From the Guidelines
Transesophageal echocardiography (TEE) is indicated for the evaluation of suspected infective endocarditis, particularly when transthoracic echocardiography (TTE) provides inadequate imaging or when specific cardiac conditions require enhanced visualization, as supported by the most recent guidelines 1.
Indications for TEE
The primary indications for TEE include:
- Evaluation of suspected endocarditis to detect vegetations, with a sensitivity of up to 98.6% negative predictive value in suspected infective endocarditis 1
- Assessment of prosthetic heart valves for potential dysfunction or paravalvular leaks, with TEE being significantly more accurate than TTE 1
- Diagnosis of aortic dissection or aneurysm
- Detection of cardiac sources of embolism, particularly in patients with cryptogenic stroke
- Evaluation of complex congenital heart disease
Clinical Applications of TEE
TEE is also valuable for:
- Guiding interventional cardiac procedures such as transcatheter valve replacements, left atrial appendage closures, and septal defect closures
- Monitoring cardiac function during major cardiac and non-cardiac surgeries in the perioperative setting
- Providing superior imaging of posterior cardiac structures, including the left atrium, atrial septum, and mitral valve, due to the proximity of the esophagus to these structures
Procedure Considerations
The procedure requires sedation and carries small risks of esophageal trauma, so it should be performed by experienced operators with appropriate patient preparation, including:
- Fasting for 6 hours prior to the procedure
- Removal of dentures
- Assessment for contraindications such as esophageal strictures or recent esophageal surgery As noted in the guidelines, TEE has better sensitivity and accuracy than TTE for detecting vegetations and paravalvular abscesses, making it a crucial diagnostic tool in the evaluation of suspected infective endocarditis 1.
From the Research
Indications of Transesophageal Echo
- Transesophageal echocardiography (TEE) is useful in various clinical scenarios, including:
- Hemodynamically unstable patients with suboptimal transthoracic echocardiography (TTE) images or if mechanically ventilated 2
- Patients with suspected aortic dissection or aortic injury 2
- Patients with suspected endocarditis, cardiac or aortic source of emboli 2
- Atrial fibrillation patients undergoing cardioversion, to detect atrial thrombi and guide risk stratification 3, 4
- TEE is also indicated in critically ill patients, including those in shock, cardiac arrest, or trauma, and for guiding endovascular procedures 5, 6
- The use of TEE can provide excellent visualization of cardiac structures, impact patient management, and has a low complication rate 2
Specific Clinical Scenarios
- Atrial fibrillation: TEE can detect atrial thrombi, guide cardioversion, and reduce the risk of thromboembolic events 3, 4
- Cardiac arrest: TEE can be used to evaluate cardiac function and guide resuscitative efforts 6
- Trauma: TEE can be used to assess cardiac function and guide management in trauma patients 6
Benefits and Limitations
- TEE provides high-quality images and allows for continuous monitoring during hemodynamic interventions 6
- TEE has a low complication rate, making it a safe and feasible modality in critical care settings 2, 5
- However, the use of TEE requires specialized training and equipment, and may not be available in all clinical settings 5, 6