TEE VIEWS

BASIC AND MODIFIED TTE &TEE
VIEWS

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

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

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

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

PARASTERNAL LONG AXIS VIEW
(PLAX)

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

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

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.

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

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

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

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

Sub–Costal 4 Chamber View
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

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.

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

Inferior vena cava
• Transducer is
tilted medially.

Abdominal aorta
• Transducer is
tilted laterally

Suprasternal View
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.

Transesophageal Echocardiography

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

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

• 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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• 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

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°.

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

Transgastric short axis 0 degrees
mitral valve level

Transgastric short axis 0 degrees
at papillary muscle level

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

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

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

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

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

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

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

ME RV Inflow-Outflow View
• omniplaneangleto 60-
75°

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

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

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

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.

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.

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.

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

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

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

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

TEE VIEWS

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TEE VIEWS