Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 268--278

Practice guidelines for perioperative transesophageal echocardiography: Recommendations of the Indian association of cardiovascular thoracic anesthesiologists

Kanchi Muralidhar1, Deepak Tempe2, Murali Chakravarthy3, Naman Shastry4, Poonam Malhotra Kapoor5, Prabhat Tewari6, Shrinivas V Gadhinglajkar7, Yatin Mehta8,  
1 Department of Anaesthesia and Critical Care, Narayana Hrudayalaya Hospitals, Bangalore, Karnataka, India
2 Department of Anaesthesiology and Intensive Care, G.B. Pant Hospital, New Delhi, India
3 Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bangalore, Karnataka, India
4 Department of Anesthesia, SAL Hospital, Ahmedabad, Gujarat, India
5 Department of Cardiac Anaesthesia, Cardio Neuro Centre, All India Institute of Medical Sciences, New Delhi, India
6 Department of Anaesthesiology, SGPGIMS, Lucknow, Uttar Pradesh, India
7 Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
8 Department of Critical Care and Anaesthesiology, Medicity-The Medanta, Gurgoan, Haryana, India

Correspondence Address:
Kanchi Muralidhar
Department of Anaesthesia and Critical Care, Narayana Hrudayalaya Hospitals, #258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore - 560 099, Karnataka


Transoesophageal Echocardiography (TEE) is now an integral part of practice of cardiac anaesthesiology. Advances in instrumentation and the information that can be obtained from the TEE examination has proceeded at a breath-taking pace since the introduction of this technology in the early 1980s. Recognizing the importance of TEE in the management of surgical patients, the American Societies of Anesthesiologists (ASA) and the Society of Cardiac Anesthesiologists, USA (SCA) published practice guidelines for the clinical application of perioperative TEE in 1996. On a similar pattern, Indian Association of Cardiac Anaesthesiologists (IACTA) has taken the task of putting forth guidelines for transesophageal echocardiography (TEE) to standardize practice across the country. This review assesses the risks and benefits of TEE for several indications or clinical scenarios. The indications for this review were drawn from common applications or anticipated uses as well as current clinical practice guidelines published by various society practicing Cardiac Anaesthesia and cardiology . Based on the input received, it was determined that the most important parts of the TEE examination could be displayed in a set of 20 cross sectional imaging planes. These 20 cross sections would provide also the format for digital acquisition and storage of a comprehensive TEE examination. Because variability exists in the precise anatomic orientation between the heart and the esophagus in individual patients, an attempt was made to provide specific criteria based on identifiable anatomic landmarks to improve the reproducibility and consistency of image acquisition for each of the standard cross sections.

How to cite this article:
Muralidhar K, Tempe D, Chakravarthy M, Shastry N, Kapoor PM, Tewari P, Gadhinglajkar SV, Mehta Y. Practice guidelines for perioperative transesophageal echocardiography: Recommendations of the Indian association of cardiovascular thoracic anesthesiologists.Ann Card Anaesth 2013;16:268-278

How to cite this URL:
Muralidhar K, Tempe D, Chakravarthy M, Shastry N, Kapoor PM, Tewari P, Gadhinglajkar SV, Mehta Y. Practice guidelines for perioperative transesophageal echocardiography: Recommendations of the Indian association of cardiovascular thoracic anesthesiologists. Ann Card Anaesth [serial online] 2013 [cited 2019 Jul 16 ];16:268-278
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Full Text


Perioperative transesophageal echocardiography (TEE) is a diagnostic and monitoring imaging tool with widespread applications in the operating rooms and intensive care settings. [1] This modality is being used in both government institutions and private hospitals all across India. In view of increasing application of TEE in Indian context, it has become imperative to establish protocol/guidelines for the practice of TEE. This document is expected to assist physicians to help appropriate application of TEE and improve the perioperative management of surgical patients. These recommendations may be adapted and modified according to the local institutional policies, circumstances and expertise; and are not intended to be absolute regulatory requirements. Further, these recommendations are subject to the availability of TEE facility in a given hospital and its availability is not binding for carrying out surgical procedures [Table 1]. The guidelines do not address training, certification, establishing credentials and quality assurance.{Table 1}

 Indications for Perioperative TEE

The American Society of Anesthesiologists and Society for Cardiovascular Anesthesiologists in its updated report on TEE recommends the use of TEE for all adult open-heart and thoracic aortic procedures and transcatheter intracardiac procedures. [2] However, the Indian Association of Cardiovascular Thoracic Anesthesiologists recommendations are categorized as follows:

Technique for insertion of a TEE probe in an anesthetized individual: The following steps are followed for insertion of TEE probe in anesthetized and intubated patients:

Mouth is examined for abnormalities and loose teethAn informed consent from the patient is obtained prior to the procedureA suitable general anesthesia is administeredA nasogastric/orogastric tube is inserted to decompress the stomach and is removed prior to the passage of the TEE probeA bite-guard is inserted to prevent injury to the probe by the patient's teethThe probe is lubricated generously with jellyThe probe is inserted by displacing the mandible anteriorly and advancing the probe gently in the midline; manipulation of the neck by flexion of the neck will help in some cases; if blind insertion of the probe is not easy, a laryngoscope may be used to expose the posterior pharynx and permit direct passage of the probe into the esophagus; undue force should never be applied at any stage during insertion of the probe; [4] once in the esophagus, the transducer should never be forced through a resistanceThe tip of the transducer is allowed to return to the neutral position before advancing or withdrawing the probe and undue force is never applied when flexing the tip with the control wheelsCleaning and decontamination of the probe should be performed after each use based on hospital practiceIt is recommended to have an electrocardiogram trace on the echocardiographic imaging screen.

Complications associated with TEE (rare) [5]

Esophageal ulceration/injury/bleedingEsophageal perforationEsophageal hematomaLaryngeal palsyDysphagiaDental injuryAccidental tracheal extubationCardiac arrhythmia (especially supraventricular tachycardia in children)Airway obstruction and increased ventilatory pressureHypoxia/unintentional endobronchial intubationDistraction from anesthetic careDeath.

Contraindications to TEE: [6]


 Terminology for Manipulation of Probe

The terminology used to describe manipulation of the probe and transducer during image acquisition is described here. [7] With the patient supine, the imaging plane is directed anteriorly from the esophagus through the heart. With reference to the heart, superior means toward the head, inferior means toward the feet, posterior means toward the spine and anterior means toward the sternum. The terms right and left denote the patient's right and left sides, except when the text refers to the image display. [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26]{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}{Figure 10}{Figure 11}{Figure 12}{Figure 13}{Figure 14}{Figure 15}{Figure 16}{Figure 17}{Figure 18}{Figure 19}{Figure 20}{Figure 21}{Figure 22}{Figure 23}{Figure 24}{Figure 25}{Figure 26}

"Advancing:" pushing the tip of the probe distally into the esophagus or the stomach; "withdrawing:" pulling the tip in the opposite direction proximally; "turning to the right;" rotating the anterior aspect of the probe clockwise within the esophagus toward the patient's right; "turning to the left:" rotating the probe counterclockwise. Flexing the tip of the probe anteriorly with the large control wheel is called "anteflexing" and flexing it posteriorly is called "retroflexing." Flexing the tip of the probe to the patient's right with the small control wheel is called "flexing to the right," and flexing it to the patient's left is called "flexing to the left." Finally, axial rotation of the multiplane angle from 0° toward 180° is called "rotating forward," and rotating in the opposite direction toward 0° is called "rotating back."

The images displayed at the top of the screen are in the near field and structures in the far field are at the bottom of the screen. At a multiplane angle of 0° (the horizontal or transverse plane), with the imaging plane directed anteriorly from the esophagus through the heart, the patient's right side appears in the left of the image display and vice versa. Rotating the multiplane angle forward from 0° to 90° moves the left side of the display inferiorly (caudad) and right side of the display superiorly (cephalad). Rotating the multiplane angle to 180° places the patient's right side to the right of the display, will be a mirror image of 0°. Approximately distance of the probe tip from lips is 20-25 cm for upper esophageal (UE) views, 30-40 cm for midesophageal (ME) views and 40-45 cm for transgastric (TG) view in an average sized adult male; however, placement of the transducer into desired location is primarily accomplished by waiting the image to develop as the probe is manipulated rather than depth markers on the probe.

 The 17-Segment Model for Regional LV Assessment and Coronary Arterial Distribution

From base to the apex, the LV is divided into basal, mid and apical thirds corresponding to the proximal, middle and apical segments of the coronary arteries. The scheme divides the ventricle into 17 segments [Figure 27], six segments both in the basal and mid portions (anteroseptal, inferoseptal, anterior, anterolateral, inferolateral and inferior walls) and five at the apex (septal, anterior, lateral, inferior and apical). [8] As these segments can be recorded from three SAX and several longitudinal views, it is possible (and useful) to evaluate a segment from more than one view [Figure 27].{Figure 27}

The ME four-chamber view (transducer at 0°, posterior to the LA) allows simultaneous imaging of the LV and RV. It is advisable to retroflex the probe to avoid foreshortening of the left and RV cavities. In this view, the segmental function of the infero septal, antero-lateral walls and apex can be assessed. With the transducer at 90°, the ME two-chamber view allows visualization of the inferior and anterior walls and adjacent portions of the apex. Further transducer rotation up to 120-150° will result in a LAX view and visualization of the anterior septum and inferolateral wall on the right and left respectively. Using the trans-gastric approach, a series of SAX views can be obtained at 0-20° by modifying probe depth and anteflexion. For example, maximal anteflexion will generally allow visualization of the basal ventricular segments and the mitral valve. A lesser degree of ante-flexion or slight probe advancement will result in SAX views at the high and low papillary muscle levels. In these SAX views, the inferior wall is seen at the top of the screen, the anterior wall at the bottom, the inferolateral and anterolateral walls to the right and the anterior and inferior septal walls to the lower left and upper left of the screen. Further probe advancement will often result in a SAX view of the LV apical segments. Because ventricular segments perfused by each of the three major coronary arteries are represented in the SAX view at the mid-papillary muscle level, it is commonly used intraoperatively to evaluate global and segmental function. [9] Transducer rotation to 90° yields a two-chamber view, with the inferior and anterior walls at the top and bottom of the screen, respectively. Further rotation to 120-150° will result in a LAX view, with the inferolateral wall on top and the anterior septum at the bottom of the screen. [Figure 28]{Figure 28}


The authors are deeply indebted to Dr. Navin C Nanda and Dr. PK Neema for making valuable suggestions in writing of this manuscript.


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