Transesophageal echocardiogram:

A transesophageal echocardiogram, or TEE (TOE in the United Kingdom, reflecting the

spelling transoesophageal), is an alternative way to perform an echocardiogram. A specialized
probe containing an ultrasound transducer at its tip is passed into the patient's esophagus.[1]This
allows image and Doppler evaluation which can be recorded.
It has several advantages and some disadvantages compared to a transthoracic
echocardiogram (TTE).

Indications
Specialty medicine professional organizations recommend against using transesophageal
echocardiography to detect cardiac sources of embolization after a patient's health care
provider has identified a source of embolization and if that person would not change a patient's
management as a result of getting more information.[2] Such organizations further recommend
that doctors and patients should avoid seeking transesophageal echocardiography only for the
sake of protocol-driven testing and to agree to the test only if it is right for the individual patient.[2]

Advantages
The advantage of TEE over TTE is usually clearer images, especially of structures that are
difficult to view transthoracically (through the chest wall). The explanation for this is that the
heart rests directly upon the esophagus leaving only millimeters that the ultrasound beam has to
travel. This reduces the attenuation (weakening) of the ultrasound signal, generating a stronger
return signal, ultimately enhancing image and Doppler quality. Comparatively, transthoracic
ultrasound must first traverse skin, fat, ribs and lungs before reflecting off the heart and back to
the probe before an image can be created. All these structures, along with the increased
distance the beam must travel, weaken the ultrasound signal thus degrading the image and
Doppler quality.
In adults, several structures can be evaluated and imaged better with the TEE, including
the aorta, pulmonary artery, valves of the heart, both atria, atrial septum, left atrial appendage,

and coronary arteries. TEE has a very high sensitivity for locating a blood clot inside the left
atrium.[3]

Disadvantages

TEE requires a fasting patient. The patient must follow the ASA NPO guidelines (i.e.
usually not eat anything for eight hours and not drink anything for two hours prior to the
procedure.)

Requires a team of medical personnel

Takes longer to perform than TTE

May be uncomfortable for the patient

May require sedation or general anesthesia

There are some risks associated with the procedure (esophageal perforation[4]1 in
10,000,[citation needed] and adverse reactions to the medication.)

Process
Before inserting the probe, mild to moderate sedation is induced in the patient to ease the
discomfort and to decrease the gag reflex, thus making the ultrasound probe easier to pass into
the esophagus. Mild or moderate sedation can be induced with medications such
asmidazolam (a benzodiazepine with sedating, amnesiac qualities), fentanyl (an opioid),
or propofol (a sedative/general anesthetic, depending on dosage) . Usually a local anesthetic
spray is used for the back of the throat, such a xylocaine and/or a jelly/lubricant anesthetic for
the esophagus. Children are anesthetized. Unlike the TTE, the TEE is considered an invasive
procedure and is thus performed by physicians in the U.S., not sonographers.

Clinical uses
In addition to use by cardiologists in outpatient and inpatient settings, TEE can be performed by
a cardiac anesthesiologist to evaluate, diagnose, and treat patients in the peri-operative period.
Most commonly used during open heart procedures, it can be used in the setting of any
operation if the patient's status warrants it. TEE is very useful during many cardiac surgical

procedures like mitral valve repair.it's actually an essential monitoring tool during this
procedure.it helps to detect and quantify the disease preoperatively and assess the results of
surgery immediately after the procedure.if the repair is found to be inadequate showing
significant residual regurgitation surgeon can decide whether to go back to CPB and try to
correct the defect. aortic dissections are another important condition where TEE is very helpful
TEE can also help the surgeon during insertion of catheter for retrograde cardioplegia.