Similar to a TTE, the necessary equipment’s are the portable echocardiography unit; an ultrasound probe with multiplane imaging capabilities and trained personnel in sedation and transesophageal echocardiography based on the ACC/AHA competency guidelines. The TEE probe is a modified gastroesophageal probe with a 3–7 Mhz ultrasound transducer at its tip. The diameter of an adult transducer is 9–14 mm and can be maneuvered in a left-right direction and retroflexion/anteflexion using a rotating knob/wheel at the proximal operator end. The transducer tip is equipped with a multiplane that can be rotated from 0° to 180°.

The TEE room should be equipped with vitals monitor to record BP, HR, pulse oximeter, oxygen supply, oral suction, bite guard, pillow wedge to position the patient, and a cardiopulmonary resuscitation crash cart.

In addition to the physician, at least two additional personnel are required: a sonographer to operate the echocardiographic machine, optimize and acquire the images, and a nurse that will be monitoring the patient vitals (BP, HR, RR, oxygen saturation), administering sedatives/analgesics, and suctioning the oropharynx.

The procedure starts with patient and room preparation. The room should be equipped with all the supplies/medications required as indicated above. TEE is considered a semi-invasive procedure and a thorough conversation should be performed with the patient explaining the indications, alternatives and possible complications; informed consent should then be obtained. To avoid or reduce the risk of aspiration, the patient should be NPO for at least 6 h. Prior to the start of the procedure, a review of the patients’ history, medications, allergies and laboratory data should be performed. A physical exam should also be performed with attention made to the respiratory, cardiovascular system and the Mallampati score (Class I–IV) (Also see Chap. 17). The physical status classification according to the American Society of Anesthesiologists (ASA) should be performed, Classes I–VI, with a level of III and above requiring anesthesiology support. A recent coagulation profile should be reviewed and if patients are on anticoagulation, those agents should be held hours or days prior depending on the type of agent.

The patient is positioned in left lateral decubitus position at a 30–45° inclination to reduce the risk of aspiration. Local anesthesia spray is then performed using tongue depressors to anesthesize the oropharynx. A bite guard is placed to protect the TEE probe from inadvertent biting. Two techniques have been described for the esophageal intubation: hands-in or hands-out techniques. Using the hands-in technique, two fingers are placed inside the oropharynx and are used to depress the tongue and guide the probe (transducer ultrasound facing towards the tongue) towards the posterior pharynx. If patient is under conscious sedation, he/she can be asked to swallow which assists the probe to easily intubate the esophagus. If resistance is encountered at any point, the probe should not be forced further. The probe has markings to help with localization (distance from incisors to mid esophagus approx. 30–35 cm and distance to the stomach 40–45 cm). Throughout the procedure, the vital signs should be monitored and the oropharynx suctioned as necessary.