Why would a Transesophageal Echocardiogram (TEE) be ordered if cardiac catheterization or angiogram (angio) did not show any significant findings?

Why TEE May Be Ordered After Normal Cardiac Catheterization

TEE evaluates completely different cardiac structures and pathologies than coronary angiography—while catheterization visualizes coronary arteries and hemodynamics, TEE excels at detecting valvular vegetations, intracardiac thrombi, structural abnormalities, perivalvular abscesses, and sources of embolism that are invisible on angiography. 1, 2

Distinct Diagnostic Capabilities

What Catheterization Cannot See

• Cardiac catheterization primarily evaluates coronary artery anatomy and hemodynamic pressures—it does not visualize valve leaflets, vegetations, thrombi, or intracardiac masses 1

• Angiography cannot detect endocarditis vegetations, which TEE identifies with 88-96% sensitivity 2, 3

• Perivalvular abscesses, fistulae, and pseudoaneurysms are completely missed by catheterization but readily identified by TEE 1, 4

TEE's Superior Diagnostic Targets

• TEE is the gold standard for detecting intracardiac sources of embolism (thrombi, vegetations, tumors, patent foramen ovale) with >90% sensitivity—these are never visualized on coronary angiography 1, 3, 5

• For prosthetic valve dysfunction or suspected endocarditis, TEE achieves ~90% sensitivity versus only 50% for transthoracic echo and 0% for catheterization 2, 3

• Aortic dissection, a life-threatening emergency, is diagnosed with TEE (appropriateness score 9/9) but may be completely missed on standard catheterization 1

Common Clinical Scenarios Requiring Both Tests

Suspected Endocarditis with Bacteremia

• In Staphylococcus aureus bacteremia, TEE is recommended even after negative catheterization because vegetations and perivalvular complications occur in normal coronary anatomy 1, 2

• Gram-positive bacteremia with prosthetic valves or intracardiac devices mandates TEE regardless of catheterization findings 2

• TEE detects all nine periannular complications of endocarditis (abscesses, fistulae) versus only two detected by other imaging 4

Embolic Events of Unknown Origin

• After normal catheterization and ECG, TEE identifies cardiac embolic sources in approximately 40% of stroke/TIA patients 6

• Left atrial appendage thrombus—the most common major cardiac embolic source (16% of cases)—is only visible on TEE, never on angiography 6

• TEE appropriateness score is 8/9 for cardiovascular source of embolic events, making it essential even with normal coronary anatomy 1

Hemodynamic Instability Despite Normal Coronaries

• Cardiac tamponade, acute valvular regurgitation, and ventricular septal rupture cause shock but have normal coronary angiograms 1, 7

• TEE identifies cardiac causes of shock with 100% sensitivity and 95% specificity in critically ill patients 7

• Acute aortic regurgitation from dissection or endocarditis requires TEE diagnosis even when coronaries appear normal 1

Timing and Repeat Imaging Considerations

When Initial TEE Is Negative

• If clinical suspicion persists after negative TEE, repeat TEE in 5-7 days because early abscesses appear only as nonspecific thickening 1, 2, 5

• A single negative TEE cannot rule out endocarditis—vegetations may develop over time or be missed initially 1

• TEE has 98.6% negative predictive value but false negatives still occur, particularly with early or small lesions 3, 5

Intraoperative Reassessment

• Intraoperative TEE is recommended during valve surgery even after preoperative catheterization because anatomical changes occur between studies 1

• Vegetation embolization or extension of infection beyond valve tissue may develop in the interval between catheterization and surgery 1

Critical Pitfalls to Avoid

• Never assume normal coronary angiography excludes structural heart disease—valvular, pericardial, and intracardiac pathology require echocardiographic evaluation 1

• Do not rely on transthoracic echo alone in prosthetic valves, intracardiac devices, or suspected endocarditis—TEE sensitivity is nearly double (90% vs 50%) 2, 3

• Persistent fever, new murmur, embolic events, or conduction abnormalities mandate TEE even with normal catheterization and negative transthoracic echo 1, 2

• In mechanically ventilated or critically ill patients, TEE should be the first-choice test rather than catheterization for suspected cardiac causes of instability 1