When is Transesophageal Echocardiogram (TEE) recommended and what are the guidelines for its performance?

Transesophageal Echocardiography (TEE): Clinical Indications and Performance Guidelines

TEE should be ordered as the first-line imaging modality when transthoracic echocardiography (TTE) is expected to provide suboptimal images based on patient characteristics (mechanical ventilation, chest wall deformities, post-operative state) or when high-stakes diagnoses requiring superior visualization cannot be missed (acute aortic syndrome, prosthetic valve dysfunction, endocarditis complications, massive pulmonary embolism). 1

Primary Clinical Scenarios for TEE as First-Line Test

Patient characteristics predicting poor TTE quality:

• Mechanically ventilated patients in the ICU 1, 2
• Intraoperative or immediate post-operative patients 1
• Severe chest wall deformities or injuries 1
• Lung emphysema 1
• Post-operative dressings or chest tubes preventing adequate TTE positioning 2

High-mortality diagnoses requiring definitive visualization:

• Acute aortic dissection or aortic syndrome 1, 2
• Acute severe valvular regurgitation 1
• Acute prosthetic valve dysfunction 1
• Acute massive pulmonary embolism 1
• Chest trauma with suspected aortic transection 1

Atrial fibrillation/flutter management:

• Pre-cardioversion assessment to exclude left atrial thrombus 1, 3
• Guidance during radiofrequency ablation procedures 3, 2

TEE as Second-Line After Non-Diagnostic TTE

When TTE is inconclusive or inadequate:

• Suspected infective endocarditis with adequate pre-test probability (fever, positive blood cultures, new murmur) 1, 2
• Hemodynamically unstable patients with poor TTE windows 2, 4
• Evaluation of paravalvular complications or abscesses 1
• Assessment of intracardiac thrombi or masses when TTE is non-diagnostic 2

Important caveat: Current TTE imaging identifies cardiac causes of shock in 99% of cases with 100% sensitivity when images are adequate, so TEE should not be reflexively ordered without attempting TTE first in stable patients 4. However, 15% of critically ill patients have relative contraindications to TEE 4.

Mandatory Intraoperative TEE Indications

Cardiac surgery:

• Surgical septal myectomy for hypertrophic cardiomyopathy to assess mitral valve anatomy and adequacy of myectomy 1
• All open heart and thoracic aortic surgical procedures 3
• Coronary artery bypass graft surgeries 3
• Mitral valve repair procedures 3

Intraprocedural guidance:

• Alcohol septal ablation with intracoronary contrast injection to identify target septal perforators 1
• Transcatheter aortic valve implantation (TAVI) for pre-procedural evaluation and sizing 2
• Catheter/device placement in interventional procedures, particularly for congenital heart disease 2

Infective Endocarditis-Specific Algorithm

TEE is recommended when:

• All patients with known or suspected IE and non-diagnostic TTE results 1
• Intracardiac device leads are present 1
• Complications have developed or are clinically suspected (new murmur, embolism, persistent fever, heart failure, abscess, atrioventricular block) 1
• Staphylococcus aureus bacteremia without known source 1
• Prosthetic valve with persistent fever without bacteremia or new murmur 1

TEE should NOT be performed for:

• Transient fever with known alternative infection source 2
• Negative blood cultures with atypical pathogens 2
• Low pre-test probability scenarios 2

Hypertrophic Cardiomyopathy-Specific Indications

TEE is useful when:

• TTE is inconclusive for clinical decision-making regarding medical therapy 1
• Planning for surgical myectomy (mandatory intraoperatively) 1
• Excluding subaortic membrane or structural mitral valve abnormalities 1
• Assessing feasibility of alcohol septal ablation 1

Critical Care and Emergency Settings

TEE is reasonable for:

• Unexplained persistent life-threatening hypotension when TTE is inadequate 3
• Unexplained hypoxemia of suspected cardiac origin 3
• Hemodynamically unstable patients with suspected cardiac etiology 1, 2

Note: The European Association of Cardiovascular Imaging emphasizes that TEE can be used as first choice when TTE suboptimal images are expected, rather than routinely performing TTE first in these high-risk scenarios 1.

Absolute Contraindications to TEE

Do not perform TEE in patients with:

• Active esophageal pathology (stricture, tumor, diverticulum) 3, 5
• Recent esophageal surgery 5, 6
• History of dysphagia suggesting esophageal disease 6
• Active gastric disease 3

Relative contraindications requiring risk-benefit assessment:

• Esophageal varices 5, 6
• Active upper gastrointestinal bleeding 6

Ordering Provider Patterns

Cardiac anesthesiologists routinely order TEE for all open heart, thoracic aortic, and CABG surgeries to confirm preoperative diagnoses, detect unsuspected pathology, and assess surgical results 3.

Critical care physicians order TEE for hemodynamically unstable ICU patients when TTE provides inadequate images 3.

Cardiologists order TEE as a diagnostic tool when TTE is inadequate or when superior visualization of posterior cardiac structures (left atrium, left atrial appendage, interatrial septum, aortic valve, prosthetic valves) is required 3, 2.

Post-Procedure Follow-Up

Repeat TEE is recommended:

• Within 3-6 months after septal reduction therapy (myectomy or ablation) to evaluate procedural results 1
• For patients with IE and clinical change (new murmur, embolism, persistent fever) 1
• Before completion of oral antibiotic therapy for IE (baseline TEE before switching to oral therapy, repeat 1-3 days before completion) 1

TEE should NOT be used for:

• Routine surveillance of asymptomatic patients with indwelling catheters 2
• Routine repeat testing without clinical indication 2