A transesophageal echocardiogram test or TEE test is done using an echo probe passed via the mouth and throat into the esophagus. The transesophageal echocardiogram test takes a continuous picture of the heart while it beats, which is then transferred to a monitor that is close by. The esophagus is the food pipe connecting the mouth with the stomach esophagus. The transesophageal echocardiogram probe takes the images of the heart from the back of the heart. We can take both two-dimensional (2D) and 3D images with a transesophageal echocardiogram. TEE has also got M-mode and Doppler features. Doppler helps assess the direction of the flow of the blood and the speed of the blood.

TEE heart test full form

 

TEE test stands for Transesophageal echocardiography test

TTE test full form

 

Transthoracic two-dimensional echocardiography is the full form of TTE. A Transthoracic two-dimensional echocardiogram test is done using an echo probe placed over the left side of the chest (heart area). It gives a continuous picture of the heart while it beats, which is then transferred to a monitor that is close by. It takes the images of the heart from the front.

Is the machine the same for TTE and TEE

 

Few echocardiogram machines do not have a TEE facility. Few echocardiogram machines or ultrasound machines have the software to do TTE and TEE. They both need different probes.

 

Why is a transesophageal echocardiogram performed?

 

Transthoracic two-dimensional echocardiography (TTE) is the most commonly performed echocardiogram in the clinical practice of cardiology. Transesophageal echocardiography (TEE) may be needed when Transthoracic two-dimensional echocardiography (TTE) is non-diagnostic. TEE  has got a higher resolution for the structure of the heart, which lies on the back.

Structure of the heart that lies on the back

 

These are the structure of the heart that lies posteriorly. These structures are more close to the food pipe. As we pass the TEE probe into the food pipe and take images of the heart, these are better visualized with TEE.

• Atria (Upper chambers of the heart)
• Mitral valve
• Pulmonary veins
• Descending Aorta
• Left atrial appendage
• Aortic leaflets and aortic root

TTE vs. TEE: Which is better

Lung and bone (ribs) intervene in the clarity of the images of the heart acquired by TTE. There is no intervening lung and bone in TEE, so image quality is high here.

Posterior structures (described above) are less well visualized on transthoracic echocardiography as they are more distant from the anterior TTE transducer probe. TTE better visualizes anterior structures than TEE. Left ventricular pathologies are better seen with TTE.

 

But TEE cardiac test is an invasive procure,  hence is reserved for certain indications only. TEE test is expensive when compared with TTE. TEE tests take a longer time. TEE test needs sedation, whereas TTE does not.

 

Therefore, the TTE test should remain the initial test of choice for those requiring an echocardiogram. The TTE study should always precede the TEE  to decide the need for TEE.

Transesophageal echocardiography indications

 

TEE is most commonly performed to evaluate

1. Cause of brain stroke

 

Embolization of clots or vegetations from the heart presents as a brain stroke. Then your doctor should address the heart problem along with the brain stroke. TEE test can frequently identify the source of the embolism for brain stroke, such as patent foramen ovale, a clot in the left atrial appendage. In that way, the TEE test has a valuable role in stroke.

 

2. To assess valves for endocarditis

 

Infection of the valves of the heart is referred to as IE. It presents as a fever that does not respond to routine antibiotics. TEE is a valuable tool for establishing the diagnosis of infective endocarditis. Vegetations are frequently seen in the TEE diagnostic test with IE. Even complications of endocarditis (e.g., fistula, abscess) can also be seen.

 

3. To exclude left atrial appendage (LAA) thrombi

 

Atrial fibrillation is a common heart rhythm abnormality where the heart beats chaotically and irregularly. It predisposes to blood clots in the left atrium, especially the left atrium appendage. The decision to convert atrial fibrillation to normal rhythm needs information about the clot. Cardioversion can be done for Afib if a transesophageal echocardiogram shows no clot.

 

 

4. Prosthetic heart valve dysfunction

 

A prosthetic heart valve is a device that substitutes for the natural valve. The prosthetic valve may be implanted to replace a diseased or defective heart valve. These valves are prone to several complications like clot formation on top of them and infective endocarditis (infection of the prosthetic valve). Even fibrous tissue can grow over them and hold them from opening well. This is referred to as pannus. Prosthetic heart valves are also prone to regurgitation. TEE well visualizes a blood clot, vegetation, pannus, and regurgitation than TTE

5. Native valvular disease

 

Valvular heart disease is a condition where valvular structures in the heart are not functioning correctly. Valves are two-part structures that control blood flow from one chamber to another. Blood can sometimes leak backward, which should normally not happen. This is called regurgitation. Sometimes valves are narrowed or blocked. This is called stenosis of the valve, where the valve can not open fully as it should be. Mitral valve stenosis, aortic valve regurgitation, and mitral valve regurgitation are better seen with the TEE diagnostic test.

 

6. Aortic disease

 

The aorta is the largest artery in your body, and it moves blood from your heart to the rest of the body. It is sometimes prone to diseases like dissection, aneurysm dissection, and intramural hematoma. They are not better visualized with TTE; either ct scan chest or TEE is needed to visualize these pathologies better. CT scan is frequently used for aortic aneurysm/dissection, and TEE is helpful when the patient can not be shifted to a CT scan room.

 

7. During cardiac surgical procedures

 

Surgeries for congenital heart disease (diseases with which you are being born)or valve repairs need TEE help to verify anatomy and to monitor the success of the procedure.

 

8. As imaging guidance during   percutaneous cardiac interventions

 

Certain procedures for the heart are done through your groin like transcatheter aortic valve replacement (TAVR), transcatheter mitral valve repair, balloon mitral valvotomy and transcatheter left atrial appendage closure also need TEE help to complete the procedure

 

9. Atrial septal defect (ASD)- Guiding management plan

 

The atrial septum is the wall that separates the two upper chambers of the heart called the atria. The two upper chambers are the right atrium and left atrium. They lie posteriorly and are closely associated with food pipe, and It is better seen with TEE than TTE. Diseases that can occur in the septum are atrial septal defects and patent foramen ovale

To look for the size of ASD and its suitability for device closure, TTE is helpful. To ascertain the presence of patent foreman ovale, TEE is needed. Patent foramen ovale is present in more than 20% general population and is also responsible for more than 20% of brain strokes.

Uses of TEE in critical care

 

• Unexplained low blood pressure (hypotension)
• Unexplained low oxygen levels in the body
• Suspected complications following a heart attack
• Blunt chest trauma

Is a TEE test painful?

 

TEE is not a painful procedure if it goes smoothly. You may feel a little discomfort during the procedure. Even though You are given spray to numb your throat,  you may feel like gagging when the tube goes in. You may also have a sore throat for a couple of days.

What tests are needed for the TEE test?

TEE test is an invasive procedure. You need basic tests like

• Complete blood picture
• PT, INR
• Viral markers
• ECG test
• TTE test
• Assessment of airway

TEE procedure time

 

The TEE procedure takes 10 to 15 minutes. Before and after the test, you should be in observation for 15 to 30 minutes. Overall the test can be completed in an hour.

PATIENT PREPARATION FOR TEE

 

For patients undergoing a TEE, the preparation is similar to endoscopy. It is very important to follow directions given by medical professionals before undergoing a transesophageal echocardiography test. It may not be feasible for all people who want to undergo this procedure due to various reasons such as swallowing or breathing problems. They should avoid eating foods or taking liquids 4-6 hours before the test.

• A 2d echo technician will spray medicine on your throat to numb it and suppress the gag reflex. We usually spray 2 to 3 times before the test. Once you feel numbness, the doctor starts the procedure.

• A medical nurse puts an IV (intravenous line) in your arm and gives you a mild intravenous injection (sedative). It helps you to relax.

 

• The 2d echo technician then connects you to a monitor that checks your blood pressure, heart rate, ECG, and oxygen saturation.

• TEE probe is lubricated before insertion into your throat or esophagus.

•  You’ll be asked to lie on a table or a hospital bed toward the one side facing your doctor. Doctors preferably do it from the left side of the patient.

• The doctor then gently guides a thin, flexible tube (probe) through your mouth and down your throat. You should swallow a very cold TEE probe while your doctor gently pushes the probe from the throat to the esophagus.
• Following intubation of the esophagus, the probe is advanced in most adult patients to a depth of 28 to 30 cm from the incisors.
• Gastric imaging— Your cardiologist Advances the probe a little deeper to a length of 42 to 45 cm from the incisors into the fundus of the stomach after completing the study from the esophagus. He then takes the images of the heart from different angles.
• Once the probe is in the esophagus, the doctor takes the images of the heart from different angles. He may move the probe to and fro and rotate it left and right. He stores all the images and gives a copy to you afterward.
• The flexible tube or the probe is gently removed by your doctor after taking enough images.
•  IV cannula and electrodes are removed.
• You will be kept under observation till you are fully awake. You can not have food till you feel fully awake and numbness in the throat goes away.

TEE heart test side effects

 

TEE is safe in experienced hands. Serious complications are extremely rare. Complications occur in one in  5000 cases.

1. Esophageal perforation 

 

Perforation of the esophagus can occur due to accidental passage of the tube through the wall of the esophagus or food pipe

 2. Bleeding 

 

Bleeding from the mouth, throat, esophagus, or stomach can occur after the TEE test. This is uncommon in the general population but common in people with bleeding tendencies. Bleeding occurs if injury occurs to any of the body parts

 3. Hematoma in the throat

 

 Direct trauma to the throat may result in hematoma formation.

Absolute contraindications for TEE test

 

1. Bowel perforation

 

 TEE test should not be done with intestinal perforation

2. Esophageal stricture

 

 An abnormal narrowing of the esophagus blocks food and liquid. TEE probe can not be passed through the narrowed esophagus.

3. Esophageal tumor

 

Any mass or cancer that affects the food pipe precludes the passage of the probe and can cause complications during tee procedure

4. Esophageal perforation/laceration

 

 Rupture of the esophagus is frequently due to persistent vomiting or trauma, or medical procedure. It is an absolute contraindication for the TEE test

5. Esophageal diverticulum

 

Outpouching from the food pipe is called a diverticulum. It may not allow the probe to go in the right way. It increases the complications if a TEE test is performed

6. Ongoing bleeding from the mouth, throat or esophagus, or stomach

 

TEE test can accentuate the bleeding further

 

Increased risk for complications (relative contraindications):

• If the mental status is altered
• If the patient is uncooperative
• If a History of radiation to the head, neck,  or chest present
• History of surgery to food pipe or stomach present
• If there is a recent bleed from the throat, food pipe, and stomach
• If  Esophageal varices present ( dilated veins in the Esophageal that occur in liver disease )
• If Active infection of esophagitis
• If there is an active  ulcer in the stomach
• If there is a hernia in the esophagus
• If you have severe Cervical spine problems
• Very low platelet count
• Increased bleeding tendencies

If you have pain or difficulty swallowing, tell your doctor. He may suggest an alternative test.

Three-dimensional TEE imaging

 

Three-dimensional echocardiographic imaging is a useful adjunct for the assessment of ventricular volumes and ejection fraction, evaluation of valvular and other structural cardiac abnormalities, and the guidance of transcatheter structural interventions.

Transesophageal echo test cost in Hyderabad, India

 

A TEE test can cost anywhere between 3000 to 6000 Indian Rupees in Hyderabad,  India, depending on whether it is a 2d scan or a 3D scan and the number of parameters being checked. It varies from one center to another center.

 

Best TEE specialist in Hyderabad

 

Dr. Malleswara Rao is a senior interventional cardiologist with vast experience in the TEE test.

Transesophageal echo procedure recovery time

 

– It may take one hour to recover fully from sedation.

-Your numbness in the throat goes away in 30 to 60 minutes.

-You may feel pain in the throat for a couple of days.

 

When to seek the doctor’s help after TEE?

 

If you develop the following symptoms, consult your doctor

1. Fever
2. Bleeding from the throat or mouth
3. Shortness of breath
4. Throat pain for more than three days