Transesophageal Echocardiography (TEE)

Transesophageal Echocardiography (TEE) is an ultrasound (sound-wave imaging) test of the heart that is performed from inside the food pipe (esophagus), rather than from the outside of the chest.

A slim, flexible tube with a tiny ultrasound probe at its tip is gently guided down the throat and into the esophagus, which runs directly behind the heart. Because the probe sits so close to the heart, it produces much clearer pictures than a standard chest ultrasound can. These pictures show the heart's chambers, valves, walls, and the large blood vessels connected to it — all in real time, while the heart is beating.

TEE is used when a detailed, close-up view of the heart is needed and a standard echocardiogram (ultrasound done on the chest surface) does not provide clear enough images. It is ordered by a cardiologist (heart specialist) in a range of situations.

• Suspected blood clot (thrombus) inside the heart, especially before a procedure to correct atrial fibrillation (an irregular heartbeat in the upper chambers)
• Diseased or damaged heart valves — to measure how severe the problem is and plan repair or replacement
• Infective endocarditis (infection on the heart valves or inner lining of the heart)
• Aortic disease — problems with the aorta (the main artery leaving the heart), such as a tear (dissection) or bulge (aneurysm)
• Stroke or mini-stroke (TIA) in younger patients, to look for a heart source of a blood clot
• Congenital heart defects (heart problems present from birth), such as a hole between the heart's chambers
• Monitoring heart function in real time during open-heart surgery or certain minimally invasive heart procedures
• Assessing the result of a valve repair or replacement immediately after surgery

TEE is not suitable for everyone. The doctor will not recommend it in certain situations.

• Active bleeding or known disease of the esophagus, such as a severe narrowing, a large pouch (diverticulum), or a recent tear
• Recent esophageal or stomach surgery
• Severe, uncontrolled neck or spine problems that make swallowing the tube unsafe
• Patient is unable to cooperate or tolerate even light sedation (calming medicine)

TEE is generally considered a safe diagnostic procedure, but like any test that involves passing a tube into the body, it carries a small number of recognised risks.

• Sore throat or mild discomfort in the throat after the probe is removed — the most common side effect, usually settling within a day or two
• Temporary low oxygen levels or changes in heart rate during the procedure, monitored and managed by the clinical team
• Reaction to the sedation (calming medicine) used, such as dizziness, nausea, or, rarely, breathing difficulty
• Allergic reaction to the throat-numbing spray used before the probe is inserted
• Minor bleeding or scraping in the mouth, throat, or esophagus from the tube
• Rarely, a small tear (perforation) in the esophagus — this is uncommon but is the most serious potential complication
• Aspiration (accidentally breathing in saliva or stomach contents) during the procedure

Good preparation helps the procedure go smoothly and reduces the chance of complications. The care team will give specific instructions, but the following covers what is typically expected.

Before the procedure, patients are usually asked to fast (eat and drink nothing) for several hours — commonly around four to six hours — so the stomach is empty and the risk of aspiration is reduced. The exact fasting time will be confirmed by the hospital. Blood-thinning medicines may need to be paused for a period decided by the doctor, depending on the reason for the test. Patients who smoke are generally advised to avoid smoking in the hours before the test, as smoking can increase secretions in the throat. Alcohol should be avoided beforehand because it can interact with sedation.

The doctor will usually arrange some tests in advance, which may include:

• A standard electrocardiogram (EKG) to record the heart's electrical activity
• Blood tests to check clotting ability and kidney function
• A standard chest echocardiogram (surface ultrasound) if not already done recently
• Review of current medications, allergies, and any history of problems with the esophagus or throat

On the day of the procedure, the steps typically follow this order:

• The patient changes into a hospital gown and an intravenous (IV) line is placed in a vein, usually in the arm, for delivering sedation and other medicines if needed.
• Monitoring equipment is attached — sticky pads on the chest to record the heart rhythm (EKG), a clip on the finger to measure oxygen levels, and a blood pressure cuff.
• A local anaesthetic (numbing) spray is applied to the back of the throat to reduce the sensation of the probe.
• A mild sedative is given through the IV line to help the patient relax. Most patients remain awake but feel drowsy and comfortable.
• A small plastic guard is placed between the teeth to protect both the teeth and the probe.
• The doctor gently guides the thin ultrasound probe down the throat and into the esophagus. The patient may be asked to swallow to help the tube pass.
• The doctor takes ultrasound images from several positions along the esophagus and, sometimes, from the upper part of the stomach to get different views of the heart.
• Once all the images needed have been captured, the probe is slowly withdrawn.
• The patient rests in a recovery area while the sedation wears off.

After TEE, patients are monitored in a recovery area until the sedation has worn off and vital signs — heart rate, blood pressure, and oxygen levels — are stable. Because sedation is used, patients should not drive, operate machinery, or make important decisions for the rest of the day, and they will need someone to accompany them home. The throat may feel numb for a short while after the procedure, so eating and drinking are usually held until this sensation has fully passed — the nurse will confirm when it is safe.

• Throat soreness or mild hoarseness is normal for up to a day or two; cool fluids and soft foods can help
• Avoid driving or using machinery for at least the remainder of the day after sedation
• Resume regular food and drink only after the throat numbness has completely gone, as confirmed by the care team
• Blood-thinning or other paused medications are restarted according to the doctor's specific instructions
• The cardiologist will usually discuss the preliminary findings on the same day or soon after; a full written report follows within the timeframe set by the hospital
• If symptoms such as difficulty swallowing, chest pain, fever, or coughing up blood develop after returning home, medical attention should be sought promptly
• Further appointments — for treatment, surgery, or additional tests — will be arranged based on what the TEE images reveal