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86
E. Ablordeppey and A. Murphy-Crews
While pulmonary artery acceleration
time can be used to estimate mean pulmonary artery pressure, the calculation does
not use the modied Bernoulli equation.
The modied Bernoulli equation calculates
a pressure gradient from a velocity. One
needs to know the pressure in one of the
chambers in order to calculate the pressure
in the other.
4. Which of the following is true regarding spectral Doppler imaging?
A. Pulmonary veins can be useful in diagnos-
ing additional pathologies such as TR and
right heart failure
B. An abnormal hepatic waveform pattern is
demonstrated showing S/D<1 indication
of elevated RAP
C. The more severe the tricuspid regurgita-
tion, the less pulsatile the hepatic waveform becomes
D. Flow reversal through hepatic veins means
that the pattern cannot be used to assess
right atrial pressure
Answer: B. An abnormal hepatic waveform pattern is demonstrated showing S/D<1
indication of elevated RAP.
Pulmonary vein hemodynamics are typically more informative of left-sided diastolic function. Normal hepatic waveforms
(and pulmonary vein waveforms) are systolic dominant in adults. Severe TR can
increase hepatic vein pulsatility. Flow
reversal associated with diastolic dysfunction can offer some information about right
atrial pressures, while ow reversal associ-
ated with tricuspid regurgitation may be
less clear.
References
1. Mottram PM, Marwick TH.Assessment of diastolic
function: what the general cardiologist needs to know.
Heart. 2005;91(5):681–95.
hrt.2003.029413.
2. Kamp O. Advanced systolic and diastolic function: beyond the E-and A-wave. Semin Cardiothorac
Vasc Anesth. 2016;10(1):63–5.
org/10.1177/108925320601000111.
3. Echocardiographic assessment of diastolic function.
Digestive Dis Sci. 2019;63(12):119.
4. Garcia MJ. Comprehensive echocardiographic
assessment of diastolic function. Heart Failure
Clin. 2006;2(2):163–78.
hfc.2006.01.005.
5. Scheineld MH, Bilali A, Koenigsberg
M.Understanding the spectral Doppler waveform of
the hepatic veins in health and disease. Radiographics.
2009;29:2081–98.
rg.297095715.
6. Rudski LG, MD. Guidelines for echocardiographic
assessment of the right heart in adults: a report from
the American Society of Echocardiography. J Am Soc
Echocardiogr. 2010;23:685–713.
7. Miller D, Farah MG, Liner A, Fox K, Schluchter
M, Hoit BD.The relation between quantitative right
ventricular ejection fraction and indices of tricuspid
annular motion and myocardial performance. J Am
Soc Echocardiogr. 2004;17(5):443–7.
org/10.1016/j.echo.2004.01.010.
8. Fadel BM, Pibarot P, Kazzi BE, Al-Admawi M,
Galzerano D, Alhumaid M, Alamro B, Mahjoub H,
Echahidi N, Mohty D. Spectral Doppler interrogation of the pulmonary veins for the diagnosis of cardiac disorders: a comprehensive review. J Am Soc
Echocardiogr. 2021;34(3):223–36.
9. www.cardioserv.net.
https://doi.org/10.1136/
https://doi.
https://doi.org/10.1016/j.
https://doi.org/10.1148/
https://doi.
Transesophageal Echocardiography: Insertion, Manipulation, Risks, Complications
ChristopherKoo andDanielWalsh
8
Learning Objectives
1. Understand the indications and risks of TEE.
2. Know the complications of TEE.
3. Understand how to insert and manipulate the
TEE probe.
Indications
Point of care ultrasound (POCUS) is becoming
rapidly embraced as a noninvasive and portable
way of evaluating and directing management of
patients in the hospital setting. With the advent of
readily accessible ultrasound equipment, echocardiography has become an invaluable tool for
assessing the presence of a wide range of pathology. More specically, in the ICU, echocardiography can be used to assess hemodynamic
instability and to evaluate ventricular function,
valvular anatomy, post-surgical complications,
pericardial effusions, undiagnosed congenital
heart disease, cardiopulmonary thrombosis, and
the integrity of the aorta [1, 2].
TEE may be preferred over TTE when patients
are not suitable candidates for adequate transthoracic imaging. TTE may be inadequate in almost
40% of patients in the ICU [2]. Limitations can
include dressings or other supercial objects,
C. Koo · D. Walsh (*)
Beth Israel Deaconess Medical Center,
Boston, MA, USA
e-mail: dpwalsh@bidmc.harvard.edu
unconducive body habitus, edema, and severe
lung disease. A change in body weight of >10%
from admission, usage of PEEP>15 cmH2O,
and the presence of chest tubes are all risk factors
for an inadequate TTE examination [2–5].
Despite this potential difculty in obtaining
satisfactory exams, several studies report that up
to 32–79% of patients who received echocardiography in the ICU had some form of their management changed including changes in uid
administration, treatment limitations, surgical
intervention, or adjustments to inotropes and
vasopressors [6–8].
Post Cardiac Surgery
TEE has proven to be immensely useful in the
post-cardiac surgery patient when the potential
for accurate transthoracic echocardiograms may
be signicantly limited. Usage of TEE in the
post-cardiac surgery patient has been shown to
alter the clinical management 49–59% (medical
and surgical) of the time when compared to conventional clinical bedside assessments. Changes
in surgical management were affected by a TEE
examination approximately 10–38% of the time
with the most common indication being to reexplore for potential bleeding [9].
A potential advantage of TEE in this patient
population is the identication of pericardial
tamponade. Different studies have shown that
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_8
87
88
C. Koo and D. Walsh
TTE alone may miss the diagnosis of tamponade
in 25–59% of patients, diagnosed later by TEE
and conrmed with surgery [10–12].
Acute Cardiopulmonary Disease
Left ventricular failure is the most common cause
of cardiogenic shock. Evaluation of the left
atrium, ventricular anatomy, contractility, and
left-sided valvular defects can help quickly diagnose cases of cardiogenic shock and guide appropriate therapy [13, 14]. While “eyeballing” is a
common way of estimating potential issues with
valvular regurgitation or poor contractility, more
objective assessment can be useful in quantifying
severity of valvular pathology or the severity of
reduced ventricular function. Furthermore, quick
identication of wall motion abnormalities on
TEE exam can further help clarify the need for
revascularization therapy in a patient suffering
from cardiogenic shock.
Compared to pulmonary artery catheters and
thermodilution, TEE showed no signicant difference in estimations of cardiac output.
Furthermore, TEE can help clarify cardiac function in patients with signicant tricuspid regurgitation or intracardiac shunts, a signicant
limitation to the thermodilution method [15].
Using aortic velocity time index (VTI) helps
improve the accuracy of TEE readings of cardiac
output in patients that may not have regular symmetrical blood ow. In the case of patients with
atrial brillation, averaging approximately 13
heart beats could provide mean values of CO
similar in accuracy to those in sinus rhythm.
In addition, acute cor pulmonale (ACP) as
seen in patients with acute respiratory distress
syndrome (ARDS) or pulmonary embolus can
also be evaluated with TEE.In the case of ARDS,
the presence of ACP has been associated with
worse outcomes. Early recognition of RV dysfunction can help guide the course of treatment.
It should be kept in mind however that a complementary TTE examination may be needed in
order to fully measure pulmonary artery systolic
pressure due to difculty in anatomic alignment
and positioning with TEE [16, 17].
Hypovolemia, Fluid Responsiveness
Unexplained hypotension is often the most commonly cited reason for performing a TEE examination in the critically ill. Colreavy etal. found
that an underlying cause was found 2/3 of the
time for patients who received a TEE for unexplained hypotension, 22% leading to surgery
without further diagnostic workup [4].
Accurate prediction of whether or not a patient
will be responsive to additional volume resuscitation continues to be a topic of debate especially
for those in the ICU.Intravascular depletion can
be assessed using TEE depending on whether or
not the patient is spontaneously breathing or reliant on ventilatory support. Usage of the inferior
vena cava (IVC) and superior vena cava (SVC)
change in diameter are common metrics for
determining a patient’s uid responsiveness. In
the fully ventilator-dependent patient, a ratio of
the change in IVC diameter called the distensibility index has a reported sensitivity and specicity
of 90%. Changes in the SVC during mechanical
ventilation of >36% during inspiration has a sensitivity of 90% and specicity of 100% [13, 14].
A therapeutic response to volume resuscitation can then be subsequently assessed via a
change in SV or CO of >15% using
TEE. Measurements using VTI and CSA can
quantify stroke volume and cardiac output then
approximated using the classic CO=SV×HR
equation [14].
A study using esophageal Doppler and passive
leg raise reported that a >10% aortic blood ow
predicted uid responsiveness with a sensitivity
of 97% and specicity of 94% [18].
It is important, however, to consider the effect
of RV function as well as the rate and volume of
mechanical ventilation before relying on these
measures to guide uid resuscitation.
Endocarditis
One of the major criteria for the diagnosis of
endocarditis is identication of a characteristic
nding on echocardiogram with TEE being the
preferred modality in patients with prosthetic
8 Transesophageal Echocardiography: Insertion, Manipulation, Risks, Complications
89
valves or potential paravalvular abscesses [19,
20]. While TTE is noninvasive and can be logisti-
cally preferred in patients with potential infective
endocarditis, as discussed previously in this
chapter, adequate imaging via a transthoracic
evaluation may not always be accurate or even
feasible in the ICU.
Bai etal. compared TTE detection of vegetations on prosthetic valves against TEE and found
a sensitivity of 46% and specicity of 79%. When
used to detect intracardiac abscesses, the results
showed a wide range of reported sensitivity for
TTE of anywhere between 29% and 100% [21].
Another report showed that while TTE was able
to identify correctly 80% of the patient without
vegetations, 44% of patients who were found to
have false positives when re-examined with
TEE. Furthermore, 37% of patients with prosthetic valves and inconclusive results on TTE
were found to have vegetations on TEE examination [22].
While TTE may be satisfactory screening tests
in patients with native valves and low likelihood
of infective endocarditis, indeterminate TTE
imaging, or the presence of valvular prostheses
highlights the advantage of TEE to denitively
assess the critically ill patient for potential infective endocarditis.
Aortic Pathology
Use of TEE in assessing disease of the aorta in
the ICU setting can be considered in those with
suspected dissection, intramural hematomas, or
penetrating atherosclerotic ulcers (PAUs) and
contraindications to contrast CT imaging. With
regard to aortic dissections, TEE has been found
to have both high sensitivity and specicity for
aortic dissections reaching 99% and 89%, respectively. Localization of intimal tears can be found
using TEE up to 78–100% of the time. Sensitivity
is 100% for detecting aortic regurgitation as a
complication of dissection. Impressively, by adding the use of small amounts of peripherally
injected contrast, TEE has reportedly shown
almost perfect sensitivity and specicity for
detecting aortic dissection, intramural hematoma,
and penetrating aortic ulcers [23, 24]. TEE can
however be limited in its ability to assess the distal ascending aorta as well as proximal aortic
arch where interference by the trachea and bronchus can limit image quality [23].
In the post aortic surgery patient, TEE can
also assess the integrity of aortic arch repairs or
grafting, trauma, or the presence of endoleaks
after endovascular intervention of aneurysms. In
fact, color ow Doppler TEE has been shown to
be superior to angiography in detecting graft
leaks [25].
Assessment ofEmbolism Risk
A common indication for TEE is to assess for
presence of a potential cardiac source of embolism, particularly in the setting of atrial brillation or utter. TTE is not sufcient to rule out the
presence of thrombus in the left atrium in the setting of atrial brillation and can facilitate
decision- making in regards to anticoagulation
and cardioversion [26].
Risks andComplications
Risks of TEE can be separated into risks related
to the procedure itself and risks related to any
necessary sedation required to perform the procedure. Understandably, these risks may be reduced
in the ICU where many patients are already intubated and sedated compared to the ambulatory
setting. This discussion will focus on the risks
related to the procedure itself.
Studies of TEE safety in general report 0.5%
complication rates and a mortality rate of <0.01%
[5, 27]. Similarly, TEE in the ICU is generally
low risk in relation to major complication or mortality. From 2508 reported cases of TEE, specically in ICU patients, no incidents of
oropharyngeal, esophageal, or gastric perforations occurred. No mortalities were reported. The
most common complications included nasogastric tube removal, abrasion of oropharyngeal surfaces, transient hypotension from increased
sedation, and sometimes transient hypoxemia.
90
C. Koo and D. Walsh
Table 8.1
Complication Incidence (%)
Hemodynamic instability 0.8
Arrhythmias 0.2–0.9
Signicant bleeding 0.03–0.8
Oropharyngeal bleeding 0.01–0.7
Hypoxia 0.2
Esophageal perforation 0.01–0.3
Endotracheal tube displacement 0.03
Mortality <0.01
These less serious complications typically
occurred approximately <1–2% of the time, with
transient hypotension and trauma to the oropha-
TEE complications and incidences
instability, severe arthritis), symptomatic hiatal
hernias, esophageal varices, coagulopathy, and
severe thrombocytopenia [5, 26, 30].
ryngeal surfaces occurring most commonly [5].
Even in special populations such as those with
thrombocytopenia or esophageal varices (grade 1
Insertion
or 2) have reportedly underwent TEE without
signicant rates of adverse events [28, 29].
Table 8.1: Complications from TEE are listed
with the most frequent events listed in descending order. Because of a lack of data specic to the
ICU population, the numbers are primarily from
studies looking at both ICU and perioperative
settings [5, 27].
Prior to insertion of the transesophageal echocardiography probe, it is important to ensure adequate preparation, positioning, and resources to
perform the exam safely. Performing clinicians
should review the patient’s unique circumstances
and assess any potential contraindication to examination. Consideration of any pertinent history,
exam ndings, lab results, and prior imaging ndings should be done. The presence of an endotra-
Contraindications toTEE
cheal tube and mechanical ventilatory support,
oral or nasogastric tube, use of vasopressors or
Absolute contraindications to TEE include the
presence of a perforated viscus, esophageal
abnormalities such as strictures, tumors, lacerations, or diverticula, as well as active upper gastrointestinal bleeding. Physical defects and
deformities can lead to difculty placing the
device safely and potentially worsen already
existing lesions further jeopardizing the patient.
Relative contraindications should be carefully
inotropes, and sedating medications should also
be taken into account prior to examination.
Depending on the indication, paralysis prior to
insertion of the probe may be helpful. The ability
of the patient to tolerate repositioning should be
also claried. Last, ensure that all equipment has
been cleaned and safe for use in a new patient and
that additional assistance can be quickly called for
should it be required [26, 30, 31].
considered against a risk versus benet analysis
of the patient’s current clinical status and potential diagnostic value. Examples of relative contra-
For Insertion oftheTEE Probe
indications to consider before performing TEE
on a critically ill patient include prior radiation to
the neck and mediastinum, prior gastrointestinal
surgery, recent upper gastrointestinal bleeding,
Barrett’s esophagus, active esophagitis or peptic
ulcer disease, a reported history of dysphagia,
reduced cervical range of motion (atlantoaxial
1. The operator should be at the head of the bed
with the patient ideally in the left lateral decubitus position. The height of the bed should be
adjusted based on the operator’s comfort.
2. If there is an endotracheal tube in place, it
should be carefully secured to the left corner
8 Transesophageal Echocardiography: Insertion, Manipulation, Risks, Complications
91
of the patient’s mouth to allow for easier passage of the TEE probe.
3. If the patient is sedated, consider additional
sedation during initial passage of the TEE
probe from the mouth into the esophagus as
this may be particularly stimulating. Careful
monitoring of vital signs is recommended.
4. A bite block can be placed, being careful not
to push the patient’s tongue posteriorly and
occlude the hypopharynx.
5. Topical lubricant should be applied to the
probe.
6. After ensuring the probe is not in the locked
position, the probe can be inserted into the
patient’s mouth, midline, to avoid placement
into the piriform fossae. An assistant can help
thrust the mandible forward or to ex the
patient’s neck while the operator lightly anteexes the probe to help follow the natural
curvature of the hypopharynx into the
esophagus.
7. If resistance is met while inserting the probe,
efforts to insert the probe should stop to prevent injury to the pharynx, esophagus, or
stomach.
8. Direct or videolaryngoscopy can be used to
help visualize and guide the TEE probe down
the esophagus if there is continued
difculty.
1
9. When advancing the probe, it is important to
generally avoid ante- or retroexion of the
probe head as this may cause injury.
Manipulation
Standardized terminology provided by the
American Society of Echocardiography is commonly used to describe handling and operation of
a TEE probe. The patient is assumed to be in the
standard anatomic position and supine. The
imaging plane from the probe is thus anterior
pointing from the esophagus towards the heart
1
Currently, while some studies have shown a decreased
number of insertion attempts and mechanical trauma with
the use of direct or videolaryngscopy for TEE insertion,
the evidence is not robust [32].
and sternum while posterior directs the user
towards the spine. In this position, superior is
meant to refer towards the head and inferior
towards the feet. Right and left are in relation to
the patient’s right and left. It is important to keep
in mind that the image displayed from the TEE
probe is typically inverted from anatomic position with structures located on the patient’s right
viewed on the left side of the TEE image.
Advancement is used to describe further insertion of the TEE probe into the esophagus and
withdrawal to mean retraction of the probe out of
the esophagus. Rotation along the parallel axis of
the esophagus is turning to the right and left.
Movement of the probe tip out of the axis parallel
to the esophagus or “curving” the probe can be
performed by most standard TEE probes by a
large control wheel with anterior and posterior
movement of the probe tip described as anteexing and retroexing, respectively. Lateral exion
to the right and left is performed via a smaller
control knob that typically sits atop of the larger
counterpart.
Altering the angle of the imaging plane from
0° to 180°, or the horizontal/transverse plane, is
called rotating forward. Rotating from 180° back
to 0 is rotating backward. When the imaging
plane is at 90°, it is referred to a vertical or longitudinal plane. These movements can be performed typically by buttons on the probe that
increase or decrease the angle. Keep in mind that
due to the horizontal inversion from the patient’s
anatomic position and the image displayed,
movement from 0° to 90° of the imaging plane
will cause the left side of the image to now display inferior structures instead of anatomy on the
patient’s right side [26, 30, 33] (Fig.8.1).
An example using the midesophageal four
chamber view for assessment of MV and TV
function, global LV and RV systolic function, and
regional LV inferoseptal and anterolateral wall
motion is provided:
1. Advance the probe to 30–35cm until immedi-
ately posterior to the left atrium.
2. Turn the probe to the left or right to center the
patient’s mitral valve and left ventricle in the
imaging display.
92
Turn to
the Left
Turn to
the Right
Withdraw
Advance
Anterior Posterior Right
Anteflex Retroflex
Fig. 8.1 Manipulation terminology. (Illustration from
Hahn etal. [26])
0°
Rotate
Forward
Flex to
the Right
90°
180°
Rotate
Back
Left
Flex to
the Left
3. If necessary, adjust the multiplane angle up to
about 10–20°.
4. Slight retroexion of the probe can be used to
further align the MV and LV apex.
Summary Points
• TEE can be useful when TTE is nondiagnostic
or not sufciently diagnostic.
• TEE is a low-risk procedure with complica-
tion rates generally 0.5% incidence or
lower.
• Complications can include bleeding, esopha-
geal damage, airway or hypoxia issues, or
hemodynamic instability.
• There are very few absolute contraindications
to TEE but they include severe esophageal
pathology such as perforations, strictures,
diverticula, or bleeding.
• Considerations for insertion include patient
positioning, patient sedation, placement of
bite block, and probe position.
C. Koo and D. Walsh
• Use of standardized terminology allows for
discussion of probe manipulation to systematically obtain views and make assessments.
Questions
1. You would like to perform a TEE in order to
evaluate a patient with a history of prosthetic
valve replacement who continues to have
unexplained hemodynamic instability. Before
performing the exam, you review the patient’s
chart to identify any possible contraindications. Which of the following is neither a relative nor absolute contraindication to
performing TEE?
A. Symptomatic hiatal hernia
B. Scleroderma
C. Therapeutic anticoagulation
D. Esophagitis
Answer: C. Therapeutic anticoagulation.
While active GI bleeding is an absolute contraindication and coagulopathy and recent GI
bleeding are both relative contraindications, the
use of therapeutic anticoagulation is not. The
risk of oropharyngeal or esophageal trauma
should always be considered when considering
the use of TEE, but serious injury or complication is rare even in critically unstable patients.
2. On a mid-esophageal four chamber view, you
note that you have a foreshortened ventricle
and would like to manipulate the probe to
optimize your image. You would like to retroex the probe by:
A. Adjusting the large wheel on the probe
B. Pressing the down button on the probe
C. Pushing on the midshaft of the probe
while leaning forward
D. Adjusting the small wheel on the probe
Answer: A.Adjusting the large wheel on
the probe. The large wheel on the probe allows
the probe to ex anteriorly or posteriorly,
described as anteexing and retroexing,
respectively. The smaller wheel on the probe
allows the probe to move in a lateral motion.
The buttons on the probe rotate the imaging
plane and do not move the probe itself.
8 Transesophageal Echocardiography: Insertion, Manipulation, Risks, Complications
93
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Transesophageal Windows
andViews
MarkHamlin andArielBensimhon
9
Abbreviations
2D Two-dimensional
3D Three-dimensional
AA Ascending aorta
Ao Aorta
AV Aortic valve
CS Coronary sinus
DTG Deep transgastric
IAS Interatrial septum
IVS Interventricular septum
LA Left atrium
LIPV Left inferior pulmonary vein
LSPV Left superior pulmonary vein
LV Left ventricle
LVOT Left ventricular outow tract
ME Mid esophageal
MV Mitral valve
PA Pulmonary artery
PV Pulmonic valve
RA Right atrium
RAA Right atrial appendage
RIPV Right inferior pulmonary vein
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 80038- 2_9.
M. Hamlin (*) · A. Bensimhon
Department of Anesthesiology, University of
Vermont, University of Vermont Medical Center,
Burlington, VT, USA
e-mail: Mark.Hamlin@uvmhealth.org
RSPV Right superior pulmonary vein
RV Right ventricle
RVOT Right ventricular outow tract
TEE Transesophageal echocardiography
TG Transgastric
TV Tricuspid valve
UE Upper esophageal
2D Transesophageal Imaging
The transesophageal echocardiographic (TEE)
exam for adults with structurally normal hearts,
i.e., those without profound congenital heart malformations, will consist of images obtained in the
upper esophageal (UE), mid esophageal (ME),
transgastric (TG), and deep transgastric (DTG)
esophageal probe positions. Image optimization
will utilize probe manipulations seen in Fig.9.1.
Image acquisition sequences are based on anatomy, echo view, or cardiac segment and are inuenced by clinical situation and institutional
protocols. Figure9.2 offers a pictorial representation of probe movements used to complete an
exam. Within each image, structure morphology
and function should be noted, with interrogation
including color ow and spectral Doppler where
applicable [1–3].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_9
95