Can Physician Assistants Perform TEE?
No, physician assistants (PAs) should not independently perform transesophageal echocardiography (TEE) based on current ACC/AHA competence guidelines, which explicitly require physician-level training in cardiovascular diseases, Level 2 transthoracic echocardiography competence, and completion of 50 supervised TEE examinations under an experienced echocardiographer. 1
Training Requirements for TEE Performance
The ACC/AHA clinical competence statement establishes strict prerequisites that effectively limit independent TEE performance to physicians:
Mandatory Prerequisites
- Cardiovascular disease training: ABIM certification or certificate of successful completion of training, or letter from training program director 1
- Level 2 TTE competence: Documentation of advanced transthoracic echocardiography training 1
- Supervised TEE training: Performance and interpretation of 50 supervised TEE cases under a Level 3 echocardiographer 1
- Maintenance requirement: 25-50 TEE examinations per year to maintain competence 1
Required Knowledge Base
The operator must possess 1:
- Thorough knowledge of cardiovascular disorders and hemodynamic alterations
- Understanding of diagnostic issues for specific clinical presentations
- Mastery of ultrasound imaging principles and Doppler hemodynamic assessment
- Ability to distinguish adequate from inadequate TEE examinations
- Knowledge of other cardiovascular diagnostic methods for correlation
Technical Skills Required
Competent TEE operators must demonstrate proficiency in 1:
- Using conscious sedation safely and effectively
- Safely passing the TEE transducer into the esophagus and stomach
- Adjusting probe position to obtain necessary tomographic images
- Operating ultrasonographic instruments correctly
- Recognizing cardiac structural and functional abnormalities from transesophageal windows
- Performing qualitative and quantitative analyses of echocardiographic data
- Producing cogent written reports with clinical implications
Current Practice Patterns
Physician Specialties Performing TEE
In academic medical centers, TEE interpretation responsibility is divided between 2:
- Anesthesiologists: 54% of institutions
- Cardiologists: 46% of institutions
Emergency Medicine Experience
Recent data demonstrates that emergency physicians without fellowship training can successfully perform focused TEE (F-TEE) after structured training, with 75% of examinations performed by physicians without advanced ultrasound training beyond residency 3. However, this represents physician-level training, not PA practice.
Clinical Context for Atrial Fibrillation
Role of TEE in AF Management
TEE serves critical functions in AF patients 1:
- Detecting left atrial/left atrial appendage thrombus (present in 5-15% of AF patients before cardioversion)
- Guiding cardioversion decisions
- Stratifying thromboembolic risk
- Identifying contraindications to cardioversion
TEE-Guided Cardioversion Strategy
For AF patients, TEE-guided cardioversion produces comparable outcomes to traditional 3-week pre-cardioversion anticoagulation, with thromboembolic rates less than 1% 1. This requires expert interpretation to detect thrombus and guide anticoagulation decisions 4, 5.
Critical Safety Considerations
Why Physician-Level Training Matters
The ACC/AHA guidelines emphasize that TEE operators must 1:
- Prioritize the most pressing diagnostic issues first, particularly in critically ill patients
- Review available clinical and diagnostic information to focus the examination appropriately
- Recognize when specialized training is insufficient (e.g., complex congenital heart disease, intraoperative valve repair assessment)
Procedural Risks
TEE carries risks requiring physician-level judgment 6, 7:
- Pharyngeal and esophageal trauma
- Adverse reactions to conscious sedation
- Rare methemoglobinemia from benzocaine administration
- Risk of esophageal perforation in contraindicated patients
Practical Implications
PAs may assist with TEE procedures under direct physician supervision but should not independently perform or interpret TEE examinations. The combination of required cardiovascular disease training, Level 2 TTE competence, and 50 supervised TEE cases represents a training pathway available only through physician residency and fellowship programs 1.
For AF patients requiring TEE before cardioversion, the examination must be performed by a credentialed physician (cardiologist or appropriately trained anesthesiologist) who can integrate TEE findings with clinical risk stratification and anticoagulation management 1, 5.