What are the indications for transesophageal echocardiography (TEE)?

Indications for Transesophageal Echocardiography

Transesophageal echocardiography (TEE) should be performed when transthoracic echocardiography (TTE) provides inadequate imaging or when superior visualization of specific cardiac structures is required for diagnosis and management decisions that impact patient outcomes.

Primary Diagnostic Indications

When TTE is Inadequate or Suboptimal

• Hemodynamically unstable patients with poor TTE windows 1
• Mechanically ventilated patients where chest wall access is limited 1
• Post-operative patients with dressings or chest tubes preventing adequate TTE positioning 1
• Patients with congenital or acquired heart disease when significant diagnostic information cannot be obtained by TTE 1

Valvular Disease Assessment

• Suspected infective endocarditis with adequate pre-test probability (avoid in patients with transient fever, known alternative infection source, or negative blood cultures with atypical pathogens) 1
• Prosthetic valve dysfunction evaluation 2
• Pre-operative assessment prior to valvular repairs and closures of septal defects 2

Aortic Pathology (Class I Indications)

• Suspected aortic dissection - TEE is the procedure of choice in hemodynamically unstable patients 1
• Suspected traumatic aortic injury with mediastinal widening post-injury 1
• Thoracic aorta assessment when detailed visualization is required 2

Embolic Source Evaluation

• Assessment of cardiac source of embolism - TEE is superior to TTE for this indication 3, 2
• Thromboembolic events in infants, children, or adolescents 1
• Left atrial appendage evaluation for thrombus detection 4

Trauma (Class I Indications)

• Serious blunt or penetrating chest trauma with suspected pericardial effusion or tamponade 1
• Hemodynamically unstable multiple-injury patients with mechanism suggesting cardiac or aortic injury (deceleration or crush) 1
• Suspected myocardial contusion or rupture, septal defects, or valvular regurgitation from trauma 1
• Potential iatrogenic injury from catheters, guidewires, pacer electrodes, or pericardiocentesis needles 1

Procedural Guidance and Monitoring

Interventional Procedures

• Transcatheter aortic valve implantation (TAVI) - for pre-procedural evaluation of aortic valve anatomy, annulus sizing (preferably 3D TEE), and assessment of coronary ostium distance 1
• Intraoperative monitoring during cardiothoracic procedures when risk exists for residual shunting, valvular insufficiency, obstruction, or myocardial dysfunction 1
• Guidance during catheter/device placement in interventional catheterization or radiofrequency ablation, particularly in congenital heart disease 1
• Monitoring patients with intra-atrial baffles where thrombus potential is a concern 1

Perioperative Use in Non-Cardiac Surgery

• High-risk non-cardiac procedures with anticipated hemodynamic instability 5
• Moderate-risk procedures in patients with significant cardiac disease (low ejection fraction, hypertrophic cardiomyopathy, severe valve lesions, congenital heart disease) 5
• Vascular procedures involving the aorta, blunt trauma management, and liver transplantation 5
• "Rescue TEE" for unexplained and unexpected hemodynamic instability to identify underlying cause 5

Pediatric-Specific Indications

• Congenital heart disease when precise structural abnormalities or hemodynamics are unclear 1
• Monitoring patients with complex lesions requiring follow-up of ventricular function and atrioventricular valve regurgitation (e.g., single ventricle post-Fontan, transposition post-Mustard) 1
• Superior vena caval syndrome in presence of central venous catheter 1

Important Caveats

Inappropriate Uses to Avoid

The most common inappropriate indication is searching for endocarditis in patients with low pre-test likelihood (transient fever, known alternative infection source, negative blood cultures with atypical organisms) 1. This represents overuse that should be avoided.

Routine surveillance of asymptomatic patients with indwelling catheters is not indicated (Class III) 1.

Complementary Role

TEE should be viewed as complementary to TTE, not a replacement 2, 6. TTE remains the primary echocardiographic window, with TEE reserved for defined clinical applications where it provides superior or essential diagnostic information 6.

Quality Considerations

The 2007 ACCF/ASE appropriateness criteria emphasize that initial evaluation of cardiac structure and function is viewed favorably, while routine repeat testing and general screening in certain scenarios are viewed less favorably 1.

The 2014 EACVI guidelines highlight the expanding role of 3D TEE for complex measurements and linking with fluoroscopic images during interventional procedures 1.