BASIC TEE VIEWS AND MODIFIED VIEWS

1. BASIC AND MODIFIED TTE &TEE
VIEWS

2. Seminar outline
• TTE imaging windows and planes
• Basic TTE views
• Modified TTE views
• TEE imaging windows and planes
• Basic TEE views
• Modified TEE views

3. Views
• PLAX
• PSAX – Aortic Valve
• PSAX – Mitral Valve
• PSAX – Papillary Muscle
• PSAX - Apex
• Suprasternal Long Axis
• Suprasternal Short Axis
• Apical 4-Chamber
• Apical 2-Chamber
• Apical 3-Chamber (Apical
Long Axis)
• Apical 5 Chamber
• Subcostal 4 Chamber
• Subcostal 5 Chamber
• Subcostal Short Axis

4. Echocardiographic Examination

6. Standard positions on the
chest wall are used for
placement of the
transducer called “echo
windows

9. PATIENT POSITIONING

10. PARASTERNAL AND APICAL VIEWS

11. SUBCOSTAL VIEW

12. SUPRASTERNAL VIEW

13. Parasternal Long-Axis View (PLAX)
• Patient position:Left
lateral
• Transducer position: left
sternal edge 3rd
– 4th
intercostal space.
• Indicator direction:
points towards right
shoulder.

14. Structures visualized

15. PARASTERNAL LONG AXIS VIEW
(PLAX)

16. PARASTERNAL LONG AXIS – RV
INFLOW VIEW
• Modification of PLAX.
• Tilting the head of
transducer down toward
patient right hip.

17. Structures visualized

19. PARASTERNAL LONG AXIS – RV OT
VIEW
• Modification of PLAX.
• Tilting the head of transducer
down toward patient left
shoulder
• For evaluating pulmonic stenosis
and regurgitation

20. Structures visualized

22. Parasternal Short Axis View
(PSAX)
• Transducer position: left
sternal edge; 2nd
– 4th
intercostal space
• Marker dot direction:
points towards left
shoulder(900
clockwise
from PLAX view)
• By tilting transducer on
an axis between the left
hip and right shoulder,
short axis views are
obtained at different
levels, from the aorta to
the LV apex.

29. Apical 4-Chamber View
(AP4CH)
• Transducer position:
apex of heart
• Indicator direction:
points towards left
shoulder

32. APICAL 5 CHAMBER VIEW
• modified apical 4
chamer view
• Sight clockwise
rotation & tilting the
transducer towards
the patient’s head

36. Apical 2-Chamber View
• Transducer
position: apex of
the heart
• Marker dot
direction: points
towards left side of
neck (450
anticlockwise from
AP4CH view)

39. APICAL LONG AXIS VIEW
(Apical three chamber view)
• Modification of
apical 4 chamer
view.
• Transducer rotated
counterclockwise
approximately 60
degrees

41. Apical 3 chamer

42. Sub–Costal 4 Chamber View
• Transducer position:
under the xiphisternum.
• Indicator position: points
towards left shoulder.
• The subject lies supine
with head slightly low (no
pillow). With feet on the
bed, the knees are
slightly elevated

45. SUBCOSTAL SHORT AXIS
• Transducer is
rotated
counterclockwis
e from long-axis
position.
• basal to apical
apical angling of
transducer
produces planes
at aortic
valve,mitral
valve,mid LV
and apical LV
levels.

49. SUBCOSTAL GREAT VESSEL VIEW
• Transducer rotated
counterclockwise from 4
chamber subcoastal view
• Indicator
position:12o’clock(toward
s head)

50. Inferior vena cava
• Transducer is
tilted medially.

51. Abdominal aorta
• Transducer is
tilted laterally

52. Suprasternal View
• Transducer position:
suprasternal notch
• Indicator direction: 1 o’clock
(points towards left jaw)
• The subject lies supine with
the neck hyperextended and
rotated slightly towards the
left.

53. SUPRASTERNAL LONG AXIS

55. SUPRASTERNAL SHORT AXIS

56. TRANSESOPHAGEAL ECHO

57. Transesophageal Echocardiography

58. TEE views
Upper oesophageal (UE) level
20-25cm
Mid Esophageal (ME) level 30-
40cm
Trans Gastric (TG) level
beyond 40 cm

59. I- UPPER ESOPHAGEAL
II- MID ESOPHAGEAL
III- TRANSGASTRIC
I
III
II

61. • Standard imaging planelevels(from the
incisors):
• upper or high esophageal (25–28 cm)
• mid-esophageal (29–33 cm)
• gastroesophageal junction (34–37 cm)
• transgastric (38–42 cm)
• deep-transgastric (>42 cm)

62. TEE probeorientation :

63. Transducer manipulation options:
[1] Advancement/withdrawal (for inferior or superior structuresrespectively)
[2] Rotation (clockwiseto view rightward structuresand counter- clockwisefor
leftward structures)

64. [3] Anteflexion and retroflexion of theprobeshaft (to view structures
towardstheheart baseor towardstheapex)
[4] Leftward and rightward flexion of theprobeshaft
[5] Electronic imageplanerotation (0–1800
)

67. Midesophageal views

68. MID ESOPHAGEAL 4 CHAMER
VIEW
• TRANSDUCER
POSITION:position theprobein
themid-esophagusbehind the
LA.
• OMNIPANEANGLE:0-10
DEGRESS.

70. Structures visualized

71. ME Mitral Commissural View
• TRANSDUCER
POSITION:position the
probein themid-
esophagusbehind the
LA.
• OMNIPANEANGLE:
50 and 70 DEGRESS.

73.  turning the probe
leftward
(counterclockwise) --
PML (P3P2P1).
 Turning the probe
rightward (clockwise )
----AML (A3A2A1).

74. ME Two-Chamber View
• TRANSDUCER
POSITION:position the
probein themid-
esophagusbehind the
LA.
• OMNIPANEANGLE:
80 and 100 DEGRESS.

76. ME LAX View
• TRANSDUCER
POSITION:position
theprobein themid-
esophagusbehind the
LA.
• OMNIPANEANGLE:
120 and 140
DEGRESS

78. ME BICAVAL VIEW
• From the2 chamber
view(90°).
• Turn theentireprobe
right.

80. Descending Aorta SAX Views
• From the4 chamber
view(0°).
• Turn theentireprobe
left.
• Decreasedepth to 5cm.

81. • Aortic Pathology
• Color flow reversal: AI
severity
• IABPposition

82. ME DA LAX(90°)
• From ME DA SAX
• OMNIPANEANGLE:
90 DEGRESS

83. • Distal aortaisto thedisplay
left and theproximal aorta
to thedisplay right.

84. Trans gastric views

85. ADVANTAGES
• best for evaluating left and right ventricular
function
• commonly employed intra operative TEE to
assess ejection fraction and wall motion post-
operatively.
• to obtain accurate gradients across the aortic
valve to assess the degree of AS or AR

86. TG Basal SAX View
• From the ME views and
at a transducer angle of
0° to 20°
• the probe is
straightened and
advanced into the
stomach
• the probe is then
anteflexed

87. • This view demonstrates
the typical SAX view or
“fish mouth” appearance
of the MV
• anterior leaflet on the left
of the display and the
posterior leaflet on the
right.
• The medial commissure
is in the near field, with
the lateral commissure in
the far field

88. TG Midpapillary SAX View
• from the TG basal SAX
view.
• the anteflexed probe,
relaxed to a more
neutral position.
• transducer angle
maintained at 0° to 20°.

89. TG Apical SAX View
• From the TG
midpapillary SAX view
(0°-20°)
• the probe is advanced,
to obtain the TG apical
SAX view

90. Transgastric short axis 0 degrees
mitral valve level

91. Transgastric short axis 0 degrees
at papillary muscle level

92. TG Two-Chamber View
• From mid TG SAX (0°)
• Rotateomniplaneangle
to 90°.
• Anteflex until LV is
horizontal

93. • LV function
• Mitral Valve
subvalvular pathology
• Theanterior and inferior
wallsof theleft
ventricleareimaged in
addition to thepapillary
muscles, chordae, and
MV.

95. TG RV Inflow View
• From the TG two-
chamber view (90° to
110°),
• turning to the right
(clockwise).

97. TG LAX
• From TG 2 chamber
(90°)
• omniplaneangleto 110-
120°.
• Imaging planeis
directed longitudinally
thru theLV to imagethe
aortic root.

98. • MV: leaflets,
subvalvular
• LV systolic function
• AV Doppler gradient
• LVOT Doppler gradient
• Ventricular septal
defect (VSD)
• Prosthetic AV function

99. ME Five-Chamber View
• From ME 4 chamber
view(0°) withdraw
cephalad to obtain the
ME 5C(0°).

101. ME AV SAX (30-45°)
• From ME 5C (0°)
• Omniplaneangleto 30-
45degrees.

103. ME RV Inflow-Outflow View
• From ME 5C (0°)
• omniplaneangleto 60-
75°

105. • Pulmonic valve pathology
• Pulmonary artery
pathology
• RVOT pathology
• TV pathology
• Atrial septal defect (ASD
secundum)
• Ventricular septal defect
(VSD)

107. ME AV LAX View
• From ME 5C (0°)
• Omniplaneangleto 120
-150°
• From ME 4C (0°),
decreasing sector depth.

109. ME Ascending Aorta LAX View
• From the ME AV LAX view, withdrawal of the
probe, typically with backward rotation to
approximately 90 to 110, results in theME
ascending aorta LAX view.
• This view allows evaluation of the proximal
ascending aorta.
• The right pulmonary artery (PA) lies posterior
to the ascending aorta in this view

110. ME Ascending Aorta LAX View

111. ME Ascending Aorta SAX View
• From the ME AV and ascending aorta view,
backward transducer rotation to approximately 0
to 30 results in the ME ascending aorta SAX view.
• In addition to the ascending aorta in SAX and the
superior vena cava in SAX, the main PA and right
lobar PA can be seen.
• From this neutral probe orientation, turning the
probe to the left (counterclockwise) allows
imaging of the PA bifurcation.

112. . ME Ascending Aorta SAX View

113. ME Right Pulmonary Vein View
• From the ME ascending aorta SAX view, advancing the
probe and turning to the right (clockwise) will result in
the ME right pulmonary vein view.
• The right pulmonary veins can also be imaged from the
90 to 110 view by first obtaining a ME bicaval view and
turning the probe to the right (clockwise).
• the left pulmonary veins may be imaged by turning
the probe to the left (counterclockwise) just beyond
the left atrial appendage.

114. ME Right Pulmonary Vein View

115. ME LA Appendage View
• From the ME left pulmonary vein view (at a transducer angle of 90°
to 110°), turning the probe to right (clockwise) with possible
advancement and/or anteflexion of the probe will open the LA
appendage for the ME LA appendage view.
• Backward rotating from 90° to 0° while imaging the LA appendage
and/or simultaneous multiplane imaging should be performed.
• Color flow Doppler and pulsed-wave Doppler may be useful,
particularly for assessment of emptying velocities.

116. ME LA Appendage View

117. upper esophageal
High esophageal views are helpful for
evaluating the great vessels including
the aortic root and coronary arteries,
ascending aorta and the pulmonary
artery

118. UE Aortic Arch LAX (0°):
• From ME(0°)… ME
Descending AortaSAX
(0°) view.
• Withdraw probeuntil
aortachangesinto oval
shape.
• Turn probeslightly to
theright.

119. • Imaging planeis
directed thru the
transverseaortic arch in
SAX and thepulmonary
artery in LAX.

120. UE Aortic Arch SAX(60-90°):
• From UE Aortic Arch
LAX (0°) view
• Rotatetheomniplane
angleto 60-90°
• Bring thepulmonic
valveand pulmonary
artery in view

121. • Imaging planeis
directed thru the
transverseaortic arch in
SAX and thepulmonary
artery in LAX.

122. THANK YOU