GUIDELINES AND STANDARDS

Guidelines for Performing a Comprehensive
Transesophageal Echocardiographic
Examination in Children and All Patients with Congenital Heart
Disease: Recommendations from the American Society of
Echocardiography
Michael D. Puchalski, (Chair), MD, FASE, George K. Lui, MD, FASE, Wanda C. Miller-Hance, MD, FASE,
Michael M. Brook, MD, FASE, Luciana T. Young, MD, FASE, Aarti Bhat, MD, FASE, David A. Roberson, MD,
FASE, Laura Mercer-Rosa, MD, MSCE, Owen I. Miller, BMed (Hons), FRACP, David A. Parra, MD, FASE,
Thomas Burch, MD, Hollie D. Carron, AAS, RDCS, ACS, FASE, and Pierre C. Wong, MD, Salt Lake City, Utah;
Stanford, San Francisco and Los Angeles, California; Houston, Texas; Seattle, Washington; Chicago, Illinois;
Philadelphia, Pennsylvania; London, United Kingdom; Nashville, Tennessee; Boston, Massachusetts; and Kansas City,
MissouriThis document is endorsed by the following American Society of Echocardiography International Alliance Partners:
Argentina Society of Cardiology, Asian-Pacific Association of Echocardiography, British Society of Echocardiography,
Department of Cardiovascular Imaging of the Brazilian Society of Cardiology, Echocardiography Section of the Cuban
Society of Cardiology, Indian Academy of Echocardiography, Indian Association of Cardiovascular Thoracic
Anaesthesiologists, Indonesian Society of Echocardiography, Italian Association of Cardiothoracic Anesthesiologists,
Japanese Society of Echocardiography, Korean Society of Echocardiography, National Society of Echocardiography of
Mexico, Saudi Arabian Society of Echocardiography.

Keywords: Transesophageal echocardiography, TEE, Congenital heart disease, CHD, Echocardiography

From the University of Utah, Primary Children’s Hospital, Salt Lake City, Utah
(M.D.P.); Stanford University School of Medicine, Stanford, California (G.K.L.);
Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas(W.C.M-H.); University of California, San Francisco, California (M.M.B.); Seattle
Children’s Hospital and University of Washington, Seattle, Washington (L.T.Y.
and A.B.); Advocate Children’s Hospital, Chicago, Illinois (D.A.R.); University ofPennsylvania Perelman School of Medicine, The Children’s Hospital ofPhiladelphia, Philadelphia, Pennsylvania (L.M-R.); Evelina London Children’s
Hospital, London, United Kingdom (O.I.M.); Vanderbilt Medical Center,
Nashville, Tennessee (D.A.P.); Tufts Medical Center, Boston, Massachusetts(T.B.); Children’s Mercy Hospital, Kansas City, Missouri (H.D.C.); Children’s
Hospital, Los Angeles, California (P.C.W.).
The following authors reported no actual or potential conflicts of interest in relation
to this document: Michael D. Puchalski, MD, FASE, George K. Lui, MD, FASE, Hollie D. Carron, AAS, RDCS, ACS, FASE, Laura Mercer-Rosa, MD, MSCE, Owen I.
Miller, BMed (Hons), FRACP, Wanda C. Miller-Hance, MD, FASE, David Parra,
MD, FASE, Luciana T. Young, MD, FASE.
The following authors reported relationships with one or more commercial interests: Michael Brook, MD, FASE receives research funding from Siemens. Thomas
Burch, MD is owner and manager of PTEmasters, LLC, a board review website for
the PTEeXAM. David A. Roberson, MD, FASE serves on the speakers bureau forPhilips Ultrasound. Pierre C. Wong, MD, serves on the speakers bureau for Astra
Zeneca.
NOTICE AND DISCLAIMER: This report is made available by ASE as a courtesy
reference source for members. This report contains recommendations only andshould not be used as the sole basis to make medical practice decisions or fordisciplinary action against any employee. The statements and recommendations
contained in this report are primarily based on the opinions of experts, rather
than on scientifically-verified data. ASE makes no express or implied warranties
regarding the completeness or accuracy of the information in this report, including

the warranty of merchantability or fitness for a particular purpose. In no event shallASE be liable to you, your patients, or any other third parties for any decision madeor action taken by you or such other parties in reliance on this information. Nordoes your use of this information constitute the offering of medical advice by
ASE or create any physician-patient relationship between ASE and your patientsor anyone else.
Reviewers: This document was reviewed by members of the 2017–2018 ASE
Guidelines and Standards Committee, ASE Board of Directors, and ASE Executive
Committee. Reviewers included Alicia Armour, BS, MA, RDCS, FASE, Federico M.
Asch, MD, FASE, Scott D. Choyce, RDCS, RVT, RDMS, FASE, Frederick C. Cobey, MD, FASE, Gregory J. Ensing, MD, FASE, Craig Fleishman, MD, FASE,
Mark K. Friedberg, MD, FASE, Neal Gerstein, MD, FASE, Yvonne E. Gilliland,
MD, FASE, Robi Goswami, MD, FASE, Lanqi Hua, RDCS (AE/PE/FE), FASE, PeiNi Jone, MD, FASE, James N. Kirkpatrick, MD, FASE, Stephen H. Little, MD,
FASE, Rick Meese, ACS, RDCS, RCS, RCIS, FASE, Andy Pellett, PhD, RCS,
RDCS, FASE, Dermot Phelan, MD, PhD, FASE, and David H. Wiener, MD, FASE.
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Copyright 2018 by the American Society of Echocardiography.
https://doi.org/10.1016/j.echo.2018.08.016

173

174 Puchalski et al

Abbreviations

2D = Two-Dimensional

Journal of the American Society of Echocardiography
February 2019

INTRODUCTION

Since its introduction nearlyfour decades ago, transesopha3D = Three-Dimensional
geal echocardiography (TEE)
ACHD = Adult Congenital
has witnessed a remarkable
Heart Disease
evolution.
The
importantstrides made in improving TEE
ASE/SCA = American
technology – including develSociety of Echocardiography/
Society of Cardiovascularopment of multiplane phased
Anesthesiologists
array transducers, matrix arraytransducers
forthreeAoV = Aortic Valvedimensional (3D) imaging, and
Asc Ao = Ascending Aorta
extensive improvements inechocardiographic
imaging
CA = Coronary Artery
platform technology – have
CHD = Congenital Heart
catalyzed the establishment ofDiseaseTEE as a critically important cardiovascular imaging modality.1-15
DTG = Deep TransgastricThe esophageal position of the
IVC = Inferior Vena Cava
ultrasonic transducer provides
LA = Left Atrium
superior cardiac imaging andallows monitoring of the heart
LAX = Long Axis
before, during, and after cardiac
LV = Left Ventricleor
non-cardiac
procedures
without interruption.
LVOT = Left Ventricular
TEE in the pediatric populaOutflow Tracttion became widespread after
ME = Midesophageal
the introduction of commerciallyavailable miniaturized probes in
MV = Mitral Valvethe late 1980s.1-3 Since then,PA = Pulmonary Arterythe safety and invaluable clinicalutility of this technique for
PV = Pulmonary Valve
many types of pediatric andRA = Right Atrium
adult congenital cardiac surgery
RV = Right Ventricle
andcardiacinterventional
procedures has become well
RVOT = Right Ventricularestablished.4-15 The increasing
Outflow Tractapplications of TEE coupled
SAX = Short Axis
with newer technology led
the American Society of
SVC = Superior Vena Cava
Echocardiography
andtheTG = TransgastricSocietyof
Cardiovascular
Anesthesiologists(ASE/SCA)TTE = Transthoracic
to publish the most recent
Echocardiography
recommendationsfora
TEE = Transesophageal
comprehensiveTEEevaluation
Echocardiography
in 2013 geared primarily to
TV = Tricuspid Valveadult patients with structurally
normal hearts.16
UE = Upper Esophageal
Similarly, pediatric TEE has
incorporated the use of 3Dtechnology and exploited the advances in probe and software
technology, leading to the need for a position document to update the current state-of-the-art for pediatric and congenital cardiology.12,17-32 The current document was written to provide
guidelines for the use of TEE, and recommendations forstandardized TEE views and techniques that can be used in theassessment of children or any patient with congenital heartdisease (CHD).

Table 1 Indications for TEE in the patient with CHD
Diagnostic Indications
 Patient with suspected CHD and non-diagnostic TTE
 Presence of patent foramen ovale (PFO) with and without agitatedsaline contrast and direction of shunting as possible etiology forstroke Evaluation for cardiovascular source of embolus with no identified
non-cardiac source Evaluation of intra- or extra-cardiac baffles following the Fontan,
Senning, or Mustard procedure Suspected acute aortic pathology including but not limited todissection/transection (e.g., Marfan syndrome, bicuspid aortic
valve, coarctation of the aorta)
 Intra-cardiac evaluation for vegetation or suspected abscess Evaluation for intra-cardiac thrombus prior to cardioversion for
atrial flutter/fibrillation and/or radiofrequency ablation
 Pericardial effusion or cardiac function evaluation and monitoring
postoperative patient with open sternum or poor acoustic
windows
 Evaluating status of prosthetic valve in the setting of inadequate
TTE images
 Re-evaluation of prior TEE finding for interval change (e.g.,resolution of thrombus after anticoagulation, resolution ofvegetation after antibiotic therapy)
Perioperative Indications
 Immediate preoperative definition of cardiac anatomy andfunction Postoperative surgical results and function
 Intraoperative monitoring of ventricular volume and function
 Monitoring of intra-cardiac/intravascular air and adequacy of
cardiac de-airing
TEE-guided Interventions
 Guidance for placement of occlusion device (e.g., septal defect,
Fontan or intra-atrial baffle fenestration)
 Guidance for blade or balloon atrial septostomy
 Guidance for creation/stenting of interventricular communication
 Guidance during percutaneous valve interventions
 Guidance during radiofrequency ablation procedure Assessment of results of minimally invasive surgical incision orvideo-assisted cardiac procedure Guidance during placement of catheter-based cardiac assist
device (e.g., Impella â heart pump)
Modified from Ayres et al.31

GENERAL GUIDELINES
Indications and Contraindications for TEE
Indications in the Pediatric Patient. TEE in children iscommonly used for the assessment of anatomy and function during
cardiac surgery, typically for CHD (Table 1).11,31 However, due tocertain inherent limitations in the imaging of key cardiac structures(discussed below), it should not serve as the sole or primary
diagnostic modality for assessment of pediatric heart disease. Instead,thetask force recommends preoperativetransthoracic
echocardiography (TTE) for all children undergoing cardiac surgery
as it may provide information unobtainable with intraoperative TEE
alone. Intraoperative TEE performed immediately prior to thesurgical intervention allows the operative team to review thepreoperative diagnostic findings, identify any new findings, and assist
in the assessment of hemodynamics and myocardial function prior
to onset of the operative procedure. TEE may facilitate catheter
placement, real-time monitoring of volume status and myocardial

Puchalski et al 175

Journal of the American Society of Echocardiography
Volume 32 Number 2

function in order to inform selection of anesthetic agents, inotropic
support, and management decisions.33-36 In the intraoperative
setting, TEE can be used to assess cannula position and venous
drainage during cardiopulmonary bypass, facilitate intra-cardiac deairing, and characterize rhythm disturbances. An important role ofthe post-intervention TEE is to evaluate the adequacy of the surgicalrepair and assess ventricular function. However, it should be recognized that the postoperative TEE findings could be influenced by anumber of factors such as anesthetic depth, hemodynamic state, andvasoactive drug administration. Decisions to return to bypass, therefore, should consider not only the TEE findings, but also clinical information, hemodynamics, and the risk versus benefit of a re-intervention.
TEE serves an important role in the cardiac catheterization laboratory.37-39 During placement of septal closure devices, TEE provides
precise identification of the location, geometry, and number ofdefects, allowing the interventionalist to develop clear strategies forclosure.40-42 TEE use during catheter-based procedures limits fluoroscopy time, decreases contrast load, and improves the overall safety of
the interventions.38,39,43,44
Outside of the procedural setting, TEE is used to provide diagnostic
images when the patient has poor acoustic windows, if TTE is nondiagnostic, or in cases where TEE imaging has proven superior,such as evaluation for atrial thrombi prior to cardioversion, assessment for intra-cardiac shunting in patients with a cerebrovascular accident, visualization of the Fontan pathway, assessment of prosthetic
valve function and associated pathology, and evaluation of endocarditis on both native and prosthetic valves.33-35,45-48
Intraoperative TEE use is increasing for monitoring myocardial function and ventricular loading conditions in patients with CHD and otheracquired pathologies undergoing high-risk non-cardiac procedures, aswell as for the visualization of landmark structures during minimallyinvasive surgery.36,49-54 In the intensive care unit, TEE provides
diagnostic information in the postoperative patient with suboptimaltransthoracic windows or an open sternum, and in the managementof patients undergoing mechanical circulatory support.46,55-57
Indications in the Adult with Congenital Heart Disease(ACHD)TEE is indicated in the ACHD patient for many of the same reasons as
noted above: inadequate TTE images, guidance of cardiac interventions in the operating room or catheterization laboratory, assessmentof intra-cardiac thrombus (particularly prior to elective cardioversion
or radiofrequency ablation), and for diagnosis of infective endocarditis with moderate to high pretest probability.16 TEE is often superior to
TTE for assessment of interatrial shunts, anomalous pulmonary
venous return, atrioventricular valves (AV), complex atrial baffle procedures, the Fontan pathway, prosthetic heart valves and conduits,
and coronary artery anomalies.
TEE may be very useful in the assessment of all ACHD patients who
are undergoing cardiac surgery for the first time and during reoperations
for management of residual hemodynamic lesions as well as in the settingof non-cardiac surgery.58 In these settings, TEE can provide complete
morphologic and functional assessment of simple to complex CHD.9
Contraindications in the Pediatric Patient
Probe placement and esophageal instrumentation are semi-invasive
and carry potential risks. The patient’s history should be reviewed
for relative and absolute contraindications (Table 2). If the contraindication is relative, potential benefits should outweigh the associatedrisks. For example, special consideration must be given to the patient

Table 2 Contraindications to TEE
Absolute

Relative

Unrepaired
tracheoesophageal fistula
Esophageal obstruction or
stricture
Perforated hollow viscus
Active gastric or esophageal
bleeding
Poor airway control
Severe respiratory depression
Uncooperative, unsedated
patient

History of esophageal or
gastric surgery
History of esophageal cancer
Esophageal varices ordiverticulum
Recent gastrointestinal bleed
Active esophagitis or peptic
ulcer disease
Vascular ring, aortic arch
anomaly with or without
airway compromise
Oropharyngeal pathology
Severe coagulopathy
Significant thrombocytopenia
Cervical spine injury or
anomaly
Post-gastrostomy orfundoplication limit imaging
to esophageal windows

Modified from Ayres et al.31

who has undergone esophageal surgery since it is unclear whether/when probe placement is safe. The risk/benefit ratio of TEE after gastrostomy tube/button placement (with or without associated Nissen
fundoplication) might require limiting or avoiding imaging from thestomach (transgastric or deep transgastric imaging). Care must be
taken in children with Down syndrome secondary to a relatively large
tongue, narrow hypopharyngeal structures, and/or cervical spine
instability.59 In the pediatric patient with a vascular ring, TEE is relatively contraindicated because the esophagus and trachea are
confined to a restricted space and a rigid TEE probe in the esophagus
can produce significant airway compromise.
Contraindications in the ACHD Patient
Absolute and relative contraindications to TEE in the adult are outlined in the 2013 ASE/SCA Comprehensive TEE Guidelines.16 The
same considerations described above for the child with Down syndrome or with a vascular ring apply to the ACHD population.

Key Points
1. Indications for TEE in children and all patients with CHD
include pre and postoperative evaluation of cardiac anatomy
and function, guidance of transcatheter interventions, nondiagnostic TTE, intra-cardiac thrombus, prosthetic valve function, and diagnosis of infective endocarditis.1
2. The benefits of the procedure should outweigh the risks when
patients with relative contraindications are evaluated for TEE.
Relative contraindications primarily relate to the potential ofesophageal trauma or airway compromise (Table 2).

Training and Certification
Cognitive Skills, Technical Skills, and Training Guidelines. TEE
imaging is considered an advanced skill, thus, it is expected that the pediatric or ACHD echocardiographer performing the study should haveexpertise in the TTE diagnosis of structural and acquired heart disease.
Core pediatric echocardiography skills that include medical knowledge176 Puchalski et al

Journal of the American Society of Echocardiography
February 2019

Table 3 Guidelines for training and maintenance of competence
Component

Objective

Duration

Number of cases

Echocardiography

Prior experience in performing/
interpreting TTE

6 mo or equivalent

Minimum of 450 cases across all age groups

Esophageal intubation(if part of practice)

TEE probe insertion

Variable

25 cases (50% under 2 years of age)

TEE exam

Perform and interpret with supervision

Variable

50 casesOngoing TEE experience

Maintenance and competency

Annual25-50 cases per year or achievement oflaboratory-established outcome variables

Modified from Ayres et al.31

and patient care or procedural skills as outlined in the Task Force addressing Pediatric Cardiology Fellowship Training in Noninvasive Cardiac
Imaging are recommended for pediatric cardiologists planning toperform TEE independently (Table 3).31,60 This does not preclude a
categorical fellow from starting to learn TEE skills during his/her
fellowship, including but not limited to time on a simulator which can
optimize the ability to rapidly and fluidly obtain images. Evaluation of
the anatomic and hemodynamic complexity of pediatric and ACHD
patients demands an in-depth knowledge of all congenital and acquired
pediatric cardiovascular pathologies, along with associated palliative andcorrective surgical and transcatheter procedures. In addition, a rich experience in two-dimensional (2D) 6 3D echocardiography, as well as
pulsed-wave, continuous-wave, and color flow Doppler imaging techniques, is necessary.9
Performance of TEE requires understanding of oropharyngeal anatomy, endoscopic techniques, and the indications, contraindications,and risks involved in the procedure, particularly if one is responsible
for probe insertion. In small children, proper probe selection and supervision of intubation for the novice echocardiographer can mitigate
risk.61,62 The individual responsible for probe placement should beskilled in esophageal intubation. Suggested training guidelines for
those expected to be involved in probe insertion in children include
the performance of at least 25 esophageal intubations with directsupervision by an experienced pediatric echocardiographer,gastrointestinal endoscopist, or anesthesiologist, optimally in an
active, accredited, and high-volume pediatric heart center, before unsupervised probe placement in this population is considered. This supervised experience should also include children and adults in a variety ofclinical settings, including but not limited to operating rooms, catheterization laboratories, hybrid rooms, intensive care units, and sedation
suites. The echocardiographer must develop skills in image acquisitionand optimization, probe manipulation, and interpretation of the data.
The findings should be rapidly and effectively communicated to thesurgical and/or interventional team(s) as appropriate.63
Supervised performance and interpretation of at least 50 TEE examinations in pediatric and ACHD patients prior to independent
TEE imaging is recommended.64 For ACHD imaging by practitioners
involved primarily in adult TEE, the minimum requirements fortraining and maintenance of competence are outlined in the 2013
ASE/SCA Comprehensive TEE Guidelines but ideally this imaging
should be performed by physicians with experience and/or training
in ACHD.16 In addition to cardiologists, some cardiac anesthesiologists who care for children have received appropriate training andexperience in pediatric TEE and provide interpretation in the operating room. In these cases, a second provider trained in TEE orcongenital cardiovascular anesthesiology should be available to mitigate distraction from performing peri-procedural TEE monitoring.
While some international societies support non-physician led TEE
in adult patients, in the setting of congenital heart disease it isappropriate that the procedure is performed under direct medical
supervision.
Recommendations for Physicians Not Formally Trained in
TEE Performance in Pediatric and ACHD Patients. Physicians
interested in performing TEE without a formal pediatric cardiology
fellowship will benefit from intensive training in an accredited congenital/pediatric echocardiography laboratory with emphasis on TEE imaging.31 These guidelines aim to promote safety and quality by clarifying
the necessary skills and the extent of supervised training and experienceneeded to perform TEE. There is no intent to exclude physicians fromperforming TEE, but rather to promote a standard of safety and effective
performance of the exam in complex and often frail pediatric and
ACHD populations.
Maintenance of Skills. Maintenance of skills should be achievablewith 25-50 annual TEE examinations in pediatric and/or ACHD patients. In large programs where duties are shared among many TEEcompetent physicians, it is conceivable that this metric may not be
met for each trained physician. In these cases, alternative evaluationsof maintenance of proficiency are often based on outcomes variables
established by the laboratory director. Ongoing quality improvement
is recommended, focusing upon updating laboratory guidelines andassessing outcomes as well as an annual review of the physician’s
TEE performance and accuracy of interpretation. The Intersocietal
Accreditation Commission (IAC) – an independent body that provides accreditation to pediatric echocardiography laboratories based
upon published, accepted standards – regularly updates its guidelines
for accreditation in pediatric echocardiography, including pediatricTEE (http://www.intersocietal.org/).
Certification. There is currently no certification pathway specifically designed for the physician performing TEE for the pediatric or
ACHD patient.

Key Points
1. Physicians wishing to perform TEE in children and all patientswith CHD should:
a. Receive supervised training and interpretation by a practitioner with significant TEE experience. That person canbe a pediatric echocardiographer, congenital cardiovascular anesthesiologist, or echocardiographer with experience
and/or training in ACHD.
b. Undergo supervised performance and interpretation of atleast 50 TEE examinations in pediatric and/or ACHD patients prior to independent TEE imaging.
2. There is currently no certification pathway specifically designed for the physician performing TEE for the pediatric or
ACHD patient.

Puchalski et al 177

Journal of the American Society of Echocardiography
Volume 32 Number 2

Patient Selection and Complications
The overall clinical experience with TEE demonstrates a favorable safety
profile, with a 1-3% complication rate in the pediatric age group.11,61,65-69
Most problems are seen in neonates and small infants and are associatedwith respiratory compromise or vascular compression.70-75 Mild sinus
slowing and even bradycardia for age have been reported from vagal
stimulation during probe insertion as well as alterations of cardiac
rhythm.61,76 When intraoperative TEE imaging is performed, theimaging probe ideally should be inserted before placement of steriledrapes. The preoperative study should be completed prior to skinincision in order to minimize electrocautery artifacts. At most centers,
the tip of the probe is maintained in the stomach during the bypass
phase in an effort to limit esophageal morbidity given that the widest
diameter of the probe is at its tip. Hardware availability or otherreasons may preclude leaving the probe in situ throughout the bypass
period. The probe might be removed after the preoperative study andreinserted prior to separation from bypass or used only for
postoperative assessment. In these settings, potential additional risks
should be recognized such as those associated with oropharyngeal/
esophageal instrumentation in the fully anticoagulated patient,potential tracheal extubation or tube malposition, or bypass cannula
dislodgement. Serious complications such as esophageal perforation,
inadvertent gastric laceration during sternotomy, and subglottic stenosis
have been rarely described.77,78 The risks associated with bleeding
related to TEE imaging in anticoagulated patients are largely unknown
and the risk/benefit of TEE in this setting should be considered.
The incidence of oropharyngeal dysphagia after TEE has been estimated at 18% in children undergoing open heart procedures.79-81 Risk
factors included age < 3 years, preoperative endotracheal intubation,
longer duration of endotracheal intubation, and interventions for leftsided obstructive lesions. The presence of dysphagia can affect postoperative recovery and contribute to major morbidity. Given the relatively large probe size in the neonate and small infant and thecomplexity and duration of many interventions, every effort should
be made to modify these risk factors. Another clinical concern in children is that of upper airway obstruction requiring the need for tracheal
reintubation in certain high-risk patients.82 A significant increase inendotracheal tube cuff pressure is reported during TEE probe insertion;
however, this increase is transient and returns to baseline values uponprobe advancement into the stomach.83 Although a high incidence(64%) of abnormal findings (erythema, edema, and hematoma; lessfrequently, mucosal erosion and petechiae) were found by flexible
endoscopy after TEE for pediatric cardiac surgery, no long-term
feeding or swallowing difficulties were identified.84
Special consideration should be given to critically ill infants with total anomalous pulmonary venous anomalies who might develop hypotension and hypoxemia from compression of the pulmonary
venous confluence by the imaging probe.85,86 Placement of thetransducer after sternotomy is often uneventful, however,suggesting that if TEE is used in this setting, the probe should be
inserted after the chest is open and close observation for
hemodynamic compromise is warranted.
Sedation and Anesthesia
The Pediatric Patient. Sedation and anesthesia for TEE in patientswith CHD and children should be performed by experienced providers
who understand the anatomy and pathophysiology of the specific lesions.87 Esophageal intubation can be quite stimulating, therefore
most children require deep sedation or general anesthesia, and an anesthesiologist or equivalent provider with expertise in caring for pediatricpatients is usually involved in selecting, administering, and monitoringthese agents. Close communication between the anesthesiologist andthe echocardiographer prior to and during the procedure is essential.
The ACHD Patient. TEE in the ACHD patient is routinely performed with conscious sedation as described in the 2013 ASE/SCA
Comprehensive TEE Guidelines.16 Serious complications are rare inthis patient population; however, additional considerations may apply
if there are associated hemodynamic disturbances, severe pulmonary
hypertension, residual cyanosis, or single ventricle physiology.9 In theadult with Fontan circulation, it is important to minimize changes in systemic venous volume since venodilation or dehydration can reducethe central venous pressure and decrease flow through the pulmonary
circuit.88 Intravenous hydration may be needed to offset the detrimental effects of fasting combined with the vasodilatory and/or
myocardial depressant effects of sedatives. Hypoventilation withconsequent hypoxia can increase pulmonary vascular resistance, resulting in an overall reduction in cardiac output in the Fontan patient,
therefore supplemental oxygen and capnography for monitoring arestrongly recommended.88 Since any patient with a Fontan fenestration
or residual shunt is at high risk for paradoxical embolism, meticulous
care, including the use of IV filters, should be considered. Changes inafterload can exacerbate right-to-left shunts, increasing the risk of paradoxical emboli and decreasing arterial oxygen saturation.9 Therefore,
it may be prudent to ask for the assistance of the anesthesia team when
performing TEE in the ACHD patient with Fontan physiology, unrepaired or palliated cyanotic cardiac lesions, pulmonary hypertension,or a history suggestive of moderate to severe obstructive sleep apnea.

Key Points
1. TEE demonstrates a favorable safety profile and low complication rate in children and all patients with CHD.
2. Most complications are related to respiratory compromise or
vascular compression. Rare serious complications include
esophageal perforation, gastric laceration, and subglottic stenosis.
3. While general anesthesia is typically employed for the performance of TEE in children, TEE in the adult with CHD isroutinely performed with conscious sedation. Anesthesia assistance should be considered in the adult with Fontan physiology, unrepaired or palliated cyanotic cardiac lesions orsevere pulmonary hypertension.

Probe Selection, Insertion Techniques, and Care
Probe Selection. Transducer technology for TEE imaging has
evolved significantly and probes now have higher resolution, more options for image plane acquisition, and enhanced modes to better assess
the cardiovascular system even in very small infants. Initial monoplane(single plane) TEE devices allowed only transverse or horizontal imaging planes.89 The incorporation of a second scanning plane in biplane
probes enabled the longitudinal or vertical imaging plane (90 ),thereby providing for interrogation of structures with orthogonalviews.90-94 The development of multiplane (omniplane) probes
permitted imaging in planes anywhere between 0 -180 .95-98
Advances in 3D technology for TEE devices has evolved from offline reconstruction of sequentially acquired 2D image planes, to realtime imaging using a specialized matrix-array probe. The probe renders
a selected volume of the heart as a real-time 3D dataset able to display
anatomy from any perspective, including the surgeon’s view.99,100

178 Puchalski et al

TEE probe selection for infants and children relies primarily on two
factors: the weight of the patient and the size of the probe. The pediatricmini-multiplane probe was the initial miniaturized device with multiplane capabilities available for use in neonates, infants and small children. Subsequently the pediatric micro-multiplane probe was developedfor use in the tiniest babies, representing the smallest multiplane device
available today.18,21,64 Equipment manufacturers have suggested apatient weight limit for the use of these devices (over 3.0-3.5 kg forthe mini-multiplane and over 2.5 kg for the micro-multiplane), however, in clinical practice both probes have been safely used quite extensively in patients well below these weight recommendations.19,101
Both the micro- and the mini-multiplane probes have 2D and
Doppler capabilities. The adult 2D multiplane TEE probe should beconsidered for a patient weight >25 kg, however, this device has
also been applied to smaller children. The advantage of using an adult
sized probe when possible is better image quality due to having agreater density of piezoelectric crystals, and the larger size may allow
for improved contact with the esophagus. The risk/benefit ratio ofoversizing the TEE probe should be considered on a case-by-case basis
but may be safe when placed with minimal resistance. Current 3D TEE
imaging probes have slightly larger dimensions than 2D multiplane
adult TEE probes and should be considered for a patient weight>30 kg rendering them unsuitable for use in most young children.
Intra-cardiac echocardiography catheters (8-10 F) have been used
for TEE in neonates and small infants and may provide clinically useful information in some cases.102-104 Imaging is limited to a single
longitudinal (90 ) plane, and lack of formal regulatory approval forthis specific application, coupled with the stiffness of the catheter,
have prevented widespread use.
Intraoperative epicardial echocardiography may be used in patients in whom TEE imaging is not feasible due to patient size constraints, contraindications to esophageal instrumentation, or when
TEE is not available. Epicardial imaging may also be indicated when
the patient is not able to tolerate TEE imaging or when there are concerns for probe-related hemodynamic or respiratory compromise. In
some instances, epicardial imaging can overcome limitations of TEE,
such as interrogation of the branch PAs (in particular the left PA), andin patients undergoing interventions addressing muscular ventricularseptal defects either by direct surgical closure or perventricular transcatheter interventions. While there is potential for hemodynamic alterations and rhythm abnormalities, infection risks, and a need for
operator expertise while directly touching the heart, most experienced centers have used this approach safely.
Probe Insertion Techniques. The TEE probe should be inserted
after adequate sedation/anesthesia and following an appropriate
period of fasting. The technique for probe insertion may vary among
institutions but can be facilitated by maintaining the patient’s head, as
well as the probe within the oropharyngeal cavity, in the neutral,
midline position. In most cases, the unlocked, well-lubricated transducer is blindly but gently advanced into the esophagus. Slight anteflexion of the probe tip, subluxation of the mandible, reverse
cricoid maneuver, and/or device guidance with a gloved finger canfacilitate probe insertion. Lifting the head may also help in older children. In some cases, direct laryngoscopy by an anesthesiologist may
aid visualization and esophageal intubation if there is difficulty during
blind probe-placement. Transducer insertion is an important skill in
the practice of TEE. Although some effort might be expected, distinguishing normal from excessive resistance requires expertise andongoing experience with the technique.

Journal of the American Society of Echocardiography
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In children, positioning the head to the side has been reported tofacilitate passage of the probe, as this maneuver reportedly results
in closure of the ipsilateral pyriform sinus, a site where the probe
may encounter obstruction.105 In the intraoperative setting, once
the TEE probe has been inserted, the patient’s head can be repositioned to avoid interference with the surgical field during device
manipulation. Factors that may render probe insertion difficult in infants weighing 4 kg or less include lower weight, abnormal craniofacial anatomy, prematurity, and a diagnosis of 22q11 deletion.106
Occasionally an appropriate sized probe may experience difficulty
in insertion if a cuffed endotracheal tube is used which can reduce
the esophageal lumen. Communication with the anesthesiologist to
temporarily deflate the cuff for insertion and confirmation ofadequate ventilation should be considered. If there are respiratoryor hemodynamic changes resulting in compromise, a smaller probe
can be attempted or the exam should be aborted.
Preoperative evidence by TTE or other modality of an aberrant
subclavian artery or unusual arch laterality should be communicatedto the anesthesia team allowing for intraoperative arterial pressure
monitoring to be established on the contralateral upper extremity
before TEE probe insertion given that the arterial tracing may belost or severely dampened from compression of the aberrant artery.
Probe Care. The Centers for Disease Control and Prevention(CDC) categorizes all medical devices according to their potential forpatient infection.107 Because TEE probes contact mucous membranes,
they require high-level disinfection after each use. Current recommended practices have evolved to cover the handling, cleaning, disinfection,and storage of all TEE probes. Each institution should develop a standard practice and protocol for TEE probe care that incorporates regulatory guidelines and manufacturer’s recommendations (Table 4). Careshould be taken to protect the piezoelectric crystals from roughhandling or physical trauma. The probe tip and shaft should be inspected for damage or cracks as part of routine maintenance, before
probe insertion, and after probe withdrawal. Only the probe shaft
and tip can be immersed. The handle, connector, and cable should
be cleaned separately by wiping them down with the recommended
disinfectant. Adequate rinsing is crucial for patient safety. Probes should
be labeled with a disinfection date and reprocessed according to the institution’s laboratory policy. As the recommendations evolve, the highlevel disinfection process should be updated accordingly.

Key Points
1. TEE probe selection is primarily based upon patient weightand probe size.
a. Pediatric 2D TEE probes are available as a micromultiplane probe for patients > 2.5 kg, and a minimultiplane probe for patients > 3.0-3.5 kg.
b. The adult 2D and 3D TEE probes are available for use inpatients > 25 kg and >30 kg, respectively.
c. In clinical practice, each probe has been used safely below
these weight recommendations
2. TEE probe insertion should be performed with adequate sedation/anesthesia, and after an appropriate period of fasting.
Careful monitoring for complications is essential.
3. TEE probe rinsing and high-level disinfection should be performed after each use, according to manufacturer’s instructions and institutional laboratory policy.

Puchalski et al 179

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Table 4 Steps involved in TEE probe care
Point of care wipe down

When the probe is removed from the patient, it should be immediately wiped down to remove all superficial
material with an enzymatic product before it dries and adheres to the probe.

Transported in container

The probe should then be placed in a container that protects the integrity of the fragile terminal tip of the probe aswell as preventing the contamination from secretions on the probe. This will allow for safe transportation to thelocation of cleaning and disinfection.

Cleaning

A cycle of rinsing the initial enzymatic cleaner off the probe should be followed by another enzymatic cleaning andprolonged rinse.

Manual drying

Use lint-free drying cloth to prevent dilution of disinfectant.

Electrical leakage testing

Promotes patient safety and now required for IAC accreditation

Disinfection

Manual or automated high-level disinfection with documentation. Manual processing requires strict adherence tosoaking and rinsing times to prevent probe damage and chemical burns.

Rinsing

Follow instructions of the disinfectant manufacturer and Joint Commission recommendations for water quality.

Probe drying

Probes should hang in a vertical cabinet to dry, with probe not touching anything.

Storage

Store probes in a well-ventilated dust-free cabinet with probe tip protectors covering the piezoelectric crystal. (Apositive-pressure HEPA-filtered cabinet is optimal.)Transport

Transport the probe to needed location in a clean, protective container.

Figure 1 Terminology used to describe manipulation of the transesophageal echocardiographic probe during image acquisition. (A)Terminology used for the manipulation of the transesophageal echocardiographic probe. (B) Four standard transducer positions
within the esophagus and stomach and the associated imaging planes. Reprinted with permission from Hahn et al.16
Instrument Manipulation and Probe Controls
The TEE probe can be manipulated in several directions for image
acquisition of cardiovascular structures (Figure 1). The terminology
used to describe TEE probe manipulation assumes the patient is lying
in the supine position and the imaging plane is directed anteriorly
through the heart from the esophagus. The established nomenclaturein reference to the heart considers the following positions: superior (toward the head), inferior (toward the feet), posterior (toward the spine),
and anterior (toward the sternum). The terms right and left in reference
to the patient denote his/her right and left sides, respectively.
The probe shaft can be advanced (pushed in) or withdrawn (pulledout), and rotated to the right (clockwise) or to the left (counterclockwise). The controls on the probe handle allow for movement (flexion)of the probe tip. In the adult multiplane probe, one control (the larger
wheel) allows for anteflexion (flexion anteriorly) or retroflexion(flexion posteriorly) and the other control (smaller wheel) provides
for right or left flexion. Pediatric TEE probes can be anteflexed and retroflexed but generally lack the right-left flexion control, limiting theavailable imaging planes. In small infants, minimal adjustments in probe

position allow navigation across multiple cross-sections. The multiplane probe tip allows the imaging plane angle to rotate between 0 180 (forward rotation) and from 180 toward 0 (backward rotation).
Role of the Sonographer
ASE recognizes that sonographers are an integral part of the cardiac
imaging team and support their active role during the performanceof a TEE. However, that role should be limited to their scope of practice. Specifically, ASE supports sonographers using their expertise andskills to optimize images (i.e., adjust gain, contrast, and other machinesettings) as well as crop and display 3D data sets during the TEE exam.
ASE does not advocate for sonographers to perform TEE intubationor manipulation of the probe.108
Comprehensive Imaging Examination
The 2013 ASE/SCA Comprehensive TEE Guidelines provided a seriesof key 2D tomographic views written and oriented toward adults withstructurally normal hearts. Proper performance of a pediatric or CHD

180 Puchalski et al

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TEE examination was outside the scope of that document, requiring
modifications to address several important and unique considerations,but whenever possible this document uses the same views and follows
the same nomenclature for the sake of consistency, including theassumption that patients have levocardia with normal situs.
TEE imaging is performed from four primary positions within thegastrointestinal tract (Figure 1): midesophageal (ME), transgastric(TG), deep transgastric (DTG), and upper esophageal (UE). Images
in the ME, TG, and UE positions will be displayed in the same manneras the 2103 guidelines with near field and far field referring to structures closer and further from the probe, respectively (Figure 2). In
contrast however, we will present the DTG views inverted, with the
apex of the heart at the bottom of the screen in an ‘‘anatomically correct’’ position.
The echocardiographic evaluation of children and all patients with
CHD is based on structures rather than views. Given the wide diversity of CHD with innumerable anatomic variations, some TEE views
need to be modified to discern the precise cardiac anatomy for any
given patient. The 28 tomographic views described herein do nothave to occur in order and should serve as a starting point, with theunderstanding that improvisation and nonstandard views (using
various probe maneuvers such as left-right rotation, slow advancement/withdrawal, or slow rotation of the transducer angle) may benecessary for optimal visualization of the structure in question(Table 5). Similarly, single-beat loops of a tomographic view might
be inadequate for imaging the anatomy, and longer video clips(sweeps) may be needed to capture essential information. For any
valve or structural abnormality, 2D, color flow, and spectral
Doppler imaging in SAX and multiple LAX views, as well as 3D structural and color Doppler imaging should be utilized when appropriate.
Image resolution should be optimized by minimizing sector angle andincreasing magnification to maximize frame rate. Likewise, Nyquist
color scale, sector angle, and color depth should be adjusted to limit
the amount of color speckle in the far field.
By utilizing the 28 views outlined in this document, a comprehensive
TEE examination can be performed in virtually any pediatric patient withor without CHD, and in most ACHD patients. For each view, accompanying videos are available online at www.onlinejase.com.
1. ME 4-Ch (Video 1)
The ME Four-Chamber View is obtained after initial probe
insertion in the esophagus when all cardiac chambers–rightatrium (RA), left atrium (LA), right ventricle (RV), and left
ventricle (LV) – the interatrial (IAS) and interventricular (IVS)
septa, and the mitral (MV) and tricuspid valves (TV) are visualized. All ME views obtained below start from this ‘‘home base.’’This view simulates a transthoracic apical 4-Ch view and is oneof the most useful for evaluating intracardiac anatomy and function. It is typically obtained with some degree of probe retroflexion and transducer angle rotation between 0-10 . Withfurther probe retroflexion, the coronary sinus (CS) and entranceof the inferior vena cava (IVC) to the RA can be visualized. The
ME 4-Ch view provides information regarding regional andglobal biventricular function, and atrioventricular (AV) valve stenosis and regurgitation.
2. ME 5-Ch (Video 2)
The ME Five-Chamber View is obtained by applying slight
anteflexion from the ME 4-Ch view to allow better visualizationof the aortic valve (AoV) and left ventricular outflow tract(LVOT). Color flow and spectral Doppler can be utilized to evaluate MV, TV, and AoV stenosis and regurgitation.

Figure 2 Conventions of 2D transesophageal echocardiographic image display. The transducer location and the nearfield (vertex) of the image sector are at the top of the display
screen and far field at the bottom. (A) Image orientation at transducer angle 0 . (B) Image orientation at transducer angle 90 .
(C) Image orientation at transducer angle 180 . Of note, we present the DTG views inverted, with the apex of the heart at thebottom of the screen in an anatomically correct position. LA,
Left atrium; LV, left ventricle; RV, right ventricle. Reprinted withpermission from Hahn et al.16
3. ME Mitral (Video 3)
The ME Mitral Commissural View is obtained by startingfrom the ME 4-Ch view and rotating the transducer angle toPuchalski et al 181

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Table 5 Comprehensive transesophageal echocardiographic examination. The table lists the suggested 28 views included in acomprehensive TEE exam. Each view is shown in its imaging plane, on a corresponding 3D model, with the 2D TEE image. The
acquisition protocol and the structures imaged in each view are listed in the subsequent columns.
Imaging plane

3D model2D TEE image

Acquisition protocol

Structures imaged

Midesophageal views
1. ME 4-Ch
Transducer angle: 0 –10
Level: ME

LA/RA
IAS
LV/RV/IVS
MV (A3A2-P2P1)
TV
CS

Transducer angle: 0 –10
Level: ME

AoV
LVOT
LA/RA
LV/RV/IVS
MV (A2A1-P1)
TV

Transducer angle: 50 –70
Level: ME

LACS
LVMV (P3-A3A2A1-P1)
Papillary muscles
Chordae tendineae

Transducer angle: 80 –100
Level: ME

LA
CS
LAA
LV
MV (P3-A3A2A1)
Circumflex CATransducer angle: 120 –140
Level: ME

LA
LV
LVOT
RVOT
MV (P2-A2)
AoV
Proximal Asc Ao

2. ME 5-Ch

3. ME Mitral

4. ME 2-Ch

5. ME LAX(Continued )182 Puchalski et al

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Table 5 (Continued )Imaging plane

3D model2D TEE image

Acquisition protocol

Structures imaged

6. ME AoV LAX
Transducer angle: 120 –140
Level: ME

LA
LVOT
MV (P2-A2)
AoV
Proximal Asc Ao
LCA

Transducer angle: 90 –110
Level: ME

Mid Asc Ao
RPA

Transducer angle: 0 –30Level: ME

Mid Asc Ao
MPA/Br PAs
SVC

Transducer angle: 0
Level: ME

Mid Asc Ao
SVC
RUPV
RLPV

Transducer angle: 90 –110
Level: ME

LUPV
LLPV
LPA

7. ME Asc Ao LAX

8. ME Asc Ao SAX

9. ME Rt Pulm veins

10. ME Lt Pulm veins(Continued )Puchalski et al 183

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Table 5 (Continued )Imaging plane

3D model2D TEE image

Acquisition protocol

Structures imaged

11. ME LAA
Transducer Angle: 90 –110
Level: ME

LAA
LUPV

Transducer angle: 25 –45
Level: ME

AoV
PV
LA/RA
Superior IAS
RVOT
LCA/RCATransducer angle: 50 –70
Level: ME

AoV
PV
LA/RA
Superior IAS TV
RVOT
IVS: membranous, outlet

Transducer angle: 50 –70
Level: ME

LA/RAMid IAS
TV
SVC
IVC
CS

Transducer angle: 90 –110
Level: ME

LA
RA/RAA
IAS
SVC
IVC

12. ME AoV SAX

13. ME RV In-Out

14. ME Mod Bicaval TV

15. ME Bicaval(Continued )184 Puchalski et al

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Table 5 (Continued )Imaging plane

3D model2D TEE image

Acquisition protocol

Structures imaged

Transgastric views
16. TG IVC/Hep veins
Transducer angle: 80 –100
Level: TG

IVC
Hepatic veins

Transducer angle: 0 –20
Level: TG

LV (base)
RV (base)MV
TV
IVS: muscularTransducer angle: 0 –20
Level: TG

LV (mid)
Papillary muscles
RV (mid)
IVS: muscularTransducer angle: 0 –20
Level: TG

LV (apex)
RV (apex)
IVS: apical muscularTransducer angle: 120 –140
Level: TG

LV
LVOT
AoV
Ao rootMV

17. TG Basal SAX

18. TG Mid Pap SAX

19. TG Apical SAX

20. TG LAX(Continued )Puchalski et al 185

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Table 5 (Continued )Imaging plane

3D model2D TEE image

Acquisition protocol

Structures imaged

Deep transgastric views
21. DTG 5-Ch
Transducer angle: 0 –20
Level: DTG

LV/RV
LVOT
AoV
Ao root
MV
IVS

Transducer angle: 50 –90
Level: DTG

LV/RV
RVOT
PV
LVOT
AoV
MV
IVS

Transducer angle: 80 –90
Level: DTG

RA/RAA
LA
RPA
IAS
SVC
IVC

Transducer angle: 0 –10
Level: UE

Ao archInnominate vein

Transducer angle: 70 –90
Level: UE

Ao archInnominate vein
MPA
Br PAsPV

22. DTG RVOT

23. DTG Atr Sept

Upper esophageal views
24. UE Ao Arch LAX

25. UE Ao Arch SAX(Continued )186 Puchalski et al

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Table 5 (Continued )Imaging plane

3D model2D TEE image

Acquisition protocol

Structures imaged

26. UE PA
Transducer angle: 0 –20
Level: UE

MPA
LPA
RPA
Mid Asc Ao

Transducer angle: 0 –10
Level: UE to TG

Desc Ao

Transducer angle: 90 –100
Level: UE to TG

Desc Ao

Aortic views
27. Desc Ao SAX

28. Desc Ao LAX

CS, Coronary sinus; IAS, interatrial septum; IVS, interventricular septum; LAA, left atrial appendage; LCA, left coronary artery; LLPV, left lower pulmonary vein; LUPV, left upper pulmonary vein; RAA, right atrial appendage; RCA, right coronary artery; RLPV, right lower pulmonary vein; RUPV,
right upper pulmonary vein.

50- 70 . As the name implies, the ME Mitral view is used primarily to evaluate the MV. This imaging plane crosses boththe anterolateral and posteromedial commissures. The sectionsof MV on the image display (from left to right) are P3-A3A2A1P1. Turning the probe leftward (counterclockwise) allows imaging of the posterior leaflet scallops (P3P2P1) and rightward(clockwise) allows imaging of the anterior leaflet segments(A3A2A1). This view is also useful for evaluating the anterolateral and posteromedial papillary muscles and their corresponding tensor apparatus as well as regional LV function and MV
stenosis or regurgitation.
4. ME 2-Ch (Video 4)
The ME Two-Chamber View (orthogonal to ME 4-Ch view)
is obtained by maintaining the same neutral position androtating the transducer angle to 80-100 to allow visualizationof the LA, left atrial appendage (LAA), MV (P3-A3A2A1), and
LV. The CS is seen in cross section just above the posterior
MV annulus and basal inferior LV segment. From this view,clockwise rotation of the probe demonstrates the ME Bicaval
view (View #15 below); rotation counterclockwise visualizes
the LAA and also the left circumflex coronary artery (CA)can be seen coursing along the AV groove. Color flow Doppler
as well as spectral Doppler of the MV can aid in identification of
valvular stenosis or regurgitation.
5. ME LAX (Video 5)
The ME Long Axis View can be obtained from the ME 4-Ch
or 2-Ch views by continuing forward rotation of the transducer
angle to approximately 120-140 to visualize the LA, MV (P2A2), LV, LVOT, AoV, and proximal ascending aorta. A portionof the right ventricular outflow tract (RVOT) can also be noted
anterior to the LVOT. This view allows assessment of the MV
and AoV as well as subvalvular and supravalvular aortic anatomy. The size and function of the mitral and aortic valves andassessment of the LV inferolateral and anteroseptal walls canbe evaluated with 2D, color flow, and spectral Doppler imaging.
6. ME AoV LAX (Video 6)
The ME Aortic Valve LAX View is obtained from the ME
LAX view by slight withdrawal of the probe, while maintaining
a transducer angle of 120-140 . Transducer image depth is also
reduced to focus primarily on the LVOT, AoV, and proximal
aorta, including the sinuses of Valsalva, to allow accurate measurements with 2D, color, and spectral Doppler imaging,Journal of the American Society of Echocardiography
Volume 32 Number 2

especially when used in conjunction with the orthogonal ME
AoV SAX view (see View #12 below). Color flow Doppler
can provide a significant amount of information on LVOT and
AoV pathology. The anterior (far field) AoV cusp is the right coronary cusp, and the right coronary ostium can often be seenarising from the sinus. The posterior (near field cusp) is either
the left or noncoronary cusp, depending upon transducer rotation. When the probe is rotated counterclockwise, the origin of
the left main CA can often be seen, and with further leftward
rotation, sometimes the bifurcation into left anterior descending
and circumflex CAs can be visualized.
7. ME Asc Ao LAX (Video 7)
The ME ascending aorta LAX View is obtained from the
ME AoV LAX view (View #6 above) by withdrawal of the
TEE probe, and rotation of the transducer angle to between
90 and110 . The right pulmonary artery (PA) is seen in crosssection posterior to the ascending aorta (in the near field). Pathology involving the ascending aorta, such as supravalvularaortic stenosis and hypoplasia or aneurysmal dilation, can be
identified. Aortic flow is typically perpendicular to the angle
of insonation, hence spectral Doppler evaluation of the aorta
will be limited but color Doppler can be useful. When the image
plane is centered on the right PA, turning the probe counterclockwise can provide LAX imaging of the pulmonic valve(PV) and main PA. Probe anteflexion enables optimal colorand spectral Doppler interrogation (pulsed- and continuouswave) of the RVOT, PV, and main PA.
8. ME Asc Ao SAX (Video 8)
From the ME ascending aorta LAX view (View #7 above), backward rotation of the transducer angle to 0 -30 results in the
ME Ascending Aorta SAX View. Structures imaged fromthis view include the ascending aorta and superior vena cava
(SVC) in cross section, main PA, and proximal branch PAs. Color flow and spectral Doppler evaluation of the PA may be useful.
9. ME Rt Pulm Veins (Video 9)
The ME Right Pulmonary Veins View can be obtained
from the ME 4-Ch view, using a transducer angle of 0 androtating clockwise. The right upper (superior) and lower (inferior) pulmonary veins take slightly different angles: the right upper pulmonary vein (RUPV) is more parallel to the angle ofinsonation, and with slight probe advancement, the right lower
pulmonary vein (RLPV) can be visualized in a more perpendicular orientation. In addition, a transducer angle of 30-50 mayallow visualization of the veins simultaneously. Color flow
Doppler (sometimes with decreasing the Nyquist limit) can
display flow in both pulmonary veins, but a more favorable
angle of insonation of the RUPV makes spectral Doppler ofthis pulmonary vein preferable. In addition to the right pulmonary veins, the superior vena cava (SVC) and ascending aorta
can be visualized in cross-section.
10. ME Lt Pulm Veins (Video 10)
The ME Left Pulmonary Veins View displays the left pulmonary veins from a sagittal plane, orthogonal to that described
for the ME Rt Pulm Veins view (View #9 above). From the ME
neutral position behind the LA, forward rotation of the transducer angle to 90 -110 and turning counterclockwise, one
can visualize separately the left upper (LUPV) and left lower(LLPV) pulmonary veins as they converge and enter the LA.
The left PA can also be seen just superior to the LUPV. If the

Puchalski et al 187

probe is turned clockwise, the IAS, SVC, IVC (View #15
below), and finally the right pulmonary veins become visible.
Of note, the left pulmonary veins can also be imaged using atransducer angle of about 0 with rotation of the probe counterclockwise to visualize the LAA and veins adjacent and lateral to
it by advancing and withdrawing the probe.
11. ME LAA (Video 11)
The ME Left Atrial Appendage View can be obtained from
the ME Lt Pulm Veins view (View #10 above) using the sametransducer angle of 90 -110 and turning the probe slightly
clockwise with some probe advancement and/or anteflexion
as necessary. Given the highly variable anatomy of the LAA, a
complete assessment of this structure typically requires using
multiple views, including backward rotation of the transducer
from 90 to 0 (while imaging the appendage) and/or simultaneous multiplane imaging. Color flow and spectral Doppler canalso be used to assess flow in the LUPV as well as into and out of
the LAA.
12. ME AoV SAX (Video 12)
From the ME 5-Ch view, the AoV is located in the center of thedisplay and the probe is withdrawn slightly and anteflexed while
maintaining a transducer angle between 25 -45 to obtain the
ME Aortic Valve SAX View. For a trileaflet valve, the left
coronary cusp will be posterior (near field) and to the patient’s
left, the right coronary cusp anterior (far field) and adjacent to
the RVOT, and the noncoronary cusp rightward and adjacentto the IAS. The morphology and function of the AoV can be displayed both by 2D imaging and color flow Doppler, allowing for
precise localization of stenotic and/or regurgitant jets. Slightwithdrawal of the probe can reveal the anterior origin of theright CA and posterior origin of the left CA from their respective
sinuses. A change in transducer angle to between 0 -40 canoften be useful to see the origins (0 -20 for right CA, 30 40 for left CA). The superior portions of the left and right atria
and the anterior portion (aortic rim) of the IAS, as well as the
RVOT and PV in the far field can be seen. Color flow and spectral Doppler can aid in evaluation of these areas. Of note, theorthogonal view obtained during simultaneous biplane imaging
is the ME AoV LAX view (View #6 above).
13. ME RV In-Out (Video 13)
The ME RV Inflow-Outflow View can be obtained from the
ME AoV SAX view or ME 5-Ch view by rotating to 50 -70and applying some anteflexion until the TV, RV, RVOT, PV,and proximal main PA are displayed simultaneously. Thisview is the equivalent of an inverted transthoracic parasternal
SAX view, so the LA, RA, and IAS can also be seen. RV sizeand function, TV and PV morphology and function, distinguishing membranous from outlet IVS (and visualizing VSDs in theseareas), and RVOT stenosis can be evaluated, especially in conotruncal abnormalities (see below). Color flow and spectral
Doppler should be utilized to evaluate flow across the TV andPV, and identify any possible VSDs.
14. ME Mod Bicaval TV (Video 14)
From the ME RV In-Out View, the ME Modified Bicaval TV
View can be obtained by maintaining a transducer angle of50 -70 and turning the probe clockwise until the TV iscentered in the view. The LA, RA, IAS, IVC, SVC, and sometimes the right atrial appendage (RAA) can be seen. Detailed
evaluation of the TV by both 2D and Doppler imaging shouldbe performed.

188 Puchalski et al

15. ME Bicaval (Video 15)
The ME Bicaval View is obtained by rotating the transducer
angle forward to 90 -110 from the neutral ME position andturning the probe clockwise until both SVC and IVC are visualizedalong with the LA, RA, RAA (far field), and IAS (which is positioned perpendicular to the insonation beam). Atrial septal defects(ASD) and aneurysms can be seen with 2D, color, and spectral
Doppler imaging of the atrial septum. Color flow Doppler is also
useful to visualize IVC and SVC inflow. The orthogonal view
(seen by simultaneous biplane imaging) is the ME 4-Ch viewand further turning the probe clockwise can visualize the right pulmonary veins (orthogonal to View # 9, ME Rt Pulm Veins).
16. TG IVC/Hep Veins (Video 16)
The TG IVC/Hepatic Veins View is obtained by straightening
and advancing the TEE probe from the ME views into the stomach
and adjusting the transducer angle to 80 -110 . The probe is thenturned clockwise and anteflexed slightly to maintain contact withthe stomach wall. The IVC is seen in LAX and, with a small amountof probe withdrawal and left/right probe rotation, the hepatic veins
can be visualized entering the IVC. With slow probe withdrawal to
the ME position, the IVC/RA junction is visualized. Color flow
Doppler can be used to evaluate flow patterns in the veins; spectral
Doppler can be performed to evaluate hepatic venous flow forassessment of right-sided diastolic function, as well as any highervelocity flow such as anomalous pulmonary venous drainage.
The orthogonal view, using a transducer angle of 0 -20 and slightright/left probe rotation, demonstrates the IVC in SAX as it courses
through the liver, receives hepatic veins, and returns to the RA.
17. TG Basal SAX (Video 17)
The TG Basal SAX View is obtained by adjusting the transducer angle to 0 -20 from the TG IVC/Hep Veins view toallow the left and right ventricles to be seen in SAX with thetypical ‘‘fish mouth’’ appearance of the MV. The anterior leaflet
is on the left of the display and the posterior leaflet is on theright. MV morphology and function can be assessed by 2D imaging and color flow Doppler as well as a global assessment ofright and left ventricular function and wall motion, and presenceof mid muscular VSDs. Advancing and turning the probe clockwise, while applying slight anteflexion, can display the TV in a
SAX view to allow similar interrogation as the MV.
18. TG Mid Pap SAX (Video 18)
From the TG Basal SAX position, the anteflexed TEE probe canbe advanced further into the stomach with the same transducer
angle (0 -20 ) to obtain the TG Mid Papillary SAX View.
The LV papillary musculature, the muscular IVS, and the RV
papillary musculature (by turning the probe clockwise) can beevaluated. This view is principally utilized to evaluate LV sizeand function (global and segmental).
19. TG Apical SAX (Video 19)
From the TG Mid Pap SAX View (View #18), the TEE probe
continues to be advanced while maintaining contact with thegastric wall to obtain the TG Apical SAX View. Evaluationof the apical segments of both ventricles and also visualizationof apical muscular VSDs is possible by rotating clockwise.
20. TG LAX (Video 20)
The TG LAX View is obtained by rotating the transducer angle
to 120 -140 from the neutral position. This view allows visualization of the subvalvular MV apparatus (including the chordae
tendineae), MV, LVOT, AoV, LV inferolateral and anteroseptal
walls, and proximal aortic root. Color flow Doppler should be
used to evaluate flow across the MV and LVOT/AoV.

Journal of the American Society of Echocardiography
February 201921. DTG 5-Ch (Video 21)
The DTG views require advancement of the TEE probe further
into the stomach, often with significant anteflexion to direct theultrasound plane posteriorly. The DTG Five-Chamber View
is obtained using a transducer angle of 0 -20 to visualize theMV, RV, LV, IVS, LVOT, AoV, and aortic root. The inlet, membranous, and trabecular portions of the IVS can be evaluated bycolor flow Doppler to search for possible VSDs. The MV and
LVOT should be interrogated with color and spectral Doppler.
When DTG views are not available, the TG LAX view (View#20) serves as a suitable alternative for spectral Doppler evaluation of the LVOT and AoV.
22. DTG RVOT (Video 22)
From the DTG 5-Ch View, the probe is withdrawn slightly andthe transducer angle rotated forward to 50 -90 to obtain the
DTG RV Outflow Tract View. Some probe rotation clockwise might also be needed to display the RVOT and PV. The
MV inflow and AoV outflow can be visualized, as well as thetrabecular and outflow portions of the IVS for any shunting suggestive of a VSD. Color and spectral Doppler can be used toevaluate the RVOT, MV, and LVOT with forward rotation to80 -90 and the TEE probe rotated slightly counterclockwise.
This view is very useful for evaluation of conotruncal malformations (see below).
23. DTG Atr Sept (Video 23)
From the DTG RVOT View, the transducer angle is rotated forward to 80 -90 and the TEE probe rotated clockwise until the
SVC, RA, RAA, LA, and IAS are seen, producing the DTG
Atrial Septal View. This view simulates a transthoracic subcostal bicaval image, providing excellent visualization of theatrial septal morphology and length. Color Doppler is usefulfor evaluation of interatrial shunting, and SVC flow can be visualized and evaluated by color and spectral Doppler. To visualize
the IVC entrance to the RA, the probe is advanced slightly andthe transducer angle rotated forward to 100 -120 . If the transducer angle is instead rotated back to 0 -10 , the IAS can beseen in an orthogonal plane, as can the RA, entrance of the rightand left pulmonary veins into the LA, and both ventricles andatrioventricular valves.
24. UE Ao Arch LAX (Video 24)
Withdrawal of the probe to the UE position (transducer angle0 -10 ) can be used to obtain the UE Aortic Arch LAX
View. Color and spectral Doppler will demonstrate pulsatile
antegrade flow in the Ao and with further slight withdrawal,
the innominate vein can be seen crossing anterior to the Aoarch. Because the left mainstem bronchus typically crosses between the esophagus and the Ao, a portion of proximal Aoarch and distal ascending Ao might not be visualized. If no
innominate vein is seen, the probe should be rotated counterclockwise to determine whether a left SVC is present in SAX.
25. UE Ao Arch SAX (Video 25)
From the UE Ao Arch LAX view, the transducer angle is rotatedforward to 70 -90 to obtain the UE Aortic Arch SAX View.
The Ao arch is seen in SAX, and the main PA and PV canfrequently be seen in LAX in the far field. The innominate
vein is also seen in cross section just superior and anterior to
the Ao arch. Color and spectral Doppler of the PV and main
PA is very effective here, and a patent ductus arteriosus canalso be seen in this view, entering the PA. With the main PA
centered in the image, counterclockwise and clockwise rotationof the probe provides visualization of the left and rightPuchalski et al 189

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pulmonary arteries, respectively. The head and neck arteries(right brachiocephalic, left common carotid, left subclavian)can sometimes be seen arising from the Ao arch.
26. UE PA (Video 26)
From the UE Ao Arch LAX View (View #24), the probe isadvanced slowly (transducer angle 0 -10 ) and rotated slightly
clockwise to obtain the UE Pulmonary Artery View that
demonstrates the junction between main PA and right and left
pulmonary arteries. From this position, clockwise probe rotation
displays the right PA behind the ascending Ao and right SVC(both seen in SAX). Counterclockwise rotation along with slightprobe advancement can visualize the proximal to mid left PA.
Color and spectral Doppler should be used to determine thepresence of stenosis across both branch PAs. A patent ductus arteriosus can be seen by color flow Doppler with counterclockwise probe rotation and advancing/withdrawing the probe.
Spectral Doppler can also be performed to assess the gradient between Ao and main PA through the patent ductus arteriosus.
27 and 28. Desc Ao SAX (Video 27) and Desc Ao LAX (Video 28)
From the UE Ao Arch LAX view (transducer angle 0 -10 ), theprobe is rotated counterclockwise and slowly advanced tofollow the Ao arch as it becomes the Descending Aorta
SAX View. Rotating the transducer angle to 90 -100 produces the Descending Aorta LAX View. While keeping
the Ao in the center of the image, the probe can be advanced
slowly with either view in order to evaluate the entirety of thedescending thoracic Ao. The lack of internal anatomic landmarks can make it difficult to describe the precise location of
the probe and any detected pathology, so one solution is torotate the probe clockwise to identify the cardiac anatomy atthat level, thereby providing a point of reference. Color andspectral Doppler can be used to evaluate the pulsatility of aortic
flow. Intercostal arteries can sometimes be seen arising posteriorly from the descending Ao, with pulsatile flow directed away.
Transesophageal 3D Examination Protocol
Since the publication of the last pediatric and congenital TEE guidelines document in this journal,31 there have been major advancements in 3D echocardiography, including a) high quality real-time
imaging, b) adult-size 3D TEE transducers, c) efficient cropping tools,
and d) quantitative 3D software programs.16,109-115 In pediatric andcongenital cardiology, the most useful applications of 3D TEE are
during catheter-based therapies and CHD surgeries. In the recent
3D echocardiography in CHD guidelines document,116 specific recommendations for the particular anomalies and procedures in which
3D TEE is recommended (and also some in which 3D TEE has beenused effectively) are presented in Table 6.
Three-dimensional echocardiography generally requires increased
technical training and expertise as compared to conventional 2D imaging regarding specific optimization and acquisition protocols forvarious displays that best highlight CHD. These most commonly
include options of ‘‘live’’ narrow angle, wide angle or zoom imaging,full volume, and live multiplane.16,110-113 These methods must be
mastered in order to effectively perform 3D TEE in the timeconstrained settings of the cardiac catheterization laboratory andoperating room. 3D TEE imaging protocols should be routinely utilized in conjunction with other echocardiographic modalities as partof the regular workflow of either a detailed segmental study or amore focused TEE examination. It is important that image orientationfor viewing the 3D dataset be practical and foster clear communica-

Table 6 Reported clinical use of 3D TEE in congenital heartdisease3D TEE has been recommended for:ASD device closure guidance
VSD device closure guidance
Visualization of catheters, delivery systems, and devices
Measurement of defects visualized in en face views
Analysis of the anatomy and function of atrioventricular valves
Visualization of the aortic valve and left ventricular outflow tract
3D TEE has been used effectively during:
Fontan fenestration closure
Ruptured sinus of Valsalva aneurysm device closure
Coronary artery fistula device closure
Prosthetic valve paravalvular leak device closure
Atrial switch baffle leak device closure and baffle obstruction
stenting
Atrial septum trans-septal puncture during various procedures
Biventricular pacemaker synchrony assessment and leadplacement guidancetion among cardiovascular care providers.29,113 Where applicable,
recommendations regarding the use of 3D TEE to analyze specificanomalies, procedures, and quantitative parameters have been
added to the respective sections of this document.

Key Points
1. We recommend a series of 28 tomographic views be used toperform a comprehensive TEE examination in children andall patients with CHD.
2. The views are obtained from four primary positions within theesophagus/stomach: midesophageal (ME), transgastric (TG),deep transgastric (DTG), and upper esophageal (UE). All views
are presented with the standard ‘‘apex up’’ orientation except
for the DTG views, which are inverted to an ‘‘apex down’’ position to present an ‘‘anatomically correct’’ display.
3. The views serve as a starting point for CHD evaluation, andcan be altered as needed. The exam should be structurebased, not view-based, and include a minimum of 2D imaging,color flow and spectral Doppler, obtained from multiple
views.
4. 3D TEE imaging can be performed in conjunction with 2D
TEE in patients > 30 kg, and involves the use of specific 3D
techniques including adjustable sector, full volume, and live
multiplane methods. Table 6 lists a number of clinical usesfor 3D TEE in CHD.

SPECIFIC STRUCTURAL IMAGING
The following section describes the anatomy and imaging of specificstructures and congenital anomalies. Clear and precise visualization isessential for detecting and quantifying structural and functional abnormalities prior to and during any intervention and will be discussed
in detail. The focus will be on differentiating features from normal
valve anatomy and acquired pathology, which was extensively

190 Puchalski et al

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Figure 3 Schematic of the MV with leaflet scallops (or segments) labeled. Corresponding images from different standard imaging
views are labeled with the respective scallops and segments. Although this labeling scheme is applicable in the majority of cases,
the exact regions of the MV leaflets image vary on the basis of the relation of the heart to the esophagus as well as transesophageal
echocardiographic probe position within the esophagus. Ao, Aorta; LAA, LA appendage; LAX, long-axis; Mitral, mitral commissural;
2Ch, two-chamber; 4Ch, four-chamber. Adapted from Hahn et al.16
covered in the 2013 ASE/SCA Comprehensive TEE Guidelines, andan array of congenital cardiac abnormalities.30
Mitral Valve
Anatomy. The basic components of the MV apparatus include theanterior and posterior valve leaflets, annulus, chordae tendineae, andpapillary muscles. Several views are employed for examining the
MV and have been shown to correlate well with surgical evaluation.117
The ME views (4-Ch, 5-Ch, Mitral, 2-Ch, LAX, and AoV LAX) axiallytransect the MV leaflets from 0 – 140 , and are helpful for delineating
all scallops of both leaflets (Figure 3).16 The TG and DTG views provide
further characterization of valve and commissural anatomy and areespecially valuable for demonstrating congenital abnormalities.
TEE imaging is useful for distinguishing primary etiologies of mitralvalve dysfunction from secondary etiologies such as mitral regurgitation related to annular dilation. Primary causes of mitral valve
dysfunction are associated with intrinsic valve pathology and may
include 1) congenital abnormalities such as clefts (Figure 4), double
orifice mitral valve, mitral arcade, or abnormal papillary musculature

Puchalski et al 191

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Figure 4 TEE 3D midesophageal wide angle left atrial en faceview of a left atrioventricular (mitral) valve cleft associated withan ostium primum atrial septal defect. A, Anterior/superior
component of the anterior leaflet in a cleft left atrioventricularvalve; AoV, aortic valve; ML, mural leaflet; MV, mitral valve; P,
posterior/inferior component of the anterior leaflet in a cleft left
atrioventricular valve.
(i.e. parachute mitral valve); 2) myxomatous changes resulting in prolapse, elongation of the chordae, or flail; 3) infectious damage from endocarditis; or 4) inflammatory effects related to rheumatologic or
collagen vascular diseases.118,119
Role of TEE in Mitral Valve Repair. TEE imaging is reliable forassessing adequacy of mitral valve repair, and for determining theneed for return to bypass.11,120 Early identification of findings
requiring modification of the repair may prevent need for a reoperation at a later date, and may decrease morbidity, mortality,
and overall hospital costs over the long term.15 The decision shouldtake into account several factors, including hemodynamic status, aswell as severity of the residual lesion.
Although there are no established echocardiographic measures toquantify severity of residual mitral dysfunction in the pediatric population, criteria do exist for grading residual mitral stenosis and regurgitation by Doppler.121 With regard to mitral stenosis, the following
measures have been used: insignificant = pulsed/CW Doppler mean
gradient #5 mm Hg potentially significant = pulsed/CW Doppler
mean gradient of 5-8 mm Hg; and significant = pulsed/CW Doppler
mean gradient of > 8 mm Hg. A mean mitral valve inflow gradientof more than 5 mm Hg has been suggested as a cut-off point for consideration of further repair or valve replacement.122 In the presence of residual regurgitation, the mitral valve should be carefully examined forleaflet prolapse, abnormal leaflet excursion, or persistent annular dilatation. Dynamic systolic anterior leaflet motion can displace the coaptation point of the leaflets toward the left ventricular outflow tract
resulting in a posteriorly directed jet of mitral regurgitation, which
may be exacerbated by a hypovolemic, hypercontractile left ventricle
upon separation from cardiopulmonary bypass.123 Objective parameters such as width of the vena contracta should be taken into consideration and used to grade mitral regurgitation as follows:
insignificant = absent or trivial regurgitation jet width (<2 mm) by color
at the level of the valve leaflets; potentially significant = regurgitant jet
width 2-4 mm by color Doppler at the level of the valve leaflets; andFigure 5 Midesophageal LAX view around 125 shows a subaortic fibromuscular ridge associated with subvalvar aortic stenosis. Ao, Aorta; LA, left atrium; LV, left ventricle; RV, right ventricle.
significant = regurgitant jet width > 4 mm by color Doppler at the levelof the valve leaflets.121 Additionally, the ratio of the maximum regurgitant jet area by color Doppler to the left atrial area on 2D imaging canbe used for quantifying MR, with mild defined by a ratio of #30%.
Return to bypass for further correction or valve replacement should
be considered for more than mild MR, as the risk for reoperation isincreased. This is typically a joint decision made by the surgeon andthe echocardiographer and may require a more comprehensive evaluation of the valve to make the right decision.124
Use of 3D TEE in Mitral Valve Assessment. The best 3D TEEview of the MV is obtained using the wide-angle live 3D modality
from the ME position viewed from the LA aspect. Examples of thisapproach are presented in Figure 4, Videos 29 and 30. Live 3D
with color flow Doppler mapping may be useful if the temporal resolution (volume rate) is adequate. Biplane 2D imaging and color flow
Doppler mapping methods are useful and can be time saving because
two views are obtained simultaneously.
Aortic Valve and Aorta
Anatomy of Aortic Valve. The AoV complex includes the left ventricular outflow tract, aortic valve, and aortic root. The AoV complex
should be carefully evaluated for potential subaortic, aortic, and supravalvular obstruction in the ME LAX (Figure 5), ME AoV LAX (Video31), and DTG 5-Ch views. Familiarity with all of these structures isimportant, as obstruction or dilatation at any level may ultimately affect
AoV function. Measurement of the AoV annular diameter is performed at the hinge points of the valve leaflets, while the sinuses of
Valsalva and sinotubular junction are measured from inner edge-toinner edge at end-systole or at the maximal diameter in pediatrics.116
However, in adult patients, the ASE guidelines recommend leadingedge-to-leading edge at end-diastole or at the maximal diameter.125
Role of TEE in Aortic Valve Repair and Left Ventricular
Outflow Surgery. A thorough understanding of the underlying
mechanism of AoV dysfunction, including leaflet and root192 Puchalski et al

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Figure 6 Midesophageal 4-Ch view of Ebstein’s anomaly including apical displacement of the septal leaflet of the tricuspid valve,
redundancy of the anterior leaflet, and atrialization of the right ventricle. On the right hand side, color Doppler shows regurgitationof the tricuspid valve starting in the body of the right ventricle due to the apical displacement. RA, Right atrium; aRV, atrialized rightventricle; fRV, functional right ventricle; LA, left atrium; LV, left ventricle.
morphology, is needed prior to any transcatheter or surgical intervention on the valve. In pediatric patients undergoing AoV repair,
TEE imaging is used to identify markers for recurrent regurgitationnecessitating early reoperation.126 While shorter coaptation lengthand decreased coaptation height have been designated as predictorsof need for early reoperation in adults, coaptation asymmetry,measured as an increased percentage difference in short-axis coaptation lengths, has been shown to be a strong predictor of early reoperation for residual aortic regurgitation in pediatric patients
following valve repair.127
Quantification of valve stenosis and regurgitation should be performed according to previously published echocardiographic guidelines.118 For AoV/LVOT stenosis, the TG LAX and DTG 5-Ch views
provide excellent angles of insonation for both PW and CW
Doppler evaluation of preoperative and postoperative gradients. A
peak gradient >40 mm Hg in the LVOT may be hemodynamically significant and require reintervention. However, in the setting ofdecreased ventricular function and low cardiac output immediately
post-bypass, TEE may not accurately reflect the degree of residual
obstruction in all cases.121
For aortic regurgitation, a regurgitant jet width >4 mm by color
Doppler at the level of the valve leaflets may represent a risk for hemodynamically significant aortic regurgitation postoperatively.127
Additional reported risk factors for early reoperation include concomitant valve-sparing aortic root and/or ascending aortic replacement,
and leaflet prolapse.128,129
Use of 3D TEE in Aortic Valve Assessment. Live narrow-angle
3D TEE in the ME AoV SAX view provides excellent views of the
AoV. Examples of a normal and abnormal AoV are shown in Video
32. Biplane 2D imaging and color flow Doppler mapping methods
are useful if the frame rate is adequate and can be time saving because
two views are obtained simultaneously. Imaging to guide device
closure of a ruptured sinus of Valsalva aneurysm can also be helpful(3D Video 33).
Anatomy of Thoracic Aorta. Visualization of the mid ascending
Ao, Ao arch, and descending Ao is best achieved from the ME, UE,
and aortic views. Doppler interrogation of flow in the descending
Ao may confirm severe aortic regurgitation if other views arelimited.16,130,131 In patients undergoing arch repair (i.e., coarctation
or interrupted aortic arch), color and spectral Doppler interrogationof flow in the descending Ao can be helpful in identifying residualarch obstruction. Imaging in the setting of aortic dissection isaddressed in detail in other guidelines.132,133
Tricuspid Valve
Anatomy. The tricuspid valve is anatomically and functionally complex, comprising three leaflets attached to a fibrous annulus, chordal
apparatus, and papillary muscles. The ME 4-Ch view demonstrates
the anterior and septal leaflets, as well as abnormalities such as tethering, flail segments, involvement of the septal leaflet in tricuspid
septal aneurysmal tissue in a membranous VSD, apical displacement
and tethering of the septal leaflet in Ebstein anomaly (Figure 6 andVideo 34), and endocarditis related to these leaflets. Color Doppler
in this view demonstrates the flow pattern across the TV, and is often
well aligned with a central regurgitant jet, which is typically physiologic. Clockwise rotation and if possible rightward flexing of the probefrom the Modified Bicaval TV view may best assess the posterior
leaflet and its coaptation with the adjacent leaflets.
TV abnormalities may be anatomical, such as Ebstein anomaly, TV
dysplasia, stenosis, pacemaker lead-induced non-coaptation, flailleaflet, straddling or over-riding valves in complex CHD; or functional, secondary to right-sided (pulmonary hypertension, RV
dysfunction and dilatation), or left-sided (elevated LA filling pressuresfrom various causes and abnormal septal contour) dysfunction.
Role of TEE in TV Repair/Replacement. It is not unusual for an
intra-operative evaluation to underestimate the extent of tricuspid
regurgitation (TR) in an intubated, anesthetized child with low preload due to overnight feeding restrictions. The ME 4-Ch, ME RV
In-Out, and ME Mod Bicaval TV views show a larger TR jet comparedto other views.134 Incorporating multiple views at multiple time points
in the post-bypass period (with variable systemic and pulmonary arterial pressure, improving contractility post-cardioplegia, and return of
AV synchrony) can assist in surgical decision-making, such as theneed to return to bypass to address residual lesions if TR is significant
or indicates an elevated RV systolic pressure.120
Physiologic TR is common, always less than mild, and can be usefulin predicting RV systolic pressures. These jets, which are typicallysmall or intermittent, when combined with substantial throughplane motion, may be elusive in the rapidly changing post-bypass
period. It may be helpful to annotate simultaneous central venousPuchalski et al 193

Journal of the American Society of Echocardiography
Volume 32 Number 2pressure as well as systemic arterial pressure along with Doppler measurements of peak instantaneous pressure gradients. A Nyquist limitof 50 to 60 cm/s may be set to compare pre- and post-bypass images
at the same technical settings, as TR may be underestimated at higher
scale settings.135 Accurate Doppler assessment of TR is important fora variety of reasons: high TR velocities after VSD repair raise concern
for a sizeable residual defect, may indicate residual outflow obstruction after an RVOT repair, or need for initiation of inhaled nitric oxide
in a patient with late presentation of an unrestricted left to right shunt;
TR velocities discrepant from the systemic arterial pressures may alert
toward residual arch obstruction when the RV is the systemic
ventricle; and low TR velocities may indicate high filling pressureswith decreased cardiac function.
Transvenous pacemaker leads can be imaged as they traverse theTV, sometimes causing regurgitation due to leaflet retraction, fibrosisof leaflet edges, leaflet tethering, or perforation. In this situation, analysis of the TV anatomy as well as lead position will aid in planning forvalve repair. Lead- or central line-related endocarditis require detailed
assessment of right sided structures.
Use of 3D TEE in TV Assessment. The best 3D TEE view of the
TV is usually obtained using the wide-angle live 3D modality from theME 4-Ch position viewed from the RA aspect and may better clarify
dysfunction of specific leaflets. Live 3D with color flow Doppler mapping may be useful if the volume rate is adequate. Biplane 2D imaging
and color Doppler flow mapping methods are useful and timeefficient. Normal TV, Ebstein anomaly, and Sapien valve replacementin the catheterization lab are presented in Videos 35-37.
Pulmonary Valve
Anatomy. The PV is the anterior, leftward, and cephalad of the twosemilunar valves in the structurally normal heart. Its anterior location in
the chest can make it difficult to assess by TTE and ironically, its distancefrom the TEE probe as well as proximity to the left upper lung lobe canalso make it difficult to visualize in detail. The ME RV In-Out and DTG
RVOT views profile the PV. Pulmonary stenosis may occur at the subvalvular, valvular, or supra-valvular regions. Supravalvular narrowing
can be seen in the MPA at the level of the systolic excursion ofdysplastic leaflets or as a circumferential fibrotic waist in patients withsupravalvular pulmonary stenosis (e.g., Williams syndrome). Stenosis
within valved or non-valved conduits can be similarly assessed, thoughfibrosis and calcification of native valves or conduits can challenge image resolution. In these situations, color and spectral Doppler can beutilized to estimate location and severity of obstruction. Increased systolic flow velocity across the PV may be secondary to increased transpulmonary flow, but is usually less than 2 m/s in this situation. An
increase in peak pulmonic velocity may be seen in large left-to-rightshunts, and focused imaging of the PV to rule out dysplasia will prevent
surgical intervention. Functional pulmonary regurgitation is common
and is seen as a small, central jet from the PV. More significant jets
are likely to be wider; a jet width in excess of 50-65% of the right ventricular outflow tract indicates severe regurgitation,136 as does a moreholodiastolic pattern of leakage.137 Rapid flow deceleration, earlytermination of diastolic flow, and diastolic flow reversal in the branch
PAs almost always indicates significant pulmonary regurgitation.
Role of TEE in PV Repair/Replacement. Determining the presence and severity of residual obstruction in subvalvular, valvular, or
supravalvular regions may guide decisions regarding method of treatment (e.g., approach via TV, PVor right ventriculotomy/infundibulotomy in rare situations). Dynamic or fixed pulmonary stenosis atdifferent levels is an important cause for elevated RV systolic pressures and should be investigated. A quick and accurate assessmentof residual RVOT obstruction can be obtained from the DTG
RVOT view where the entire RVOT, PV, and supravalvular regions
can be aligned and ‘stepped-through’ to determine the exact locationand extent of obstruction. Similarly, patients undergoing replacement(either surgical or catheter based) in the setting of a dilated RVoutflow
tract may have a paravalvular leak, which should be carefully looked
for because it may be easily addressed in most cases.
Use of 3D TEE in Pulmonary Valve Assessment. Due to the
distance of the PV from the esophagus, 3D TEE imaging of the PV
is often limited. Narrow-sector live 3D or full-volume 3D acquisitions
with cropping may provide sufficient views in some cases.

Key Points
1. Primary causes of MV dysfunction include congenital abnormalities, myxomatous changes, infectious damage from endocarditis, or inflammatory disorders. The ME views (4-Ch,
5-Ch, Mitral, 2-Ch, LAX, and AoV LAX) from 0 - 140 aremost helpful to delineate MV anatomy and physiology but
TG and DTG are especially valuable for congenital abnormalities. Color flow and spectral Doppler aid in return to bypass
decisions following MV repair.
2. Assessment of the entire AoV complex includes the LVOT,
AoV, aortic root and supravalvular region. Both ME SAX
and LAX views provide complete evaluation of AoV and LV
outflow tract morphology and function. TG LAX and DTG
5-Ch views are very useful for assessment of PW/CW Doppler
gradients.
3. The ascending and descending thoracic aorta are best visualized systematically using a combination of ME and UE views,
at different levels of the esophagus, with appropriate transducer rotation to visualize the various portions of the thoracic
aorta.
4. Tricuspid valve abnormalities may be anatomical, such as Ebstein anomaly, TV dysplasia, stenosis, pacemaker leadinduced non-coaptation, flail leaflet, straddling or over-riding
in some complex CHD; or functional, secondary to right or
left-sided ventricular dysfunction. ME views provide assessment of TV morphology and function.
5. The pulmonary valve complex includes the sub-valvular,
valvular and supra-valvular regions. ME, DTG, and UE Ao
Arch SAX/PA views allow visualization of the PV complex.
Color flow and spectral Doppler can be used to assess the degree of stenosis or regurgitation across this area. Due to the distance of the PV from the esophagus, 3D TEE is often limited.
6. 3D TEE provides further evaluation of valve size, pathology,
mechanism and severity of valve dysfunction.

Assessment of Ventricular Size and Function
The assessment of ventricular size and function is an important part of
TEE in children and adults with CHD in the following settings: before
and after congenital heart surgery, during percutaneous CHD interventions or electrophysiology studies, during some complex non-cardiac surgeries, and in the setting of a non-diagnostic TTE.138,139 Additionally, theimmediate postoperative setting in the intensive care unit is a challenging
time for TTE, with open sternotomies and poor acoustic windows, and isanother area where TEE can be beneficial in children, especially in194 Puchalski et alpatients with transposition of the great arteries after arterial switch,
immediately after heart transplantation, or following implantation of aventricular assist device.140
Left Ventricle. Normal LV assessment is reviewed in the 2013 ASE/
SCA Comprehensive TEE Guidelines.16 Standard imaging planes formeasurement of size have not been established in TEE but there is general agreement between TTE and TEE measurements in adults.
Guidelines suggest using the TG Mid Pap SAX or the orthogonal TG
LAX of the LV for measurement of ventricular size, as measurementsin the ME views have reduced lateral resolution.16,141-143 In children,
the recommended approach is the Mid Pap SAX view, because theLAX view does not account for the lateral motion of the LV seen in
many children and does not guarantee circular LV short-axis geometry
throughout the cardiac cycle. Simultaneous multiplane imaging should
be used to ensure that LV diameter measurements are made perpendicular to the chamber. The modified biplane Simpson’s or area-length
methods have been suggested to calculate LV volume in children.116
The ME 4-Ch and 2-Ch views allow tracing of the LV endocardial borders and using the formula for calculating LV volume. Linear measurements may be made from M-mode tracings or 2-D images in TG viewsas there are normative pediatric data from TTE imaging.116,144
LV Systolic Function. Assessment of ventricular function requires
reviewing multiple imaging planes in TEE. Qualitative assessment isgenerally reported as either normal or with variable degrees of dysfunction such as mild, moderate, or severe. Quantitative parameters for LV
systolic function include linear shortening fraction (SF), fractional areachange, and 2D volumetric ejection fraction.116 SF can be assessed in
TG SAX projections at the level of the MV leaflet tips in young patientsor at the level of the papillary muscles in older patients and adults.116
Ejection fraction (EF) can be obtained from ME 4- and 2-Ch views using the modified biplane Simpson’s method. It is important to optimize
ME views so that the LV is not foreshortened and endocardial borders
are clear. Using fractional area change is fraught with error and difficult
to reproduce so it should only be used as a qualitative measure.145
Multiple orthogonal views should be employed to assess regional
wall motion abnormalities. TG Basal SAX, Mid Pap SAX, and Apical
SAX views best facilitate assessment of all 17 segments for radial function. Orthogonal views at TG LAX as well as ME 4-Ch, 2-Ch, and 5Ch allow for confirmation and evaluation of longitudinal function.
LV Diastolic Function. LV diastolic filling assessment is generally performed with TTE. Similar measurements can be made in TEE views,
including the ME 4-Ch, to assess MV inflow velocities, pulmonaryvein velocities, and tissue Doppler velocities, but attention must be
paid to differences in mitral inflow parameters and PW Doppler tissue
velocities by age group.146,147 In addition, these Doppler parameters
are affected by loading conditions and heart rate, which may makeassessment of diastolic function in the operating room with TEE
challenging in individuals with CHD. A simplified algorithm forgrading diastolic dysfunction using only E-wave velocity and lateral
mitral annular early diastolic tissue velocity (e’) was shown to predict
adverse outcome in adults after coronary artery bypass graft surgery
but there is no data in patients immediately after congenital heart
surgery.148 A transmitral E to e’ ratio <10 is considered normal.146
Right Ventricle. The normal RV is crescent-shaped and composedof three portions: inflow, muscular, and outflow. The inlet portion
contains the TV, whose septal leaflet is apically positioned relative
to the MV hinge point. Coarse muscular trabeculations and a moderator band are exemplary of the body of the RV while the outlet

Journal of the American Society of Echocardiography
February 2019

portion is composed of the infundibulum. The normal RV also has
unique chordal insertions from the tricuspid valve onto the septum
as opposed to the discrete papillary muscles in the normal LV.
Assessment of RV size and function is an integral part of TEE evaluation in patients with CHD. While acoustic windows in TTE are often
challenging, TEE provides excellent visualization of the complex geometric shape of the RV. The ME 4-Ch, ME RV In-Out, TG Mid Pap
SAX, TG Basal SAX, and DTG RVOT offer evaluation of RV inflow,
basal, and outflow views. Quantification of RV function includes fractional area change (FAC), tricuspid annular plane systolic excursion(TAPSE), and Doppler measurements (MPI, RV dP/dt, and annular tissue Doppler velocity). While various quantitative methods exist formeasuring RV function, in most cases function is assessed qualitatively
including contraction of the free wall, longitudinal motion of base towards apex, and bulging of the ventricular septum into the RV cavity.149
This is especially true in the case of congenitally corrected transpositionof the great arteries (l-TGA) or complete transposition of the great arteries (d-TGA) after atrial switch, where the shape of the normal RV
is altered significantly in the systemic position, so visual estimation ofsystolic function from the ME 4-Ch or TG SAX views are best used.
Use of 3D TEE in Assessing Ventricular Volumes andFunction. Contrary to 2D echocardiographic methods, 3D echocardiography does not rely on geometrical assumptions to calculate
LV volumes, and has been applied in patients with CHD andabnormally-shaped ventricles.150,151 Measurement of LV and RV
volume requires a full acquisition from the ME 4-Ch view and application of one of the semi–automated quantitative volumetric programs available on cart and on off-line workstations.

Key Points
1. Measurement of LV size is recommended in the TG SAX
views in children because the TG LAX view does not accountfor the lateral motion of the LV seen in many children.
2. LV systolic function is generally assessed qualitatively but canbe quantified with linear shortening fraction and 2D/3D volumetric ejection fraction.
3. Assessment of RV size and function is generally assessed qualitatively but 3D volumetric programs do allow for quantitative
assessment.

Atria, Systemic and Pulmonary Veins
Anatomy. Determining the atrial situs (solitus, inversus, ambiguous)is essential in children and adults with CHD and can be obtained byvisualization of the atrial appendages. The right atrial appendage istriangular and broad-based while the LAA is narrow-based andtubular (finger-like). The atrial septum and its components complement the identification of atrial situs and have been discussed in detailin the 2013 ASE/SCA Comprehensive TEE Guideline.16
Venous structures, particularly the suprahepatic portion of the IVC,
the Eustachian valve, and the ostium of the CS, are markers of amorphologic RA and can be visualized in the ME 4-Ch view. The
SVC can be seen as it enters the RA with the ME Bicaval view andthe DTG Atr Sept view, where a sweep from right to left at 90 helps
identify the presence of a left SVC (LSVC).
Determining drainage of the pulmonary veins into the LA can beaccomplished with the ME right and left pulmonary veins views.
Evaluation of the pulmonary veins by color flow and spectral

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Figure 7 Midesophageal 4-Ch view with transducer angle rotated forward to 36 , focused on the left atrium and cor triatriatum membrane. Note the location of the membrane lies above the left atrial appendage (LAA). The membrane divides the left atrium into proximal and distal portions. On the right hand side, color Doppler shows turbulent flow through the membrane (arrow) indicative ofobstruction. LV, Left ventricle.
Doppler is required for evaluation of venous obstruction. The
Doppler pattern of the pulmonary veins is triphasic with a forward
S and D wave and a short reverse-flow A wave. In young children
and infants the S wave of forward flow is dominant.152 Mean gradients across pulmonary veins should be measured over 1 or 2 cardiac
cycles, and stenosis should be recognized as loss of the phasic flow
pattern. One must be aware that gradients can be deceiving, as
flow can be redistributed to other lung segments drained by patentveins. The assessment of pulmonary venous Doppler patterns canhelp assess other conditions such as LA hypertension caused by mitral
regurgitation (presence of a prominent A wave), and the signal canalso help distinguish junctional versus sinus rhythm by associating
the A wave with the ECG tracing (in sinus rhythm the A wave precedes the QRS while in a junctional rhythm it is dissociated).
Role of TEE in Abnormalities of the Atria. Cor Triatriatum.–
Cor triatriatum involves the presence of a fibromuscular band that divides the atria into proximal and distal parts.153,154 An importantdistinction from a supravalvular mitral ring is the location of the
LAA, which is always distal to the membrane in cor triatriatum
sinister (Figure 7 and Video 38). The TEE assessment of this lesion begins in the ME 4-Ch view, with the probe slightly retroflexed to prevent
compression of a possible hypertensive pulmonary venous chamber.
The probe is then turned counterclockwise to identify the membrane
and its insertion below the left pulmonary veins but above the LAA.
Adding color Doppler interrogation helps identify the connection(s)of the proximal and distal chamber in both the ME 4- and 2-Ch views.
Not infrequently, the communicating orifices are eccentric and need to
be visualized by color Doppler at varying angles of interrogation to findthe best alignment for Doppler assessment of the degree of stenosis
and estimation of pulmonary venous pressure. A delineation of thepulmonary venous return needs to be complete, as partial forms ofcor triatriatum may exist with only the right or left veins entering theproximal chamber. In addition, one must interrogate the atrial septum

to identify an ASD or a patent foramen ovale from the ME 4-Ch, ME
Bicaval view and DTG Atr Sept views. Finally, there should be an evaluation of the mitral valve to exclude obstructive lesions or mitral regurgitation. After surgical resection of the membrane, TEE helps identify
adequacy of the repair (residual membrane, residual atrial level shunting) and drainage of the pulmonary veins.155
Juxtaposed Atrial Appendages.–Juxtaposition of the atrial appendages is a rare anomaly (approximately 0.8% of CHD), frequently seenin association with other complex CHD. It is more common to have‘‘left juxtaposition’’ in which both appendages are oriented side byside on the left, especially when associated with transposition of thegreat arteries, tricuspid atresia, and heterotaxy syndrome.156-158
Recognizing juxtaposition of the atrial appendages is challenging,and confirmation requires identification of the anatomical featuresof the atrial appendages (previously described) with a series ofsweeps from posterior to anterior in several planes. Imaging theatrial appendage crossing behind the great arteries is a first clue;
however, suspicion for this anomaly arises with a lateral deviationof the mid-portion of the atrial septum and a frontal orientation of
the antero-superior portion forming the floor and posterior wall of
the junction of the right atrial appendage with the venous componentof the atrial cavity.159 The ME 4-Ch and ascending Ao SAX views candemonstrate the RAA behind the aorta and anterior to the LA. The
use of color and pulsed-wave Doppler can help distinguish flow
into the atrial appendage from an ASD. Although the diagnosis of
juxtaposed atrial appendages may be an incidental finding, its recognition is important during interventions to guide catheter position orballoon catheter tips across the atrial septum and not into the RAA. In
addition, thrombus has been noted in the juxtaposed RAA and LAA
in patients with atrial fibrillation prior to cardioversion.160,161
Role of TEE in Systemic Venous Anomalies. Left Superior
Vena Cava to Coronary Sinus.–Drainage of the LSVC into the CS

196 Puchalski et al

is a relatively frequent finding in the normal heart, and can be found in
3-10% of patients with CHD.162 Recognition of an LSVC is importantin the operating room for cannulation, and in the planning of complex
repairs such as atrial baffles and the superior cavopulmonary connections (Glenn or Hemi-Fontan) discussed below, but its presence
should be known prior to cardiac surgery.
Imaging the LSVC can be accomplished by identifying a dilated CS
in the ME 4-Ch view with retroflexion and slight advancement of theprobe, and also in the ME 2-Ch view. Once the dilated CS is identified,an LSVC can be imaged with a counterclockwise probe rotation in the
ME to UE level and a transducer angle between 60-80 . The LSVC is
located on the left of the descending Ao and anterior to the left PA,
where it usually connects to the CS. Intravenous injection of agitated saline into the left arm can help identify this vein, as the saline fills the CS.
Failure to recognize the LSVC-to-CS connection can lead to misinterpretation of the dilated CS ostium for an ASD. Other conditions thatcan be associated with a dilated CS and not an LSVC should be considered, including anomalous pulmonary venous return, anomalous
drainage of hepatic veins, or stenosis of the ostium of the CS.
Left Superior Vena Cava to Left Atrium.–The LSVC can drain
directly into the dome of the LA in up to 8% of cases, rarely in isolation, and mostly associated with other congenital heart defects.163,164
Identification of the LSVC by TEE can be challenging in this case, as anormal size CS does not raise suspicion. Direct visualization of the
LSVC entering the roof of the LA while interrogating thepulmonary veins, or actively searching for this connection whenidentifying a small right-sided SVC, is what helps identify this anomalous drainage. The use of agitated-saline injection through the left
arm can help identify connection of the LSVC with the LA.
Interrupted Inferior Vena Cava.–Interruption of the IVC is rare andis characterized by absence of the IVC below the hepatic veins.165 The
IVC connects to the azygous vein, which drains into the SVC. Becauseof the drainage into the SVC, this finding has important implications
during surgery at the time of cannulation. Imaging by TEE starts at the
TG IVC/Hep Veins view and will show the hepatic veins but not the
IVC, even with forward rotation of the transducer angle to 90 .
Following the azygous vein into the right or left SVC can be challenging and multiple sweeps by 2D and color Doppler imaging are
required, as the azygous vein travels from a retrocardiac position anteriorly into the SVC, with the esophagus in its path. The use of agitatedsaline injection from the leg can help identify this connection byentrance of saline bubbles into the SVC.
Right Superior Vena Cava to Left Atrium.–The right SVC drainage
into the LA is rare and sometimes biatrial drainage is also
possible.166,167 Using the DTG Atr Sept view or the ME Bicaval
view with color Doppler demonstrates flow into the LA. The use ofagitated-saline injection from the right arm can help identify thisdrainage by entrance of bubbles into the LA.
Role of TEE in Pulmonary Venous Anomalies. Partial Anomalous Pulmonary Venous Return (PAPVR).–PAPVR is mostcommonly associated with an ASD, either sinus venosus (up to 85%
and described below) or secundum type (10-15%), but can occur in isolation.168 The most common type of PAPVR is the connection of right pulmonary veins to the SVC and RA.169 The evaluation of anomalous right
pulmonary veins into the SVC can start with the probe in the ME Rt
Pulm Veins view. While withdrawing the probe in this plane, the SVC
is circular, and a distortion of this vessel to a ‘‘tear drop’’ appearance suggests the anomalous entrance of the pulmonary vein. Once identified in

Journal of the American Society of Echocardiography
February 2019

this view, forward rotation of the transducer angle to a ME Bicaval view(90-100 ) will show the pulmonary veins entering the SVC, and allows
an estimate of distance from the SVC/RA junction, which is helpful for
surgical planning. Advancing the probe inferiorly in these same views canidentify drainage of the veins into the RA or IVC. This maneuver can beapplied to identify Scimitar syndrome, where some or all of the rightsided veins drain to the IVC. Partial anomalous connections of the leftsided veins is typically to a left vertical vein draining superiorly into theleft innominate vein. This can be visualized with 2D and color
Doppler imaging, using the UE Ao arch SAX view with leftward rotation.
Total Anomalous Pulmonary Venous Return (TAPVR).–Theanomalous drainage of all pulmonary veins to the systemic circulation
occurs in 2.2% of all children with CHD.170 They can be classified inorder of prevalence: supracardiac, infracardiac, cardiac, or mixed.
The use of TEE in TAPVR can be limited because the location of thepulmonary venous confluence is subject to compression by the probe,
which may cause hemodynamic compromise.85 Insertion of the probe
after sternotomy has been reported to be a safer alternative.86
When a TEE probe can be placed without causing hemodynamic
compromise, it is most helpful to visualize the anomalous venous return of the supracardiac variant by starting in the ME 4-Ch view toward the left and identifying the confluence. Each individual
pulmonary vein can be seen draining into the confluence by rotating
the probe clockwise from left to right. The right veins are imaged byrotating the transducer angle forward to 30-50 , and the left veins will
be seen best at 90-110 or closer to the descending Ao.
The infradiaphragmatic variants are difficult to assess by TEE, however, there is often high-velocity return into the portal system with dilated
hepatic veins. The evaluation of TAPVR to the CS requires long sweeps,
advancement and withdrawal of the probe, and/or change in imaging
planes to follow the venous confluence to the CS. Prominent color flow
seen returning into the CS and RA can be helpful. The evaluation of
mixed veins employs all of the techniques noted above.
Evaluation of the pulmonary venous confluence anastomosis to
the LA and any individual pulmonary vein stenosis is essential in a patient after repair of TAPVR (Figure 8 and Video 39). The presence of
turbulent flow at the anastomotic site may suggest intrinsic stenosis or
torsion of the confluence, and while spectral Doppler interrogation
will determine the degree of obstruction, return to bypass may be
indicated and should be discussed with the surgeon.

Key Points
1. Determination of atrial situs can be performed by identification of the atrial appendages and key systemic venous structures. While the ME views are most commonly used, all
TEE positions and views should be employed.
2. TEE can identify unusual systemic venous anomalies such asleft SVC to coronary sinus or left atrium, interrupted hepatic
portion of the IVC, and atrial anomalies such as juxtaposed
atrial appendages and cor triatriatum.
3. TEE provides excellent visualization of normal left and right
pulmonary venous return and enables accurate pulmonary
venous Doppler assessment, which can be utilized in the evaluation of stenosis within individual veins or the pulmonary
venous confluence.
4. TEE can also be used to evaluate partial and total anomalous
pulmonary venous return. However with the latter, care must
be taken because hemodynamic compromise has been
described with TEE probe insertion/manipulation.

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Figure 8 Modified midesophageal LAA view shows: (A) Narrowed orifice of the left upper pulmonary vein with corresponding color
Doppler mapping indicating flow turbulence. Mild mitral regurgitation is also seen (arrow). (B) Some loss of phasic flow in the left upper pulmonary vein with a mean gradient of 4 mm Hg consistent with mild stenosis. LA, Left atrium; LV, left ventricle; LUPV, left upper
pulmonary vein.

Septal Defects
Atrial and ventricular septal defects are common types of CHD thatcan occur as isolated defects or in combination with other cardiac
anomalies.167,171-179 Atrial septal defects undergo both surgical andcatheter-based closure, often with TEE guidance, so an understandingof the septal anatomy, as well as type and location of the defects isimportant and outlined in detail in a previous ASE guideline22(Figure 9).
Ostium secundum ASDs are often amenable to catheter device
closure provided the surrounding rims are adequate and the defect198 Puchalski et al

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views and extending to the lower esophagus for an inferior sinus venosus defect.
Coronary sinus ASD is a rare anomaly in which partial or complete
unroofing of the CS into the LA typically results in shunting from the
LA to the CS and into the RA.180 It is almost always associated with an
LSVC connecting to the CS (see above).
Role of TEE in ASD Repair. Preoperative TEE during surgicalrepair of an ASD can confirm the size and location of the ASD, evaluate for additional associated cardiac lesions, including partial anomalous pulmonary venous return, assess ventricular size and function,and estimate PA pressures. Postoperative TEE focuses on residual
atrial level shunting, assessment of the vena cavae, presence of residual AV valve regurgitation, and ventricular function.

Figure 9 Subtypes of atrial septal communications whenviewed from the right atrium (RA). Patent foramen ovale (PFO)
is not illustrated. SVC, Superior vena cava; IVC, inferior vena
cava. Reprinted with permission from Silvestry et al.22
is not too large. Secundum ASDs are seen well from the ME 4-Ch,
ME AoV SAX, ME RV In-Out, ME Bicaval and DTG Atr Sept views.
The echocardiographer must define a number of features and parameters, including the ASD dimensions and number, size, and location of orifices. If closure is being performed in the catheterization lab,
one must measure the length of the aortic, superior, inferior, posterior,and crux rims. An important factor in choosing ASD closure device
size is the stop-flow occlusive balloon waist diameter. TEE is also
used to perform live monitoring of device deployment, configuration,and stability. Once the device is fully deployed and released one mustassess for residual shunting as well as for blood flow obstruction anddevice impingement on surrounding anatomic structures including
the aortic root, roof of the LA, AV valves, right pulmonary veins, caval
veins, and the CS. Lastly, assessment for complications such as pericardial effusion, thrombus, and device embolization is necessary.
Ostium primum ASDs are located at the apical margin of the atrial
septum immediately adjacent to the AV valves. This type of ASD iswithin the spectrum of AVSD and is almost always associated witha cleft mitral valve. Ostium primum ASD is best seen from the ME
4-Ch view. After primum ASD repair, the mitral valve should be assessed for residual cleft, stenosis, and regurgitation in the ME 4-Ch,
Mitral, 2-Ch, and LAX views. Further interrogation of the mitral valve
cleft should include the TG Basal SAX view. LVOTobstruction should
also be assessed in the DTG 5-Ch view where spectral Doppler canrule out residual obstruction.
Sinus venosus ASD may be one of two types: superior or inferior.
The superior form involves the uppermost portion of the atrial
septum and extends superiorly. It is associated with the SVC overriding the defect and almost always has anomalous connections ofsome or all of the right pulmonary veins to the SVC near the cavoatrial junction. The inferior type sinus venosus ASD is associatedwith the IVC overriding the defect and is less commonly associatedwith anomalous pulmonary venous connection. Sinus venosus
ASDs are best seen from the ME Bicaval and DTG Atr Sept views.
After a sinus venosus repair, it is important to assess for pulmonary
venous stenosis or baffle obstruction. This is best imaged with ME
Rt Pulm Veins and Bicaval views and including the UE for a superior
sinus venosus defect, or using the ME RV In-Out and ME Bicaval

Use of 3D TEE in ASD Imaging. Imaging of atrial septal defects
using 3D TEE is very useful during interventional-catheter treatment
and prior to surgery. For ASD imaging, the wide-angle ME RA and LA
en face views are very effective, as is the DTG Atr Sept live 3D narrowsector view. These renderings accurately and rapidly demonstrate theimportant features of an ASD. Biplane TEE with and without color
Doppler flow mapping is time-efficient because it provides 2 simultaneous views. Secundum atrial septal defect en face views are demonstrated with device closure of a secundum ASD using 3D TEE
guidance (Video 40).
Ventricular Septal Anatomy. The ventricular septum has inlet,
trabecular, and outlet portions. The right side has a septal band towhich the moderator band attaches. It extends from the apex toward
the base and bifurcates into two limbs that form a ‘‘Y’’ or ‘‘U’’ shape. A
VSD can occur in any of these locations (Figure 10). In addition, there
may be multiple VSDs in the same patient, malalignment relative tothe septal band of muscular septum, and association with other typesof congenital cardiac anomalies.
Ventricular Septal Defects. We will focus on 5 types: perimembranous, muscular, inlet, malaligned, and outlet.
Perimembranous.–Defects in this region are common and may beisolated or associated with any other type of CHD.
Perimembranous VSDs are best seen in the ME 4-Ch, 5-Ch, AoV
SAX, and RV In-Out views.
Muscular.–Multiple defects and associated other cardiac anomalies
are fairly common. These defects may be amenable to catheter device
closure if clinically necessary. Muscular VSDs are usually best seen in
the ME 4-Ch, ME 5-Ch, and TG Basal SAX views.
Inlet.–Associated with coplanar AV valves and atrioventricular septal
defect (AVSD) lesions, inlet VSDs are best seen in the ME 4-Ch view.
Malaligned.–This type of VSD is present in tetralogy of Fallot (TOF),
double-outlet right ventricle (DORV,) and interrupted aortic arch
complex. Malaligned VSDs are best seen in the ME 4-Ch, 5-Ch,
LAX, AoV SAX, and RV In-Out, as well as the DTG 5-Ch and
RVOT views.
Outlet.–This type of VSD is also called a supracristal VSD and can beseen alone or in lesions such as truncus arteriosus, for example. It canbe associated with aortic cusp prolapse. Outlet VSDs can be displayedwith the ME 4-Ch, 5-Ch, AoV SAX, LAX, and RV In-Out, DTG 5-Ch
and RVOT views.

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Figure 10 Subtypes of ventricular septal defects (VSDs) when viewed from the right ventricle (RV). Malalignment ventricular septal
defect is not illustrated but is caused by anterior or posterior deviation of the infundibular or conal septum and is typically present
in tetralogy of Fallot, double outlet right ventricle, or interrupted aortic arch complex.
Role of TEE in VSD Repair. Preoperatively, the focus is on confirmation of the anatomic findings including type, number, size, shuntdirection, and assessment of adjacent structures. Postoperative assessment addresses residual septal defects or patch integrity, PA pressures,
ventricular function, and device configuration in interventional cases.
Assessment for a residual VSD should always occur in more than one
view and the decision to return to bypass should take into accountseveral factors, including associated aortic regurgitation, outflow tract
obstruction, and hemodynamic significance. Most residual VSDs
# 2 mm will spontaneously resolve with time.181 Residual VSDs
# 3 mm are typically not hemodynamically significant and somewill spontaneously resolve. Residual VSDs measuring 3 to 4 mm
require careful analysis including measurement of Qp:Qs by echocardiographic or blood oxygen saturation analysis to better determine
need of return to bypass. A Qp:Qs of > 1.5:1 or a residual VSD $4 mm should have an additional attempt(s) at closure in mostcases.182,183
Use of 3D TEE in VSD Imaging. Imaging of VSDs is effectivefrom the ME 4-Ch view using live 3D, biplane echo, and fullvolume 3D with cropping. The en face views from RV and LV aspects,
along with the ME 4-Ch view best demonstrate the anatomic features. Live 3D color flow Doppler mapping is used to assess residual
shunts. Biplane TEE has color flow Doppler mapping frame rates thatare significantly higher than for live 3D color flow Doppler, thereby
overcoming the limited temporal resolution of the latter modality insome cases. Perimembranous VSD en face views are demonstrated
in Video 41. The use of live 3D TEE guidance of VSD device closure
can be useful and is illustrated in Figure 11 (closure of muscular VSD).
Atrioventricular Septal Defects
Anatomy. Atrioventricular septal defect, also called AV canal defect,
results from incomplete development of the endocardial cushions,leading to defects in atrial and ventricular septa as well as the AV
valves.184 There can be morphologic variability at many levels, therefore this lesion comprises an anatomic spectrum that can range frompartial to complete forms. The variability includes the following: a)size or extent of deficiency in the primum atrial septum; b) size or
extent of deficiency in the ventricular septum, here called the ‘‘ventricular component;’’ c) degree of commonality or anatomical separation of the left- and right-sided AV valves; d) AV valve morphology
and function; and e) degree of commitment of the AV valves to theventricles.
The primum ASD, which is present in almost all AVSDs, is best outlined when the atrial septum is perpendicular to the transducer andcan be accomplished from the ME 4-Ch view with slight clockwise
rotation. Additional defects in the secundum septum can be identified
here as well. The ventricular component is best viewed from the ME
4-Ch view in systole, during which time assessment of the valve relationship to the septum can be obtained (Figure 12 and Video 42). In
addition, commitment of the AV orifice to the underlying ventricles
can also be defined. Given that the common AV valve junction isshared between both ventricles, the aorta is unwedged and positioned more anterosuperiorly instead of between the normal mitraland tricuspid valves.
Complete AVSD can occur in isolation or associated with othermore complex congenital heart lesions such as disorders of laterality (heterotaxy/isomerism). Partial AVSD, where there is a defectin the primum atrial septum but no discernible ventricular component, will have a lack of AV valve offset and a cleft in the anterior
leaflet of the left AV valve, which can be visualized in the TG Basal
SAX view. The ME LAX and DTG 5-Ch views are used todemonstrate the LVOT and confirm the separation between theleft AV valve inlet and the aortic outlet. Accessory tissue fromthe superior bridging leaflet may cause LVOT obstruction.
Backward rotation of the probe from the ME LAX view canshow the inlet muscular septum and presence/extent of any

200 Puchalski et al

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February 2019

Figure 11 Transesophageal three-dimensional (3D) echocardiography live narrow sector views during catheter device closure of a
muscular ventricular septal defect (VSD). (A) The left sided en face view of the apical muscular VSD (arrow). (B) The frontal view of thedevice (arrow) with the left side deployed in the left ventricle (LV) and the device still attached to the catheter (C) delivery system. (C)The device in its final position with the discs of the device (arrows) on opposites sides of the ventricular septum. L, Left; LA, left atrium;
P, posterior; R, right; RV, right ventricle; S, superior; VS, ventricular septum.

Role of TEE in AVSD Repair. Transthoracic echocardiography
will demonstrate most of the relevant preoperative diagnostic data
in AVSD with few exceptions.185 TEE is indicated preoperatively inessentially all patients with AVSD, but particularly in the older infant/child in whom surgical decision-making might require delineation of the degree and mechanism of AV valve regurgitation,mechanism of outflow tract obstruction, and or suitability for biventricular correction. TEE can also add value in the clarification of pulmonary and systemic venous drainage, particularly in heterotaxy.
Intraoperative and immediate postoperative TEE can detect clinically significant residual findings, thereby prompting a return to cardiopulmonary bypass in both the native valve repair and in older
children and adults being considered for reintervention to improve
AV valve function or to close residual septal defects following prior
AVSD repair.11,186,187
Figure 12 Midesophageal 4-Ch view of a complete atrioventricular septal defect including primum atrial septal defect (white arrow), inlet ventricular septal defect (black arrow), and common
atrioventricular valve. RA, Right atrium; LA, left atrium; RV, rightventricle; LV, left ventricle.

ventricular component to the septal defect. The AV valves can beseen using the TG Basal SAX view, and the site of AV valve regurgitation shown with color Doppler.

Use of 3D TEE in AVSD Imaging. A multi-beat full-volume 3D
acquisition from a ME 4-Ch view can provide a complete view of
the AV junction from both atrial and ventricular aspects, allowing
clear appreciation of the anatomical relationships and fine details ofboth the bridging and mural leaflets. Novel en face views of the atrial
and ventricular septa obtained by cropping away the ventricular freewalls will show the curved crest of the IVS and size and shape of any
septal defects (Video 43). 3D TEE with color flow Doppler provides
further spatial information and the precise site(s) of AV valve regurgitation, which enhances surgical planning for the repair.

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Puchalski et al 201

Figure 13 Midesophageal AoV SAX view in a patient with anomalous origin of the left coronary artery from the right sinus of Valsalva.
Note the slit like orifice as the left coronary artery arises from the right sinus. The color Doppler clip demonstrates the interarterial
course between the aorta and pulmonary artery.Ao, Aorta; PA, pulmonary artery.

Key Points
1. Atrial septal defect (ASD) subtypes include secundum, primum, sinus venosus, and coronary sinus defects (Figure 9).
2. Ventricular septal defect (VSD) subtypes include perimembranous, inlet, muscular, outlet, and malalignment (the last is associated with conotruncal defects) (Figure 10).
3. TEE plays an important role in monitoring of ASD and VSD
closures in the catheterization laboratory.
4. TEE is important for postoperative assessment of VSD closure,especially for determination of significant residual VSDs,
outflow tract obstruction, and aortic regurgitation, as well as
whether return to bypass is indicated.
5. TEE is indicated preoperatively in essentially all patients with
AVSD, but particularly in the older infant/child in whom surgical decision-making might require delineation of the degreeand mechanism of AV valve regurgitation, mechanism ofoutflow tract obstruction, and or suitability for biventricular
correction.
6. 3D TEE is useful for assessment of ASD and VSD
morphology, and for monitoring of ASD/VSD closure in thecatheterization laboratory. 3D TEE can also facilitate preoperative assessment of atrioventricular septal defects.

Coronary Anomalies
Anatomy. Complete evaluation of the CAs for preoperative confirmation of suspected anomalies should include multiple planes to visualize the coronary connections to the great artery as well as the courseand size of the arteries as they pass in the AV groove.188-190 Color flow
Doppler assessment should be performed to document connections
since 2D imaging can at times be deceptive. The imaging of CA
origins is performed primarily using the ME AoV SAX and RV InOut views. These two views provide excellent imaging of all aortic
cusps and can show the connections to the aorta. Anteflexion of theprobe to move the imaging plane slightly superiorly may be necessary
to properly demonstrate the origins, as they can arise above the aortic
valve sinuses. Forward rotation of the transducer angle to between 020 , along with rotation of the probe toward the patient’s right, dem-

onstrates the right CA course in the anterior AV groove. The left CA
courses inferiorly in the anterior left AV groove. Starting from the
ME AoV SAX view, the probe is advanced slightly to move the planeinferiorly, using a transducer angle of 30-40 . Rotation of the probe to
the patient’s left demonstrates the left AV groove and the bifurcation of
the left main CA into the left anterior descending and circumflex CAs.
Role of TEE in Anomalous Origin of the Coronary Artery.
Anomalous Origin of the Coronary Artery from the Aortic
Root.–Anomalous origin of the CA from the opposite sinus of
Valsalva is associated with an abnormal slit-like origin, an intramuralcourse, and may include a course between the great arteries. TEE
can be very helpful in the diagnosis of anomalous origin from the inappropriate sinus.189,191,192(Figure 13 and Video 44) The demonstrationof anomalous origin from the aorta requires careful interrogation withboth 2D imaging and color Doppler. Because the anomalous artery
frequently has an intramural segment, 2D imaging can give the appearance of a normal origin from the appropriate sinus. In this setting, careful color flow Doppler interrogation of the aortic wall is important indemonstrating abnormal flow in the intramural segment.193 Color
Doppler shows an abnormal narrow region of flow that appears within
the wall of the aorta. When the right CA arises from the left sinus,
demonstration of the course requires forward rotation of the transducer angle from the ME AoV SAX view to 30-50 . In addition, theME LAX view can show a circular cross-section of the right CA immediately anterior to the aorta. To image the left CA arising from the rightsinus of Valsalva, the transducer angle is either kept the same or rotatedbackward to 0-25 and the transducer is rotated to the patient’s left.
Coronary Imaging in the Setting of Anomalous Origin of the Leftor Right Coronary Artery from the Pulmonary Artery (ALCAPA
and ARCAPA).–As is the case in anomalous origin from the aorta, systematic and detailed evaluation of the coronary origins by 2D imaging,
supplemented by documentation of flow using color Doppler, is criticalto making an accurate diagnosis of anomalous CA from the PA.194,195
Starting from the ME AoV SAX view, anteflexion of the probe brings
the imaging plane superior to the PA and can directly show theanomalous connection. In some cases the artery arises laterally andmay require rotation of the transducer to the patient’s left to visualize
the lateral wall. In addition, other important hallmarks of these defects

202 Puchalski et al

Journal of the American Society of Echocardiography
February 2019

Figure 14 Deep transgastric 5-Ch view of double outlet right ventricle (DORV) with subaortic ventricular septal defect (‘‘tetralogy
type’’ DORV). The aorta overrides the ventricular septal defect (arrow) to receive blood from the RV and LV. Ao, Aorta; RV, rightventricle; LV, left ventricle.
(particularly ALCAPA) should be evaluated, including segmental wallmotion abnormalities, ventricular dysfunction, mitral regurgitation, andechogenic and fibrotic papillary muscles.

Key Points
1. Imaging of the coronary artery origins is primarily done in the
ME SAX views.
2. The demonstration of anomalous origin of a coronary arteryfrom the opposite sinus of Valsalva requires careful interrogation with both 2D imaging and color Doppler.
3. In ALCAPA and ARCAPA, the anomalous origin of the coronary artery from the pulmonary artery can be visualized using
the ME views.
4. Segmental wall motion abnormalities, ventricular dysfunction
and mitral regurgitation should be assessed.

Conotruncal Defects
Anatomy. Conotruncal defects are a group of CHDs characterized
anatomically by abnormal ventriculo-arterial connections including
TOF, DORV, truncus arteriosus, d-TGA, and l-TGA, which can occur
in isolation or in association with heterotaxy and l-looped hearts.
Delineating the anatomic features is important for accurate diagnosis,
pre-operative planning, and post-operative evaluation; in particular theventriculo-arterial alignment, the anatomy of the conus, and the VSD.
The ventriculo-arterial alignment can be normal (TOF), or abnormalsuch as in TGA, DORV, and double-outlet left ventricle (rare, not discussed here). The great arteries can be positioned anteroposteriorly or

mediolaterally. The fibrous continuity between a great artery and an
AV valve is important along with the anatomy of the conal septum,
which should be described regarding 1) location: sub-pulmonary(normal), as in TOF, sub-aortic conus, as in TGA, and bilateral conus,
as in types of DORV; 2) position: the conal septum can be anterior orposteriorly malaligned; and 3) size: the conus can be hypoplastic or absent. Associated VSDs can be subaortic (‘‘tetralogy type’’ DORV,
Figure 14 and Video 45), subpulmonary (as in the Taussig-Bing type of
DORV), remote (usually the canal or inlet type, but can be muscular),or doubly committed (absence or hypoplasia of the conal septum).
TEE allows evaluation of outflow tract patency/obstruction, residual
VSDs, residual atrial level communications, AVor semilunar valve insufficiency, and ventricular function. An important consideration in conotruncal defects in general is the presence of a residual intramural VSD(communication located anterior to the VSD patch between the greatartery and right ventricular trabeculations). These defects are distinct
from the more common peri-patch defects and their identification isimportant, as they tend to increase in size over time and are associatedwith worse post-operative outcomes.196,197 Each type of defect will be
reviewed in detail with the focus being on post-operative factors.
Tetralogy of Fallot.–In the current era, most patients with tetralogy of
Fallot are operated upon in infancy and therefore the pre-operative
assessment is usually achieved with TTE. However, TEE can be complementary if there are remaining questions, such as the presence of additional VSDs, and is useful postoperatively to assess residual
lesions.198,199 Starting with the ME 4-Ch view, the probe is withdrawn
to a ME 5-Ch view to profile the VSD patch, which is then interrogatedwith color Doppler for residual shunting and direction of flow
(Figure 15). Further withdrawal of the probe with rightward rotation

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Puchalski et al 203

Figure 15 Midesophageal 5-Ch view with color Doppler in a patient with tetralogy of Fallot shows a large residual VSD (arrow)with left to right shunting into the right ventricle (RV). Asc Ao,
Ascending aorta; LV, left ventricle.

Figure 16 Modified midesophageal RV In-Out view around 90 in
a patient after truncus arteriosus repair. The ventricular septal
defect patch is seen (arrow) as well as the right ventricle (RV) topulmonary artery conduit. RVOT, Right ventricular outflow tract.

will display the IAS at 0 -30 to assess for residual ASDs. The ME RV InOut view can evaluate for residual RVOT obstruction and can also be
used to obtain a TR peak velocity for estimation of RV systolic pressure.
Residual RVOTobstruction can also be assessed in the DTG RVOT view,
with the transducer angle at 50 -90 . It is important to remember that a
hypercontractile state can exist following surgery so if the obstruction is
dynamic, rather than fixed, it does not warrant surgical revision.200

alize in some patients and may require forward rotation to 90 with aturn to the left. The LV-to-truncal-valve pathway can be seen well in the
ME AoV LAX or 5-Ch views, which, along with the ME AoV SAX
view will allow assessment of truncal stenosis and regurgitation.201
When available, the DTG views (5-Ch and RVOT) can provide visualization of the LVOTand proximal RV-to-PA conduit, as well as an excellent angle for spectral Doppler assessment. The ME Asc Ao SAX andUE PA views are the best to demonstrate the PAs.

Double Outlet Right Ventricle.–Preoperative TEE can help determine the location and size of the VSDs, relationship of the great vessels
to each other and to the VSD, restriction at the level of the VSDs, anatomy of AV valves (e.g., straddling), and coronary anomalies to help inthe determination of optimal surgical strategy. The ME 5-Ch view withprobe anteflexion profiles the great vessels arising from the RV. The ME
AoV LAX view allows for profiling the LVOT and potential pathway tothe aorta. In a physiologic two-ventricle repair, a VSD patch is placed tobaffle the LVoutflow to the Ao and care must be taken to evaluate thisarea as significant obstruction from subaortic conus or the VSD patch ispossible. In patients with DORV and TGA (Taussig-Bing anatomy), theVSD patch is placed to baffle the LV outflow to the PA and is followedby the arterial switch operation. The DTG 5-Ch and RVOT views provide visualization of the great arteries and their relationship to the VSD
in all conotruncal defects.
Truncus Arteriosus Communis (Referred to as Truncus Arteriosus).–The pre-operative assessment of truncus arteriosus is mostly
achieved with TTE, however, TEE can provide additional information
with respect to the anatomy and function of the truncal valve, additional VSDs, and origin of the branch PAs in addition to a complete
evaluation for residual lesions post-operatively. Withdrawing the probefrom a near TG position through the ME position with the transducer
angle at 0 profiles the VSD patch, which is then interrogated with color Doppler for residual shunting and direction of flow. The ME RV InOut view is useful to demonstrate a peri-patch residual leak. In addition, the RV-to-PA conduit is best seen in this view with a counterclockwise turn of the probe toward the left side of the patient (Figure 16).
Rotation of the probe to the ME ascending Ao LAX view and withdrawal to the UE Ao arch SAX view will demonstrate the most distal
portion of the conduit as it is connected to the branch pulmonary arteries. Backward rotation to 0–10 , using the UE PA view, provides
good visualization of the right PA but the left PA can be difficult to visu-

d-TGA with Arterial Switch.–In d-TGA with an intact ventricular
septum, preoperative TEE may not be needed if the coronary arteries
are well defined by TTE, but this varies by institution.202 Post-operative
TEE should assure patent right and left ventricular outflow tracts after
transection and ‘‘switching’’ of the great arteries, determine regionaland global systolic ventricular function after transfer of the coronary arteries, and provide assessment of residual intracardiac shunts. The ME
4-Ch view provides a global assessment of ventricular performance.
The TG Basal and Mid Pap SAX views allow determination of regional
wall motion abnormalities consistent with coronary obstruction, which
may result from transfer to the neo-aorta.203 Attempts at coronary imaging is often helpful to determine if there is adequate flow or narrowing seen by 2D to explain ventricular dysfunction. The supravalvularregions are evaluated as the probe is withdrawn to the UE PA view(as well as the branch PAs, which are anterior and straddling theascending Ao) and rotated in the ME plane to the ME AoV LAX
view. Importantly, the function of the neo-aortic and -pulmonic valves
should be determined, because valve distortion can occur with the procedure. With the color flow Doppler scale reduced, coronary bloodflow in diastole can also be seen in some cases.
d-TGA with Rastelli.–In cases of d-TGA with posterior malalignment
VSD and LVoutflow tract stenosis (subpulmonary/PV stenosis), othersurgical options may be considered, including the Rastelli operation(intracardiac tunnel baffling the LV to the rightward aorta) with RVto-PA conduit placement. Postoperative TEE should include surveillance for a residual VSD, assurance of an unobstructed pathway
from the LV to the aorta, and assessment of function of the RV-toPA conduit in a fashion similar to that described in truncus arteriosus,
DORV, and tetralogy of Fallot.
d-TGA with Atrial Switch (Senning or Mustard Procedure).–A
complete scan of the atrial switch pathway can begin in the TG

204 Puchalski et al

IVC/Hep Veins view with demonstration of the inferior limb of thesystemic venous baffle directing IVC blood flow to the subpulmonic
LV (Video 46).204 As the probe is gradually withdrawn to the ME
4-Ch view, the pulmonary venous pathway is now demonstrated as
it connects to the systemic RV (Figure 17 and Video 47). Further
probe withdrawal into the upper esophagus (30-45 plane) exposes
the superior limb of the systemic venous atrium. The ME Bicaval
view (90 plane) provides visualization of both the inferior and superior limbs of the systemic venous baffle. With counterclockwise proberotation, the pulmonary venous pathway can also be seen in the ME
Bicaval view. Doppler interrogation of continuous turbulent flow allows for estimation of pressure gradients across a pathway obstruction. The DTG Atr Sept view provides excellent angles of
insonation for venous return, particularly for the superior systemic
venous pathway. A dilated SVC/IVC or presence of significant
venous collaterals should provide a clue for downstream obstructionin the systemic venous pathway. Color Doppler should be employed
to assess location and size of baffle leaks in conjunction with anagitated-saline study. Simultaneous biplane imaging further enhances
the assessment of the atrial pathways with the orthogonal view.
Finally, assessment of intracardiac thrombus is often indicated after
stroke or in the setting of tachyarrhythmias before cardioversion. In
the normal heart, thrombus is typically assessed in the LAA as previously discussed; however, the LAA is part of the systemic venous
pathway in the atrial switch patient. Therefore, thrombus should
also be excluded in the pulmonary venous pathway.
Congenitally Corrected TGA (also known as l-TGA).–Pre-operative and post-operative assessments require an evaluation similar towhat was discussed for the other conotruncal lesions. In particular,
the preoperative assessment involves evaluation of the systemic AV
valve, since there is commonly an Ebstein-like malformation of theleft-sided TV. Post-operative assessment, when the repair entails ananatomic repair or ‘‘double switch’’ operation, evaluates all aspectsof the atrial and arterial switches discussed earlier.
Use of 3D TEE in Conotruncal Defects. Views that demonstrate
the VSD, outflow tracts, and semilunar valves can be analyzed individually and sequentially using focused narrow-sector live 3D. For
example, 3D Video 48 shows a patient with Taussig-Bing double
outlet right ventricle who underwent an arterial switch operation
and VSD closure. In addition, obtaining a 3D full-volume acquisition
from the ME 4-Ch or DTG 5-Ch view followed by cropping on cart or
off-line is very useful. Focused imaging of an intra-atrial baffle obstruction or leak can be effectively performed with narrow-sector live 3Dand biplane echo with color flow Doppler mapping. Imaging of theentire baffle requires 3D full-volume acquisition and cropping.205-207

Journal of the American Society of Echocardiography
February 2019ular function. A combination of ME, TG, and DTG views
should be used for evaluation.
4. 3D TEE can be used to provide further elucidation of the
VSD/outflow tract anatomy and semilunar valve
morphology/function. Where applicable, intra-atrial baffle obstructions or leaks can also be evaluated by narrow sector live
3D, biplane echo, or full volume acquisition.

Complex Single Ventricle
Anatomy. Single ventricles encompass a number of different cardiac morphologies where either the subpulmonary ventricle or thesubsystemic ventricle is poorly developed, have a deficient or absent
inlet, or a stenotic or absent outlet. Irrespective of the underlying
morphology, the aim of surgical and/or catheter intervention is toconnect the remaining functional ventricle with an outlet to the systemic circulation and allow the pulmonary circulation to receive
blood passively from the head and body via cavo-pulmonary connections (SVC and IVC drain directly into the pulmonary arteries).
Role of TEE in Initial Palliation for Single Ventricles. The roleof routine TEE in the complex single ventricle will depend primarily
on preoperative status and surgical stage. Initial palliation (stage 1) requires either a new source of pulmonary blood flow from a modified
Blalock-Taussig shunt, central shunt, or Sano shunt, or by limiting pulmonary blood flow through a PA band. Visualization and assessmentof the shunt and branch PAs is often difficult, but can be achieved using the UE Ao arch LAX, Ao arch SAX, and PA views. The PA band isbest viewed with the DTG RVOT or UE PA views, given their alignment for spectral Doppler assessment. In patients with obstruction
to the native Ao (like hypoplastic left heart syndrome, Video 49),
stage 1 also requires construction of a neo-aorta with a DamusKaye-Stansel (DKS) procedure. The DKS procedure is an anastomosis
between the native MPA and ascending Ao, which allows systemic
outflow from the native Ao or native MPA to be delivered to the brain
and body. When this procedure is coupled with an arch reconstruction it is called the Norwood procedure. The DKS anastomosis isbest viewed in the ME AoV LAX and ME Asc Ao LAX views and

Key Points
1. Conotruncal defects include TOF, DORV, truncus arteriosus,
d-TGA and l-TGA.
2. Anatomic assessment should include great artery positioning(anteroposterior, mediolateral), as well as conal septum location (sub-pulmonary, subaortic or bilateral), position (anterioror posterior), and size (hypoplastic or absent). Associated
VSDs can be classified as subaortic, subpulmonary, remoteor doubly committed.
3. For all conotruncal defects, TEE allows for pre- and post-operative evaluation of outflow tract patency/obstruction, residual
VSDs (including intramural VSDs), residual atrial level communications, AV or semilunar valve insufficiency, and ventric-

Figure 17 Midesophageal 4-Ch view of D-transposition of thegreat arteries after atrial switch repair (Mustard or Senning operation). The pathway (arrow) to the pulmonary venous atrium(PVA) is demonstrated to the systemic right ventricle (RV). LV,
left ventricle.

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Puchalski et al 205

Figure 18 Midesophageal AoV LAX view with backwards rotation of the transducer angle to 90-120 and slight probe withdrawal
demonstrating a Damus-Kaye-Stansel anastomosis (arrow) between the ascending aorta (Ao) and main pulmonary artery (MPA).
lies just above the semilunar valves (Figure 18 and Video 50). The
neo-aorta is best visualized with the ME AoV LAX view. Additional
Ao arch and descending Ao views include the ME Asc Ao LAX,
the UE Ao arch LAX (with clockwise or counterclockwise probe rotation to visualize the aortic arch), and Desc Ao SAX and LAX.
Role of TEE in Glenn Assessment. Stage 2 reconstruction, thesuperior cavopulmonary anastomosis or Glenn procedure, involves
an anastomosis between the SVC and the right PA, left PA, or both.
Visualization of the Glenn anastomosis is often difficult with TEE
but it does offer the ability to assess for any narrowing or turbulenceat the anastomotic site to the PA. The best views for the Glenn
connection are in the mid to upper esophagus (ME Asc Ao LAX,
UE Ao arch SAX) with clockwise or counterclockwise rotation of
the probe, depending upon if it is a right- or left-sided Glenn.
Additionally, thrombus in the cavopulmonary connection can also
be ruled out with TEE (early or late) in the setting of suspected or
persistent oxygen desaturation.
Role of TEE in Fontan Assessment. Stage 3 reconstruction, theFontan operation, directs IVC flow to the pulmonary circulation using
an intracardiac lateral tunnel or an extracardiac conduit, although there
are still some atrio-pulmonary connections in the ACHD population.208,209 The initial assessment of the Fontan cavopulmonary
connection utilizes the ME 4-Ch view. From this position, the probe
is advanced to the TG position, until the IVC is identified within theliver. The probe is then withdrawn until the Fontan is visualized in crosssection. Changing the transducer angle to 90 in this position (TG IVC/
Hep Veins view) will allow for visualization of the baffle longitudinallyand as the probe is withdrawn to the ME Bicaval view, more of the
Fontan pathway is seen (Figure 19). The addition of color and spectral
Doppler can evaluate a Fontan fenestration or residual right-to-leftshunting and, if needed, agitated saline injected into the systemic

Figure 19 Midesophageal Bicaval view (transducer angle
around 90 ) in a patient after lateral tunnel or extracardiac Fontan. The length of the Fontan tunnel is shown here.

venous circulation from below the diaphragm can be helpful.
Importantly, positive pressure ventilation for TEE under general anesthesia may impede venous return to the heart, and caution should be
exercised in this patient group. Interventional device closure or creation of a Fontan fenestration can be guided largely or even exclusively
using 2D and 3D TEE. Finally, all views that profile intracardiac structures can be used for assessment of thrombus, including, but notlimited to the ME 4-Ch, LAA, and RV In-Out views.210-212
Single Ventricle Function. Quantification of functional single ventricles remains difficult. Function may differ between the morphologic
left and right single ventricles.213 There are important alterations in206 Puchalski et alloading conditions that affect systolic function before and after Glennand Fontan palliation. Superior cavopulmonary anastomosis results in asignificant reduction in preload in the single ventricle. Ventricular function may acutely fall and then normalize over a period of months, withventricular remodeling.214 The Fontan operation results in further
reduction in preload and subsequent decrease in ventricular function,
however, subsequent ventricular remodeling and normalization ofventricular size and function vary with age at Fontan and magnitudeof pre-Fontan volume overload.215 Qualitative assessment in multiple
orthogonal planes is recommended in the ME 4-Ch, TG Mid Pap SAX,
or TG LAX views. There is poor correlation between echocardiographic geometric assessment of single ventricular function (modified
biplane Simpson’s method) and MRI-derived EF.216 Non-geometricindices may offer the best method for quantifying ventricular function
in an objective and reproducible manner.
Use of 3D TEE in Single Ventricle. In the single-ventricle patient,
the use of 3D TEE is almost entirely performed after the Fontan procedure, given the needed body size of >30 kg to allow probe insertion. Interventional catheterization procedure guidance, atrial andFontan thrombus analysis, and assessment of AV valve function are
frequently required. The Fontan, if not too large, can be imaged using
a narrow-sector live 3D longitudinal view which allows analysis in a
rapid fashion, free of stitch artifact. In those patients with atriopulmonary type connections, a full-volume 3D acquisition with cropping provides the best option. More recently, fusion imaging of 3D
TEE and angiography allows simultaneous use of both modalities ata lower total radiation dose.217

Key Points
1. The role of TEE in the complex single ventricle will depend
upon the underlying anatomy and also the stage of surgicalpalliation: (1) Damus-Kaye-Stansel (DKS) or Norwood procedure with modified Blalock-Taussig shunt or Sano shunt;(2) superior cavopulmonary (Glenn) procedure; (3) total cavopulmonary (Fontan) operation.
2. The DKS anastomosis is best viewed in the ME AoV LAX andME Asc Ao LAX views and lies just above the semilunar
valves. Visualization and assessment of the shunt and branch
PAs is often difficult, but can be achieved using the UE Aoarch LAX, Ao arch SAX, and PA views.
3. Visualization of the Glenn anastomosis is often difficult withTEE but it does offer the ability to assess for any narrowing
or turbulence at the anastomotic site to the PA. The best views
are in the ME Asc Ao LAX and UE Ao arch SAX.
4. TEE in the Fontan patient allows for assessment of thrombus,
residual Fontan fenestration, AV valve function and ventricularfunction. It is important to assess the Fontan pathway in both
ME 4-Ch view and ME Bicaval view so that the entire conduit
is visualized from IVC to PA.
5. Interventional device closure or creation of a Fontan fenestration is guided with both 2D and 3D TEE. 3D TEE can also be
used to assess atrial and Fontan conduit thrombus and AV
valve function.

Future Developments
The past several years have brought significant advances in both hardware and software technology that have directly impacted TEE in children. The development of 3D TEE transducers by most of the major

Journal of the American Society of Echocardiography
February 2019

vendors has facilitated evaluation of older children and ACHD patients.
Likewise, the development of automated or semi-automated assessment of 3D function, wall motion, and ventricular strain have not
only enhanced the ability to care for patients but also have increased
our understanding of cardiac mechanics in normal and disease states.
Limitations remain, however, and include: suboptimal 3D color flow
analysis, lack of a 3D TEE probe for pediatric patients, and lack of ahigh-quality TEE probe for the smallest neonates on all platforms.
Probe Development. The limitations above represent design challenges that push against the physics of ultrasound probe development. The current micro-multiplane probe contains 32 elements, as
opposed to 64 in the standard pediatric TEE probe.19 This places
limits on the imaging quality of the probe. A very small multiplane
TEE probe capable of passage through the esophagus of smaller neonates needs to balance a transducer size with the need for excellent
image quality. Although advances in computer technology have miniaturized the electronics and computers, some of these miniaturizations cannot translate directly to imaging. Image resolution isdependent not only upon element number and transducer frequency,
but also upon aperture size, which is proportional to element size.218
Therefore, miniaturization of probe size ultimately places limits oneither element number or size, which limits resolution, or on other aspects, such as the ability to manipulate the array plane. On the other
hand, a 3D TEE probe for pediatric patients may be possible. Threedimensional arrays, albeit somewhat limited ones, have been developed that fit into an intracardiac echocardiography catheter.219,220
Clearly this array cannot be manipulated and exists in only thelongitudinal (90 ) plane; however, it does raise the possibility for a
3D array that can be placed into an endoscope of reasonable sizefor the infant, if not neonatal patient.
Three-Dimensional Printing/Virtual Reality. The developmentof 3D printers promises to impact the TEE community significantly.
MRI- and CT-based algorithms have been shown to be useful in thesurgical planning of an array of CHD.221-223 3D echocardiography
has been shown to be feasible for printing accurate models but as
the spatial and temporal resolution of 3D TEE improves andprinting speed and cost decreases, the potential exists for printing tobecome a standard component of the preoperative evaluation.224-226
Virtual reality (VR) applications in medicine are rapidly expanding
into the field of CHD. VR is being used to create virtual 3D models foreducation, and has been used for surgical planning.227-229 The abilityof TEE to create accurate 3D datasets opens the possibility of building
not only VR databases for education, but potentially to build 3D
models quickly for planning and diagnosis in the operating room.
Software Automation/Flow Measurement/Image Analysis.
Automated image analysis has the potential to not only shorten scantime but also to improve accuracy and enhance the analysis of theechocardiogram. Three-dimensional EF by echocardiography has
been shown to be superior to standard methods but by definition requires a 3D probe.230 Vendors have begun to provide automatedmeasurement capabilities and automated EF and strain. However,the 3D dataset contains a large amount of flow data that has notbeen used and can be localized to specific areas of the heart. This information has the potential to allow echocardiography to provide
flow information currently only available by MRI such as simultaneous chamber volumes, valvular flow and regurgitant fraction,
regional flow measurement, and shunt fractions. Additionally, this dataset has the ability to provide automated global and regional strain, as
well as advanced information such as LV torsion. As vendors increase

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Puchalski et al 207

Table 7 Recommended TEE imaging views in selected CHD diagnostic scenarios
Primary lesion and corresponding views

Common associated lesions and corresponding views(where appropriate)

Atrial septal defect Location, size, number, morphology, andsuitability for device closure: ME 4-Ch (View 1),
ME AoV SAX (View 12), ME RV In-Out (View 13),ME Bicaval (View 15), DTG Atr Sept (View 23)

 Partial anomalous pulmonary venous return:
ME Rt and Lt Pulm veins (Views 9 and 10), ME
Bicaval (View 15), DTG Atr Sept (View 23)
 May require extending to UE and LE to evaluate
superior and inferior sinus venosus defect LSVC to CS: ME 4-Ch with retroflexion (View 1),
ME 2-Ch (View 4), ME Bicaval (View 15) and UE
Ao Arch SAX (View 25), both with leftward
rotation of TEE probe

Ventricular septal
defect Location, size, number: ME 4-Ch (View 1), ME
5-Ch (View 2), ME LAX (View 5), ME AoV LAX(View 6), ME Ao SAX (View 12), ME RV In-Out(View 13), DTG 5-Ch (View 21), DTG RVOT
(View 22), TG Basal SAX (View 17), TG Mid Pap
SAX (View 18), TG Apical SAX (View 19)

 AoV prolapse: ME AoV LAX (View 6), ME Ao
SAX (View 12)
 Double chamber right ventricle: ME AoV SAX(View 12), ME RV In-Out (View 13), DTG RVOT
(View 22)

Atrioventricular septal
defect Primum ASD and inlet VSD: ME 4-Ch (View 1),
TG Basal SAX (View 17), TG Mid Pap SAX (View18)
 Common Atrioventricular Valve: ME 4-Ch (View1), ME LAX (View 5), TG Basal SAX (View 17), TG
LAX (View 20), DTG 5-Ch (View 21), DTG RVOT
(View 22)

 Cleft mitral valve: ME 4-Ch (View 1), ME Mitral(View 3), ME 2-Ch (View 4), ME LAX (View 5), TG
Basal SAX (View 17)
 Subaortic obstruction: ME 5-Ch (View 2), ME
LAX (View 5), ME AoV LAX (View 6), DTG 5-Ch
(View 21), DTG RVOT (View 22)

Ebstein’s anomaly Morphology of leaflets, and suitability for repair(mobility of anterior leaflet, choral attachments
to RVOT, number of regurgitant jets): ME 4-Ch
(View 1), ME RV In-Out (View 13), ME Mod
Bicaval TV (View 14), TG Basal SAX (View 17)
with rightward probe rotation, DTG RVOT
(View 22)

 ASD: see above Noncompaction of LV: ME 4-Ch (View 1), ME 2Ch (View 4), TG Apical SAX (View 19), TG LAX(View 20)

Conotruncal defects(TOF, DORV,
truncus arteriosus,
D-TGA)

 Great artery position including conal septal
location (subpulmonary, subaortic or bilateral),position (anterior or posterior) and size
(hypoplastic or absent): ME 5 Ch (View 2), ME
AoV LAX (View 6), ME RV In-Out (View 13), DTG
5-Ch (View 21), DTG RVOT (View 22)
 Location and size of VSD (subaortic,
subpulmonary, doubly committed, remote): ME
5-Ch (View 2), ME AoV LAX (View 6), ME Ao SAX(View 12), ME RV In-Out (View 13), DTG 5-Ch
(View 21), DTG RVOT (View 22), TG Basal SAX(View 17), TG Mid Pap SAX (View 18), TG Apical
SAX (View 19)

 RV size and function: ME 4-Ch (View 1), ME AoV
SAX (View 12), ME RV In-Out (View 13), TG
Basal SAX (View 17), TG Mid Pap SAX (View 18),TG Apical SAX (View 19), DTG RVOT (View 22)
 AV valve abnormalities (stenosis, regurgitation,
straddling/overriding): ME 4 Ch and ME 5 Ch
(Views 1 and 2), ME Mitral (View 3), ME 2-Ch
(View 4), ME LAX, (View 5), ME RV In-Out (View
13), ME Modified Bicaval TV (View 14), TG Basal
SAX (View 17), TG Mid Pap SAX (View 18), DTG
5-Ch (View 21), DTG RVOT (View 22)

TOF (postoperative) Residual VSD: ME 5-Ch (View 2), ME AoV LAX(View 6), ME Ao SAX (View 12), ME RV In-Out(View 13), DTG 5-Ch (View 21), DTG RVOT
(View 22)
 RVOT obstruction: ME RV In-Out (View 13),
DTG RVOT (View 22), UE Ao Arch SAX (View 25)
with leftward rotation of TEE probe Pulmonary regurgitation: ME Ao SAX (View 12),ME RV In-Out (View 13), UE Ao Arch SAX (View
25) with leftward rotation of TEE probe, UE PA(View 26), DTG RVOT (View 22)

DORV (postoperative) Residual VSD: see above
 LV to aorta pathway: ME 5-Ch (View 2), ME AoV
LAX (View 6), DTG 5-Ch (View 21), DTG RVOT
(View 22)
(Continued )208 Puchalski et al

Journal of the American Society of Echocardiography
February 2019

Table 7 (Continued )Primary lesion and corresponding views

Common associated lesions and corresponding views(where appropriate)

Truncus arteriosus(postoperative) Residual VSD: see above Anatomy and function of truncal valve: ME AoV
LAX (View 6), ME Ao SAX (View 12), DTG 5-Ch
(View 21)
 Location, size and function of RV to PA conduit:
ME RV In-Out (View 13), DTG 5-Ch (View 21),
DTG RVOT (View 22)
 PA size and residual PA stenosis: ME Asc Ao
LAX (View 7) and SAX (View 8), UE Ao Arch SAX(View 25), UE PA (View 26).
 LV to aorta pathway: ME 5-Ch (View 2), ME AoV
LAX (View 6), DTG 5-Ch (View 21)

d-TGA/arterial switch
procedure Right and left ventricular outflow tract: ME 5-Ch
(View 2), ME LAX (View 5), ME AoV LAX (View 6),
ME RV In-Out (View 13), DTG 5-Ch (View 21),
DTG RVOT (View 22)
 Supravalvular region: UE Ao Arch LAX (View 24)
and SAX (View 25), UE PA (View 26)
 Anatomy and function of neo-aortic valve: ME
AoV LAX (View 6), ME AoV SAX (View 12), DTG
5-Ch (View 21)
 Coronary reimplantation: ME AoV SAX(View 12)

d-TGA/Rastelli Residual VSD: see above Location, size and function of RV to PA conduit:
ME LAX (View 5), ME RV In-Out (View 13), DTG
RVOT (View 22)
 LV to aorta pathway: ME 5-Ch (View 2), ME LAX(View 5), ME Ao LAX (View 6), DTG 5-Ch (View21), DTG RVOT (View 22)

d-TGA/atrial switch
procedure Pulmonary venous baffle: ME 4-Ch (View 1)
 Superior and inferior limb of systemic venous
baffle: ME Bicaval (View 15), ME Mod Bicaval
TV (View 14), TG IVC/Hep Veins (View 16), DTG
Atr Sept (View 23), UE Ao Arch SAX (View 25),
UE PA (View 26)
 May require gradual sweeps in order to scan
the superior and inferior limbs of systemic
venous baffle including clockwise/
counterclockwise probe rotation

 Systemic RV size and function: ME 4-Ch (View1), ME AoV SAX (View 12), ME RV In-Out (View
13), TG Basal SAX (View 17), TG Mid Pap SAX(View 18), TG Apical SAX (View 19), DTG RVOT
(View 22)
 Systemic AV valve regurgitation: ME 4-Ch (View1), ME RV In-Out (View 13), ME Mod Bicaval TV(View 14)
 Subpulmonary LV size and function: ME 4-Ch
(View 1), ME 2-Ch (View 4), ME Mitral (View 3),
ME LAX (View 5), TG Basal SAX (View 17), TG
Mid Pap SAX (View 18), TG Apical SAX (View
19), TG LAX (View 20), DTG 5-Ch (View 21)

l-TGA

 Systemic RV size and function: ME 4-Ch (View1), ME 2-Ch (View 4), ME Mitral (View 3), ME
LAX (View 5), TG Basal SAX (View 17), TG Mid
Pap SAX (View 18), TG Apical SAX (View 19), TG
LAX (View 20), DTG 5-Ch (View 21)
 Systemic AV valve regurgitation: ME 4-Ch (View1), ME Mitral (View 3), ME LAX (View 5)
 Subpulmonic LV size and function: ME 4-Ch
(View 1), ME AoV SAX (View 12), ME RV In-Out(View 13), TG Basal SAX (View 17), TG Mid Pap
SAX (View 18), TG Apical SAX (View 19), DTG
RVOT (View 22)

 Physiologic repair (VSD closure and/or LV to PA
conduit): see VSD and conduit views above Anatomic repair (Atrial switch repair and arterial
switch repair or Rastelli): See D-TGA arterial
switch repair and D-TGA Rastelli views

 LV size and function: ME 4-Ch (View 1), ME 2Ch (View 4), ME LAX (View 5), TG Basal SAX(View 17), TG Mid Pap SAX (View 18), TG Apical
SAX (View 19), TG LAX (View 20), DTG 5-Ch
(View 21)(Continued )Puchalski et al 209

Journal of the American Society of Echocardiography
Volume 32 Number 2

Table 7 (Continued )Primary lesion and corresponding views

Common associated lesions and corresponding views(where appropriate)

Single Ventricle Stage 1

 Assessment of size and function of modified
Blalock-Taussig shunt, central shunt or Sano
Shunt: UE Ao Arch LAX (View 24) and SAX (View25), UE PA (View 26)
 Assessment of PA band: DTG RVOT (View 22),
UE PA (View 26)
 Assessment of Damus-Kaye-Stansel (DKS)
procedure: ME AoV LAX (View 6), ME Asc Ao
LAX (View 7) and SAX (View 8), UE Ao Arch SAX(View 25), UE PA (View 26)
 Assessment of Norwood and aortic arch: ME
AoV LAX (View 6), ME Asc Ao LAX (View 7) andSAX (View 8), UE Ao arch LAX (View 24) andSAX (View 25), Desc Ao SAX (View 27) and LAX(View 28)

 Stage 2 (Glenn) ME Asc Ao LAX (View 7) and SAX (View 8), UE
Ao arch SAX (View 25)
 May require clockwise or counterclockwise
rotation of the probe Stage 3 (Fontan)

 Atriopulmonary Connection: ME 4-Ch (View 1),
ME RV In-Out (View 13), ME Asc Ao SAX (View8), TG IVC/Hep Veins (View 16)
 Lateral tunnel/extracardiac connection: ME 4Ch (View 1), ME Asc Ao SAX (View 8), ME Mod
Bicaval TV (View 14), TG IVC/Hep Veins (View
16), DTG Atr Sept (View 23)
 Pulmonary artery flow: ME Asc Ao SAX (View 8),
UE Ao Arch SAX (View 25)

 Right pulmonary vein compression by dilated
right atrium of atriopulmonary connection: ME
Rt Pulm Veins (View 9)
 Right atrial clot in atriopulmonary connection:
ME 4-Ch (View 1), ME Mod Bicaval TV (View
14), DTG Atr Sept (View 23)
 Lateral tunnel and extracardiac patency, clot,
and fenestration: ME 4-Ch (View 1), ME 2-Ch
(View 4), ME Bicaval (View 15), TG IVC/Hep(View 16), DTG Atr Sept (View 23)

ASD, Atrial septal defect; ALCAPA, anomalous origin of the left main coronary artery from the pulmonary artery; AV, atrioventricular; CS, coronary
sinus; d-TGA, complete transposition of the great arteries; DORV, double outlet right ventricle; DTG, deep transgastric; l-TGA, congenitally corrected transposition of the great arteries; LSVC, Left superior vena cava; LV, left ventricle; RV, right ventricle; TG, transgastric; TOF, tetralogy
of Fallot; TV, tricuspid valve; VSD, ventricular septal defect.
Modified from Hahn et al.16

utilization of the dataset, ultrasound systems can take over tasks such asmeasurement and flow assessment, allowing clinicians to focus on the
anatomy and physiology to obtain advanced diagnostic information.

SUPPLEMENTARY DATACONCLUSIONSREFERENCES

Transesophageal echocardiography in children and patients with
CHD is clearly a unique and distinct discipline. The aim of this document was to provide the reader with an in-depth review of what isrequired to perform this procedure, as well as a comprehensive protocol for image acquisition. Given the tremendous amount ofanatomic variability in CHD, these guidelines are meant to serve asa starting point from which additional customization may be needed
to obtain information crucial for clinical decision-making in each patient. We have attempted to encapsulate much of CHD in summary
Table 7 for ease of use. The continued incorporation of new andadvanced technologies designed to shorten acquisition time, improveaccuracy, and enhance analysis will further benefit patient care andreinforce the vital role of this imaging modality in a variety of clinicalsettings.

Supplementary data related to this article can be found at https://doi.
org/10.1016/j.echo.2018.08.016.

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