What are the indications for Transesophageal Echocardiography (TEE) in patients with candidemia?

Indications for TEE in Patients with Candidemia

TEE should be performed in all patients with candidemia who are at high risk for Candida infective endocarditis (CIE), particularly those with fungal infections, prosthetic valves, existing valvular heart disease, or persistent fever, as fungal endocarditis carries exceptionally high mortality (36-49%) and requires aggressive diagnostic evaluation. 1, 2

Risk Stratification for TEE

High-Risk Patients Requiring TEE

Patients with the following characteristics warrant TEE evaluation:

• Fungal infections (including candidemia) - explicitly identified as high-risk for complications requiring reevaluation with TTE and/or TEE 1
• Prosthetic heart valves - TEE is reasonable in the presence of persistent fever without bacteremia or new murmur 1
• Pre-existing valvular heart disease - strongest predictor of CIE with adjusted odds ratio of 7.66 3
• Persistent fever despite appropriate antifungal therapy - suggests possible endocarditis 1
• New murmur or change in clinical status - warrants reevaluation 1
• Intracardiac device leads - TEE recommended when present 1

Lower-Risk Patients (TEE May Not Be Necessary)

The following factors are associated with decreased risk of CIE:

• C. glabrata infection (adjusted OR 0.17) 3
• Hematologic malignancy (adjusted OR 0.09) 3
• Receipt of total parenteral nutrition (adjusted OR 0.38) 3

Diagnostic Algorithm

Initial Evaluation

1. Start with TTE in all candidemic patients - TTE has 70% sensitivity for native valves but only 50% for prosthetic valves 4
2. Proceed directly to TEE if:
   • Prosthetic or mechanical valve present (TTE sensitivity only ~50% vs TEE ~90%) 4, 5
   • TTE is nondiagnostic but clinical suspicion persists 1
   • Patient has high-risk features (fungal infection, existing valve disease, persistent fever) 1

TEE Performance Characteristics

TEE demonstrates superior diagnostic accuracy:

• Sensitivity >90% for detecting intracardiac lesions in infective endocarditis 6
• Negative predictive value up to 98.6% 5, 6
• Specificity 91-100% across all valve types 5

Follow-Up Imaging

If initial TEE is negative but clinical suspicion persists:

• Repeat TEE after 3-5 days 6
• A negative TEE never completely rules out infective endocarditis 6

Clinical Context and Prevalence

The incidence of CIE among candidemic patients is 2.5-5.9%, with approximately one-third of cases being clinically unsuspected 3, 7. In one prospective study, CIE was diagnosed in 4.2% of all candidemic patients and 5.9% of those who underwent echocardiography, with three of 11 confirmed cases being clinically unsuspected 7.

Critical Prognostic Implications

TEE findings have direct mortality implications:

• Intracardiac abscess detected on echocardiography independently predicts both in-hospital and 1-year mortality 6
• Valve perforation independently predicts 1-year mortality 6
• Left ventricular ejection fraction <40% combined with intracardiac abscess predicts in-hospital mortality 6
• Overall 90-day mortality for CIE is 48.9% 3

Important Caveats

TEE has limitations despite high sensitivity:

• Acoustic shadowing from prosthetic materials can limit visualization 5
• Anterior prosthetic ring abscesses may be missed 5
• False negatives can still occur despite 98.6% negative predictive value 5, 6
• Cardiac CT may provide complementary information when TEE is inconclusive for prosthetic valve endocarditis 5

Large, heterogeneous vegetations are characteristic of Candida endocarditis, and hyperechogenic heterogeneous myocardial texture suggests extensive myocardial involvement warranting early surgical intervention 8.