📚 Guideline basis
Hahn RT, et al. Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists — the 28-view protocol (JASE 2013;26:921–64); ASE 2024 prosthetic valve guideline (deep oesophageal views for tricuspid intervention).
Probe manipulation vocabulary
Standardised terminology is a reporting requirement, not a stylistic preference — a described view is only reproducible if the manoeuvres are named consistently.
Manoeuvre | Action |
Advance / withdraw | Move the probe deeper into or out of the oesophagus |
Turn right / turn left | Rotate the entire shaft clockwise / anticlockwise |
Anteflex / retroflex | Large control wheel; tip moves anteriorly (toward the heart) or posteriorly |
Flex right / flex left | Small control wheel; lateral tip deflection |
Rotate forward / back | Electronic multiplane angle, 0° to 180° |
Four probe depths define the view groups: upper oesophageal (~20–25 cm), mid-oesophageal (~30–40 cm), transgastric (~40–45 cm), and deep transgastric (~45–50 cm).
The comprehensive 28-view set
Grouped by depth, with the multiplane angle and the question each view answers.
Mid-oesophageal views
View | Angle | Structures | Answers |
ME four-chamber | 0–10° | All four chambers, mitral and tricuspid valves, septa | Chamber size, biventricular function, MR/TR, septal defects |
ME two-chamber | 80–100° | LA, LV anterior and inferior walls, LA appendage | Regional function, LAA thrombus |
ME long axis | 120–140° | LVOT, aortic valve, ascending aorta, anterior septum, posterior wall | AV and MV mechanism, LVOT obstruction, aortic root |
ME mitral commissural | 60–80° | P3–A2–P1 scallops | Mitral scallop localisation |
ME AV short axis | 30–45° | Aortic cusps en face, interatrial septum, coronary ostia | Bicuspid valve, vegetation, cusp perforation |
ME AV long axis | 120–140° | Root, sinotubular junction, proximal ascending aorta | AR mechanism, dissection flap, abscess |
ME right ventricular inflow–outflow | 60–75° | RA, TV, RV, RVOT, pulmonic valve | TR, PV disease, RVOT, pulmonary embolus in the main PA |
ME bicaval | 90–110° | SVC, IVC, RA, interatrial septum | PFO/ASD bubble study, SVC collapsibility, cannula and lead position |
ME ascending aorta short and long axis | 0° / 90° | Ascending aorta, right PA | Dissection, atheroma, aortic cannula |
ME descending aorta short and long axis | 0° / 90° | Descending thoracic aorta | Dissection, atheroma, intramural haematoma |
Transgastric views
View | Angle | Value |
TG mid short axis (papillary level) | 0–20° | The workhorse haemodynamic view: LV size, global and regional function, septal shape and D-shaping, rapid volume assessment |
TG two-chamber | 90–110° | Subvalvular apparatus, chordae, papillary muscles |
TG long axis | 120–140° | LVOT and aortic valve alignment for Doppler |
TG RV inflow | 100–120° | RV free wall, tricuspid subvalvular apparatus |
Deep TG long axis | 0–20°, anteflexed and advanced | The only reliable TEE window for LVOT and aortic valve spectral Doppler |
Upper oesophageal views
Aortic arch short and long axis; pulmonary artery views for pulmonic regurgitation and proximal PA thrombus.
The abbreviated ICU sequence
A comprehensive 28-view study takes 20–30 minutes and is rarely the right examination for an unstable patient. A defensible focused sequence, acquiring roughly 90% of the decision-relevant information in 5–8 minutes:
- ME four-chamber — biventricular size and function, effusion, gross valve function
- ME long axis — LVOT, aortic and mitral valve mechanism
- ME AV short axis — aortic cusps, interatrial septum
- ME bicaval — septal position, SVC collapsibility, cannulae and leads
- ME RV inflow–outflow — RV, tricuspid and pulmonic valves
- TG mid short axis — LV function, septal shape, volume
- Deep TG long axis — LVOT VTI and any aortic gradient
- Descending aorta — on withdrawal, at no additional cost
Add targeted views for the specific question: 3D en face for a mitral prosthesis or paravalvular leak; ME two-chamber for the appendage; ascending aorta and arch for dissection.
Haemodynamic acquisition by TEE
TEE outperforms TTE for several haemodynamic measurements in the ventilated patient, and this is under-exploited.
Measurement | View | Advantage over TTE |
LVOT VTI / stroke volume | Deep transgastric long axis | Obtainable when no transthoracic window exists; angle is often better than the TG long-axis view |
SVC collapsibility (≥ 36% predicts fluid responsiveness) | ME bicaval, M-mode | Intrathoracic vein, unaffected by intra-abdominal pressure — more specific than IVC distensibility |
Pulmonary venous flow | ME four-chamber with anterior tilt, left or right upper vein | Far more feasible than TTE, where the ASE 2025 diastolic guideline explicitly notes poor ICU feasibility |
Interatrial septal position | ME bicaval | Neutral, right-bulging (LAP > RAP) or left-bulging; a direct LAP–RAP comparison |
Hepatic vein flow | Deep TG / modified | Congestion assessment |
LV filling and septal shape | TG mid short axis | Best single view for volume and RV overload |
TEE-specific pitfalls
Pitfall | Mechanism | Mitigation |
The ascending aorta blind spot | Air in the trachea and left main bronchus interposes between the oesophagus and the distal ascending aorta / proximal arch | Acknowledge explicitly; CT if the question is dissection extent |
Doppler misalignment in ME views | Flow is perpendicular to the beam in most mid-oesophageal planes | Use deep transgastric for spectral Doppler; never angle-correct |
LV foreshortening in ME four-chamber | The probe is behind the base; the apex is in the far field and easily cut off | Retroflex and withdraw slightly; use TG views for volumes |
Underestimation of anteriorly located pathology | Near-field structures shadow far-field ones; the LAA and anterior aortic root are affected differently on TEE than TTE | TEE and TTE are complementary for prosthetic aortic valves — TEE sees the posterior root, TTE the anterior |
Reverberation from prosthetic material or leads | Mimics vegetation, flap, or thrombus | Confirm in two orthogonal planes and across gain settings |
Missing a PFO | Inadequate provocation or wrong injection site | Right-arm injection; agitated saline with a small blood component; provoke with a Valsalva release or a brief airway pressure release in the ventilated patient; watch the left atrium for 3–6 beats after right-sided opacification |
Documentation
The report should state probe depth and multiplane angle for each key finding, the views obtained and any that could not be obtained, the sedation used, complications, and — for prosthetic valve and endocarditis studies — an explicit statement of what was and was not excluded. Store loops of every acquired view; the 3D data sets in particular are frequently re-analysed by the surgical team.
🛑 Critical pitfall: Reporting "no dissection" after a TEE without noting the distal ascending aorta / proximal arch blind spot. Tracheal air makes this segment unreliable, and type A dissection can be missed.
🛑 Critical pitfall: Measuring LVOT VTI from a mid-oesophageal view. Alignment is poor and the velocity will be underestimated; use the deep transgastric long axis.
🛑 Critical pitfall: Concluding "no PFO" from a bubble study without adequate provocation. In a ventilated patient, a positive-pressure breath abolishes the transient right-to-left gradient that reveals the shunt; a release manoeuvre is required.
- 💡 Clinical pearl: SVC collapsibility from the ME bicaval view is the most specific echocardiographic index of fluid responsiveness available in the ventilated patient, and it takes seconds once the probe is in.
- 💡 Clinical pearl: Withdraw slowly at the end of every study, imaging the descending aorta and arch. It costs nothing and finds atheroma, dissection and intramural haematoma.
- 💡 Clinical pearl: The transgastric mid short-axis view answers "is this ventricle full, is it contracting, and is the septum shifted?" faster than any other single image in the ICU.
References
- Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination. J Am Soc Echocardiogr 2013;26:921–64.
- Nagueh SF, Sanborn DY, Oh JK, et al. ASE 2025 diastolic function update. J Am Soc Echocardiogr 2025;38:537–69.
- Vieillard-Baron A, Chergui K, Rabiller A, et al. Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med 2004;30:1734–9.
- Zoghbi WA, Jone PN, Chamsi-Pasha MA, et al. Guidelines for the evaluation of prosthetic valve function with cardiovascular imaging. J Am Soc Echocardiogr 2024;37:2–63.