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Guide to Intraoperative TEE at the UWMC

Author: Donald Oxorn, MD [COS Biography]
Revised: February, 2004

This document will serve as a guide to what I perceive as a complete intraoperative examination. This will have to be modified as dictated by the patient's specific pathology. The reader is referred to the document published in Anesthesia and Analgesia by Shanewise et al (J Am
Soc Echocardiogr 1999;12:884-900 Adobe Acrobat file
for conventional views and nomenclature.

  1. 4 chamber view, with demonstration of the A-V valves, both atria, interatrial septum, right ventricular free wall, interventricular septum, lateral wall of the LV. Some degree of anteflexion should reveal the LVOT +/- the aortic valve. High resolution of the AV valves should allow more detailed examination of the leaflets, as well as annular measurements. Colour Doppler should be applied to the AV valves, while withdrawing and advancing the probe to intersect jets in different planes. (Shanewise fig 3a)
  2. Rotation of the transducer to 30-60 degrees, and probe depth adjustment should reveal the aortic valve in cross section. Colour Doppler should be applied. The coronary ostia may be seen here. (Shanewise fig 3h)
  3. Rotation to 40-60 degrees and imaging of the mitral valve will reveal the commisural view (Shanewise fig 8). Colour Doppler should be applied to the mitral valves, while withdrawing and advancing the probe to intersect jets in different planes. Remember that if MR is present, 2 jets are the norm as the commissural plane is intersected twice. (Shanewise fig 3g)
  4. Rotation to 70-90 degrees will reveal the anterior and inferior walls of the LV (2 chamber view) (Shanewise fig 3b)
  5. Rotation to 120 degrees will reveal the posterior and anterior-septal walls of the LV, the RVOT, the mitral valve, the aortic valve long axis, and the ascending aorta. Colour should again be applied to both valves. The aortic annulus is measured here; it is essential that the aortic valve not be foreshortened, or else the annular measurement will be inaccurate. (Shanewise fig 3c)
  6. With the transducer at 90 degrees, and the probe rotated rightward, the bicaval view is obtained. (Shanewise fig 3l) Advancing the probe may allow imaging of the tricuspid valve, and as the probe is advanced into the stomach, the IVC will be seen in long axis. Withdrawing the probe back into the esophagus and rotating the transducer back to 40-50 degrees allows the right sided inflow outflow view to be obtained. (Shanewise fig 3m)
  7. With the transducer again at 0 degrees, advancing the probe allows visualization of the coronary sinus. Passing into the stomach, the RV can be seen, as well as the short axis of the LV at basal (mitral) levels, midpapillary, and apical views (Shanewise fig 3d+f). The corresponding LV segments should be examined as per Shanewise. Deep entry and strong anteflexion should reveal the LVOT and aortic valve. (Shanewise fig 3k) Rotating the probe rightward the right side of the heart is imaged. Slowly rotating the transducer should reveal the tricuspid valve in short axis. Further rotation to about 90 degrees should reveal the long axis of the RA and RV, as well as the tricuspid valve (Shanewise fig 3n).
  8. Turning the probe posterior, the descending aorta is seen, and should be followed up to the arch both at 0 degrees, and approximately 90 degrees. At 90 degrees as the descending aorta turns to the arch, the left subclavian artery will be seen as well as the main pulmonary artery and pulmonic valve. Rotating to 0 degrees should reveal the pulmonary artery bifurcation and a cross section of the ascending aorta and SVC. (Shanewise fig 3o)
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