What type of medical provider orders a Transesophageal Echocardiogram (TEE)?

Who Orders Transesophageal Echocardiography (TEE)

TEE is primarily ordered by cardiologists, cardiac anesthesiologists/anesthesiologists, and intensivists/critical care physicians, with the specific ordering provider depending on the clinical context—cardiac surgery, critical care, or diagnostic evaluation. 1

Primary Ordering Providers by Clinical Setting

Cardiac Anesthesiologists

• Cardiac anesthesiologists routinely order and perform TEE during all open heart (valvular procedures) and thoracic aortic surgical procedures, as well as coronary artery bypass graft surgeries. 1
• They use TEE intraoperatively to confirm preoperative diagnoses, detect new or unsuspected pathology, adjust the anesthetic and surgical plan, and assess surgical results. 1
• During transcatheter intracardiac procedures (septal defect closure, atrial appendage obliteration, catheter-based valve replacement/repair), cardiac anesthesiologists order TEE when general anesthesia is provided and intracardiac ultrasound is not used. 1
• For noncardiac surgery, anesthesiologists order TEE when patients have known or suspected cardiovascular pathology that might result in hemodynamic, pulmonary, or neurologic compromise. 1

Intensivists and Critical Care Physicians

• Critical care physicians order TEE for hemodynamically unstable patients in the ICU, particularly when transthoracic echocardiography (TTE) provides inadequate images. 1, 2
• TEE is ordered for mechanically ventilated patients, those who cannot be appropriately positioned, or those with postoperative dressings or chest tubes preventing adequate TTE. 1
• Intensivists order TEE for unexplained persistent life-threatening hypotension despite corrective therapy, unexplained hypoxemia, and suspected aortic dissection. 1
• Critical care TEE is ordered for trauma patients with serious blunt or penetrating chest trauma, suspected pericardial effusion or tamponade, and hemodynamically unstable multiple-injury patients. 1

Cardiologists

• Cardiologists order TEE as a diagnostic tool for outpatient and inpatient evaluation when TTE is inadequate or when superior visualization of specific cardiac structures is required. 1
• TEE is ordered as the first-line test when visualization of structures best seen by TEE is necessary, including the mitral valve, atria, great vessels, and prosthetic valves. 1
• Cardiologists order TEE for evaluation of endocarditis and its complications, aortic dissection, intracardiac thrombi and masses, valvular disorders including prosthetic valve function, and congenital heart defects. 3
• TEE is ordered for monitoring during cardioversion for atrial fibrillation/flutter and for guidance during radiofrequency ablation procedures. 3

Pulmonologists

• Pulmonologists order limited echocardiography with bubble studies (which may include TEE) when screening for shunts in patients with elevated right ventricular systolic pressure (RVSP > 45 mmHg) as part of pulmonary hypertension assessment. 4
• They order bubble studies with echocardiography for risk stratification in patients with massive or submassive pulmonary embolism to detect patent foramen ovale. 4
• TEE may be ordered by pulmonologists to evaluate unexplained hypoxemia when distinguishing between cardiac and non-cardiac causes of dyspnea. 4

Key Clinical Decision Points

When TEE is Preferred Over TTE

• TEE should be ordered as the first-line test when suboptimal TTE images are anticipated based on patient characteristics alone—patients who are intubated, recently post-operative, requiring intraprocedural study, have severe chest wall abnormalities, or have COPD. 1
• TEE provides superior visualization of posterior cardiac structures, has higher spatial resolution, and provides unobstructed views of the heart compared to TTE. 3
• TEE has higher sensitivity (51% vs. 32%) for detecting shunts compared to TTE, making it the preferred test for bubble studies when detailed assessment is needed. 4

Common Pitfalls to Avoid

• Only 8-10% of indicated TTE studies require supplementary TEE studies, so TEE should not be routinely ordered without specific clinical indications. 5
• TEE should not be ordered routinely in all patients with lung disease without clinical suspicion of cardiac involvement. 4
• The ordering provider must ensure that the patient does not have absolute contraindications (esophageal pathology, gastric disease) before ordering TEE. 1
• Providers ordering TEE must ensure that trained echocardiographers who understand indications, potential complications, and proper interpretation are available to perform the procedure. 5, 6

Training Requirements

• Relatively few anesthesiologists have completed formal TEE training, with only 11% reporting echocardiography training in one survey. 7
• Among anesthesiologists with formal echocardiography training, TEE is significantly preferred over pulmonary artery catheter monitoring. 7
• TEE requires training in safe insertion and handling of the echoscope, proper acquisition and interpretation of echocardiographic data, and understanding of ultrasound physics and machine controls. 5, 6