From the Guidelines
Transesophageal echocardiography (TEE) imaging views for adult congenital heart disease (ACHD) should include standard views such as the midesophageal four-chamber view, midesophageal five-chamber and two-chamber views, midesophageal long-axis view, and midesophageal RV inflow-outflow view, as well as additional specialized views based on the specific congenital anomaly, as recommended by the American College of Cardiology/American Heart Association guidelines 1. When evaluating patients with ACHD, it is essential to use a comprehensive protocol that includes standard views plus additional specialized views based on the specific congenital anomaly.
- Begin with the midesophageal four-chamber view to assess chamber sizes, ventricular function, and septal defects.
- Then obtain midesophageal five-chamber and two-chamber views to evaluate the left ventricle, mitral valve, and left atrium.
- The midesophageal long-axis view is crucial for examining the left ventricular outflow tract, aortic valve, and proximal ascending aorta.
- For right-sided structures, use the midesophageal RV inflow-outflow view to assess the tricuspid valve, right ventricle, and pulmonary valve.
- Deep transgastric views provide accurate assessment of ventricular function and septal defects. For specific ACHD lesions, additional views are necessary:
- Bicaval views for atrial septal defects,
- High esophageal views for patent ductus arteriosus,
- And modified views for tetralogy of Fallot to evaluate the right ventricular outflow tract and pulmonary arteries. In patients with transposition complexes, carefully assess the great vessel relationships, ventricular outflow tracts, and any baffles or conduits. Color Doppler, spectral Doppler, and 3D imaging should be incorporated throughout the examination to evaluate flow patterns, gradients, and complex spatial relationships, as recommended by the American College of Cardiology/American Heart Association guidelines 1. This comprehensive approach ensures accurate diagnosis and guides management decisions in ACHD patients.
From the Research
Recommended TEE Imaging Views in ACHD Diagnostic Scenario
According to the American Society of Echocardiography (ASE) and Society of Cardiovascular Anesthesiologists (SCA) guidelines, the following TEE imaging views are recommended in the diagnostic scenario of Adult Congenital Heart Disease (ACHD):
- Horizontal plane TEE imaging provides important additional information concerning:
- Pulmonary venous connections
- Atrial baffle function
- Atrioventricular anatomy and function
- Left ventricular outflow tract lesions
- Great artery positional relationships 2
- Vertical plane TEE enhances imaging of:
- Systemic and pulmonary venous connections
- Atrial situs
- Venosus atrial septal defects
- Atrioventricular anatomy and function
- The ventricular septum and outflow tracts
- Complete assessment of complex right ventricular outflow tract anatomy, ventriculoarterial alignment, and the sizing of all aortic segments in coarctation of the aorta 2
Importance of TEE in ACHD Diagnosis
TEE is essential in the follow-up of operated and unoperated adult patients with ACHD, as well as in surgical and interventional procedures 2, 3. The use of TEE in ACHD diagnosis is supported by the fact that the population of adults with congenital heart disease is increasing, and many of these adults require lifelong procedural interventions 4, 5, 6.
Multidisciplinary Approach to ACHD Management
A multidisciplinary team approach is necessary for the optimal management of ACHD, including the use of TEE in diagnostic and interventional procedures 5, 6. This approach ensures that patients with ACHD receive comprehensive care, addressing their complex medical needs and improving their outcomes.