Transesophageal echocardiography is a critically important cardiovascular imaging modality. The proximity of the esophagus to much of the heart and great vessels makes it an excellent ultrasonic window so that TEE provides additional and more accurate information than transthoracic echocardiography TTE. TEE has proven utility in a number of clinical areas including the operating room, intensive care unit, interventional laboratory, and outpatient setting. TEE has become an essential imaging tool for cardiac surgeons, anesthesiologists, cardiac interventionalists, and clinical cardiologists. TEE examination in the outpatient setting is usually done for diagnostic purposes by cardiologists facilitated with local aerosol sprays or viscous gels to anesthetize the pharynx. For intraprocedural TEE examination in the operating room and catheterization laboratory where anesthesiologists are involved, probe insertion is carried out under general anesthesia with endotracheal intubation. The TEE probe resembles a flexible endoscope that consists of probe tip with acoustic lens, shaft, handle and a connector to attach to the echo machine. Even though TEE examination is a semi invasive procedure, it is not without complications which are related mainly to the probe insertion. The list of complications varies from minor injury to major bleeding. However, the complications of TEE examination in the hands of trained physicians are rare, if the test is performed diligently and patiently.  Different techniques of TEE probe insertion have been described such as blind insertion through the midline with the mandible lifted, jaw thrust maneuver, reverse Sellicks maneuver, rigid laryngoscope assistance or optical guided insertion and video laryngoscope. Factors that predict difficult endotracheal intubation included age, sex, BMI, Modified Mallampati Criteria and Modified Cormack Lehane grade would be helpful in the evaluation of  difficult TEE probe placement.

We propose to do a  prospective observational study aimed at identifying the predictive factors for difficult insertion of TEE probe in anesthetized adult patients undergoing cardiac surgery and to correlate the predictive factors with the maneuver  required to insert the TEE probe.