anterior and inferior walls (AAA rule), apex, look for LAA thrombus
See SAX coronary sinus on L (can check for cannula) and LAA on R
LV “lengthening” or excessive apical motion suggests foreshortening
Increase multiplane for next view
Midesophageal Long Axis: 130°-140°, depth 16 cm
Goal: Assess anteroseptal and inferolateral walls
Should see LVOT, MV, AV, typically no papillary muscles
Decrease multiplane, advance into stomach, gentle anteflexion for next view
Transgastric Mid Short Axis: 0° (always at 12 cm depth)
Goal: Evaluate global and regional LV systolic function, preload, afterload
Advance and anteflex gently to contact stomach wall, should see both papillary muscles
Evaluate thickening of each segment, representing all coronary distributions
Center LV, increase multiplane for next view (can be done as x-plane)
Transgastric 2 Chamber: 90°, depth ~10 cm
Goal: Evaluate LV size and thickness, anterior and inferior walls
Rotate to ensure maximal LV diameter, minimize foreshortening with multiplane
Return to 0°, rotate left, and withdraw for next image
Descending Aorta Short Axis: 0° (decrease depth, max MHz)
Screen for plaque (severe = mobile or diameter = 0.5+ cm), dissection, pleural effusion
Don’t decrease depth so much that a left effusion will be missed
Withdraw probe until you reach arch, rotate back to right, advance back to
midesophageal window
Prepared by Josh Zimmerman, MD, FASE
Images from Hahn, R. et. al, JASE ‘13
