A TEE, or transesophageal echocardiogram, is a heart imaging test that uses sound waves to create detailed pictures of your heart and upper aorta from inside your body. Unlike a standard echocardiogram, which places a device on the outside of your chest, a TEE involves guiding a small ultrasound probe down your throat and into your esophagus. Because your esophagus sits directly behind your heart, the probe captures much sharper images without bones, lungs, or skin getting in the way.
Why TEE Produces Better Images
A standard echocardiogram, called a transthoracic echo (TTE), works from the outside of your chest. It’s painless and noninvasive, but the ultrasound signal has to pass through your ribs, lung tissue, and skin before reaching the heart. That journey weakens the signal and can blur the final image, especially in people with larger body frames, lung disease, or certain chest wall conditions.
A TEE bypasses all of that. The esophagus runs just millimeters behind the heart, so the ultrasound probe gets an almost unobstructed view. This proximity allows the test to pick up small structures that a chest-wall echo might miss entirely, like tiny blood clots, subtle valve damage, or infections on heart valves. When a standard echo doesn’t provide enough detail, or when the stakes of missing something are high, a TEE is typically the next step.
Conditions a TEE Can Detect
Doctors order a TEE for a focused set of reasons, almost always when they need a level of detail a standard echo can’t deliver. The most common indications include:
- Blood clots in the heart. Specifically, TEE is used to check for clots in a small pouch called the left atrial appendage. This is especially important for people with atrial fibrillation, where blood can pool and form clots that travel to the brain and cause a stroke.
- Heart valve infections (endocarditis). Bacteria can attach to heart valves and form small growths called vegetations. These are often too small for a standard echo to detect but show up clearly on TEE.
- Valve disease and prosthetic valve problems. TEE gives a close-up view of how well natural and artificial valves are opening, closing, and sealing. If a replacement valve is leaking or malfunctioning, TEE is one of the best ways to see it.
- Aortic emergencies. A tear in the wall of the aorta (aortic dissection) or an aortic aneurysm can sometimes be evaluated with TEE, particularly in urgent situations where speed matters.
- Source of a stroke or embolism. When someone has had a stroke and doctors suspect a clot originated in the heart, TEE is the go-to test to look for the source.
TEE also plays a real-time role during certain heart surgeries and catheter-based procedures. Surgeons use it during valve repairs, congenital heart surgeries, and newer procedures like transcatheter mitral valve repair to verify anatomy before the repair and confirm success immediately after.
What Happens During the Test
The actual imaging portion of a TEE takes about 20 minutes, but you should expect to be at the facility for 60 to 90 minutes total once you account for preparation and recovery time.
Before the probe goes in, your throat is numbed with a lidocaine spray to reduce the gag reflex. You’ll also receive sedation through an IV, which makes you drowsy and relaxed. Most people are in a twilight state during the procedure, aware enough to follow simple instructions like swallowing on cue but not fully alert. The level of sedation can vary, and your care team adjusts it based on how you’re responding.
Once you’re sedated, the doctor gently guides a flexible tube, roughly the width of a finger, into your mouth and down your esophagus. The tip of this tube contains a tiny ultrasound transducer. As it’s positioned at different levels behind the heart, it captures images from multiple angles. You may feel some pressure in your throat, but pain is uncommon. The probe is removed as soon as the imaging is complete.
How to Prepare
You’ll need to fast before the procedure, typically for at least six hours. An empty stomach is important both for safety during sedation and to reduce the risk of aspiration. Your doctor’s office will give you specific timing instructions based on when your test is scheduled.
Because you’ll be sedated, you won’t be able to drive yourself home. Arrange for someone to pick you up beforehand. You should also let your doctor know about any esophageal problems you’ve had in the past, such as narrowing (strictures), swallowing difficulties, or a history of radiation to the chest, since these can affect whether the procedure is safe for you.
Recovery After a TEE
After the probe is removed, you’ll rest in a recovery area while the sedation wears off. Your throat will likely feel numb for a while from the lidocaine spray. You’ll be asked to wait before eating or drinking anything, usually about one to two hours, until the numbness fades and your swallowing reflex returns to normal. This prevents food or liquid from going down the wrong way.
A mild sore throat is the most common aftereffect and usually resolves within a day. Most people return to normal activities the following day, though you should avoid driving or making important decisions for the rest of the day due to lingering sedation effects.
Risks and Complications
TEE is considered a safe procedure for the vast majority of patients. The most serious potential complication is a perforation, or tear, in the esophagus. This is rare, occurring in an estimated 0.03% to 0.09% of cases performed during cardiac surgery. When it does happen, it’s a serious event associated with extended hospital stays and significant mortality, which is why doctors carefully screen for esophageal conditions before proceeding.
More common but less serious issues include mild throat soreness, temporary difficulty swallowing, and minor bleeding at the throat. Reactions to sedation medications, such as a drop in blood pressure or slowed breathing, are possible but monitored closely throughout the test. The care team tracks your heart rate, oxygen levels, and blood pressure the entire time.
People with known esophageal conditions, including strictures, large varicose veins in the esophagus (varices), recent esophageal surgery, or significant swallowing disorders, may not be candidates for the test. In those cases, doctors will use alternative imaging methods to get the information they need.