JDMS 21:309–317 July/August 2005 309

ARTICLE
10.1177/8756479305275569

JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY July/August 2005 VOL. 21, NO. 4

TRANSESOPHAGEAL ECHOCARDIOGRAPHY / Brickner

JDMS 21:309–317 July/August 2005

JDMS 21:309–317 July/August 2005

Transesophageal
Echocardiography
Transesophageal echocardiography (TEE) has
M. ELIZABETH BRICKNER, MD become a widely used imaging modality that
provides important and complementary infor-
mation to standard transthoracic imaging.
Sonographic imaging of the heart is performed
In accordance with ACCME Standards, authors are required to using a flexible endoscope with an ultrasound
disclose any commercial affiliations or financial interests that might be transducer mounted near the end. The close
perceived as a real or apparent conflict of interest related to the content proximity of the heart to the esophagus allows
of their JDMS CME article. The author, M. Elizabeth Brickner, MD,
did not disclose any real or apparent conflict(s) of interest. the use of a high-frequency transducer, which
gives high-quality images of cardiac structure
and avoids interference from air-containing
lungs. TEE allows high-quality imaging of most
cardiac structures, including posterior structures
such as the atria and their appendages as well as
the thoracic aorta. However, anterior structures
such as the true left ventricular apex and the pul-
monic valve may be better imaged from the
transthoracic position. While there are many in-
dications for TEE, the most common indications
are to rule out endocarditis or, in the clinical
situation of stroke, to rule out cardiac-source
emboli.

Key words: indications, contraindications, pa-

tient preparation

Preprocedure Assessment
Since transesophageal echocardiography (TEE)
is an invasive procedure with some small risk to the
patient, it is important that the procedure be per-
formed for appropriate indications.1 Each individ-
ual patient’s risk for the procedure must be
addressed.2 Extremely rare complications of TEE
have included death (less than 0.01%) and esopha-
Correspondence: Society for Diagnostic Medical Sonography, c/o geal perforation (0.02%-0.03%). Transient vocal
Dawn Sanchez, 2745 N. Dallas Parkway, Suite 350, Plano, TX 75093.
E-mail: dsanchez@sdms.org.
cord paralysis and arrhythmias (predominantly
Article originally published by the SDMS Educational Foundation supraventricular tachycardia) have also been re-
within the Integrated Reference Guide, volume 2. JDMS expresses ported but are uncommon. The major risk associ-
appreciation to S. Michelle Bierig, MPH, RDCS, RDMS, for editing ated with TEE is respiratory depression associated
and updates.
with sedation. Contraindications to TEE are listed
DOI: 10.1177/8756479305275569 in Table 1.
310 JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY July/August 2005 VOL. 21, NO. 4

Patients should be questioned about previous TABLE 1.

exposure to anesthetic agents and any adverse reac- Contraindications to Transesophageal Echocardiography
tions. Their drug allergies and current medications 1. Known esophageal pathology that would predispose
should be reviewed, and significant medical prob- the patient to esophageal perforation or bleeding
lems such as liver or renal disease, which could po- (e.g., malignancy, diverticuli, stricture, “significant
varices”)
tentially interfere with drug metabolism, need to be 2. Severe, uncontrolled bleeding disorders; active upper
assessed. A history of respiratory problems such as gastrointestinal hemorrhage
obstructive sleep apnea, CO2 retention, or other 3. Unstable respiratory status
significant pulmonary disease should be identified 4. Uncooperative patient
prior to the procedure. The possibility of esopha- 5. Unstable cervical spine
geal pathology must also be addressed. The pa-
tients should be asked for any history of known
esophageal problems (strictures, varices, tumors, agents such as naloxone (reverses narcotics) and
etc.) and whether they experience any difficulty flumazenil (reverses benzodiazepines) should also
swallowing. Patients with a history of significant be available.
dysphagia or significant esophageal pathology Topical anesthesia to the oropharynx is used to
should not undergo TEE. The presence of loose minimize patient discomfort. A variety of topical
teeth and any lesions in the mouth or pharynx anesthetic agents can be used, including sprays and
should also be assessed. Coagulation abnormalities gargles. In most health centers in the United States,
and other bleeding problems should also be evalu- intravenous medications are used to reduce anxi-
ated prior to this procedure. Of note, therapeutic ety, improve compliance, and produce retrograde
anticoagulation is not a contraindication for per- amnesia. Commonly used medications include
forming TEE. midazolam, Demerol, and fentanyl. Some labora-
A brief, directed physical examination should tories use anticholinergic agents as well to decrease
also be performed. Baseline vital signs should be the amount of oropharyngeal secretions. The goals
recorded. The airway should be examined to iden- of using intravenous sedation should be to achieve
tify those patients who are at higher risk for airway a state of conscious sedation (i.e., drowsiness and
obstruction (including patients with large, thick relaxation in the patients while maintaining their
tongues and any patient in whom the posterior ability to respond to verbal and tactile stimuli). Ex-
pharynx cannot be visualized) or at risk for difficult treme caution should be taken when using sedation
intubation (limited neck flexion, limited mouth in patients with a history of obstructive sleep
opening, loose teeth). A brief examination of the apnea, CO2 retention, or a high-risk airway. If pos-
heart and lungs should also be included. 3 sible, these patients should undergo the procedure
without sedation. Providing a dark, quiet environ-
Patient Preparation ment also aids in patient relaxation and comfort.
The patient is placed in the left lateral decubitus po-
Patients should be held NPO for a minimum of 4 sition, which allows oropharyngeal secretions to
to 6 hours prior to the procedure to minimize the pool in the side of the mouth. Heart rate, blood
potential risk of aspiration. Patients should be in- pressure, and oxygen saturation, as well as level of
formed about the risks of respiratory depression as- consciousness and respiratory effort, should be
sociated with sedative drugs, the risk of vomiting carefully monitored throughout the procedure and
and aspiration, and the possibility of trauma to the the recovery period.
oropharynx or the esophagus. Written, informed Prophylactic antibiotics should be considered
consent for the procedure should be obtained. In- for high-risk patients. The official recommenda-
travenous access should be established (even in tion from the American Heart Association for the
those patients who do not receive intravenous prevention of bacterial endocarditis states that anti-
drugs for sedation). Supplemental oxygen, suction biotic prophylaxis is not necessary for esopha-
equipment, monitoring equipment, and a crash cart goscopy. While there is no clear consensus among
should be immediately available. Antagonist
 TRANSESOPHAGEAL ECHOCARDIOGRAPHY / Brickner 311

cardiologists, certain high-risk patients (i.e., active Equipment

dental infection, complex congenital heart disease,
history of endocarditis, and perhaps prosthetic In addition to the physician performing the pro-
valves) should probably receive antibiotic cedure, a cardiac sonographer may be present to
prophylaxis. operate the ultrasound machine. This allows the
physician to concentrate on probe manipulation
Procedure and image acquisition. In addition, a nurse is re-
quired to monitor the patient’s vital signs, respira-
A bite block is placed in the patient’s mouth, and tory effort, and level of comfort, as well as to
the probe is inserted into the patient’s mouth and to administer medications. The person assigned to
the back of the pharynx. Either finger-guided or monitor the patient should have no other
control-guided probe insertion can be performed. responsibilities during the procedure.
The operator’s finger may be inserted into the pa- The imaging frequencies used for trans-
tient’s mouth to help guide the probe to the correct esophageal imaging are routinely higher than those
position in the oropharynx. Alternatively, the available with transthoracic probes. Standard adult
amount of flexion and the direction of the probe TEE probes usually operate from 5 to 7 MHz.
can be controlled with the probe handle. The tip of Some transducers offer multiple frequencies and
the transducer should be placed at the back of the harmonics, which can be utilized during the proce-
oropharynx at the upper esophageal sphincter and dure as needed to optimize image quality. In gen-
the patient asked to swallow. The probe should be eral, the highest available frequency that provides
advanced while the patient is swallowing and there adequate resolution should be used.
is no sensation of resistance to moving the probe. Initial transesophageal probes allow for imaging
The probe should be advanced well below the up- in only a single plane horizontal to the long axis of
per esophageal sphincter to minimize gagging (we the body. Biplane probes have two ultrasound
routinely advance the probe into the stomach). Im- transducers placed on the same probe (one in a hor-
ages are then obtained from the stomach and the izontal orientation and one in a longitudinal orien-
esophagus in multiple views (to be described later). tation). Using this type of probe, the operator shifts
Patients should be monitored carefully throughout back and forth between horizontal and longitudinal
the procedure with continuous electrocardiogram imaging. Currently, multiplane or steerable probes
(ECG) monitoring and pulse oximetry, frequent should be used for optimal imaging acquisition.
blood pressure checks, and frequent checks of re- These probes have a steerable transducer that al-
spiratory effort and level of comfort. It is important lows the imaging plane to be rotated between 0°
to note that agitation during the procedure may be a and 180° (see Fig. 1). In addition to the use of the
sign of hypoxemia, in which further sedation could multiplane wheel, rotation of the transducer left
be extremely detrimental.4 and right, movement up and down in the esopha-
gus, and flexing and retroflexing the tip of the
Recovery probe are also necessary to obtain optimal images.

As noted above, patients should be monitored Image Acquisition

carefully during the procedure as well as during the
recovery period. After the probe is removed, the While images can be obtained in any order, it is
patient should be carefully monitored for a mini- useful to establish a routine protocol to ensure that
mum of 20 to 30 minutes until his or her mental sta- complete studies are routinely performed.5 Imag-
tus has returned to baseline. The patient should ing is usually begun from the transgastric position.
remain NPO until the gag reflex has returned and With the transducer positioned in the stomach,
oropharyngeal anesthesia has worn off. Patients some flexion of the probe tip is usually required to
undergoing the study as outpatients should have an establish adequate contact with the gastric wall. A
alternative driver for transportation needs after the short-axis image of the left ventricle should be ob-
procedure. tained from this position. Forward flexion of the
312 JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY July/August 2005 VOL. 21, NO. 4

FIG. 1. Types of transesophageal probes.

probe will result in short-axis images of the base of

the left ventricle, while retroflexion of the probe
will allow short-axis imaging of the ventricle
through the ventricular apex (Fig. 2a). In order to
view the left ventricle in long axis, a short-axis
FIG. 2. Transgastric images. (a) Short-axis view of the left
view of the left ventricle at the mid-papillary mus- ventricle. RV, right ventricle; Sep, septum; Inf, inferior wall;
cle level should be obtained. Rotation to a 90° an- Lat, lateral wall; Ant, anterior wall; PM, posteromedial
gle or switching to the longitudinal plane of a papillary muscle; AL, anterolateral papillary muscle. (b) Two-
biplane probe will result in a two-chamber view of chamber view of the left ventricle. LA, left atrium. (c) Long-
the left ventricle and left atrium (Fig. 2b). This axis view of the left ventricle. Post, posterior wall; AS,
anteroseptal wall; Ao, aorta. (d) Two-chamber view of the
view is particularly useful in evaluating papillary right ventricle. RA, right atrium; SVC, superior vena cava.
muscle-chordal-mitral valve continuity. Further
rotation to 120° will yield a long-axis view of the
left ventricle, with the left ventricular outflow tract
and aorta visualized (Fig. 2c). Returning to a 90° view. Further examination of the mitral valve
angle with a sharp clockwise rotation of the entire should be performed in multiple views. This can be
probe will result in a long-axis image of the right accomplished by placing the mitral valve in the
ventricular inflow tract (Fig. 2d). center of the scan sector and gradually rotating the
It is recommended when using a multiplane multiplane probe in approximately 30° increments.
transducer that the imaging plane be returned to At approximately 60°, a two-chamber view of the
zero before making substantial changes in the left atrium and left ventricle is usually obtained
probe position in the esophagus or stomach. For (Fig. 3c). At approximately this angle, the left atrial
this reason, it is recommended that the transducer appendage is usually well visualized on the right-
be returned to 0° (horizontal plane) and then slowly hand side of the screen. With further manipulation
withdrawn to the gastroesophageal junction.6 The of the multiplane angle, a long-axis view of the left
junction of the inferior vena cava and the right ventricle with both inflow and outflow portions can
atrium, the tricuspid valve, and the right ventricle be obtained, usually at 120° (Fig. 3d). This view is
should be visualized as the lowest structures from excellent for observing the ascending aorta and is
the esophageal imaging position (Fig. 3a). As the essential for ruling out proximal aortic dissection.
probe is withdrawn further up into the esophagus, a With a biplane probe, a modification of this view
standard four-chamber image will be obtained can often be obtained using the longitudinal plane
(Fig. 3b). Both the mitral and tricuspid valves can with leftward flexion of the probe tip. When view-
be visualized and examined in this four-chamber ing the ascending aorta in a longitudinal plane,
 TRANSESOPHAGEAL ECHOCARDIOGRAPHY / Brickner 313

pulling the probe back out of the esophagus allows

more of the ascending aorta to be seen. The aortic
valve can also be visualized in a short axis at the
base of the heart (Fig. 4). This is usually obtained at
35° to 60° with some anteflexion of the probe tip.
The origin of the coronary arteries can also be iden-
tified from this position as well as the pulmonic
valve. This can be performed with a 60° to 80°
angulation, which allows the right ventricular out-
flow tract, the pulmonic valve, and the pulmonary
artery to be visualized (Fig. 5). Anterior structures
such as the pulmonic valve and right ventricular
outflow tract are sometimes more difficult to visu-
alize from the transesophageal position and may be
better seen in a transthoracic study. The bifurcation
of the pulmonary artery can usually be obtained by
returning to the horizontal plane, placing marked
anterior flexion on the probe, and withdrawing the
probe upwards in the esophagus above the level of
the aortic valve. The main pulmonary artery and its FIG. 3. Esophageal views. (a) Right ventricular inflow view.
bifurcation are visualized in most patients (Fig. 6). RA, right atrium; LA, left atrium; cs, coronary sinus; RV, right
The proximal right pulmonary artery can be seen as ventricle. (b) Four-chamber view. LV, left ventricle. (c) Two-
it courses posterior to the aorta and the superior chamber view of the left ventricle. LAA, left atrial appendage;
PM, posteromedial papillary muscle; AL, anterolateral
vena cava. Usually, only the origin of the left pul-
papillary muscle. (d) Long-axis view of the left ventricle.
monary artery can be visualized as the left bron- RPA, right pulmonary artery; AO, aorta.
chus is positioned between the esophagus and the
left pulmonary artery. Next, the atrial septum
should be visualized in multiple views. Imaging is
performed in a standard four-chamber view with
care taken to visualize the thin portion of the fossa
ovalis. Switching to a longitudinal plane (usually
90°-120°) allows imaging of both the inferior and
superior vena cava as well as the right atrial ap-
pendage (Fig. 7). This view is especially critical in
those patients being evaluated for possible atrial
FIG. 4. Short-axis view of the aortic valve. RVOT, right
septal defects. It is useful to perform color Doppler
ventricular outflow tract; N, noncoronary cusp; R, right
imaging focused on the interatrial septum because coronary cusp; L, left coronary cusp.
the image is changed from a standard horizontal to
a longitudinal plane as small PFO jets may be seen
only in an off-axis plane. A shunt study or bubble
study is usually performed at this point. Care
should be taken to optimize visualization of the
thin portion of the fossa ovalis as well as visualiz-
ing an adequate amount of the left atrium. This al-
lows assessment of the presence and magnitude of
interatrial shunting. The patient may be asked to
cough or perform the Valsalva maneuver in order
to transiently increase the right atrial pressure and
provoke right-to-left shunting. FIG. 5. Right ventricular outflow tract. PA, pulmonary artery.
314 JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY July/August 2005 VOL. 21, NO. 4

FIG. 6. Pulmonary artery. RPA, right pulmonary artery; SVC,

superior vena cava; Ao, ascending aorta; PA, pulmonary
artery.

FIG. 7. Atrial septum in long-axis view. LA, left atrium; RA,

right atrium; IVC, inferior vena cava. FIG. 8. Pulmonary veins in longitudinal views. LLPV, left
lower pulmonary vein; LUPV, left upper pulmonary vein;
LPA, left pulmonary artery; RLPV, right lower pulmonary
vein; RUPV, right upper pulmonary vein.
To assess diastolic filling parameters, the trans-
ducer should be placed in the midesophagus in a
horizontal plane (0°). Doppler examination of mi- in the cardiac image to visualize the thoracic aorta.
tral inflow can be performed at this point. The pul- In the horizontal plane, the thoracic aorta appears
monary veins can be visualized, using either as a round circle with a smooth contour on its inner
horizontal or longitudinal plane imaging (Fig. 8). (intimal) surface. The descending aorta can be vi-
The left upper pulmonary vein is usually the most sualized in the longitudinal plane. With the trans-
easily identifiable vein. It lies immediately poste- ducer in the horizontal plane, gradual withdrawal
rior to and mirrors the curvature of the left atrial ap- of the probe allows the thoracic aorta to be evalu-
pendage. The right upper pulmonary vein should ated in a retrograde fashion from a distal to a more
be seen at approximately the same level on the op- proximal location. As the aortic arch curves away
posite side of the left atrium. The upper pulmonary from the esophagus, the circular image of the tho-
veins have a marked curvature coursing anteriorly. racic aorta becomes oblong as one approaches the
The lower pulmonary veins have a straight hori- distal end of the arch. With forward flexion, clock-
zontal connection with the left atrium and can be wise rotation, and gradual withdrawal of the probe,
imaged by retroflexing and/or advancing the probe the majority of the aortic arch can be visualized in
lower into the esophagus. Pulsed Doppler the horizontal plane. Switching to the longitudinal
examination of the pulmonary veins is not difficult plane at this point will result in the aortic arch ap-
to perform during TEE and can be quite useful, pearing as a circular rather than a longitudinal
especially in assessing the severity of mitral structure. The origin of the left subclavian artery at
regurgitation. the distal end of the aortic arch can be identified in
Finally, the thoracic aorta is visualized as the many patients. With further probe manipulation,
probe is being removed. The probe is turned 180° the origin of the left common carotid artery can
 TRANSESOPHAGEAL ECHOCARDIOGRAPHY / Brickner 315

also be seen. There is a blind spot at the proximal TABLE 2.

end of the aortic arch; therefore, visualization of Indications for Transesophageal Echocardiography
the brachiocephalic artery is usually not feasible. Cardiac source of embolism
Endocarditis
Prosthetic valve dysfunction
Hints for Obtaining Good-Quality Aortic dissection, other diseases of thoracic aorta
Transesophageal Images Precardioversion in atrial fibrillation cardiac masses
Congenital heart disease
1. Having a calm, relaxed, and cooperative patient Intraoperative studies
is essential for obtaining adequate images. Pa- Evaluation of critically ill and injured persons
tients who are uncomfortable and actively gag- Technically difficult transthoracic studies
ging or retching during the procedure will
continually swallow air, which will result in
poor-quality images because of the loss of con-
tact between the transducer and the esophagus or diac surgery), as well as those patients in whom
stomach. transthoracic imaging is technically difficult (e.g.,
2. Use a standard protocol for obtaining images in patients on mechanical ventilation). Because this
various imaging planes, and perform this in a procedure does pose some risk to the patient, TEE
systematic pattern for each transesophageal should not be performed in cases in which the in-
study. This will avoid important images being formation obtained would not substantially affect
overlooked or omitted. the management of the patient.
3. Patients who are known or suspected to have
more complicated problems usually require CARDIAC SOURCE OF EMBOLISM
more sedation to remain comfortable throughout
a longer procedure. Evaluation for a potential cardiac source of
4. In terms of image orientation, the horizontal emboli has become the most common indication
plane is the easiest for establishing or reestab- for TEE.7 In unselected patient populations, TEE
lishing image orientation. Thus, it is recom- has a higher yield than transthoracic echo-
mended that the operator return to the horizontal cardiography in detecting potential cardiac sources
position whenever confusion occurs regarding
of emboli. Although transthoracic echocardi-
the orientation of the image.
5. When using a multiplane probe, the area of inter- ography is adequate or even preferable in detecting
est should be placed in the center of the sector. If some potential cardiac sources of emboli (e.g., left
the probe is not allowed to rotate to the right or ventricular thrombi, dilated cardiomyopathy, mi-
left, the structure of interest (e.g., the mitral tral stenosis, mitral valve prolapse, etc.), TEE is su-
valve) will remain in the center of the sector as perior in detecting left atrial thrombus and
the multiplane angle is changed. spontaneous echo contrast, atrial septal aneurysms,
patent foramen ovale (present in 20%-25% of the
Clinical Applications population), and atherosclerotic debris in the tho-
racic aorta.8,9 Protruding debris or atherosclerosis
Transesophageal echocardiography is useful in thicker than 4 mm in the ascending aorta or aortic
many clinical situations (see Table 2). It is fre- arch is associated with an increased risk of
quently performed as an adjunct to transthoracic ischemic stroke.
imaging, to further evaluate abnormalities seen in
transthoracic imaging or to evaluate posterior ENDOCARDITIS
structures of the heart and the thoracic aorta, which
When compared with transthoracic studies, TEE
are frequently not adequately visualized in
results in a higher yield for detecting vegetations,
transthoracic imaging alone. Another indication
especially if transthoracic windows are limited.
for TEE is to evaluate patients in whom adequate
TEE is particularly important in diagnosing com-
transthoracic imaging cannot be performed. This
plications of endocarditis, including abscess for-
includes both patients in whom the chest wall is in-
mation, paravalvular leaks, valve leaflet perfora-
accessible (e.g., intraoperative studies during car-
tion, and fistula formation.10 An abscess cavity is
316 JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY July/August 2005 VOL. 21, NO. 4

defined as an echolucent area or an area of reduced ther side of the flap. The dissection may involve the
echodensity within the valve annulus or the adja- ascending aorta (Stanford type A) or may be con-
cent myocardium in the setting of valvular infec- fined to the descending aorta (Stanford type B).
tion. TEE should be performed in any patient in The sensitivity of TEE is excellent for diagnosing a
whom a complication of endocarditis is suspected. dissection (97%-100%). With biplane or multi-
In addition, TEE should be performed on patients plane probes, the specificity of TEE is at least 95%.
with suspected endocarditis if transthoracic However, specificity is lower for single-plane
echocardiography results are negative or nondiag- probes because they do not allow adequate visual-
nostic and in all patients with suspected prosthetic ization of the ascending aorta. In addition to defin-
valve endocarditis. ing the location and extent of the dissection, TEE
can also detect the presence of important complica-
PROSTHETIC VALVES tions of aortic dissection such as aortic regurgita-
Acoustic shadowing occurs when an ultrasound tion (due to the disruption of aortic valve leaflets)
beam cannot penetrate a prosthetic device. This re- or pericardial effusion (due to a rupture in the
sults in significant limitations when using pericardial space). The ability to visualize involve-
echocardiography to assess prosthetic valves. ment of the arch vessels is limited. Conditions that
From a transthoracic window, prostheses cause may mimic aortic dissection can also be evaluated
shadowing of more posterior structures such as the by TEE, including intramural hematomas and
left atrium. Thus, valve-related complications such penetrating atherosclerotic ulcers of the thoracic
as valve thrombosis, valvular vegetations, and aorta.
periprosthetic regurgitation may be missed by the
transthoracic approach. TEE provides alternate CARDIOVERSION IN ATRIAL FIBRILLATION
acoustic windows and can help overcome the prob-
Prior to elective cardioversion for atrial fibrilla-
lem of acoustic shadowing in some situations. It
tion, anticoagulation for 3 to 4 weeks is recom-
has been found to be particularly useful in the as-
mended. Because of the inherent risk associated
sessment of prosthetic mitral valves because the
with anticoagulation, TEE can be performed prior
left atrium, the atrial surface of the valve, and the
to cardioversion to rule out atrial or atrial append-
valve annulus can be easily viewed. It may also be
age thrombus.11 If there is no evidence of atrial
useful in assessing prosthetic aortic valves, al-
thrombi, cardioversion can be performed. It should
though the location of the transesophageal probe
be borne in mind that embolic events have occurred
may not be optimal to assess areas both above and
in patients who underwent cardioversion after a
below the valve. Especially in the setting of aortic
negative TEE result. These events were presum-
valve prostheses, a combined transthoracic/TEE
ably due to thrombus formation in the stunned
approach is usually required to fully characterize
atrial appendage after the cardioversion. It is now
valve function. TEE is not recommended for rou-
recommended that patients be anticoagulated dur-
tine follow-up of prosthetic valves but should be
ing the TEE and for 3 to 4 weeks after cardiover-
strongly considered if prosthetic valve dysfunction
sion.12
is suspected.

AORTIC DISSECTION INTRACARDIAC MASSES

TEE provides an important means of assessing Most intracardiac masses, excluding atrial
nearly the entire extent of the thoracic aorta and has thrombi, can be visualized adequately by trans-
been proven to be a very valuable tool in the evalu- thoracic imaging. Atrial thrombi are usually better
ation of aortic disease. Aortic dissection can be rec- seen by TEE. In addition, TEE can provide impor-
ognized by the presence of a thin, mobile intimal tant structural details about cardiac masses (such as
flap within the lumen of the aorta. Color flow attachment site and compression or invasion of
Doppler reveals flow in opposite directions on ei- contiguous structures).13
 TRANSESOPHAGEAL ECHOCARDIOGRAPHY / Brickner 317

CONGENITAL HEART DISEASE functional information to be gained by TEE should

TEE is useful in the assessment of adult patients be weighed against potential risks of the procedure.
with congenital heart disease and is used as a sup-
plementary technique to transthoracic studies. It is References
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