TEE Views: A Comprehensive Overview for Cardiovascular Imaging

Transesophageal echocardiography (TEE) is a critical imaging technique for evaluating cardiac structures and function with high precision. By positioning the ultrasound probe in the esophagus, TEE provides detailed views of the heart that are often superior to transthoracic echocardiography, particularly in critically ill patients or during surgery. Its real-time imaging capability makes it invaluable for diagnosing cardiovascular conditions and guiding interventions.

Standardized TEE views facilitate a thorough assessment of cardiac chambers, valves, and major vessels. Each view has specific clinical applications, optimizing pathology detection and improving patient outcomes.

Mid Esophageal Four Chamber View

This fundamental TEE perspective provides a comprehensive visualization of the heart’s major chambers and atrioventricular valves. By positioning the probe at approximately 0 to 10 degrees in the mid esophagus, this view captures the left and right atria, left and right ventricles, mitral valve, and tricuspid valve. It is essential for evaluating chamber size, wall motion abnormalities, and valvular function in both diagnostic and intraoperative settings.

A key application is assessing ventricular function, particularly in patients with suspected cardiomyopathy or ischemic heart disease. Left ventricular systolic function can be evaluated by measuring ejection fraction and regional wall motion abnormalities, while right ventricular function—often challenging to assess transthoracically—is more clearly visualized here, aiding in the diagnosis of right ventricular dysfunction due to pulmonary hypertension or acute pulmonary embolism.

This view is also crucial for detecting valvular pathology. The mitral and tricuspid valves can be examined for regurgitation, stenosis, or structural abnormalities such as prolapse or vegetation. Doppler imaging enhances the ability to quantify regurgitant jets and assess pressure gradients, aiding surgical decision-making. In mitral valve repair or replacement, intraoperative TEE ensures proper valve function post-intervention, reducing the risk of residual regurgitation or stenosis.

Additionally, this view helps identify intracardiac thrombi, particularly in the left atrium or left atrial appendage, common sources of embolism in atrial fibrillation. Its high sensitivity makes it essential before cardioversion or catheter-based procedures such as left atrial appendage occlusion. It also aids in diagnosing congenital abnormalities like atrial septal defects and patent foramen ovale, enabling bubble contrast studies to detect right-to-left shunting.

Mid Esophageal Long Axis View

This essential TEE perspective provides an elongated cross-section of the left ventricle, left atrium, aortic valve, and portions of the ascending aorta. By positioning the probe in the mid esophagus and adjusting the multiplane angle to approximately 120 to 150 degrees, this view offers a detailed assessment of left ventricular outflow tract dynamics and valvular function.

A primary advantage is its ability to assess aortic valve morphology and function with high spatial resolution. The long axis orientation clearly delineates aortic valve leaflets, aiding in the diagnosis of aortic stenosis, regurgitation, or congenital anomalies such as bicuspid aortic valve. Doppler imaging enables precise measurement of transvalvular gradients, crucial for grading stenosis severity and guiding management. In aortic valve replacement, intraoperative TEE ensures proper prosthetic valve function, confirming leaflet motion and the absence of perivalvular regurgitation.

Mitral valve evaluation is another significant application, as this view captures both anterior and posterior leaflets in motion. It is particularly valuable for assessing mitral valve prolapse, leaflet thickening in rheumatic disease, and functional mitral regurgitation secondary to left ventricular dilation. The ability to visualize the subvalvular apparatus aids in determining the mechanism of mitral regurgitation, essential for surgical planning. Color Doppler imaging further enhances assessment by identifying regurgitant jets.

Beyond valvular assessment, this view helps evaluate left ventricular systolic function and regional wall motion. By capturing the interventricular septum and posterior left ventricular wall, it detects ischemic changes indicative of coronary artery disease. This perspective also aids in assessing ventricular remodeling in hypertrophic cardiomyopathy, where asymmetric septal thickening can be precisely measured.

Mid Esophageal Two Chamber View

This TEE perspective isolates the left atrium and left ventricle, providing a sagittal cross-section that emphasizes longitudinal myocardial motion. By rotating the probe to approximately 90 degrees, this view effectively detects regional wall motion abnormalities, crucial in ischemic heart disease evaluation.

It is particularly useful in assessing left ventricular systolic function, allowing precise measurement of endocardial excursion and myocardial thickening. Hypokinesis, akinesis, or dyskinesis in the anterior or inferior walls can indicate coronary artery disease. This orientation also facilitates strain imaging, which detects subtle dysfunction before ejection fraction declines, an increasingly important tool in monitoring chemotherapy-induced cardiotoxicity.

Mitral valve pathology assessment is another key application. This view provides a detailed profile of both leaflets, aiding in the diagnosis of mitral regurgitation or stenosis. It is particularly beneficial for evaluating the anterior leaflet, which plays a dominant role in coaptation. In degenerative mitral disease, prolapse or flail segments can be clearly visualized, assisting in surgical planning. Additionally, Doppler imaging facilitates accurate assessment of transmitral gradients, essential for grading stenosis severity.

Aortic Valve Short Axis View

This TEE perspective provides a cross-sectional image of the aortic valve, offering detailed insight into its structure and function. By positioning the probe in the mid esophagus and adjusting the multiplane angle to approximately 30 to 60 degrees, this view captures an en face image of the aortic valve leaflets, allowing precise evaluation of morphology, motion, and coaptation.

Aortic stenosis assessment benefits significantly from this view, as it allows direct visualization of leaflet thickening, calcification, and restricted motion. The ability to correlate leaflet appearance with Doppler-derived pressure gradients enhances diagnostic accuracy. This view is also essential for detecting bicuspid aortic valve, a congenital anomaly associated with early calcification and an increased risk of aortopathy.

For aortic regurgitation, this perspective helps determine the origin and severity of regurgitant jets, differentiating between primary leaflet pathology and secondary regurgitation due to annular dilation. It is also indispensable in evaluating endocarditis, where vegetations, abscesses, or leaflet perforations can be identified, guiding surgical intervention.

Transgastric Short Axis View

This widely utilized TEE perspective provides a cross-sectional visualization of the left ventricle at different levels. By advancing the probe into the stomach and adjusting the multiplane angle to approximately 0 degrees, this view captures circular cross-sections of the left ventricle, allowing precise assessment of myocardial function and wall motion.

A primary application is evaluating left ventricular systolic function. This view detects hypokinesis, akinesis, or dyskinesis, indicative of coronary artery disease. It is particularly useful in intraoperative settings, where real-time myocardial monitoring guides surgical decision-making and hemodynamic management. Additionally, this perspective is instrumental in assessing mechanical complications of acute myocardial infarction, such as ventricular septal rupture.

Bicaval View

This specialized TEE perspective focuses on the superior vena cava (SVC) and inferior vena cava (IVC), providing insights into venous return, right atrial dynamics, and interatrial septal integrity. By positioning the probe in the mid esophagus and rotating the multiplane angle to approximately 90 to 110 degrees, this view captures a longitudinal section of both vena cavae as they drain into the right atrium.

It is particularly valuable for assessing right atrial thrombi, which can occur in deep vein thrombosis with embolization or in patients with central venous catheters. This view is also essential for detecting patent foramen ovale (PFO) or atrial septal defects (ASD) using contrast-enhanced imaging.

Beyond thrombus detection, this view is instrumental in guiding transcatheter interventions, such as inferior vena cava filter placement or monitoring cannula positioning during extracorporeal membrane oxygenation (ECMO).

Descending Aorta View

This TEE perspective is critical for evaluating aortic pathology, particularly in detecting aortic dissection, atherosclerosis, and aneurysmal dilation. By positioning the probe in the esophagus and directing it posteriorly, this view provides high-resolution imaging of the aortic wall.

It is essential for detecting aortic dissection, where intimal flaps and false lumens can be visualized. This view also aids in assessing intramural hematomas and mobile atheromatous plaques, which serve as potential embolic sources for stroke.

Pulmonary Vein Inflow View

This specialized TEE perspective focuses on pulmonary veins as they drain into the left atrium, providing insights into pulmonary venous return and left atrial function. It is particularly important in evaluating atrial fibrillation, pulmonary venous stenosis, and left atrial pressure abnormalities.

This view is essential for assessing pulmonary vein flow patterns, mapping pulmonary vein anatomy in atrial fibrillation ablation, and detecting pulmonary vein thrombosis, a rare but serious complication following left atrial interventions.