Transesophageal Echocardiogram – Preparation, Procedure, Views, Complications

We often come across times when we are required to undergo an ultrasound or an x-ray, occasionally even an Echocardiography. Echocardiography is an ultrasound of the heart. An echocardiogram views and creates images of the structures of the heart.

What is A Transesophageal Echocardiogram?

A transesophageal echocardiogram is a non-invasive, painless investigative procedure which creates high quality pictures of structures of the heart and its blood vessels. It shows the size and shape of the chambers of the heart and valves of the heart along with their functioning.

Why is A Transesophageal Echocardiogram Performed?

A transesophageal echocardiogram can be done in both children as well as adults have one of the following conditions

• Heart Valve Disease or Abnormalities
• Cardiomyopathy
• Congenital Heart Diseases
• Coronary Artery Disease
• Myocardial Infarction (Heart Attack)
• Aortic Aneurysm
• Endocarditis
• Arrhythmias or Stroke Due To Presence of Blood Clots

Transesophageal echocardiography is also a useful tool while performing cardiac surgeries for assessment of the patient during and after surgery. It also works as a guide during cardiac surgeries and cardiac catheterization.

Transesophageal Echocardiography Views

Transesophageal echocardiography can provide images in both 2-dimensional and 3-dimensional forms.
Images can be observed in the following 4 basic views

1. Basal Short Axis View – To visualize the ascending aorta and pulmonary artery. Right ventricular outflow tract, coronary arteries, right atrium and aortic valves can also be viewed.
2. Long Axis Views – To visualize the aortic valve, mitral valve, left ventricular outflow tract and right atrium and ventricle.
3. Ventricular Short Axis Views – Ventricles at various levels can be visualized.
4. Mid Papillary Short Axis View – Ventricular ischemia and Segmental Wall Motion Abnormalities (SWMA) can be visualized by mid-papillary short axis view.
5. Descending Thoracic Aorta and Aortic Arch View – Both descending portion of aorta along with the aortic arch can be visualized using 4 views. Useful to diagnose aortic dissection and atheromas.
6. Mid Esophageal View Has 2 Variants
   ● Mid Esophageal Aortic View – Views proximal ascending aorta and the aortic valve, aortic root and inter-atrial septum, vena cava, tricuspid valve and the right ventricle.
   ● Mid Esophageal Ventricular View – Right and left atrium, left ventricle, inter-ventricular septum and the mitral valve.
7. Trans Gastric View – This view is important for an assessment of Left Ventricular (LV) function. Right and left ventricles and the mitral valve, ejection fraction and volume status can also be assessed.

In deep trans-gastric views, aortic valve, ventricular outflow tract and all four chambers of the heart can be observed. Cardiac output can also be measured through this view.

Transesophageal Echocardiogram Preparation

A transesophageal echocardiogram is always performed in a cardiac unit having an in-patient facility. Therefore your cardiologist will inform you about preparing for this procedure beforehand.

• You will be required to remain fasting for about 4-6 hours before the procedure.
• Any kind of prosthesis or faux dentures will have to be removed before the surgery
• Your clinician may advise a minute dose of medicine before surgery which will help you relax.
• Blood pressure and pulse will be monitored before the procedure.

Transesophageal Echocardiogram Procedure

To perform a transesophageal echocardiogram, your clinician will introduce a probe having a transducer at the tip through your mouth and throat into the esophagus.

Since the esophagus is right behind your heart, the transducer will be able to achieve a better picture of the heart and its functioning. While performing a transesophageal echocardiography, a transducer sends sound waves to the heart.

• The cardiologist may insert the probe in a patient who is either awake or under anesthesia.
• The airway is anesthetized by the topical anesthetic spray.
• The patient is placed on the left lateral side. This allows easy access to the esophagus by probe.
• The probe has to be well lubricated so that it passes through the mouth and throat smoothly without causing any damage.
• Special maneuvers may be required to perform this procedure in patients who have hematemesis (vomiting of blood), difficulty in swallowing, cervical spine diseases and those who have been intubated.
• An intravenous access is secured before beginning the procedure and a crash cart trolley with airway and oxygen system is kept ready.
• Antibiotics are administered to prevent infection post-procedure.
• The patient is required to be fasting for at least 1-4 hours after the procedure. Topical anesthesia wears off during this period.

How Long does A Transesophageal Echocardiogram Take?

An uncomplicated procedure of transesophageal echocardiography takes about 20-40 minutes. Time taken for sedation along with the procedure is about 90 minutes. A person can resume his/her normal activities 24 hours after the procedure.

Transesophageal Echocardiography Guidelines

Guidelines have been laid down by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists for performing a transesophageal echocardiogram. Indications for transesophageal echocardiography can be separated into 3 categories.

Transesophageal Echocardiography is Contraindicated in the Following Conditions

1. Perforated Viscus or Breach in Wall of The Gastrointestinal Tract
2. Esophageal Varices
3. Esophagitis
4. Strictures of Esophagus
5. Diverticular Diseases
6. Tumors
7. Scleroderma
8. Recent Upper Gastrointestinal Tract Surgery
9. Hiatus Hernia
10. History of Irradiation to The Chest Due to Any Cause
11. Atlantoaxial Disease
12. Blood Clotting Disorder or Coagulopathy

Transesophageal Echocardiogram Complications

There is a very small risk complications associated with this procedure. This is the reason why it can be performed in adults as well as children. It is a relatively safe procedure. Yet, it can also have some fatal complications. The complications can arise either due to the probe used for a procedure or due to the procedure itself.

Probe Related Complications Include

1. Injuries due to thermal pressure
2. Soft tissue injury to throat, esophagus or stomach insertion
3. Injuries can lead to bleeding, tear or disruption of the soft tissues.

Procedure Related Complications Include

1. Hypertension or hypotension
2. Arrhythmias
3. Hypoxia or Reduced Oxygen Supply to the Lungs
4. Spasm of the Larynx (air pipe) or Bronchus
5. Transient Vocal Cord Paralysis Has Also Been Reported

You may feel some sickness in your stomach but this goes away with adequate rest and medications. There may also be transient soreness in the throat and difficulty in swallowing due to irritation caused by the probe.