Management of Heparin Drip Prior to Transesophageal Echocardiogram (TEE)
Heparin drip should be continued during a TEE procedure, as there is no evidence supporting the need to hold anticoagulation prior to TEE, and maintaining anticoagulation is particularly important in patients with atrial fibrillation or other high thrombotic risk conditions.
Risk Assessment for TEE Procedures
- TEE is considered a low-bleeding risk procedure that can be safely performed while maintaining therapeutic anticoagulation 1
- Unlike cardioversion procedures, which have specific anticoagulation protocols before and after the procedure, TEE itself is primarily a diagnostic tool that does not require interruption of anticoagulation 1
- For patients with atrial fibrillation or other high-risk conditions, maintaining anticoagulation is critical to prevent thromboembolic events 1, 2
Evidence Supporting Continuation of Heparin
- Guidelines from the American College of Cardiology/American Heart Association/European Society of Cardiology do not recommend discontinuation of anticoagulation for diagnostic TEE procedures 1
- In patients with atrial fibrillation or atrial flutter, TEE is often used specifically to identify left atrial appendage thrombus, and interrupting anticoagulation could potentially increase thromboembolic risk 1
- For patients who are on heparin as a bridge to cardioversion or for other indications, maintaining therapeutic anticoagulation is essential to prevent thrombus formation 2
Special Considerations
- For patients undergoing TEE-guided cardioversion, intravenous heparin should be administered before the procedure and continued afterward if the patient is not already on adequate anticoagulation 1
- In cases of hemodynamic instability requiring immediate cardioversion after TEE, intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin should be initiated before the procedure 1
- For patients already on therapeutic heparin infusion, maintaining the infusion at therapeutic levels (aPTT 1.5-2.5 times control) is recommended throughout the TEE procedure 3, 4
Potential Exceptions
- In the extremely rare case of patients with known esophageal varices or other high-risk esophageal pathology where the risk of bleeding during TEE is substantially elevated, individual risk assessment may be warranted 1
- For patients with severe thrombocytopenia or other coagulopathies in addition to being on heparin, additional caution may be needed 5
Practical Approach
- Continue heparin infusion at the prescribed therapeutic dose during TEE 3, 4
- Monitor aPTT to ensure therapeutic anticoagulation (1.5-2.5 times control) 3, 4
- If TEE is being performed as part of a cardioversion procedure, ensure anticoagulation is maintained for at least 3 weeks before and 4 weeks after cardioversion 1
Common Pitfalls to Avoid
- Unnecessarily holding anticoagulation before TEE, which could increase thromboembolic risk, especially in high-risk patients 1, 2
- Confusing TEE-only procedures with TEE-guided cardioversion procedures, which have different anticoagulation requirements 1
- Failing to restart anticoagulation promptly if it was held for any reason 1