4/8/10
Normal TTE/TEE
Examinations
Geoffrey A. Rose, MD FACC FASE
Sanger Heart & Vascular Institute
Before you begin imaging...
•  Obtain the patient’s
•  Height
•  Weight
•  BP
PLAX View
•  Is apex @ 9-10 o’clock?
• 
If not, change interspace
•  Image at end diastole
• 
Check ECG
•  Impression of left pleural
effusion? (See arrow.)
• 
Reduce gain to ↓artifact
PLAX View
•  Is the RV big?
•  View descending
thoracic aorta
(large arrow)
•  Coronary sinus evident?
(small arrow)
•  Enlarged CS + nl RV =
Persistent L-SVC
PLAX View
•  Assess LV cavity shape.
•  Do septum and
inferolateral walls
converge toward apex?
•  Overall wall thickness?
•  Septal and inferolateral
PLAX View
Diastolic Evaluation
•  Do aortic leaflets coapt
centrally?
•  Anything in LVOT?
•  Mitral valve morphology?
walls symmetric in
thickness? Screen for bicuspid Ao valve
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PLAX View
PLAX View: M-mode
Systolic Evaluation
Perpendicular
to LV long axis?
•  Do aortic leaflets dome
during systole?
AoV
•  Anything in LVOT?
•  MV geometry?
• 
• 
MV
Pap Level
Pap
Prolapse?
IL wall
Tethering?
Screen for bicuspid Ao valve
Sweep: Aortic valve to Pap Muscle tips
PLAX View: M-mode
Box-like
opening?
PLAX View: 2D
measurements
‘Uncorrected’ M-mode
measurements would
overestimate LV cavity size
and wall thickness
(dotted line)
E + A waves?
AoV
MV
Premature
AoV closure?
SAM?
Diastolic
fluttering?
Diastolic Evaluation
PLAX View: 2D
measurements
Note that LA measurement
should be perpendicular to
LA long axis
(dotted line)
PLAX View: Color Doppler
•  Reduce width and length
of color sector
•  PRF > ±50 cm/sec
•  Laminar flow vs
turbulent flow in LVOT?
Systolic Evaluation
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RV Inflow View
RV Inflow View
Imaging Plane
Anterior TV leaflet
•  Only view to assess
coaptation of anterior
and posterior tricuspid
leaflets
Posterior TV leaflet
Posterior TV leaflet
Ant TVL
SVC
Septal
Leaflet
Plane
•  May see Chiari network
in plane (dark arrow)
between IVC and
Coronary Sinus
Anterior TV leaflet
SVC
Post TVL
CS
IVC
IVC
IVC
RV Inflow View
RVOT View
Anterior TV leaflet
RVOT
Posterior TV leaflet
SVC
•  Prominent Eustachian
valve may appear as a
mass (dark arrow)
•  Turbulent flow in
RVOT?
•  Diastolic color flow in
LPA? Think PDA.
IVC
LPA
RPA
RVOT View: Doppler
RVOT
• 
• 
Parabolic flow
profile
Max velocity
~ 1 m/sec
Short Axis: Base
•  Determine
Ao Valve
bicuspid vs
trileaflet
morphology
during systole
•  Raphe w/
R
L
N
bicuspid valve
can make it
appear trileaflet
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4/8/10
Short Axis: Base
Short Axis: Base
Bicuspid Valve
open completely
as a circle (not
oval) if valve is
indeed trileaflet
Ao Valve
R
•  Leaflets should
N
L
Short Axis: Base
•  Look for ostia of
Right and L Main
coronary arteries
•  Set Doppler
color ±20 cm/sec
Short Axis: Mitral Valve
Ao Valve
R
•  Note orientation
•  Use color
N
Doppler to
localize MR jet in
medial-lateral
plane
L
•  LV circular
/A1
A3/A2
of segments of
mitral leaflets
Short Axis: Papillary Level
Lateral
Medial
P1
P3/P2/
Short Axis: Apical Level
•  This is our first
shape should
become a
smaller circle
AL
•  Assess septal
‘roundedness’ in
both systole and
diastole
Trileaflet Valve
PM
view of the LV
apex!
•  Note:
counterclockwise
twist.
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Apical: 4 chamber view
Apical: ‘5’ chamber view
• 
•  Be certain you are
imaging through
true apex. Take
note of length L1.
L1
•  Normal RV area is • 
~1/3 to 1/2 of LV
area
RLPV
• 
• 
Adjust color gate &
image depth so that
color Doppler
velocity range > ±50
cm/s to assess MR.
Pulse Doppler at
mitral valve tips
LUPV
LAA
Limited spatial
resolution within LVOT
in this view.
RUPV
Apical: 4 chamber view
• 
Think of the LVOT as a
staircase from LV to
Ao valve. In this view,
you are ‘looking down
the stairs’. You can’t
estimate accurately the
length of the staircase.
Apical: 4 ch Tissue Doppler
Expect E’L > E’S
E’S
Pulse Pulmonary vein
E’L
Apical: 4 chamber view
•  Assess TR
•  Assess atrial
septal mobility
•  View is of limited
use to assess
septal integrity
Chiari network in Right Atrium
Embryologic remnant of R valve of Sinus Venosus
Not ASD/PFO. Color Artifact.
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Apical: 4 chamber view
• 
• 
• 
• 
Apical: 2 chamber view
•  LA volume index: LA volume index: 8 (A4C * A2C)/3∏L
8 (A4C * A2C)/3∏L
L2
•  Image obtained at
“L” is the shorter of
the LA lengths in 4ch
and 2 ch views
maximal LA area
(end-systole)
Image obtained at
maximal LA area
(end-systole)
•  Normal:
22±6 ml/m2
Remember LV ‘L1’
from 4 ch view
L= 5.3 cm
L= 4.7 cm
Apical: 2 chamber view
Apical: 2 chamber view
4ch: Ant ML on left side of image
•  Mitral leaflets
move more as a
piston than as a
gate
2ch: Ant ML center of image
•  No Ao or RV in
should be image
P1
P3
A2
P3
ApLAX: Ant ML on right side of image
Apical: Long-axis view
Subcostal views
•  IVC and hepatic vein
•  Best view of
pulse Doppler
LVOT VTI
• 
Better spatial
discrimination
•  Remember LV
‘L1’ from 4 ch
view
L3
flow blue as flow is
away from
transducer
•  Aortic flow orange
and should be
laminar
•  Continuous flow in
visceral arteries
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4/8/10
Subcostal views
Aortic Arch views
•  Circle is where
•  RA and RV are
head is
anterior
RV
•  Look for pericardial
•  Large arrow points
where coarctation
would be
RA
effusion
LV
•  Notice liver
•  Good view of
•  Small arrow:
pulmonary artery
LA
interatrial septum
Doppler flow in desc Ao
TEE
A2 and P2 of Mitral Valve
•  Invasive test: address clinical concern first
•  Systematic assessment of IAS, LAA,
pulmonary veins
•  4 ch LV at
Aorta (A1/P1), mid (A2/P2), and
deep (A3/P3)
•  PA/Ao/Bicaval/RUPV are all at 120 degrees
with counterclockwise rotation of probe
TEE: 4 chamber view
0° view
A2
TEE: 4 Chamber and 2 Chamber views
P2
Mitral Valve Prolapse
Reconciling 3D Surgical View with Standard 2D View
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4/8/10
60° view
P3
A1 and A2
Mitral Valve Prolapse
TEE
Reconciling 3D Surgical View with Standard 2D View
Long Axis view
CTA to guideTEE
RUPV
SVC
Aorta
90°
Pulm Artery
120°
TEE: Long Axis view
Esophagus
0°
IVC
SVC
TEE: Bicaval view
TEE: Bicaval view
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TEE
RUPV
IVC
SVC
∘
TEE: Bicaval view @ 120 ⟷ 140
∘
‘Q-tip sign’ or ‘Warfarin ridge’ separating LAA from LUPV
TEE: Left Atrial Appendage Assessment
Use Biplane Views
TEE: Left Atrial Appendage Assessment
Don’t be fooled by fat in the transverse sinus
A3
A2
A1
P3
P2
P1
TEE: transgastric images
TEE: transgastric images
Remember 12 0‘clock is the inferior wall
Remember 12 0‘clock is the inferior wall
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4/8/10
Typically only see 4-5 cm of ascending aorta
A3
A2
A1
P3
P2
P1
TEE: transgastric images
Localize MR in medio-lateral plane
Aortic TEE Images
Ascending aorta and Aortic arch
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