TEE mid-esophageal views
There are many mid-esophageal views. This page reviews the 6 basic and most common ones to know as you get started, and are akin to transthoracic views. More complex views to target specific structures (for example, the left atrial appendage and valves) are discussed elsewhere in the structure specific views page.
Unlike TTE, TEE images are not necessarily acquired in the same stereotypes order. Image order is often based on the indication. For example if the interest is in assessing mitral valvular pathology and cause of regurgitation, then the initial images will focus on that, with the axiom that you should always try to answer the clinical question first then move to the rest of the exam.
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All sections below will show cartoon drawings of the view, a the 2D video clip and then a still image with labels for anatomy. Abbreviations for below:
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LA - left atrium, MV - mitral valve, LV - left ventricle, RV - right ventricle, RV - tricuspid valve, RA - right atrium, LVOT - left ventricular outflow tract, LAA - left atrial appendage, CS - coronary sinus, RVOT - right ventricular outflow tract, AV - aortic valve, Ao - aorta, IAS - intra-atrial septum
4 Chamber 0 degree view
The ultrasound beam cuts through the LV and RV apex
This is the standard starting view for most studies, starting with the omniplane angle at 0 degrees and no rotation. If the aortic valve is seen, insert further. Frequently, retroflexion is needed to get a non-forshortened 4 chamber view. This view is in part used to assess RV and LV function. Note the LV wall segments are similar to that seen in the apical 4 chamber on transthoracic images. Changes in rotation along with changing the probe depth can be used to assess the pulmonary veins in this view, as well as better visualize the atria, which are near field structures.
5 Chamber 0 degree view
Antiflex and withdraw probe to get the 5 chamber view.
Antiflexion and withdrawing the probe from the 4 chamber view will bring in the aortic root and left ventricular outflow tract. Here we are seeing the anteroseptum, similar to the 5 chamber view in transthoracic ECH
2 Chamber 90 degree view
At 90 degrees rotation only LA and LV are seen
By keeping the probe in the same position adjusting the omniplane angle 90 degrees, you will get the 2 chamber view. This is similar to the Apical 2 chamber view where often the left atrial appendage in seen.
Long Axis View, 120-150 degrees
At 120-150 degrees the aortic root and valve are in view
Increasing the omniplane angle, while slightly rotating the probe counterclockwise brings in the long axis view, with similar structures seen as that in the parasternal long axis and apical long axis of transthoracic echo. This in the best view to look at the LVOT and anteroseptum as well as A2 and P2 of the mitral valve.
Short Axis View, 30-60 degrees
At 60 degrees with clockwise rotation 3 valves can be seen - AV, PV and TV
This view is commonly found perpendicular to the long axis view. So if the ideal long axis view was found at 120 degrees, then a good short axis view typically is found between 30 and 60 degrees of omniplane. Often some clockwise rotation is needed to bring this plane into view. This view is similar to the parasternal short axis view at the aortic valve level, but with different orientation of the structures. Note the non coronary cusp (NCC) abuts the intra-atrial septum. Look closely and in this video you will also see the left main coronary artery arising from the left coronary cusp (LCC).
Bicaval view 90-110 degrees
At 90-110 degree and extreme clockwise rotation, RA and vena cava are seen
This is one important view which has no main equivalent in transthoracic echo unlike the other views shown above. Somewhere along 90-110 degrees, rotate the probe extreme clockwise (toward the right sided structures) to obtain this view, which lays out the intra-atrial septum. This is a great view in which to look for PFOs, ASDs or to perform a bubble study. This is also an excellent view to evaluate the IVC, SVC, eustachian valve, and right atrial appendage