Can a Transesophageal Echocardiogram (TEE) be performed in a patient with dysphagia?

Transesophageal Echocardiography in Patients with Dysphagia

Transesophageal echocardiography (TEE) should be avoided or used with extreme caution in patients with dysphagia, as it can worsen swallowing function and potentially cause esophageal trauma. 1, 2

Risk Assessment for TEE in Dysphagia

Dysphagia represents a significant contraindication to TEE due to several important considerations:

Contraindications

• Absolute contraindications to TEE include:

  • History of dysphagia
  • Current pathologic conditions of the esophagus
  • Recent esophageal operations 3

• Relative contraindications requiring risk-benefit assessment:

  • Esophageal varices
  • Active upper gastrointestinal bleeding 3

Evidence of Harm

Recent research demonstrates that TEE can negatively impact swallowing function:

• A prospective, randomized controlled trial found significant worsening of dysphagia measures in stroke patients after TEE, with effects lasting at least 24 hours 2
• Complications from TEE can be related to:
  • The probe itself
  • The procedure
  • Medications used during examination 3

Alternative Approaches

Pre-TEE Assessment

If TEE is clinically necessary despite dysphagia:

• Consider esophagogastroduodenoscopy (EGD) before TEE
  • Research shows 15% of patients evaluated with EGD before TEE were not cleared due to:
    • Esophageal surface abnormalities (esophagitis, ulcers)
    • Structural abnormalities (varices, strictures, rings, webs)
    • Other combinations of pathology 4

Alternative Imaging Options

When TEE is contraindicated, consider:

1. Transthoracic echocardiography (TTE) as first-line approach 1
2. Epicardial echocardiography when TEE is not feasible 5
3. CT imaging in specific clinical scenarios 1

Clinical Decision Algorithm

1. Assess dysphagia severity:

   • Obtain detailed history of swallowing difficulties
   • Consider formal swallowing evaluation if diagnosis uncertain

2. Determine clinical necessity of TEE:

   • For suspected endocarditis, prosthetic valve assessment, or cardiac source of embolism, TEE provides superior diagnostic information 1
   • For routine cardiac assessment, TTE may be sufficient

3. If TEE is deemed necessary despite dysphagia:

   • Consider EGD first to evaluate esophageal patency and safety 4
   • Implement additional precautions during procedure:
     • Use smaller probe if available
     • Minimize sedation to maintain protective reflexes
     • Have experienced operator perform the procedure

Important Caveats

• TEE can worsen dysphagia for at least 24 hours post-procedure, particularly concerning in stroke patients who already have swallowing difficulties 2
• Upper airway obstruction has been reported as a complication of TEE 6
• The risk of aspiration may be increased following TEE in patients with pre-existing dysphagia
• In patients with known esophageal disease or upper GI symptoms, pre-TEE assessment with EGD can change management in approximately 15% of cases 4

When balancing diagnostic needs against patient safety, the evidence suggests that alternative imaging approaches should be strongly considered before subjecting patients with dysphagia to the risks of TEE.