Editing Transesophageal echocardiogram (section)

==Details==
[[Image:Transesophageal echocardiography diagram.svg|thumb|Transesophageal echocardiography diagram]]

TEE is a semi-invasive procedure in that the probe must enter the body but does not require surgical (i.e., invasive) cutting for this procedure.
Before inserting the probe, mild to moderate sedation is induced in the patient to ease the discomfort and to decrease the [[gag reflex]].
Usually a local anesthetic spray (e.g., [[lidocaine]], [[benzocaine]], [[xylocaine]]) is used for the back of the throat or as a jelly/lubricant anesthetic for the esophagus.
Sedation and anesthesia are required to make the procedure tolerable and safer, as biting the probe, coughing, vomiting, and patient movement would drastically reduce the value of the procedure.{{citation needed|date=January 2022}}

Mild or moderate sedation can be induced with medications such as [[midazolam]]  (a [[benzodiazepine]] with sedating, amnesiac qualities), [[fentanyl]] (an opioid), or [[propofol]] (a sedative/general anesthetic, depending on dosage).
Children are [[anesthesia|anesthetized]]. Adults are sometimes anesthetized as well if moderate sedation is unsuccessful.{{citation needed|date=January 2022}}

Due to the procedure being invasive, sonographers do not perform this procedure unlike transthoracic echo.{{cn|date=July 2024}}

Once adequate sedation and anesthesia are achieved, the probe is passed through the mouth and into the esophagus.
From here, the protocol used for the procedure is highly variable.
As the study could be terminated any second (e.g., respiratory compromise, hypotension, intolerance to the probe) the structures of particular interest could be visualized first. For example, if the TEE is ordered to look for
[[mitral regurgitation]] then the mitral valve may be fully inspected first. At the completion of the study, the probe is removed and patient is monitored for recovery from sedation.{{cn|date=July 2024}}

===Advantages===
The advantage of TEE over TTE is usually clearer images, especially of structures that are difficult to view transthoracically (through the chest wall). This difficulty with TTE is exemplified with obesity and COPD, as both of these can drastically limit both the window available and the quality of the images obtained through those windows. This reduces the attenuation (weakening) of the ultrasound signal, generating a stronger return signal, ultimately enhancing image and Doppler quality. Comparatively, transthoracic ultrasound must first traverse skin, fat, ribs and lungs before reflecting off the heart and back to the probe before an image can be created. All these structures, along with the increased distance the beam must travel, weaken the ultrasound signal thus degrading the image and Doppler quality.{{citation needed|date=January 2022}}

In adults, several structures can be evaluated and imaged better with the TEE, including the [[aorta]], pulmonary artery, valves of the heart, both atria, atrial septum, [[left atrial appendage]], and [[coronary arteries]].
TEE has a very high sensitivity for locating a blood clot inside the left atrium.<ref>{{cite web|url=http://www.heartsite.com|title=Welcome to HeartSite.com|first=Dr. Abdulla M|last=Abdulla|website=www.heartsite.com|access-date=12 April 2018}}</ref>

TEE is also frequently used concurrently with cardiac surgery to provide immediate visualization, inspection, and monitoring of the patient throughout the procedure. Its intraoperative utility includes real-time hemodynamic monitoring by the cardiac anesthesiologist, evaluation of relevant cardiac pathologies before and after surgical repair, and immediate assessment of the success of surgical interventions after cardiopulmonary bypass. TEE can also evaluate for unintended complications  from surgery, for example unintended injury to cardiac valves, the aorta, or other structures during the procedure.<ref name="pmid23998692">{{cite journal | vauthors = Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH | title = Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists | journal = J Am Soc Echocardiogr | volume = 26 | issue = 9 | pages = 921–64 | date = September 2013 | pmid = 23998692 | doi = 10.1016/j.echo.2013.07.009 }}</ref>

===Disadvantages===
TEE has several disadvantages, although they should be weighed against its significant benefits. The patient must follow the ASA NPO guidelines<ref>{{Cite web|url=https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933410|title=Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration|website=ASA Publications|access-date=August 9, 2019}}</ref> (usually not eat anything for eight hours and not drink anything for two hours prior to the procedure). Rather than one sonographer, a TEE needs a team of medical personnel of at least one nurse to monitor/administer sedation and a physician to perform the procedure (a third physician/sonographer can be used to push buttons on the ultrasound machine). It takes longer to perform a TEE than a TTE. It may be uncomfortable for the patient, who may require general anesthesia at the extreme to perform a TEE safely. Due to being an invasive procedure often involving sedation, it is more technically difficult to perform and requires experience to do it well while maintaining safety.{{cn|date=July 2024}}

TEE is limited to available anatomy. For example, if the patient has [[esophageal varices]], [[esophageal stricture]], [[Barrett's esophagus]], or other esophageal or stomach problems then this can increase the risk of a TEE significantly.
Performing an esophagogastroduodenoscopy (EGD) beforehand may be necessary to visualize the anatomy for safety, which exposes the patient to a second procedure.
The anatomy may result in prohibitive risk.{{cn|date=July 2024}}

With transthoracic echo, numerous measurements are taken to aid in diagnosis and grading of diseases.
These [[normal range]]s are not as well defined for TEE and so there is less accepted standards (e.g., left atrial enlargement).{{cn|date=July 2024}}

Some risks are associated with the procedure, such as esophageal perforation<ref name= "pmid17720433">{{cite journal |vauthors= Ramadan AS, Stefanidis C, Ngatchou W, LeMoine O, De Canniere D, Jansens JL |title= Esophageal stents for iatrogenic esophageal perforations during cardiac surgery |journal= Ann. Thorac. Surg. |volume= 84 |issue= 3 |pages= 1034–6 |date=September 2007 |pmid= 17720433 |doi= 10.1016/j.athoracsur.2007.04.047 |doi-access= free }}</ref> around 1 in 10,000,<ref>{{cite journal |last1=Min JK |first1=Spencer |title=Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations |journal=J Am Soc Echocardiogr |volume=18 |issue=9 |pages=925–929 |date=September 18, 2005 |doi=10.1016/j.echo.2005.01.034 |pmid=16153515 }}</ref> and adverse reactions to the medication.

[[Specialty (medicine)|Specialty medicine]] [[professional organizations]] recommend against using transesophageal echocardiography to detect cardiac sources of embolization after a patient's health care provider has identified a source of embolization and if that person would not change a patient's management as a result of getting more information.<ref name="ASEfive">{{Citation |author1 = American Society of Echocardiography |author1-link = American Society of Echocardiography |title = Five Things Physicians and Patients Should Question |publisher = [[American Society of Echocardiography]] |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |date = 20 December 2012 |url = http://www.choosingwisely.org/doctor-patient-lists/american-society-of-echocardiography/ |access-date = February 27, 2013}}, which cites
* {{Cite journal | doi = 10.1016/j.jacc.2010.11.002 | last1 = Douglas | first1 = P. S.| last2 = Garcia | first2 = M. J. | last3 = Haines | first3 = D. E. | last4 = Lai | first4 = W. W.| last5 = Manning | first5 = W. J. | last6 = Patel | first6 = A. R. | last7 = Picard | first7 = M. H.| last8 = Polk | first8 = D. M.| last9 = Ragosta | first9 = M.| last10 = Ward | first10 = R. P. | last11 = Douglas | first11 = R. B.  | last12 = Weiner | first12 = R. B. | author13 = Society for Cardiovascular Angiography Interventions | author14 = Society of Critical Care Medicine| author15 = American Society of Echocardiography| author16 = American Society of Nuclear Cardiology| author17 = Heart Failure Society of America| author17-link = Heart Failure Society of America| author18 = Society for Cardiovascular Magnetic Resonance| author19 = Society of Cardiovascular Computed Tomography| author20 = American Heart Association| author21 = Heart Rhythm Society| title = ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography | journal = Journal of the American College of Cardiology | volume = 57 | issue = 9 | pages = 1126–1166 | year = 2011 | pmid = 21349406 | doi-access = free }}</ref> Such organizations further recommend that doctors and patients should avoid seeking transesophageal echocardiography only for the sake of protocol-driven testing and to agree to the test only if it is right for the individual patient.<ref name="ASEfive"/>