Is it safe to perform a Transesophageal Echocardiogram (TEE) in a patient with esophageal candidiasis and an acute Cerebrovascular Accident (CVA) to rule out endocarditis?

TEE in a Patient with Esophageal Candidiasis and Acute CVA

Transesophageal echocardiography (TEE) should not be performed in a patient with active esophageal candidiasis until the infection has been adequately treated with antifungal therapy. 1

Contraindications and Risk Assessment

Esophageal candidiasis presents a direct contraindication to TEE due to several important concerns:

• Risk of mucosal trauma: The TEE probe can damage the already inflamed and friable esophageal mucosa infected with candidiasis 1
• Potential for systemic spread: Trauma to infected mucosa may create portals for fungal dissemination into the bloodstream 1
• Worsening of infection: Mechanical irritation can exacerbate the existing infection 1
• Risk of esophageal perforation: A rare but potentially fatal complication, especially in patients with underlying esophageal pathology 2

Management Algorithm

1. Treat esophageal candidiasis first:

   • Administer appropriate systemic antifungal therapy
   • Ensure clinical improvement of esophageal symptoms
   • Allow adequate time for mucosal healing (typically 7-14 days)

2. Consider alternative imaging while treating candidiasis:

   • Transthoracic echocardiography (TTE) as initial assessment
   • TTE with ultrasound-enhancing agents if better visualization is needed
   • Cardiac CT or MRI as alternative diagnostic options 1

3. Assess CVA-related considerations:

   • Recent acute CVA increases risk of hemodynamic instability during sedation
   • Balance urgency of endocarditis diagnosis against risks of procedural complications
   • Consider neurological stability before proceeding with TEE

4. Proceed with TEE only after:

   • Documented resolution of esophageal candidiasis
   • Neurological stability from the CVA
   • Careful risk-benefit assessment by the cardiology team

Evidence-Based Rationale

TEE is significantly more sensitive than TTE for detecting vegetations and perivalvular complications of endocarditis 3. In patients with candidemia, TEE has identified endocarditis in 4.2-5.9% of cases that might otherwise be missed 4. However, these benefits must be weighed against the risks.

The American Heart Association guidelines support TEE for evaluation of suspected endocarditis, particularly in high-risk patients 3, but also recognize contraindications such as esophageal disease 1, 5. A case report has documented esophageal perforation during TEE in a patient with asymptomatic esophagitis, highlighting the potential for severe complications even when standard protocols are followed 2.

Important Considerations

• Timing matters: If endocarditis is strongly suspected, treating the esophageal candidiasis promptly will minimize delays in performing TEE
• Documentation: Clearly document the contraindication and treatment plan in the medical record
• Communication: Ensure all team members understand the rationale for delaying TEE
• Follow-up: Schedule TEE as soon as the esophageal candidiasis has been adequately treated

Pitfalls to Avoid

• Don't rush: Performing TEE before adequate treatment of esophageal candidiasis risks serious complications
• Don't delay treatment: Begin antifungal therapy immediately to minimize the delay in performing TEE
• Don't rely solely on TTE: While TTE can be used initially, recognize its limitations in detecting small vegetations and perivalvular complications 6
• Don't ignore newer imaging options: 3D TEE (when eventually performed) may provide superior anatomic delineation for surgical planning 7