Transesophageal Echocardiogram

Definition

An echocardiogram uses ultrasound and Doppler principles to create images of the heart. A Transesophageal echocardiogram (TEE) is a less common form of echocardiogram. It is an invasive form of ultrasound in which a probe is passed down the esophagus. It uses the same principals as a transthoracic echocardiogram (TTE) but usually has cleaner and higher definition of the heart and its structures. There are specific conditions which may require a transesophageal echocardiogram. It is not a routine procedure, and is usually used after a transthoracic echocardiogram fails to reveal the specific condition or to gain further knowledge on existing condition. It is very rarely the first form of echocardiogram to undergo (exception is under certain conditions).

Transesophageal echocardiograms are excellent in showing certain structures of the heart more clearly than a transthoracic echocardiogram.

Why Performed

The most common uses for a TEE are:

  • to evaluate valvular conditions (mitral valve, aortic valve, tricuspid valve, pulmonic valve)
  • to determine if there is a thrombus (clot) in the left atrial appendage (a small chamber attached to the left atrium) prior to a cardioversion (DCCV) for atrial fibrillation (AF) or atrial flutter (AFL)
  • in preparation for open heart surgery to provide the most information to the surgeon prior to operation for valvular problems (such as mitral valve disease, Transcutaneous Aortic Valve Replacement (TAVR or TAVI)
  • to determine if you should have your heart valve repaired or replaced (mitral valve and tricuspid valve disease)
  • to assess your valves and/or heart for infection (i.e. infective endocarditis), or assess the effectiveness of treatment/resolution of infection
  • to obtain better images that a standard echocardiogram could not obtain (poor transthoracic visualization)

Risks

A transesophageal echocardiogram (TEE) is an invasive form of echocardiogram. You will be sedated prior to the procedure. However, your throat may feel sore after the procedure. This discomfort normally lasts a few hours. Rarely, the tube may cause damage to the inside of your throat. The other risks are respiratory distress, esophageal rupture, arrhythmias (electrical disturbance of heart), and very rarely, death (because of esophageal rupture). Your vital signs and oxygenation level will be monitored during the procedure.

You should let your doctor know if you have any loose teeth, dentures, or any loose objects/structures in your mouth prior to starting the procedure. These objects may dislodge and cause damage to your throat or mouth during insertion of the TEE probe. These objects should be removed prior to starting the procedure.

There is special consideration given to patients who:

  • had radiation to the chest, neck, or mouth in the past
  • have difficulty swallowing or feeling food/liquids “getting stuck” in your throat
  • known esophageal disease

These patients are at much higher risk for sustaining damage to the esophagus or mouth during a TEE. Please inform your doctor if any of the above pertains to you.

Preparation

Prior to a transesophageal echocardiogram (TEE), you will likely be asked to avoid eating or drinking anything for at least 4-8 hours prior to the scheduled procedure. After a transesophageal echocardiogram, you will be asked not to drive the day of the procedure primarily because of the sedation you receive during your TEE. You should have someone available to drive you home if you are going home the same day as your transesophageal echocardiogram.

Expectation

During the procedure

Transesophageal echocardiograms (TEE) are performed in either a hospital room or as an outpatient basis in rooms equipped for procedures. There will be at least three people present in the room. A nurse that provides medication, the doctor performing the procedure, and the sonographer helping the doctor obtain images of your heart. A timeout will be called in which they verify information regarding you as a patient prior to starting the procedure.

Your throat is numbed prior to insertion of probe used for the test. This may consist of either a spray to the back of your throat or a thick liquid that you gargle and swallow. Most likely a bite block will be placed in your mouth to protect your teeth from the probe. Moderate sedation is used to help attain relaxation prior to the procedure. A flexible long probe is inserted down the esophagus after sedation. Ultrasound images of your heart and valves will be obtained by your doctor. The TEE itself lasts anywhere between 10 minutes and 30 minutes depending on difficulty and extent of imaging your doctor obtained. The entire procedure will take approximately 1 hour from the time you enter the room to the time the images are acquired.

After the procedure

There is a recovery time for a transesophageal echocardiogram (TEE) since you have most likely been sedated. The recovery time takes approximately 1-2 hours depending on how much sedation you received. Your vital signs (blood pressure, respiratory rate, heart rate, and pulse oximetry) will be monitored for at least 1 hour after the procedure. You may ask your doctor the results immediately since the doctor who performs the procedure is the one to formally report the findings.

Results

You may ask your doctor the results immediately since the doctor who performs the procedure is the one to formally report the findings. However, a formal report will be generated 1-2 days after the procedure. The findings may include:

  • whether or not you have a thrombus in the left atrial appendage (LAA) prior to a cardioversion for atrial fibrillation
  • how damaged your mitral valve is causing mitral regurgitation or mitral stenosis
  • how damaged your aortic valve is causing aortic stenosis or aortic regurgitation
  • assessment of your left ventricular ejection fraction (LVEF)
  • whether or not you have an abnormal communication between the top two chambers of your heart (patent foramen ovale, also known as PFO; atrial septal defect, also known as ASD)
  • whether or not you have an abnormal communication between the two bottom chambers of your heart (ventricular septal defect, also known as VSD)
  • how severe the regurgitation (leakiness) of your valves are including the mitral valve, aortic valve, tricuspid valve, pulmonic valves
  • whether or not your mitral valve should be repaired or replaced (extremely important to the surgeon)