From the Guidelines
Transesophageal echocardiography (TEE) is recommended when transthoracic echocardiography (TTE) provides inadequate visualization of cardiac structures or when more detailed imaging is required for specific cardiac conditions, such as suspected endocarditis, cardiac masses, prosthetic valve function, complex congenital heart disease, aortic dissection, and potential sources of cardiac emboli, as supported by the most recent guidelines 1.
Key Indications for TEE
- Evaluating suspected endocarditis and its complications
- Assessing cardiac masses, prosthetic valve function, and complex congenital heart disease
- Diagnosing aortic dissection and other aortic pathologies
- Identifying potential sources of cardiac emboli
- Guiding cardiac surgeries and interventional procedures
Procedure and Risks
TEE involves inserting a probe into the esophagus, which positions the ultrasound transducer closer to the heart, allowing for higher resolution images and better assessment of posterior cardiac structures. The procedure requires conscious sedation or general anesthesia and carries small risks, including esophageal injury, bleeding, and aspiration. Patients typically fast for 6 hours before the procedure, and those with esophageal disorders may not be suitable candidates.
Clinical Applications
TEE is particularly useful in patients with suspected cardiac trauma, critically ill medical or surgical patients with unstable hemodynamics, and those whose clinical status necessitates echocardiographic assessment but in whom TTE studies are technically inadequate or non-diagnostic, as noted in studies 1. The superior imaging quality of TEE makes it an essential diagnostic tool when standard echocardiography is insufficient for clinical decision-making.
From the Research
Trans Esophageal Echocardiography (TEE) Recommendations
TEE is recommended for evaluating cardiac structures in various clinical scenarios, including:
- Diagnosis of direct and indirect sources of cardioembolism, where TEE has a higher yield than transthoracic echocardiography (TTE) 2
- Detection of abnormalities of mitral prostheses and endocarditis-related complications of aortic prostheses, where TEE is highly sensitive 2
- Localization and characterization of cardiac and paracardiac masses, where TEE is superior to TTE 2
- Diagnosis of aortic dissection, where TEE can show the site, type, and extent of the tear 2
Safety and Contraindications
TEE is considered relatively safe and noninvasive, but it can cause oropharyngeal, esophageal, or gastric trauma 3. Absolute contraindications to TEE include:
- History of dysphagia
- Current pathologic conditions of the esophagus
- Recent esophageal operations 2 Relative contraindications include esophageal varices or active upper gastrointestinal bleeding, where the risk-to-benefit ratio must be assessed before TEE is performed 2
Critical Care and Training
Critical care TEE is useful in characterizing shock states and is safe, feasible, and easy to learn 4. Training and equipment are essential for performing TEE, and it is recommended as a component of advanced critical care echocardiography 4. In the critical care environment, TTE should be considered the initial and principal echocardiographic test, as it can identify the great majority of cardiac causes of shock 5
Patient Tolerance
TEE can be performed on unsedated outpatients, and the technique is well tolerated by most patients, although some may find swallowing the transducer unpleasant 6. Patient tolerance and preference for sedation or unsedation should be assessed on an individual basis.