While 28 discrete TEE windows are used in advanced TEE for cardiac surgery and interventional cardiology, 12 views are necessary for basic TEE. These twelve views are mostly midesophageal views which are useful in ruling in or out causes of hemodynamic instability. These views may be found by simple advance, withdrawal, omniplane and rotation of the TEE probe similar to maneuvers used with a TTE probe for the FATE.
The TEE "home base", insert the probe to 28-32 cm until it is immediately posterior to the left atrium (always top chamber in the near field in the midesophageal views). Turning the prob left or right centers the LV and mitral valve. Color flow doppler with Nyquist limit 50-60 may be applied over the valves to assess for stenosis or regurgitation. All four heart chambers are imaged and gross pathology ruled in. All other basic views start with this view and may be found by rotation, omniplane or advance/withdrawal of the probe.
From the four chamber view rotating the ultrasound beam 80-100 degrees (omniplane) until the right ventricle disappears will provide the ME 2 chamber view. The orthagonal view to the ME 4, simply get the LV in the middle of the screen and omniplane. Again color flow doppler with Nyquist limit 50-60 allows identification of mitral valve pathology. Excellent for assessing anterior and inferior ischemia as well as imaging the LA, LV and mitral valve.
From the ME 4 Chamber view simply get the LV in the middle of the screen and omniplane 120-150 degrees. Along with the ME 4 chamber view it is one of the three "rescue echo" views. Structures that may be interrogated in this view include the LA, MV, LV, left ventricular outflow tract, aortic valve and proximal ascending aorta. LV inferolateral and anteroseptal walls are imaged and ischemia evaluated in this view. Anterior mitral leaflet pathology and LV septum dimensions may be assessed here as well. Color doppler may be applied to the MV, LVOT and AV to assess for pathology.
The most difficult view to find for the beginner, best found by going to the ME 4 and getting the right atrium in the middle of the screen then omniplane to 80-100 degrees. Structures seen in this view include the LA, RA and intra-atrial septum. Color doppler is used here to assess for atrial septal defect and patent foramen ovale using a lower Nyquist limit (20-30). This view is also used to verify central line placement and cardiopulmonary bypass circuits. CRNA residents call it "making Mr. Moustachio", demonstrating the complete de-evolution of mankind.
From the ME 4 chamber view, the probe is withdrawn and rotated until the aortic valve is in the middle of the screen. The multiplane angle/omniplane is rotated forward to 40-60 degrees until the right ventricular outflow tract, pulmonary valve and tricuspid valve are seen. Structures seen in this view include the LA, RA, tricuspid valve, RV and main pulmonary artery. Color flow doppler may be applied to the TV and PV to assess for pathology. As well pulmonary artery pressure may be assessed using continuous wave Doppler (advanced use) using the Bernoulli equation as RV systolic pressure= (tricuspid regurgitation velocity squared) x 4 + CVP.
From the ME four chamber view the ME AV SAX view is found by placing the LVOT in the middle of the screen and withdrawing the probe until the aortic valve is seen. Typically the multiplanar angle/omniplane is rotated 10-20 degrees, such that all three aortic valve cusps (hopefully three!) are identified. The left coronary cusp should be on the right side of the image and often the left main coronary artery may be seen. The noncoronary cusp is adjacent to the intra-atrial septum, and the right coronary cusp is anterior (6 o'clock) and adjacent to the RVOT. Gross aortic valve stenosis may be identified and aortic valve estimated using an area tool. Aortic regurgitation may be identified with the use of color flow doppler.
To obtain this view, from the ME AV SAX view withdraw the probe until the ascending aorta is seen in short axis. The bifurcation of the pulmonary artery, the ascending aorta in short axis and the superior vena cava are identified. Prximal pulmonary emboli may be identified here as well as a pulmonary artery catheter and proximal aortic dissection.
From the ME Asc Ao SAX view place the aorta in the middle of the screen and omniplane 90 degrees. The right pulmonary artery may be seen in short axis in the near field of the ultrasound beam adjacent to the esophagus and posterior to the ascending aorta which is seen in long axis. Right PA emboli, a pulmonary artery catheter in the right PA and aortic dissection may be seen in this view. CRNA residents call obtaining this view "making the hot dog", once again demonstrating the lack of respect for a beautiful science.
From the ME 4 chamber view, rotate the probe to the patient's left and pick up the descending thoracic aorta in short axis. Image depth should be decreased to allow assessment for dissection and plaque. The probe may be advanced and withdrawn to image the entire descending thoracic aorta as well as look for intra-aortic balloon and aortic cannulation wires along with dissections. Additionally a left pleural effusion may be easily visualized. A right pleural effusion may be seen by rotating the probe clockwise. Biplane or x-plane may be used to visualize the SAX and LAX views simultaneously.
From the ME Desc Ao SAX view, get the aorta in the middle of the screen and omniplane 90 degrees. The probe may be advanced and withdrawn to image the entire descending thoracic aorta as well as look for intra-aortic balloon and aortic cannulation wires along with dissections. Additionally a left pleural effusion may be easily visualized. A right pleural effusion may be seen by rotating the probe clockwise. Biplane or x-plane may be used to visualize the SAX and LAX views simultaneously.
From the ME 4, get the LV in the middle of the screen and advance the probe into the stomach (50 cm or so). Typically some anteflexion is required to get the nice midpapillary view which gives allows assessment of volume and function of the LV in the middle of the heart. In addition wall motion may be assessed in this view though ischemia can only be ruled out by looking at several views. If the mitral valve leaflets are seen the probe is in the wrong plane such that the probe should either be advanced or anteflexed less. This is the third and final "rescue TEE" view.
From the TG SAX view, advance the probe until the apex of the LV is lost. Then advance another one cm, rotate to the left slightly and anteflex significantly. This is actually more of an advanced view but essential for any interventional TEE or more correct assessment of the aortic valve or LVOT/HOCM. This resembles the apical four chamber view for any TTE experts. Often the image quality is less than optimal such that color flow doppler is best used to confirm flow and location of the aortic and mitral valves.
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