Advanced Transesophageal Echo Views

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From the ME 4 Chamber view, withdraw the probe until the left ventricular outflow tract (LVOT) is seen. Similar to the ME 4 the left atrium, right atrium, left ventricle, right ventricle, mitral valve and tricuspid valve may be interrogated.  In addition left ventricular outflow tract is seen ("5" chambers). This allows interrogation of the gross competence of the aortic valve along with LVOT pathology. However because this view does not allow the true apex of the ventricles  global and regional ventricular systolic function may be limited.

From the ME 4 Chamber View omniplane 50-70 degrees with the LV in the middle of the screen. This allows assessment of the "trap door" of the mitral valve. The mitral valve scallops on the image display left to right are P3-A2-P1, although frequently adjacent A3 and A1 segments may also be imaged. Turning the probe clockwise may allow imaging f the entire anterior mitral leaflet. Rotating clockwise and counterclockwise in this plane allows imaging of the MV annulus and the sewing ring for prosthetic valves.

From the ME LAX view withdraw the probe slightly and zoom on the LVOT and aortic valve/ascending aorta for assessing the aortic valve and ascending aorta more rigorously.  Fine tuning may require rotating the probe clockwise. This view allows concentrated imaging f the LV outflow tract, aortic valve, proximal aorta, sinuses of valsalva, the sinotubular junction and a portion of the  ascending aorta. The anterior (far field) AV cusp is the right coronary cusp, and the right coronary ostium is frequently seen in this view. The posterior (near field) AV cusp can be the non-coronary cusp or the left coronary cusp, depending on the window, Color flow Doppler may be applied to identify aortic regurgitation or flow withing the right coronary ostium. This is part of advanced TEE which includes the aortic root and sizing of the aortic valve. 

From the ME bicaval view omniplane further to 110-120 degrees. The probe is turned until the tricuspid valve is centered in the screen. The left atrium, right atrium, interatrial septum, inferior vena cava and TV are all well imaged. Color flow Doppler allows interrogation of the TV for regurgitation. In addition continuous wave Doppler may be used to assess velocity. As well this view offers an alternative view of the coronary sinus. 

From the ME 4 chamber view, place the LV in the center of the screen and advance the probe until the mitral valve leaflets are seen in short axis. Mild anteflexion and omniplane up to 20 degrees may be required. The view demonstrates the mitral valve as the typical SAX or "fishmouth" view with the anterior leaflet on the left and the posterior leaflet n the right. The medial commissure is in the near field with the lateral commissure in the far field. This allows interrogation of the leaflets as well as the basal section of the LV for wall motion and ischemia. Color flow doppler may help characterize regurgitant orifice morphology and characteristics.

From the TG basal SAX view advance the probe past the TG MP SAX to obtain a view of the apical segment of the LV. This allows wall motion interrogation along with LV dysynergy. As well the RV apex may be imaged by turning the probe clockwise. Using the basal, midpapillary and apical views 12-15 segments of the LV may be assessed for wall motion abnormalities.

From the TG MP SAX view, the beam is omniplaned 120-130 degrees and the probe turned counterclockwise. Sometimes turning the probe clockwise is necessary to bring the LV outflow tract and aortic valve into view. Portions of the inferolateral wall and anterior septum are imaged as well as the LVOT, AV and proximal aorta. With parallel Doppler beam alignment of the LV outflow tract, AV and proximal aortic root, spectral and color Doppler interrogation of the LVOT and aortic vale is possible. 

From the transgastric midpapillary short axis view the LV is placed in the middle of the screen and the transducer angle rotated to 90-110 degrees. The anterior (far field) and inferior (near field) walls of the LV are imaged in addition to the papillary muscles, chordae and mitral valve. Although the left atrium and left atrium appendage may be seen, far field imaging may not allow accurate assessment of LA appendage pathology. 

 From the TG two chamber view the probe is turned to the right (clockwise) to obtain the RV inflow view. The anterior and inferior walls of the right ventricle are imaged in addition to the papillary muscles chordae and tricuspid valve. The proximal RVOT is frequently seen and slight advancement of the probe may allow imaging of the pulmonic valve.

From the upper esophageal aortic arch short axis view, activate color Doppler and create a box including the aorta and surrounding structures. Sightly rotate the probe to the right (clockwise) and identify the origin of the left subclavian artery. Finding the LSC may involve advancing or withdrawing the probe etc. This is an essential view for identifying correct IABP placement, assessing for coarctation of the aorta and extent of aortic dissection.

While imaging the ascending aorta in the ME Ascending aorta SAX view, the probe is withdrawn and the the aorta will appear elongated to demonstrate the upper esophageal long axis view. The aorta is anterior to the esophagus in this position such that the probe may need to be rotated clockwise. This allows imaging of the mid aortic arch, but a portion of the aorta may be obscured by the trachea. 

From the UE aortic arch LAX view the transducer is omniplaned 70-90 degrees to obtain the short axis view. The main pulmonary artery and pulmonic valve can frequently be seen in the far field. Because of parallel Doppler beam alignment of the pulmonary valve and main PA Doppler interrogation of the valve may be performed.