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| Transesophageal
Acoustic Windows |
Nomenclature for indicating the view of the image
is standardized by the American
Society of Echocardiography and the Society
of Cardiovascular Anesthesiologists. The acoustic window is
combined with the imaging plane to describe the image's orientation. The transesophageal acoustic windows are:
- Upper esophageal (UE)
- Middle esophageal (ME)
- Transgastric (TG)
- Deep Transgastric (DTG)
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| Animation of TEE Acoustic Windows |
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The other intraopeative acoustic windows are:
- Epiaortic (EA)
- Epicardial (EC)
- Intravascular (IV)
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| Anatomic Relationships of the Esophagus |
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| Transthoracic echocardiographic scans can yield poor quality scans because of anatomic structures or pathological/physiological conditions that cause signal attenuation. Ribs, excessive fat, improper positioning, and excessive air in the lungs may cause a poor scan. A scan from the esophagus, however, does not have any of these issues, except for air in the stomach or a hiatal hernia. High quality scans are usually possible from the esophagus. The esophagus starts at it's narrowest point, the posterior pharynx and extends through the mediastinum, posterior to the trachea and the left mainstem bronchus, posterior to the left atrium and the left ventricle, through the diaphragm, and enters the stomach. A probe placed into the stomach (transgastric) can be retroflexed to contact the inferior wall and the apex if placed distally (deep transgastric) in the stomach. Note that the axis of the esophagus and of the heart are not in parallel, therefore, some probe manipulation will be required to obtain correct cardiac axis cuts. |
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| The trachea is situated between the distal ascending aorta and the esophagus. A probe located in the esophagus cannot image this segment of the aorta. The aorta then travels from anterior to posterior, descending along with the esophagus posterior to the heart and through the diaphragm. From the esophagus, images of the heart, ascending aorta, arch aorta, descending aorta, both pleral spaces, liver, superior vena cava, and the inferior vena cava are possible. The segment of the ascending aorta that is not able to be visualized because of the intervening left mainstem bronchus is the one consistent area that cannot be scanned.
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| Transesophageal Probe Preparation Insertion |
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To Prepare the Probe:
- Attach the probe to the console
- Establish proper electrical performance by the echo machine
- Inspect the probe for cracks in the housing
- inspect the transducer for cracks
- Check the Flywheel Mechanism
- Check the buttons
- Put a bite block on the probe
- Lubricate the probe
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To Insert the Probe:
- Trap the base of the probe against the bed or place it around your neck so both or your hands are free
- Insert the probe into the mouth following the curvature of the mouth and pharynx
- Advance the probe into the esophagus - only the slightest of resistance should be present
- If significant resistance is present do one or all of the following:
- Turn the head to the left
- Deflate the cuff of the endotracheal tube
- Lift the mandible anteriorly with a jaw thrust
- Flex the head
- Use a larngoscope to place the probe under direct vision
The probe should be able to be inserted easily in almost all patients. A slight, noticeable loss of resistance should occur when the probe passes from the posterior pharynx into the esophagus. In less than 2% of patients, the probe may not be able to be inserted and alternative echocardiography scanning should be considered.
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Transesophageal
Probe Manipulation |
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The transesophageal echocardiography probe can be advanced
or withdrawn, rotated leftward(counter clockwise) or rightward (clockwise), anteflexed(anterior flexion)or retroflexed(posterior flexion),
and flexed leftward or flexed rightward. Also, the plane of the sector
scan can be rotated from transverse to longitudinal. The transesophageal
probe is advanced or withdrawn to the acoustic windows upper esophageal,
mid esophageal, transgastric, and deep transgastric. The sector scan can
be rotated from transverse to longitudinal at each acoustic window to
view the proper cardiac axis or cut. If anatomical variants exist such
that the structures are not easily visualized, the probe can be flexed
leftward or rightward to bring the image into full view. Anteflexion or
retroflexion are used at the acoustic window to view the proper cardiac
axis or plane. Rotation of the transesophageal probe allows visualization
of cardiac structures that may be peripherally located or in an anatomically
difficult area to visualize. |
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Advanced/Withdrawn |
Rotation Left/Right |
Flex Left/Right |
Anteflex/Retroflex |
Transverse/Longitudinal
Plane |
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| Complications |
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| Probe Complications |
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The complications are divided into complications to the patient and complications to the probes. Complications to a probe: |
- Piezoelectric Crystal Damage
- Housing Damage
- Electrical Wire Fracturing
- Tension Wire Damage
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Figure 5.1 Cracked Transducer |
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Transthoracic echocardiography probes are not easily damaged. The crystal in all probes is easily damaged if the crystal is struck with enough force to crack it (Figure 5.1). Proper care of the probe requires that the crystal be protected at all times and avoiding contact with hard surfaces. A protective sleeve is available for transesophageal echocardiography probes and should be utilized when being stored.
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When inserting a transesophageal echocardiography probe, a bite block should be used. The function of a bite block is to prevent injury to the patient and to prevent damage to the probe. If a patient were to bite the probe electrical leaks or electrical fiber breakage can occur. The probe should be inspected for cracks and leaks prior to each patient use and have regular maintenance to check for electrical leaks and probe function. |
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Figure 5.4 IV Pump as a Table |
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When the probe is not in use it should not be stored, as in Figure 5.5, where the probe's tubing is not at acute angles which can damage the probe housing and the wheel mechanism contained in the probe. The probe should be stored or placed where the probe is not likely to fall and damage the probe (Figure 5.4). |
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Figure 5.2
Protective Sleeve |
Figure 5.3
Bite Blocks |
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Image 5.5 TEE Probe Stored Wrong |
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| Patient Complications |
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| Complications to patients can occur with transesophageal echocardiography.
Complications include: |
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- Prolonged skin staining from the cleaning solution
- Soft tissue damage of the oropharynx
- Dental damage
- Airway obstruction
- Tracheal extubation
- Vascular compression
- Right mainstem intubation
- Esophageal erosion, burns, bleeding and/or perforation
- Gastric burns, erosion, bleeding and/or perforation
- Electrical shock
- Arrhythmias
- Vocal cord paralysis
- Dysphagia/Odynophagia
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| During a Radiofrequency MAZE procedure, the TEE probe should be withdrawn. Esophageal burns have been reported in patients who have had a Radiofrequency MAZE procedure and a TEE probe . |
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| While these complications are rare, relative contraindications such as esophageal varicies, esophageal stricture, Zenker's diverticulum, esophageal webs, history of radiation therapy to the esophagus, esophageal resections, etc should be sought during a history and physical examination. While presence of conditions that may increase the risk of complications, the appropriate risk/benefit ratios must be considered prior to utilizing transesophageal echocardiography. A hiatal hernia is not necessarily a contraindication, but it can increase the likely hood of poor imaging. Complete evacuation of air via orogastric tube may be helpful in these patients. |
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| When removing the transesophageal probe, unlock the probe so it will not remain in a rigid, flexed position during withdrawal. Withdrawing a locked transesophageal probe increases the risk of esophageal damage. |
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