How should blood thinners be managed in patients undergoing a Transesophageal Echocardiogram (TEE) to evaluate for endocarditis?

Blood Thinner Management Before TEE for Endocarditis Evaluation

For patients undergoing transesophageal echocardiography (TEE) to evaluate endocarditis, blood thinners should NOT be discontinued prior to the procedure in most cases, as the risk of thromboembolism from interrupting anticoagulation outweighs the bleeding risk associated with TEE. 1

Anticoagulation Management Algorithm

For Patients on Oral Anticoagulants:

• Continue anticoagulation without interruption for patients with:

  • Prosthetic heart valves
  • Recent history of thromboembolism
  • High CHADS₂ score (≥3)
  • Known or suspected endocarditis

• Consider minimal interruption (skipping 1-2 doses) only for patients at very low thrombotic risk who are at high bleeding risk 1

For Patients on Different Anticoagulant Types:

1. Vitamin K Antagonists (e.g., Warfarin):

   • Continue without interruption if INR <3.0
   • If INR >3.0, consider dose adjustment to achieve target INR 2.0-3.0 before TEE

2. Direct Oral Anticoagulants (DOACs):

   • Continue uninterrupted in most cases
   • If high bleeding risk, consider skipping only the morning dose on the day of procedure

3. Antiplatelet Agents:

   • Continue aspirin and P2Y12 inhibitors without interruption
   • For dual antiplatelet therapy, continue both medications

Special Considerations

For Confirmed Endocarditis:

• Maintain therapeutic anticoagulation throughout TEE procedure if endocarditis is already confirmed or highly suspected 1
• TEE is essential for detecting complications such as vegetations, paravalvular abscesses, and valvular dysfunction that may influence management decisions 1

For Patients with Prosthetic Valves:

• Never interrupt anticoagulation as these patients are at highest risk for thromboembolism 1
• TEE has >90% sensitivity for detecting prosthetic valve vegetations and abscesses, making it crucial for diagnosis 1

For Patients with Suspected S. aureus Endocarditis:

• Maintain anticoagulation as TEE is particularly important in these cases to rule out endocarditis and guide treatment duration 1
• TEE should be performed in all S. aureus bacteremia cases except when fever and bacteremia resolve within 3 days after catheter removal with no predisposing cardiac conditions 1

Procedural Considerations

• Periprocedural heparin bridging should be avoided except in very high thrombotic risk patients 1
• Target activated clotting time >300s during the procedure if heparin is used 1
• Monitor for bleeding complications during and after the procedure, particularly in the oropharynx and esophagus

Potential Pitfalls and Caveats

• Do not discontinue anticoagulation based solely on concerns about procedural bleeding, as TEE-related bleeding risk is low compared to thromboembolism risk in endocarditis
• Avoid heparin bridging in most cases as it may increase bleeding risk without providing additional protection
• Remember that negative TTE findings alone cannot rule out endocarditis; TEE has significantly higher sensitivity (>90% vs 43-98% for TTE) 1
• Consider alternative imaging (cardiac CT or MRI) only if TEE is absolutely contraindicated 2

By maintaining anticoagulation during TEE for endocarditis evaluation, you minimize the risk of thromboembolism while obtaining crucial diagnostic information that will guide appropriate treatment decisions.