Transesophageal echocardiography for prosthetic valve evaluation: is it always necessary?

Transesophageal echocardiography provides excellent images of mitral and aortic prostheses, due to its higher resolution and less interference from other cardiac structures. Since the introduction of transesophageal echocardiography, it has proved to be valuable for the evaluation of prosthetic heart valves. "Classic" indications include the evaluation of prosthetic valve endocarditis, the search for paravalvular abscesses, and the assessment of regurgitation in mechanical, especially mitral, prostheses. New technical developments such as biplane or multiplane transducers enhance the diagnostic capabilities of the technique. Transesophageal echocardiography can also have advantages in recognizing obstructive lesions such as thrombi or pannus, and help understand the complex morphology of prostheses in grafts. Transesophageal echocardiography should be considered a backup technique whenever transthoracic echocardiography, which always remains the primary approach, is inconclusive or negative in the presence of clinically suspected prosthetic valve malfunction.