Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination

TABLE OF CONTENTS Introduction 921 General Guidelines 922 Training and Certification 922 Indications for TEE 923 Management of Patient Sedation 927 Sedation and Anesthesia 929 Probe Insertion Techniques 930 Instrument Controls 930 Instrument Manipulation 931 Comprehensive Imaging Examination 932 ME Views 932 TG Views 939 Aorta Views 941 Transesophageal 3D Examination Protocol 942 Specific Structural Imaging 942 MV 942 AV and Aorta 945 PV 949 TV 950 Assessment of Ventricular Size and Function 951 LA and Pulmonary Veins 953 Right Atrium and Venous Connections 954 ACHD: TEE Imaging Algorithm 957 Conclusions 959 References 959 INTRODUCTION Transesophageal echocardiography (TEE) is a critically important cardiovascular imaging modality. The proximity of the esophagus to much of the heart and great vessels makes it an excellent ultrasonic window, so that TEE provides additional and more accurate information than transthoracic echocardiography (TTE) for some patients, for several specific diagnoses and for many catheter-based cardiac interventions. Esophageal ultrasound was first reported in 1971 to measure flow in the aortic arch.1 This was followed in 1976 by its use with M-mode echocardiography2 and then in 1977 by two-dimensional (2D) imaging using a mechanical scanning transducer.3 The modern era of TEE really began in 1982, with the introduction of flexible probes with phased-array transducers and manipulable tips,4 initially as a single, horizontally oriented transducer (monoplane), next as two orthogonally oriented transducers (biplane), and then as adjustable transducers capable of rotating 180° within the tip of the probe (multiplane). More recently, transesophageal echocardiographic probes and systems capable of producing real-time three-dimensional (3D) images have been developed and have achieved wide use. In 1999, the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA) published guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiographic examination5,6 that defined and named a set of 20 transesophageal echocardiographic views intended to facilitate and provide consistency in training, reporting, archiving, and quality assurance. Although the comprehensive intraoperative views have been widely adopted, they have a number of limitations. They were intended for intraoperative imaging and do not include some views important to other applications of TEE. The 20 views do not address any specific diagnoses and do not include some views needed to adequately examine common cardiac disorders. With significant advancement in technology, TEE has proven utility in a number of clinical arenas,7–12 including the operating room, intensive care unit, interventional laboratory, and outpatient setting. Thus, TEE has become an essential imaging tool for cardiac surgeons, anesthesiologists, cardiac interventionalists, and clinical cardiologists. The present document is thus intended to be a guide to TEE in the following situations: Diagnostic TEE: TEE performed to address a specific diagnostic question Intraprocedural TEE Surgical-based procedure Catheter-based procedure The writing group acknowledges that individual patient characteristics, anatomic variations, pathologic features, or time constraints imposed on performing TEE may limit the ability to perform all aspects of the examination described in this document. Although the beginner should seek a balance between a fastidiously complete, comprehensive examination and expedience, an experienced echocardiographer can complete the examination described here in a reasonable time period. The writing group also recognizes that there may be other entirely acceptable approaches and views of a transesophageal echocardiographic examination, provided they obtain similar information in a safe manner. In addition, although this document presents a suggested protocol of image acquisition, the order and number of views may differ for various indications. For some indications, additional special views are recommended, and these are described in the “Specific Structural Imaging” section of this document. The document is not intended to review specific indications for TEE or to cover extensively abnormalities seen with this modality. 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and the patient is specific to the procedure and are that the patient individual to in of or Sedation and Anesthesia The following section is a review of for and the of a comprehensive transesophageal echocardiographic should be that and to and and that have its The following should as a guideline and these have the with of a of or is Although an of in the have been of for of with in and of patient and the use of may be achieved with a of by or suggested that although was by was by and for by to the The may be or of the can the for of may not adequately the of has also been The and of should not be The for with use of is and to a number of clinical including of and and of include and a in by with has a with of this is with and may in and can be with and to followed by with that is with in and should be in these to the and facilitate probe and the of do not in the intensive care may as this or the for additional TEE with is The are of with the for transesophageal echocardiographic has a 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