Transesophageal Echocardiography Guidelines in Children and All Patients With Congenital Heart Disease

Editor's Note: Commentary based on Puchalski MD, Lui GK, Miller-Hance WC, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination in children and all patients with congenital heart disease: recommendations from the American Society of Echocardiography. J Am Soc Echocardiog 2019;32:173-215.

The recently published guidelines for comprehensive transesophageal echocardiographic examination (TEE) in children and in all patients with congenital heart disease (CHD) present a detailed protocol for TEE image acquisition in these populations. The document outlines techniques and recommendations applicable to TEE assessment. Methods are addressed for imaging specific structures and selected congenital anomalies, including three-dimensional (3D) TEE examination protocols.

The following are 10 highlights from the guidelines:

  1. The most frequent application of TEE in the pediatric/CHD patient is guiding cardiac surgery. Other uses include guidance during cardiac interventions in the catheterization and electrophysiology laboratories and diagnostic evaluation when transthoracic imaging is inadequate or when the suspected abnormality/pathology would be better characterized by TEE.
  2. TEE is an advanced imaging modality; therefore, the echocardiographer performing a pediatric or adult CHD study must have expertise in transthoracic echocardiographic diagnosis of structural and acquired heart disease.
  3. Important aspects of TEE practice include understanding the oropharyngeal anatomy and the endoscopic techniques, indications, contraindications and risks associated with this type of imaging. For all patients—and particularly those with relative contraindications for TEE—the benefits of the procedure should outweigh the risks. Most TEE-related complications result from respiratory impairment or vascular compression; serious complications are rare.
  4. Selecting a suitable TEE probe depends primarily on the patient's weight and the size of the imaging device. Given the larger size of a 3D probe, 3D TEE is currently suitable only for older children and adults.
  5. Most children undergo TEE under general anesthesia, whereas conscious sedation is the norm for adult CHD patients, with few exceptions.
  6. The guidelines recommend using 28 key two-dimensional (2D), cross-sectional tomographic views to facilitate the comprehensive TEE examination of children and of all patients with CHD. Included are many of the views outlined in the 2013 American Society of Echocardiography/Society of Cardiovascular Anesthesiologists Comprehensive TEE Guidelines,1 along with modifications and additions based on the pediatric and congenital focus of the current document (previous guidelines having primarily addressed the adult with a structurally normal heart).
  7. Although the standard TEE views are to be considered a foundation, the enormous anatomical and pathological variability seen in CHD may necessitate modifying these views and, in some cases, adding nonstandard views. In children and in all patients with CHD, TEE examination should focus on imaging specific structures rather than on obtaining prespecified views.
  8. TEE images are obtained from four primary positions within the esophagus and stomach; namely, the upper esophageal, midesophageal, transgastric and deep transgastric levels. Single-beat video clips may be inadequate for comprehensive echocardiographic assessment; in most cases, longer video recordings with loops and sweeps are essential.
  9. In evaluating any abnormality, a combination of modalities is recommended. These should include 2D imaging and Doppler interrogation (spectral and color flow) in multiple views, in addition to 3D structural and color Doppler imaging, as indicated. Options specific to 3D TEE include adjustable sector, full-volume acquisition, and live multiplanar methods.
  10. 3D TEE is primarily used during surgical procedures for CHD and for interventions in the cardiac catheterization laboratory. Although 3D TEE has been used effectively during various catheter-based therapies, it is especially recommended for guiding septal defect closures, measuring defects, visualizing hardware, assessing atrioventricular valves, and evaluating left ventricular outflow/aortic valves.


  1. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64.

Keywords: Conscious Sedation, Aortic Valve, Cross-Sectional Studies, Echocardiography, Transesophageal, Echocardiography, Cardiac Surgical Procedures, Tomography, X-Ray Computed, Cardiac Catheterization, Video Recording, Anesthesia, General, Electrophysiology, Heart Diseases, Pediatrics

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