When is transesophageal echocardiography (TEE) recommended for assessing cardiac structure and function?

Transesophageal Echocardiography (TEE) Indications

Transesophageal echocardiography (TEE) is recommended when transthoracic echocardiography (TTE) is non-diagnostic or when specific cardiac structures require superior visualization that cannot be achieved with TTE. 1

Primary Indications for TEE

When TEE is First-Choice Imaging

• TEE is recommended as first-line imaging when TTE is expected to yield suboptimal images due to patient characteristics such as mechanical ventilation, intraoperative or post-operative status, severe chest wall deformation/injury, or lung emphysema 1
• TEE should be first-choice in clinical scenarios where visualization of specific cardiac structures is necessary to confirm or reject diagnoses with high morbidity and mortality, including:
  • Acute aortic syndrome (dissection, transection) 1
  • Acute valvular regurgitation 1
  • Acute prosthetic valve dysfunction 1
  • Acute massive pulmonary embolism 1
  • Chest trauma with suspected aortic injury 1
• TEE is indicated in patients with symptomatic atrial fibrillation/flutter to facilitate clinical decision-making (e.g., cardioversion) 1

Infective Endocarditis Assessment

• TEE is superior to TTE for detecting vegetations, with sensitivity of 85-90% compared to 75% for TTE 1
• TEE is essential for identifying perivalvular complications such as abscesses, fistulae, and pseudoaneurysms 1
• Repeat TEE is recommended 7-10 days after initial "negative" TEE when clinical suspicion of endocarditis persists 1
• TEE should be performed as soon as possible in patients with positive TTE who are at high risk for cardiac complications 1

Cardiac Source of Embolism

• TEE has substantially higher yield than TTE for diagnosis of direct and indirect sources of cardioembolism 2, 3
• TEE is superior for detection of left atrial appendage thrombi, patent foramen ovale, and atrial septal defects 1, 3
• TEE is required before cardioversion or ablation in all unanticoagulated patients with atrial flutter/fibrillation persisting >48 hours 1

Procedural Guidance and Monitoring

• Intraoperative TEE is recommended for patients undergoing surgical septal myectomy to assess mitral valve anatomy and function and adequacy of septal myectomy 1
• TEE is indicated for guidance during alcohol septal ablation, with intracoronary ultrasound-enhancing contrast injection of candidate septal perforator(s) 1
• TEE is essential for monitoring left atrial appendage occlusion device placement, with follow-up TEE recommended at 45 days and 1 year to evaluate for device-related thrombus and peridevice leak 4

When to Use TEE After TTE

• TEE should be performed when TTE is inconclusive in clinical decision-making regarding medical therapy 1
• TEE is indicated when planning for myectomy, excluding subaortic membrane, assessing mitral regurgitation due to structural abnormalities, or evaluating feasibility of alcohol septal ablation 1
• TEE is recommended when the diagnosis of apical hypertrophic cardiomyopathy, apical aneurysm, or atypical patterns of hypertrophy is inconclusive on TTE 1

Contraindications and Precautions

• Absolute contraindications include history of dysphagia, current esophageal pathology, and recent esophageal operations 2
• Relative contraindications include esophageal varices and active upper gastrointestinal bleeding, requiring risk-benefit assessment 2, 5
• The procedure should not be performed in patients who consumed a meal 4-6 hours before the test 3
• Complication rate is very low (0.47%) in ambulatory settings, with potential complications including tracheal intubation, atrial fibrillation, and bronchospasm 6

Special Considerations

• In intensive care units (ICU), TEE is particularly valuable for ventilated, critically ill patients who cannot be adequately assessed by TTE 1, 2
• TEE has limited role in neonates, infants, and children with congenital heart disease as TTE usually provides sufficient information 2
• For patients with hypertrophic cardiomyopathy, TEE can provide critical information about mitral valve anatomy and function that may not be visible on TTE 1

TEE should be performed in an appropriately accredited laboratory by a qualified cardiologist, with patient consent obtained prior to the procedure 3. The examination should be recorded and the report should comprehensively address the clinical questions raised in the referral 3.