Transesophageal Echocardiogram (TEE): Procedure, Preparation & What to Expect

What Is a Transesophageal Echocardiogram (TEE)?

A transesophageal echocardiogram (TEE) is a specialized ultrasound test that produces detailed images of your heart by passing a thin, flexible tube with an ultrasound probe through your mouth and into your esophagus. This positioning allows doctors to see heart structures with exceptional clarity because the esophagus lies directly behind the heart with minimal tissue interference.

Unlike a standard transthoracic echocardiogram (TTE) performed through the chest wall, TEE bypasses the ribs, lungs, and fat tissue that can limit image quality. The esophagus provides a "window" to the heart that is unobstructed by these structures, resulting in images that are often 2-3 times more detailed than conventional echocardiography. This makes TEE particularly valuable for examining structures at the back of the heart, including the left atrium, left atrial appendage, mitral valve, and thoracic aorta.

The procedure uses high-frequency sound waves (ultrasound) to create real-time moving images of your heart. These sound waves are completely harmless and do not involve radiation exposure. The ultrasound probe at the tip of the flexible tube emits sound waves that bounce off heart structures and return to the probe, where they are converted into detailed images displayed on a monitor.

TEE has been used in clinical practice since the 1980s and has become an essential tool in modern cardiology. It is considered the gold standard for detecting certain cardiac conditions, particularly blood clots in the left atrial appendage, a common source of stroke in patients with atrial fibrillation. The American Society of Echocardiography and European Association of Cardiovascular Imaging have established comprehensive guidelines for TEE use.

TEE vs. Standard Echocardiogram

While both tests use ultrasound to visualize the heart, they differ in approach and capabilities. A standard transthoracic echocardiogram places the ultrasound probe on the chest wall, while TEE positions it in the esophagus directly behind the heart. This positioning difference has significant implications for image quality and diagnostic capability.

Standard echocardiography remains the first-line test for most cardiac evaluations because it is non-invasive and can be performed quickly without sedation. However, TEE is preferred when standard images are suboptimal (such as in patients with obesity or lung disease), when very detailed views are needed (such as before certain procedures), or when specific structures need evaluation (such as the left atrial appendage for clot detection).

Why Is a TEE Performed?

TEE is performed to obtain detailed heart images when standard echocardiography is inadequate, to detect blood clots before cardioversion or catheter ablation, to evaluate heart valve disease and infections, to assess aortic diseases, and to guide certain cardiac procedures in real-time.

Cardiologists recommend TEE when they need information that cannot be obtained from a standard echocardiogram. The superior image quality of TEE makes it indispensable for evaluating certain heart conditions and guiding specific medical decisions. Understanding why your doctor has ordered this test can help you prepare mentally and recognize its importance in your care.

The decision to perform TEE involves weighing its benefits against the small risks associated with sedation and esophageal intubation. In most cases, when TEE is recommended, the diagnostic information it provides significantly outweighs these minimal risks. Your cardiologist will discuss the specific reasons for recommending TEE in your case.

Blood Clot Detection

One of the most common reasons for TEE is to look for blood clots in the heart, particularly in the left atrial appendage (LAA). The LAA is a small pouch in the left atrium where blood clots frequently form in patients with atrial fibrillation (AFib). TEE is considered the gold standard for LAA clot detection, with sensitivity exceeding 95%, compared to approximately 50-60% for standard echocardiography.

Detecting these clots is critical before certain procedures like cardioversion (electrical shock to restore normal heart rhythm) or catheter ablation for atrial fibrillation. If a clot is present in the LAA and cardioversion is performed, the clot could dislodge and travel to the brain, causing a stroke. TEE helps prevent this serious complication by identifying patients who need extended anticoagulation before the procedure.

Heart Valve Evaluation

TEE provides exceptional views of all four heart valves, but is particularly valuable for evaluating the mitral and aortic valves. The procedure can detect valve leakage (regurgitation), narrowing (stenosis), and structural abnormalities with greater precision than standard echocardiography. This information is essential for planning valve repair or replacement surgery.

Surgeons often use TEE images to plan their surgical approach, and TEE is routinely performed in the operating room during valve surgery to assess repair results before completing the operation. This intraoperative use of TEE has significantly improved surgical outcomes for valve disease.

Infective Endocarditis

TEE is the test of choice when infective endocarditis (infection of the heart valves) is suspected. The procedure can detect vegetations (infected tissue masses) on heart valves that may be too small to see with standard echocardiography. According to the modified Duke criteria for endocarditis diagnosis, a positive TEE finding is considered major evidence for the disease.

Early and accurate diagnosis of endocarditis is crucial because delayed treatment can lead to valve destruction, heart failure, and septic emboli to other organs. TEE can detect vegetations as small as 2-3 millimeters, whereas standard echocardiography may miss lesions smaller than 5-10 millimeters.

Aortic Disease Assessment

TEE provides excellent visualization of the thoracic aorta and is valuable for diagnosing aortic aneurysms, aortic dissection, and atherosclerotic plaques in the aorta. In emergency situations where aortic dissection is suspected, TEE can often provide rapid diagnosis at the bedside without requiring transport to a CT scanner.

• Blood clot detection: Gold standard for finding clots in the left atrial appendage before cardioversion or ablation
• Valve disease: Detailed evaluation of mitral and aortic valve structure and function
• Endocarditis: Detection of infected vegetations on heart valves
• Aortic disease: Assessment of aortic aneurysms, dissection, and atherosclerosis
• Congenital defects: Evaluation of atrial septal defects and other structural abnormalities
• Procedure guidance: Real-time imaging during cardiac surgeries and catheter procedures

How Should You Prepare for a TEE?

Preparation for TEE includes fasting for 6-8 hours before the procedure, reviewing your medications with your doctor (especially blood thinners), arranging transportation home since you cannot drive after sedation, and informing your doctor about any esophageal problems or allergies.

Proper preparation is essential for a safe and successful TEE. The preparation requirements exist primarily to reduce the risk of aspiration (inhaling stomach contents into the lungs) during sedation and to ensure the procedure can be completed safely. Following these instructions carefully will help ensure your procedure goes smoothly.

You will typically receive specific preparation instructions from your healthcare provider's office before your appointment. If you have any questions about the instructions or your specific situation, contact your doctor's office rather than making assumptions. It's better to ask questions beforehand than to have your procedure delayed or cancelled due to inadequate preparation.

Fasting Requirements

You must not eat or drink anything for at least 6-8 hours before your TEE. This empty stomach is crucial because sedation reduces your normal protective reflexes, including the ability to swallow properly and protect your airway. If food or liquid is in your stomach during the procedure, it could be regurgitated and aspirated into your lungs, causing a serious condition called aspiration pneumonia.

Most TEE procedures are scheduled in the morning, so you would typically stop eating and drinking after midnight the night before. If your procedure is in the afternoon, your doctor will provide specific instructions about when to stop eating. Water and clear liquids may be permitted up to 2 hours before the procedure in some cases, but always follow your specific instructions.

Medication Considerations

Review all your medications with your doctor before the procedure. Some medications may need to be adjusted or temporarily stopped, while others should be continued. Blood thinners (anticoagulants) require special consideration - in many cases, they are continued because the whole purpose of the TEE may be to rule out clots before a procedure. However, your doctor will give you specific guidance based on your situation.

Diabetes medications, particularly insulin, may need dose adjustments since you will be fasting. If you take medication for blood pressure, heart rhythm, or other conditions, ask your doctor whether to take them on the morning of the procedure with a small sip of water. Never stop any medication without your doctor's explicit instruction.

What to Bring and Arrange

Because you will receive sedation, you must arrange for someone to drive you home after the procedure. You cannot drive, operate machinery, or make important legal or financial decisions for at least 24 hours after receiving sedation. Plan to have your driver stay at the facility or be available by phone to pick you up when you're ready.

Before your procedure, remove any dentures, dental bridges, or other removable dental work. You should also remove necklaces and any jewelry around your neck area. Wear comfortable, loose-fitting clothing to your appointment. Leave valuable items at home.

What Happens During a TEE Procedure?

During TEE, you'll receive IV sedation and throat-numbing spray, then lie on your left side while a thin, flexible probe is gently passed through your mouth into your esophagus. The cardiologist captures ultrasound images of your heart from various angles over 15-30 minutes, and you'll typically have little or no memory of the procedure due to sedation.

Understanding what happens during the procedure can help reduce anxiety. The medical team performing your TEE is highly trained and experienced, and they will ensure your safety and comfort throughout the process. Most patients report that the anticipation was worse than the actual procedure, and many have little or no memory of the test due to the sedation.

The entire visit, including preparation and recovery, typically takes 2-4 hours, although the actual imaging portion only takes 15-30 minutes. You'll be monitored continuously throughout the procedure, with equipment tracking your heart rhythm, blood pressure, and oxygen levels.

Before Imaging Begins

When you arrive, a nurse will review your medical history, confirm you've followed the preparation instructions, and start an intravenous (IV) line in your arm or hand. This IV is used to administer sedation medication and fluids during the procedure. Monitoring equipment will be attached to track your vital signs.

A local anesthetic spray will be applied to the back of your throat to reduce the gag reflex and make probe insertion more comfortable. This spray has an unpleasant taste and causes temporary numbness in your throat. The numbness typically lasts 30-60 minutes after the procedure.

During the Procedure

You will lie on your left side on an examination table with your head slightly flexed forward. A mouth guard will be placed between your teeth to protect them and the probe. Sedation medication will be administered through your IV, and within minutes you should feel relaxed and drowsy.

Once you're adequately sedated, the cardiologist will gently guide the ultrasound probe through your mouth and into your esophagus. The probe is about the size of your index finger and is flexible. You may feel some pressure during insertion, but the sedation should prevent significant discomfort. The probe is then advanced to various positions to obtain different views of your heart.

Throughout the imaging process, the cardiologist manipulates the probe to capture views from multiple angles. You may be asked to swallow at certain points to help advance the probe, though many patients don't remember this due to sedation. The entire imaging process typically takes 15-30 minutes, though complex cases may take longer.

Immediately After

Once imaging is complete, the probe is gently removed. You'll be taken to a recovery area where you'll be monitored until the sedation wears off, usually 30-60 minutes. A nurse will check your vital signs and ensure you're recovering appropriately before discharge.

What Should You Expect After a TEE?

After TEE, you'll rest in recovery for 30-60 minutes until sedation wears off, then wait 1-2 hours before eating or drinking to let throat numbness resolve. Expect mild sore throat for 1-2 days. You cannot drive for 24 hours. Most people can return to normal activities the next day.

Recovery from TEE is generally straightforward, and most people feel back to normal within a day. Understanding what to expect during recovery helps you plan appropriately and recognize what's normal versus what might require medical attention. The medical team will give you specific discharge instructions before you leave.

The sedation effects gradually wear off over several hours, though you may feel drowsy or have gaps in memory for the rest of the day. This is completely normal and expected. It's important to follow all post-procedure instructions to ensure a safe recovery.

Immediate Recovery

In the recovery area, you'll rest until you're alert enough to safely leave. The throat numbness from the anesthetic spray typically wears off within 1-2 hours. Until this numbness resolves completely, you should not eat or drink anything, as you could choke or aspirate food or liquid without realizing it.

Once the numbness has worn off, you can start with small sips of water. If that goes well, you can progress to other liquids and then soft foods. Many healthcare facilities will offer you water or juice and crackers before discharge to confirm you can swallow safely.

Common Symptoms After TEE

A sore throat is the most common symptom after TEE, occurring in about 20-25% of patients. This soreness is usually mild and resolves within 1-2 days. Over-the-counter throat lozenges or warm salt water gargles can help relieve discomfort. Some patients also experience a hoarse voice temporarily.

You may have some burping or mild abdominal discomfort due to air that was introduced during the procedure. This is normal and resolves quickly. Some drowsiness or fatigue is expected for the rest of the day due to the sedation.

Activity Restrictions

For 24 hours after receiving sedation, you should not drive a car, operate machinery, consume alcohol, or make important decisions. The sedation impairs judgment and reaction time even after you feel alert. Have a responsible adult stay with you or be available for the rest of the day in case you need assistance.

Most people can return to work and normal activities the day after the procedure. However, if your job requires heavy physical labor or critical decision-making, you may want to take the full day off after TEE.

What Are the Risks of TEE?

TEE is a safe procedure with serious complications being rare. The most common side effect is sore throat (20-25% of patients). Rare but serious risks include esophageal injury (less than 0.01%), aspiration pneumonia, bleeding, and reactions to sedation. The benefits typically outweigh risks when TEE is medically indicated.

Like any medical procedure, TEE carries some risks, but serious complications are uncommon. Understanding these risks helps you make an informed decision and recognize potential problems early. When TEE is recommended by your cardiologist, it's because the expected diagnostic benefit outweighs the small risks involved.

The safety of TEE has been well-established through decades of use in millions of patients worldwide. Specialized training for physicians performing TEE and improved equipment design have made the procedure increasingly safe over time. Nevertheless, awareness of potential complications is important.

Common Side Effects

Sore throat is the most frequent complaint after TEE, affecting approximately 20-25% of patients. This soreness results from the passage of the probe through the throat and usually resolves within 1-2 days without treatment. Throat lozenges and warm liquids can help ease discomfort.

Minor bleeding at the back of the throat can occur but is rarely significant. Temporary hoarseness or voice changes are also possible. These minor side effects typically resolve on their own within a few days.

Rare but Serious Complications

Esophageal perforation (a tear in the esophageal wall) is the most feared complication of TEE but is extremely rare, occurring in less than 0.01% of procedures. Patients with pre-existing esophageal disease, such as strictures, tumors, or radiation injury, are at higher risk. This is why it's crucial to inform your doctor of any esophageal problems before the procedure.

Aspiration of stomach contents can occur if the patient vomits during the procedure, which is why fasting beforehand is essential. Reactions to sedation medications, though uncommon, can include respiratory depression or allergic reactions. The medical team monitors you continuously throughout the procedure to detect and manage any such complications immediately.

Dental injury can occur if teeth are chipped or damaged during probe insertion, particularly in patients with loose or fragile dental work. This is why dentures and removable dental appliances should be removed before the procedure.

• Sore throat (20-25%): Most common side effect, resolves in 1-2 days
• Minor bleeding: Usually insignificant and self-limiting
• Esophageal perforation (<0.01%): Very rare but serious, higher risk with esophageal disease
• Aspiration: Prevented by proper fasting and sedation management
• Sedation reactions: Monitored throughout procedure
• Dental injury: Prevented by removing dentures and using mouth guard

How Are TEE Results Interpreted?

TEE results are interpreted by a cardiologist who analyzes the ultrasound images for heart structure, valve function, blood clots, and other abnormalities. Preliminary results are often available immediately, with a full report within 24-48 hours. Your doctor will discuss findings and any necessary next steps with you.

The cardiologist performing your TEE will analyze the images in real-time during the procedure and can often provide preliminary findings immediately afterward. However, a comprehensive written report is usually prepared over the next 24-48 hours, which includes detailed measurements and formal interpretations. Your referring physician will review these results and discuss them with you.

TEE provides both qualitative information (what structures look like) and quantitative measurements (sizes, velocities, pressures). The cardiologist evaluates all four heart chambers, all four valves, the aorta, and looks for any abnormal masses, clots, or structural defects. The detailed nature of TEE images allows for precise diagnosis of many cardiac conditions.

What the Report Includes

A typical TEE report describes the size and function of each heart chamber, with particular attention to the left atrium and left atrial appendage for clot assessment. Valve function is described in detail, including any regurgitation (leakage) or stenosis (narrowing) with severity grading from mild to severe.

The report also describes the aorta, noting any dilation (aneurysm), plaque buildup (atherosclerosis), or signs of dissection. If the TEE was performed to evaluate for endocarditis, the presence or absence of vegetations is specifically noted. Any other abnormal findings, such as tumors, congenital defects, or pericardial effusion, are also described.

Next Steps Based on Results

The management plan following TEE depends entirely on the findings and the original reason for the test. If the TEE was performed before cardioversion and no clots are found, the cardioversion can typically proceed as planned. If a clot is detected, anticoagulation therapy is usually extended and the procedure postponed.

For patients with valve disease, TEE findings help determine whether surgery or a catheter-based procedure is needed and guide the surgical approach. In endocarditis, TEE findings influence decisions about antibiotic duration and potential surgical intervention. Your cardiologist will explain your specific results and recommended next steps.