Why is a Transesophageal Echocardiogram (TEE) ordered after an angiogram?

Why TEE is Ordered After an Angiogram

TEE is most commonly ordered after an angiogram to evaluate for a cardiac source of embolism when the angiogram reveals evidence of stroke or systemic embolization, or to assess for infective endocarditis when there are clinical signs of infection with bacteremia. 1

Primary Clinical Scenarios

Evaluation for Cardiac Source of Embolism

• TEE is appropriate (score 8/9) for evaluating cardiovascular sources of embolic events including patent foramen ovale (PFO), atrial septal defect (ASD), thrombus, or cardiac masses when an angiogram demonstrates embolic stroke or peripheral embolization 1

• If a patient undergoes coronary or peripheral angiography and imaging reveals embolic occlusion patterns, TEE becomes the next logical step to identify the cardiac source 2

• TEE detects left atrial appendage thrombus in approximately 16% of stroke patients, which is the most common major cardiac risk factor requiring anticoagulation 2

• TEE identifies cardiac sources of embolism in approximately 40% of patients with normal transthoracic echocardiography (TTE), independent of age 2

Suspected Infective Endocarditis

• TEE is highly appropriate (score 9/9) for diagnosing and managing endocarditis with moderate or high pretest probability, particularly with bacteremia (especially Staphylococcus aureus or fungal infections) 1

• If an angiogram is performed for suspected septic emboli or mycotic aneurysm and reveals embolic patterns, TEE should be performed expeditiously to evaluate for vegetations, abscesses, and valve dysfunction 1

• TEE has approximately 90% or greater sensitivity for detecting prosthetic valve vegetations, prosthetic valve abscesses, and lead infections, significantly superior to TTE 1

• TEE should be performed within 12 hours of initial evaluation when endocarditis is suspected, with TEE preferred over TTE as the initial test 1

Assessment of Prosthetic Valves

• TEE is appropriate (score 9/9) for re-evaluation of prosthetic valves with suspected dysfunction, thrombosis, or change in clinical status 1

• Transthoracic images are greatly hampered by structural components of prosthetic valves and are inadequate for assessing the perivalvular area where infections often start 1

• If angiography is performed for other indications in a patient with a prosthetic valve and clinical deterioration is noted, TEE becomes essential for comprehensive valve assessment 1

Evaluation of Aortic Pathology

• TEE is highly appropriate (score 9/9) for evaluation of suspected acute aortic pathology including dissection or transection 1

• If an angiogram suggests aortic abnormalities or complications, TEE provides superior visualization of the thoracic aorta compared to TTE 3

• TEE identifies 92% of high-risk aortic plaques (≥5 mm) compared to only 54% detected by other imaging modalities 3

Clinical Algorithm for TEE After Angiogram

When angiogram reveals embolic patterns:

• Perform TEE to evaluate for left atrial appendage thrombus, PFO/ASD, cardiac masses, or vegetations 1, 2
• TEE detects major cardiac risk factors requiring anticoagulation in more than 1 in 8 patients with normal TTE 2

When bacteremia is present with angiographic findings:

• Perform TEE within 12 hours if high clinical suspicion for endocarditis exists 1
• TEE is mandatory even with negative TTE when prosthetic material is present or complications are suspected 1

When prosthetic valves are present:

• TEE provides complementary views to TTE and is essential for perivalvular assessment 1
• Repeat TEE 3-5 days after initial study if diagnosis remains uncertain or clinical course is worrisome 1

Important Caveats

• TEE and TTE are complementary studies, not mutually exclusive - both provide different directional views of highly attenuating structures 1

• TEE may produce false-negative results if vegetations are small, have embolized, or if performed too early in the disease course when perivalvular abscesses are incipient 1

• TEE should not be performed in patients who consumed a meal 4-6 hours before the test or when there is risk of esophageal perforation or massive gastrointestinal bleeding 4

• Serious complications from TEE are very rare, making it a relatively safe semi-invasive procedure 5, 4