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Feel free to reach out to us for further information!
IAME is accredited by ACCME to provide AMA PRA Category 1 Credit™ for physicians and healthcare professionals.
We operate in North America, Australia, and South Korea.
© 2026 Institute for Advanced Medical Education, All Rights Reserved.
By Institute for Advanced Medical Education
Transesophageal echocardiography (TEE) is a semi-invasive ultrasound examination that images the heart from the esophagus and stomach. Because the probe sits immediately behind the left atrium, TEE outperforms transthoracic echocardiography (TTE) for the left atrial appendage, interatrial septum, prosthetic valves, and thoracic aorta. This guide covers indications versus TTE, probe insertion, standard views, measurements, and complications.
Choose TEE when TTE cannot answer the question or when posterior structures will change management. Frequent indications include:
TTE remains first-line for ventricular function, native valve screening, and most pericardial effusions. When endocardial definition is the only limitation, contrast-enhanced echocardiography can restore TTE quality without intubation. TEE is still preferred for appendage thrombus, prosthesis inspection, and the aorta. A structured introduction to echocardiography reviews the surface views that should precede most TEE studies.
Do not insert a probe through known esophageal stricture, diverticulum, perforation, unrepaired tracheoesophageal fistula, or active upper gastrointestinal bleeding. Defer for cervical spine instability or an unprotected high-risk airway. Relative concerns include prior esophageal surgery, chest radiation, Barrett esophagus, coagulopathy, and large hiatal hernia. Check dentition and remove appliances before placing a bite block.
Follow institutional fasting and sedation policy. Consent should mention sore throat, dental injury, aspiration, and uncommon esophageal trauma. Establish intravenous access and monitoring, and keep suction, airway equipment, and reversal agents at the bedside. Limit topical benzocaine because of methemoglobinemia. Moderate sedation is typical in the echocardiography laboratory. Use general anesthesia with a protected airway in the operating room or when aspiration risk is high.
Confirm free anteflexion and retroflexion, then unlock the controls. Place a bite block, lubricate the transducer, and advance gently while an awake patient swallows. Never force against resistance. Mid-esophageal images are commonly obtained around 30 to 40 cm from the incisors, transgastric views deeper, and aortic views on withdrawal. Depth varies with body habitus, so navigate by the image. Optimize with multiplane rotation, advancement, withdrawal, and flexion. Record two-dimensional clips first, then color and spectral Doppler. A focused study suits one urgent question; a comprehensive exam is preferred when the patient is stable.
A complete study samples mid-esophageal, transgastric, and aortic windows:
Label clips by window and rotation. Sweep the appendage through adjacent planes before calling it empty. When aortic stenosis is the question, align continuous-wave Doppler from a deep transgastric or transgastric long-axis view and match velocity with leaflet appearance. Modern echocardiographic techniques for aortic stenosis still apply when you quantify the valve from the esophagus.
Pectinate muscles in the left atrial appendage are linear and wall-based; thrombus is usually rounded and independent of the wall. Note spontaneous echo contrast and emptying velocities. Support mitral regurgitation grade with vena contracta and pulmonary vein flow. Report aortic cusp number, coaptation, root dimensions, and any flap. Confirm septal defects with color Doppler and, when indicated, agitated saline.
If an aortic line does not persist in a second plane, does not move independently, and has no differential color flow, call it artifact until proven otherwise.
Sore throat, lip or dental injury, and hoarseness are usual. Uncommon serious events include aspiration, arrhythmia, methemoglobinemia from benzocaine, and esophageal perforation. Consider perforation if severe pain, fever, or crepitus appears later. Foreshortening underestimates volumes. Septal dropout can mimic a defect. Prosthetic reverberation can hide a vegetation or paravalvular leak. Keep the patient fasting until the gag reflex returns, and give precautions for severe odynophagia, hematemesis, fever, or chest pain.
A reliable TEE workflow complements TTE in the laboratory and operating room. IAME offers accredited ultrasound CME courses on echocardiography technique and valvular assessment. Confirm privileging and CME requirements with your institution or certifying body.
TEE is often performed shortly before electrical cardioversion when atrial fibrillation or flutter has lasted more than 48 hours, the duration is unknown, or anticoagulation has not been therapeutic. The goal is to exclude left atrial appendage thrombus. If thrombus is present, cardioversion is deferred and anticoagulation continues. If the appendage is clear, cardioversion may proceed under your laboratory protocol.
Insertion can be uncomfortable without sedation because the probe is firm. With topical anesthesia and moderate sedation, most patients do not describe TEE as painful, though a sore throat afterward is common. General anesthesia removes awareness of the probe. Severe or progressive pain after the procedure is not expected and should be evaluated promptly.
After fasting and consent, the team places monitoring and intravenous access, anesthetizes the oropharynx, and administers sedation. A bite block is inserted and the lubricated probe is advanced into the esophagus so standard views and Doppler recordings can be obtained. The probe is then withdrawn, and the patient remains fasting until the gag reflex returns.
TEE is particularly sensitive for left atrial appendage thrombus, vegetations on prosthetic valves, mitral leaflet detail, atrial septal defects, and thoracic aortic flaps. It also shows valvular stenosis and regurgitation, wall-motion abnormalities, and pericardial fluid. No single examination detects every lesion, so findings still need clinical correlation with TTE and the rest of the workup.
Stress echocardiography looks for inducible wall-motion abnormalities that suggest ischemia. It does not directly display coronary stenoses the way angiography does, and a normal study does not exclude plaque. Stress imaging is almost always transthoracic. TEE is not used for treadmill testing.
Sore throat, hoarseness, nausea from sedation, and minor lip or dental injury are the usual effects. Serious complications are uncommon and include aspiration, arrhythmia, benzocaine-related methemoglobinemia, and esophageal injury. Severe pain, fever, hematemesis, or crepitus after the exam needs urgent review.
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Feel free to reach out to us for further information!
IAME is accredited by ACCME to provide AMA PRA Category 1 Credit™ for physicians and healthcare professionals.
We operate in North America, Australia, and South Korea.
© 2026 Institute for Advanced Medical Education, All Rights Reserved.
