Techniques and Tricks for Optimizing Transesophageal Images

Techniques and Tricks for Optimizing Transesophageal Images

Loren R. Francis

Eric Nelson

Alan C. Finley

Scott T. Reeves


The accuracy and diagnostic confidence of a transesophageal echocardiographic (TEE) study depends greatly on the quality of the ultrasound image. Image quality is affected by several factors, including the patient anatomy, the quality of the ultrasound system, and the skill of the echocardiographer. This chapter discusses the controls on the echocardiography machine and the process of optimizing their settings to obtain images of the highest quality.


Preprocessing Versus Postprocessing Controls

Preprocessing controls adjust the transmission and acquisition of the ultrasound signals. Preprocessing settings control the formatting of the ultrasound signal for conversion into an electric signal. Changes in the preprocessing controls affect the information that the scanner will acquire to create an image (1), and this information is used to create an image. Postprocessing settings affect how the formatted information is displayed on the monitor. Postprocessing defines the “cosmetic appearance” of the ultrasound data displayed on the monitor.

Transmit Power

Transmit Power controls the amplitude (acoustic power) of the transmitted ultrasound signal. Modern echocardiography systems default to a high-power setting to maximize the signal-to-noise ratio. A theoretic concern is that high-power ultrasound can have deleterious effects on the tissue, particularly in fetal echocardiography. Federal standards restrict the maximal intensities allowed for Transmit Power settings on commercially available ultrasound systems. Typically, echocardiography systems default to the maximum Transmit Power. Proper adjustment of Transmit Power becomes critical when echo contrast studies are performed.


Increasing the gain increases the amplitude of the electric signal generated by returning ultrasound signals received at all depths. Unfortunately, any noise present is also amplified. Setting the gain too high or too low affects the ability to read the image correctly. When the gain is set too high, the image appears bright, and linear structures, such as the mitral valve, appear thickened. Increases in the gain also increase the amount of visible noise. For instance, with moderately excessive gain settings, the left ventricular (LV) cavity acquires a speckled appearance, which can make it difficult to differentiate the LV cavity from the myocardium. With further increases in the gain, the entire LV takes on a whitened appearance and the ability to differentiate structures is lost.

When the gain is set too low, only bright signals, such as those from the pericardium, are visible, and very-low-amplitude signals, such as the signal from an LV thrombus or “smoke” in the LV, are lost (2). Therefore, the gain should be adjusted to obtain an image with a gray scale ranging from low-amplitude (dark gray) to high-amplitude (white) signals. The gray scale, displayed as a bar graph on the right side of the image, is useful for guiding adjustments. Figure 23.1 image (Video 23.1A-C) demonstrates the effect of three separate gain settings on the same mid-esophageal two-chamber view image (Video 23.1A-C).

Clinical Pearl

The bright ambient lighting of the operating room often misleads the echocardiographer to use excessive gain settings. This problem can be overcome by eliminating the operating room lights briefly during the examination or shielding the screen with a hood.

FIGURE 23.1 The mid-esophageal two-chamber view with the gain setting normal (A), too low (B), and too high (C). See image Video 23.1A-C.

Time Gain Compensation

Attenuation results in the signals returning from the far field being weaker than signals from the near field. Therefore, the ability to selectively adjust the gain setting at each depth is essential to optimize the image and is commonly referred to as time gain compensation (2). For example, the echocardiographer can use the time gain compensation to amplify the weaker signals returning from the far field more than the signals returning from shallower depths (near field). The echocardiographer should be careful when adjusting the time gain compensation. If it is set too low, the elimination of true tissue signals is a risk. The time gain compensation should be used to eliminate gain-related artifacts and optimize far-field structures. The effects of time gain compensation settings on image quality are shown in Figure 23.2 image (Video 23.2B,C).

Clinical Pearl

In a normal examination, the time gain compensation controls are set lower in the near field and higher in the far field. However, for imaging pathology in the near field with low echogenicity (e.g., thrombus in the aorta or left atrium), the near-field time gain compensation should be increased.

Lateral Gain Compensation

Ultrasound beams transmitted through tissue side by side can be subject to different levels of attenuation. Lateral gain compensation is used to counter this effect by amplifying the weaker signals to a greater extent and ensures brightness is uniform across the entire width of the image display. The effects of lateral gain compensation can be used to amplify weaker lateral signals and aid in detection of endocardial borders. The effects of lateral gain compensation on image quality are shown in Figure 23.3 image (Video 23.3B,C).


This control selects the maximal distance to be displayed. Increasing depth beyond the structure of interest has several negative consequences.

FIGURE 23.2 A: The time gain compensation is determined by a series of sliding controls. The upper controls affect the near field and the lower controls the far field. Note the high setting of the second control and its effect on the midfield in (B). B: The mitral valve apparatus is obscured by specular noise. C: The time gain compensation controls were subsequently reduced, after which the image quality improved markedly. See image Video 23.2B,C.

  • The image size is reduced. The most obvious consequence is that the image size is reduced because a larger area of the cardiac anatomy must be displayed on a screen of fixed size. The display of the cardiac structure of interest will be smaller and therefore more difficult to evaluate.

  • The frame rate is lower. In addition, as the depth is increased, the frame rate of the two-dimensional ultrasound is slowed because the system must wait longer for signals to be received. Doubling the depth of penetration doubles the wait time before another pulse can be sent, so that the pulse repetition frequency and subsequently the frame rate are decreased (3).

Therefore, to optimize the image display and temporal resolution, the depth should be set just beyond the structure of interest, as shown in Figure 23.4.

It must also be appreciated that the lateral resolution of the ultrasound system is inversely proportional to the depth. Therefore, it is practical to have the position of the probe as close as possible to the structure of interest. For example, when the leaflets of the aortic valve are being evaluated, the mid-esophageal (ME) aortic valve short-axis view is preferable to the deep transgastric (TG) long-axis view because the probe is closer to the aortic valve and lateral resolution is improved.

Clinical Pearl

Resist increasing the depth beyond the setting that displays the structure of interest.


The focus control enables the operator to focus the ultrasound beam at a selected distance from the transducer. This is achieved by altering the sequences of electric impulses sent to the transducer elements. The
goal of focusing is to have the beam narrowest at the location of the structure being evaluated because a thinner beam improves lateral resolution (4). The user must be cognizant of the focus depth of the system, which is typically marked on the edge of the sector (Fig. 23.4; image Video 23.4A-B).

FIGURE 23.3 A: The lateral gain compensation is determined by a series of sliding controls. The left controls affect the left of the image sector while the right controls affect the right. Note the high setting on the second control from the right and its effect on visualizing the anterior wall in (B). B: The anterior wall is obscured by specular noise. C: The lateral gain compensation controls were subsequently reduced, after which the image quality improved. See image Video 23.3B,C.

If the focal zone is located too far from the area of interest, the image resolution may not be sufficient for proper evaluation. When the atrial septum is being evaluated for a patent foramen ovale, the focus should
be placed at this level. Remember that structures distal to the focal point lie in the far field and may appear “fuzzy” or abnormally thick. Avoid evaluating small structures distal to the focal point until the focal point is moved to that level.

FIGURE 23.4 The transgastric mid short-axis view with too much depth (A) and with the depth correctly set (B). Note the focal point in image (B) is located at 6 cm, exactly in the center of the left ventricle. The focal point is marked by a bar with a green circle in the middle. Also note the frame rate has decreased from 50 to 47 Hz (shown in upper left-hand corner) with increasing the depth. See image Video 23.4A,B.

Clinical Pearl

Adjust the focus point to the level of the structure of interest for high-resolution imaging.


A feature of modern TEE systems is that they are capable of multiple frequencies, so that the transmitted ultrasound frequency can be adjusted. This can be especially important in TEE applications. The basic principle is that higher-frequency beams maximize the length of the near field. When the structures being evaluated are in close proximity to the transducer (atria, aorta), higher frequencies are used to optimize resolution (5). When the structures being evaluated are farther from the transducer (deep TG views), higher frequencies may not be adequate because penetration is poor and attenuation is greater. In these situations, the frequency should be reduced until a satisfactory image is produced.

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Apr 16, 2020 | Posted by in ANESTHESIA | Comments Off on Techniques and Tricks for Optimizing Transesophageal Images
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