TEE views complete notes with echo and ecg interrelation

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TEE Views - Complete Notes with Echo and ECG Interrelation

Sources: Barash Clinical Anesthesia 9e, Miller's Anesthesia 10e, Textbook of Clinical Echocardiography (Otto)

PART 1: FUNDAMENTALS OF TEE

What is TEE?

Transesophageal echocardiography (TEE) places an ultrasound transducer inside the esophagus and stomach, immediately posterior to the heart. Because no lung or chest wall intervenes between the probe and the heart, TEE produces higher resolution images than transthoracic echocardiography (TTE), especially for posterior structures (left atrium, mitral valve, descending aorta, pulmonary veins).

TEE is the preferred intraoperative modality because it does not interfere with the surgical field. TTE is preferred outside the OR. TEE may be required outside the OR when: body habitus is unfavorable, dressings or drains limit chest-wall access, or the left atrial appendage (LAA) needs direct assessment.

PART 2: PROBE MECHANICS AND IMAGE PLANE ROTATION

The TEE probe tip sits in the esophagus or stomach. The ultrasound crystal array can rotate electronically from 0° through 180°, changing the "cut" through the heart without moving the probe tip.

TEE probe plane rotation diagram - 0° horizontal to 180° vertical

Key angles used clinically:

0° = transverse / horizontal plane
45° = oblique (RV inflow-outflow)
90° = sagittal / vertical plane
120-135° = long-axis / oblique

Probe position terminology

Term	Meaning
Advance	Push probe deeper (stomach direction)
Withdraw	Pull probe back (mouth direction)
Turn left/right	Rotate the whole probe shaft
Anteflex / retroflex	Flex tip anteriorly or posteriorly
Leflex / rightflex	Flex tip left or right

Three Primary Positions (ASE/SCA 2013 - 28 views total)

Position	Depth from teeth	Structures imaged
Upper esophageal (UE)	~20-25 cm	Aortic arch, pulmonary artery, SVC
Midesophageal (ME)	~30-40 cm	All four chambers, valves, aortic root
Transgastric (TG)	~40-45 cm	LV cross-section, papillary muscles, LVOT
Deep transgastric (dTG)	~45-50 cm	LVOT, aortic valve, 5-chamber view

PART 3: COMPREHENSIVE TEE VIEWS (ASE/SCA Guidelines)

The 2013 ASE/SCA guidelines define 28 standard views (expanded from the original 1999 set of 20). The focused "basic" study uses 12 key views as described below.

Basic TEE imaging planes - all three positions

GROUP A: MIDESOPHAGEAL (ME) VIEWS

1. ME Four-Chamber View (ME 4C) — 0°

Acquisition: Advance probe 35-40 cm, plane at 0°, retroflex to eliminate foreshortening and open the LV apex.

Structures seen: RA, RV, LA, LV, mitral valve (MV), tricuspid valve (TV), interatrial septum (IAS), interventricular septum (IVS).

Best for:

Biventricular size and systolic/diastolic function
LV septal and lateral wall motion
MV and TV function
Atrial and ventricular septal integrity

ME 4C view - LA, RA, LV, RV with MV and TV labeled

ECG correlation: The QRS onset marks end-diastole (maximum LV cavity size). Peak systolic contraction of all four walls is seen at the T wave end. In the ME 4C view, monitor the septal and lateral walls - these correspond to:

Lateral wall: left circumflex (LCx) territory → ECG changes in I, aVL, V5-V6
Septal wall: LAD territory → ECG changes in V1-V4

2. ME Two-Chamber View (ME 2C) — ~90°

Acquisition: From ME 4C, rotate plane to ~90°; turn probe left/right to center LV apex.

Structures seen: LA, LV (inferior and anterior walls), left atrial appendage (LAA), coronary sinus (CS) in inferior AV groove, posteromedial papillary muscle.

Best for:

LV inferior and anterior wall motion
LAA thrombus (key pre-cardioversion screen)
MV in orthogonal plane

ECG correlation:

Inferior wall: RCA territory → ST elevation in II, III, aVF
Anterior wall: LAD territory → ST changes in V3-V5

3. ME Long-Axis View (ME LAX) — ~120-135°

Acquisition: From ME 2C, rotate plane to ~120-135°. Equivalent to TTE parasternal long-axis (PLAX).

Structures seen: LA, LV, MV (anterior and posterior leaflets), LVOT, aortic valve (AV), proximal ascending aorta.

Best for:

LV anterior-septal and inferolateral wall function
LVOT assessment (dimension for stroke volume calculation)
Aortic valve morphology and stenosis/regurgitation
Proximal ascending aorta

ECG correlation:

Anteroseptal wall: LAD → V1-V4
Inferolateral (posterior): LCx → I, aVL, V5-V6 or RCA in some patients

4. ME Aortic Valve Short-Axis View (ME AV SAX) — ~30-45°

Acquisition: From ME LAX, withdraw probe slightly and reduce angle to ~30-45°. The AV appears in cross-section as a circle ("Mercedes-Benz" pattern of 3 cusps).

Structures seen: Aortic valve (all 3 cusps: RCC, LCC, NCC), RVOT, pulmonary valve, interatrial septum, proximal coronary ostia, tricuspid valve.

Best for:

AV morphology (tricuspid vs bicuspid)
AV orifice area planimetry in AS
Commissure orientation before TAVR
RVOT and pulmonary valve assessment

ECG note: AV cusps open at QRS (systole begins) and close at T wave completion.

5. ME Aortic Valve Long-Axis View (ME AV LAX) — ~120-135°

Acquisition: Similar to ME LAX but centered on the AV rather than MV.

Structures seen: LVOT, aortic valve, sinuses of Valsalva, sino-tubular junction, proximal ascending aorta.

Best for:

Aortic root dimensions
AI jet characterization
TAVI planning

6. ME Mitral Commissural View (ME MC) — ~60°

Acquisition: From ME AV SAX, advance probe and increase angle to ~60°.

Structures seen: Both mitral commissures (anterolateral and posteromedial), all three scallops of posterior leaflet visible.

Best for:

MV commissure pathology
Mitral stenosis (commissural fusion)
Pre- and post-mitral repair

7. ME Bicaval View — ~90-110°

Acquisition: From ME 4C, rotate plane to ~90-110° and turn probe rightward.

Structures seen: SVC (top), IVC (bottom), RA, interatrial septum, right pulmonary veins, Eustachian valve, crista terminalis.

Best for:

Interatrial septum anatomy (ASD, PFO, septal defects)
Caval cannula positioning (cardiac surgery)
Catheter/device guidance (ASD closure, TAVR, pacemaker leads)
Right atrial masses

8. ME RV Inflow-Outflow View — ~60-90°

Acquisition: Rotate plane to ~60-90° and turn probe slightly rightward from ME 4C.

Structures seen: RV inflow (TV), RV body, RVOT, pulmonary valve, proximal pulmonary artery — all in a "wrap-around" view.

Best for:

RV size and function
TV and pulmonary valve assessment
RV outflow tract
Pericardial effusion (anteriorly)

9. ME Ascending Aortic Short-Axis View (ME Asc Ao SAX) — 0°

Acquisition: Withdraw probe to upper esophagus (~25-30 cm), plane at 0°.

Structures seen: Ascending aorta in cross-section, SVC, pulmonary artery.

10. ME Ascending Aortic Long-Axis View (ME Asc Ao LAX) — ~90-120°

Acquisition: From ME Asc Ao SAX, rotate to 90-120°.

Structures seen: Ascending aorta in longitudinal section.

Best for (both ascending aortic views):

Aortic dissection (type A)
Atheroma assessment
Measurement of ascending aortic diameter

GROUP B: TRANSGASTRIC (TG) VIEWS

11. TG Mid Short-Axis View (TG Mid SAX) — 0°

Acquisition: Advance probe into stomach (~40-45 cm), anteflex to bring LV into view at 0°. The plane cuts through the LV at the papillary muscle level.

Structures seen: LV (circular cross-section), RV, IVS, anterolateral and posteromedial papillary muscles, all 6 mid LV segments simultaneously.

TG Mid SAX view - LV circle with papillary muscles, RV, IVS labeled

Best for:

Global LV systolic function (most important intraoperative monitoring view)
Regional wall motion abnormalities - all three coronary territories visible simultaneously
LV preload assessment (end-diastolic area)
Papillary muscle function

ECG-Echo correlation - CRITICAL VIEW:

The TG Mid SAX is the premier view for real-time ischemia monitoring because all three coronary territories appear simultaneously:

Wall segment (TG mid SAX)	Coronary artery	ECG leads
Anterior (top of image)	LAD	V3-V5
Anteroseptal	LAD	V1-V2
Inferior (bottom of image)	RCA	II, III, aVF
Inferoseptal	RCA (or LAD)	II, III, V1-V2
Inferolateral / posterior	LCx	I, aVL, V5-V6
Anterolateral	LCx or LAD	I, aVL, V4-V5

Key principle: New regional wall motion abnormality (RWMA) on echo precedes ST changes on ECG by approximately 2-4 minutes in experimental ischemia - echo is more sensitive for acute ischemia detection. The sequence is: diastolic dysfunction → systolic dysfunction (RWMA) → ECG changes → symptoms (angina or pain).

12. Deep Transgastric Five-Chamber View (dTG 5C) — 0°

Acquisition: Advance probe fully into stomach (~45-50 cm), maximally anteflex ("deep TG"), plane at 0°.

Structures seen: LV, RV, LA (five-chamber orientation), LVOT, aortic valve, ascending aorta.

Best for:

CW Doppler through LVOT and aortic valve (best alignment for LVOT VTI and peak aortic velocity)
Stroke volume calculation
TAVI post-procedure assessment
LV outflow tract obstruction (LVOTO)

GROUP C: DESCENDING AORTIC VIEWS

13. Descending Aorta Short-Axis View (Desc Ao SAX) — 0°

Acquisition: From any ME position, turn probe leftward (counterclockwise) until the circular descending aorta appears. At 0°, it appears in cross-section.

14. Descending Aorta Long-Axis View (Desc Ao LAX) — ~90°

Acquisition: From Desc Ao SAX, rotate to ~90°.

Best for (both):

Aortic dissection (type B)
Atheroma grading (Grades 1-5 by ASE)
Aortic aneurysm
Wire/catheter/IABP placement guidance

UPPER ESOPHAGEAL (UE) VIEWS

15. UE Aortic Arch Long-Axis View — 0°

Acquisition: Withdraw probe to ~20-25 cm, plane at 0°.

Structures seen: Aortic arch in long-axis (horseshoe curve).

16. UE Aortic Arch Short-Axis View — ~90°

Acquisition: From UE LAX, rotate to ~90°.

Structures seen: Aortic arch in cross-section, left subclavian artery, main pulmonary artery, ductus remnant.

17. UE Pulmonary Artery / Pulmonary Vein Views — ~0-90°

Structures seen: Main PA, left PA, right PA, pulmonary veins, SVC, left and right atria.

Best for:

Pulmonary embolism
Pulmonary hypertension monitoring
Pulmonary vein flow for diastolic function

PART 4: THE 17-SEGMENT LV MODEL AND CORONARY TERRITORY MAPPING

The LV is divided into 17 segments (AHA model) - 6 basal, 6 mid, 4 apical, plus apical cap. Each TEE view visualizes a subset of these segments.

Level	Segments	TEE view
Basal (6)	Anterior, anteroseptal, inferoseptal, inferior, inferolateral, anterolateral	TG basal SAX, ME views
Mid (6)	Same walls at papillary muscle level	TG mid SAX
Apical (4)	Anterior, septal, inferior, lateral	ME 4C, ME 2C, ME LAX
Apical cap (1)	Apex only	ME views (foreshortened in TEE)

Coronary Territory to ECG Lead Mapping

Coronary artery	LV walls supplied	ECG leads
LAD	Anterior, anteroseptal, apical cap, apical anterior, apical septal	V1-V6 (especially V3-V5)
RCA	Inferior (basal), inferoseptal (basal/mid), RV free wall	II, III, aVF
LCx	Lateral (all levels), inferolateral	I, aVL, V5-V6

Important caveat: There is anatomical variability - the LAD may supply mid-inferoseptal in some, and RCA or LCx may share the inferolateral territory depending on dominance.

PART 5: ECHO-ECG INTERRELATION IN CLINICAL PRACTICE

Timing of Echo Events Relative to ECG

ECG event	Mechanical correlate seen on echo
P wave	Atrial contraction - LA/RA squeeze; mitral valve moves toward LV
QRS complex	Onset of ventricular systole - MV closes; semilunar valves open
T wave end	End of ventricular repolarization - aortic/pulmonary valve closes
Diastole (T to next P)	MV and TV open; ventricular filling begins

ISOVOLUMIC CONTRACTION (IVC)

ECG: After QRS onset
Echo: Mitral valve closed, aortic valve still closed, LV wall thickening beginning
Timing measured on M-mode

ISOVOLUMIC RELAXATION (IVR)

ECG: After T wave
Echo: Both valves closed, LV pressure falling, no filling yet
Prolonged IVR = impaired relaxation (Grade I diastolic dysfunction)

Diastolic Function - Echo-ECG Timing

Doppler of mitral inflow (pulsed wave, sampled at MV tips):

E wave = early passive filling (corresponds to rapid ventricular relaxation after T wave)
A wave = late active filling (corresponds to P wave of next beat - atrial contraction)

Diastolic grade	E/A ratio	DT (ms)	IVRT (ms)	Echo finding	ECG association
Normal	1-2	160-200	60-100	Normal	Normal
Grade I (impaired relaxation)	<1	>200	>100	Reduced E, dominant A	LVH on ECG, strain pattern
Grade II (pseudonormal)	1-2	160-200	60-100	PV S<D; E/e'>14	Often LVH
Grade III (restrictive)	>2	<160	<60	High E, no A	Tall P waves, AF common

ST Changes and RWMA Correlation

Echo is more sensitive than ECG for ischemia. The cascade of ischemia:

Metabolic change (lactate, adenosine)
Diastolic dysfunction (impaired LV relaxation on TDI/echo - first sign)
Systolic dysfunction (RWMA on echo - wall becomes hypokinetic, then akinetic)
ECG changes (ST depression/elevation)
Symptoms (angina)

This means in the operating room or ICU, a new RWMA on TG mid SAX precedes ST changes on the ECG monitor - giving earlier warning of ischemia.

Grading of Regional Wall Motion

Grade	Description	ECG likelihood
Normal/hyperkinetic	>30% systolic thickening	No ischemic changes
Hypokinetic	Reduced thickening (10-30%)	May have subtle ST changes
Akinetic	No/minimal thickening (<10%)	ST changes usually present
Dyskinetic	Paradoxical outward motion	Marked ECG changes/STEMI pattern

Conduction Abnormalities on ECG Affecting Echo Interpretation

ECG abnormality	Echo finding
LBBB	Paradoxical septal motion (septum moves opposite to normal); may mimic RWMA; speckle tracking needed
RBBB	Septal motion abnormal (early); RV enlargement may be seen
Paced rhythm	Dyskinetic septal motion due to abnormal activation sequence
AF	No A wave on mitral Doppler; LAA thrombus risk
1st degree AV block	Prolonged PR → prolonged E-A fusion; elevated LV filling pressures
Complete heart block	Cannon A waves on tricuspid/mitral Doppler (atria contracting against closed valves)
WPW	Pre-excitation → regional wall motion artifact mimicking RWMA

PART 6: FOCUSED TRANSTHORACIC ECHO VIEWS (FoCUS) for Comparison

The five standard FoCUS views correlate with TEE views:

FoCUS exam - PLAX, PSAX, A4C, S4C, SIVC probe positions and images

TTE View	TEE Equivalent	Probe Window
Parasternal long-axis (PLAX)	ME LAX (~120-135°)	3rd-5th ICS, left sternal border
Parasternal short-axis (PSAX)	TG mid SAX (0°)	Same as PLAX, probe rotated 90°
Apical four-chamber (A4C)	ME 4C (0°)	5th ICS, mid-axillary line
Subcostal four-chamber (S4C)	No direct equivalent	Sub-xiphoid
Subcostal IVC (SIVC)	ME Bicaval (~90°)	Sub-xiphoid

PART 7: SPECIAL APPLICATIONS WITH ECHO-ECG RELEVANCE

Stress Echocardiography

Stress echo (dobutamine or exercise) is particularly valuable when the resting ECG is non-diagnostic (LBBB, paced rhythm, LVH with repolarization changes, pre-excitation). Echo detects new or worsening RWMA as the ischemic endpoint, independent of ECG changes.

Cardiac Arrhythmias Assessment by TEE

AF: ME Bicaval and ME 2C views to visualize LAA for thrombus before cardioversion
VT storms: Assess LV function and look for structural substrate (scar = akinetic/dyskinetic segment correlating with Q waves on ECG)
Sinus node dysfunction: No structural abnormality usually; RA size may be increased

Pulmonary Hypertension

ECG: RAD, RVH (R>S in V1), P pulmonale, RBBB
Echo: RV enlargement (>2/3 LV size in ME 4C), D-shaped septum in diastole (volume overload) or throughout cardiac cycle (pressure overload), TR jet velocity >3.4 m/s (estimated RVSP >50 mmHg)

Cardiac Tamponade

ECG: Low voltage, electrical alternans (alternating QRS amplitude)
Echo: RA collapse in systole, RV diastolic collapse, IVC plethora (no collapse with inspiration), "swinging heart"

Aortic Stenosis

ECG: LVH pattern (Sokolow criteria), strain pattern (ST depression, T inversion in V5-V6, I, aVL)
Echo: Reduced AV cusp excursion in ME AV SAX; high velocity jet (>4 m/s by CW Doppler from dTG 5C); mean gradient >40 mmHg = severe

PART 8: SYSTEMATIC TEE EXAMINATION SEQUENCE

Recommended order (depth-based, ASE):

ME 4C → biventricular function, MV, TV, septa
ME 2C → inferior/anterior walls, LAA
ME LAX → LVOT, AV, MV in orthogonal plane
ME AV SAX → AV morphology, RVOT, coronary ostia
ME AV LAX → aortic root dimensions
ME MC → MV commissures
ME Bicaval → IAS, SVC, IVC, right PV
ME RV inflow-outflow → RV, TV, RVOT, pulmonary valve
ME Asc Ao SAX/LAX → ascending aorta
TG mid SAX → LV function monitor, RWMA
TG 2C or TG LAX → LV walls in additional planes
dTG 5C → Doppler of LVOT/AV
Desc Ao SAX + LAX → aorta from arch to celiac
UE Asc Ao / Arch views → arch, great vessels

PART 9: KEY MEMORY TRICKS

View	Angle	Mnemonic
ME 4C	0°	"Zero = Four" (0° gives 4 chambers)
ME 2C	90°	"90 = Two" (rotate 90° → 2 chambers)
ME LAX	120-135°	"120-135 = Long"
ME AV SAX	30-45°	"30-45 = Aorta X-section"
ME Bicaval	90-110°	"90 + right turn = bicaval"
TG Mid SAX	0° in stomach	"Stomach, zero, circle"
dTG 5C	0° deep stomach	"Deepest, 0°, five chambers"

SUMMARY TABLE: ALL 12 FOCUSED TEE VIEWS

#	View	Angle	Depth	Key Structures	Coronary / ECG relevance
1	ME 4C	0°	35-40 cm	LA, RA, LV, RV, MV, TV	Lateral (LCx) + Septal (LAD)
2	ME 2C	~90°	35-40 cm	LA, LV (inf/ant), LAA	Inferior (RCA) + Anterior (LAD)
3	ME LAX	120-135°	35-40 cm	LV, LVOT, MV, AV, aorta	Anteroseptal (LAD) + Inferolateral (LCx)
4	ME AV SAX	30-45°	30-35 cm	AV cusps, RVOT, PV, IAS	AV timing with QRS
5	ME AV LAX	120-135°	30-35 cm	Aortic root, LVOT	Aortic root pathology
6	ME MC	~60°	35 cm	MV commissures	MV lesion localization
7	ME Bicaval	90-110°	30-35 cm	SVC, IVC, RA, IAS	RAD on ECG → check RV
8	ME RV I/O	60-90°	30-35 cm	RV, TV, RVOT, PV	RVH/RBBB on ECG
9	ME Asc Ao SAX	0°	25-30 cm	Ascending aorta (XS)	Aortic dissection
10	ME Asc Ao LAX	~90°	25-30 cm	Ascending aorta (long)	Aortic dissection
11	TG mid SAX	0°	40-45 cm	LV (all 6 mid segments), RV	All 3 coronary territories - primary ischemia monitor
12	dTG 5C	0°	45-50 cm	LV, LVOT, AV, aorta	Doppler LVOT VTI, AV velocity

References: Barash Clinical Anesthesia 9e, p. 2201-2215; Miller's Anesthesia 10e, p. 4982-4990; Textbook of Clinical Echocardiography (Otto), p. 112; ASE/SCA 2013 Guidelines for Comprehensive TEE Examination.

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