Is a Transesophageal Echocardiogram (TEE) medically indicated for a patient with Supraventricular Tachycardia (SVT) and chest pain, given a recent stress test with Lexiscan (regadenoson) showed no significant ischemic or infarct-related myocardial perfusion abnormalities?

TEE is NOT Medically Indicated in This Case

Based on the available clinical information, transesophageal echocardiography (TEE) is not medically indicated for this 58-year-old male with supraventricular tachycardia and chest pain, as he has already undergone comprehensive cardiac evaluation including a diagnostic transthoracic echocardiogram and stress myocardial perfusion imaging that showed no evidence of ischemia, structural abnormalities requiring TEE visualization, or conditions where TEE would change management.

Clinical Context and Completed Workup

This patient has undergone extensive cardiac evaluation that has already addressed the clinical questions:

• Transthoracic echocardiogram (4/24/25) demonstrated normal left ventricular systolic function (EF 65-70%), mild concentric LVH, and mild pulmonary hypertension with adequate visualization 1
• Lexiscan stress myocardial perfusion imaging (4/24/25) showed no evidence of ischemic or infarct-related myocardial perfusion abnormalities, normal LV systolic function, and nonischemic stress ECG response 1
• The patient's symptoms (SVT, chest pain, palpitations) have been evaluated with appropriate first-line imaging modalities 1, 2

Why TEE is Not Indicated

Lack of Specific TEE Indications

The American College of Radiology and multiple specialty societies clearly define when TEE is appropriate versus when TTE suffices 1:

• TEE is generally not indicated for acute chest pain evaluation when TTE provides diagnostic images and rules out acute coronary syndrome, as the semi-invasive nature and limited additional information do not justify its use 1
• TEE is not recommended as an initial imaging modality for suspected heart failure or for routine evaluation of SVT when TTE is diagnostic 1
• The primary indications where TEE would be first-choice include: aortic dissection in unstable patients, evaluation of prosthetic valve dysfunction, endocarditis with inadequate TTE visualization, intracardiac thrombus when TTE is nondiagnostic, or pre-cardioversion assessment in atrial fibrillation/flutter >48 hours 1, 2

TTE Was Diagnostic

The completed TTE provided adequate visualization of cardiac structures without the limitations that would necessitate TEE 1:

• No suboptimal imaging is documented that would require TEE for better visualization 1
• No complex valvular pathology requiring detailed TEE assessment—only mild pulmonary hypertension was noted 1
• No suspected structural abnormalities (such as atrial septal defect, patent foramen ovale, or intracardiac shunt) that would require TEE or bubble study for definitive diagnosis 3

Stress Testing Ruled Out Ischemia

The negative stress myocardial perfusion study eliminates the need for further anatomic cardiac imaging in this context 1:

• No evidence of myocardial ischemia on pharmacologic stress testing with Lexiscan 1
• Normal hemodynamic response to vasodilation with appropriate blood pressure and heart rate response 1
• The American College of Cardiology/American Heart Association guidelines support that negative stress imaging in intermediate-risk patients effectively excludes significant coronary artery disease 1

Specific Clinical Scenarios Where TEE Would Be Considered

TEE would be appropriate in this patient only if specific conditions were present 1, 2:

For SVT/Atrial Flutter Management

• Pre-cardioversion assessment: If the patient required cardioversion for atrial flutter lasting >48 hours without adequate anticoagulation, TEE would be recommended to exclude left atrial appendage thrombus 2, 4
• However, there is no documentation that cardioversion is planned or that the patient has persistent atrial flutter requiring this intervention 2

For Suspected Structural Heart Disease

• Valvular disease assessment: The diagnosis code I08.2 (rheumatic disorders of both aortic and tricuspid valves) appears in the record, but the TTE did not document significant valvular pathology requiring TEE 1
• If severe valvular dysfunction or prosthetic valve complications were suspected and TTE was inadequate, TEE would be indicated 1

For Thromboembolic Risk Assessment

• Patent foramen ovale evaluation: If the patient had cryptogenic stroke or recurrent paradoxical emboli, TEE with bubble study would be appropriate 3
• No such history is documented in this case 3

Common Pitfalls to Avoid

Overutilization Based on Diagnosis Codes Alone

• The presence of diagnosis codes (I08.2 rheumatic valve disease, I27.20 pulmonary hypertension) does not automatically justify TEE if TTE adequately assessed these conditions 1
• Clinical correlation is essential: The TTE conclusions did not describe findings requiring TEE follow-up 1

Misunderstanding TEE's Role in Chest Pain Evaluation

• TEE is not part of the standard acute coronary syndrome workup when TTE and stress testing are diagnostic 1
• The American College of Radiology explicitly states that TEE is "generally not indicated in the workup of patients with acute chest pain" 1

Ordering TEE for "Complete Evaluation"

• TEE should not be ordered simply to be thorough when TTE has answered the clinical questions 1
• The semi-invasive nature of TEE (requiring sedation, esophageal intubation, and carrying risks of esophageal injury) requires specific clinical indications 1, 5

What Would Make TEE Appropriate in Future

TEE would become medically necessary if 1, 2:

• Suboptimal TTE images precluded adequate assessment of cardiac structures (e.g., severe obesity, COPD, mechanical ventilation, recent cardiac surgery) 1
• Suspected endocarditis with inadequate TTE visualization of vegetations 1
• Planned cardioversion for persistent atrial flutter >48 hours without therapeutic anticoagulation 2, 4
• Suspected aortic pathology (dissection, transection) in an unstable patient where CT is not immediately available 1
• Evaluation for cardiac source of embolism after cryptogenic stroke when TTE is nondiagnostic 3, 6
• Intraoperative monitoring during cardiac surgery 1, 7

Documentation Gaps That Could Change Assessment

The following information, if present, might alter the recommendation 1, 2:

• Detailed characterization of the SVT: Is this new-onset atrial flutter requiring cardioversion? 2
• Severity of rheumatic valve disease: Does the patient have severe valvular dysfunction inadequately assessed by TTE? 1
• History of stroke or TIA: Is there concern for paradoxical embolism requiring PFO assessment? 3
• Quality of TTE images: Were there specific structures inadequately visualized? 1