Should a transesophageal echocardiogram (TEE) be performed in a 25-year-old male with asthma and obstructive sleep apnea (OSA) presenting with acute exertional chest pain, high fevers, chills, and fatigue, despite a normal transthoracic echo?

Should TEE Be Performed Despite Normal TTE?

Yes, TEE should be strongly considered in this 25-year-old with acute exertional chest pain, high fevers, chills, and fatigue despite a normal transthoracic echo, because these constitutional symptoms raise concern for infective endocarditis, and TEE has significantly superior sensitivity (up to 100%) compared to TTE for detecting vegetations, abscesses, and other complications that could be life-threatening if missed. 1

Clinical Context Demanding Higher Sensitivity Imaging

The combination of fever, chills, and acute symptoms in a young patient creates a high-risk scenario where missing a diagnosis could have catastrophic consequences for morbidity and mortality:

• Infective endocarditis must be excluded given the fever and constitutional symptoms, and TEE is not part of standard initial investigation but becomes essential when clinical suspicion remains high despite negative or equivocal TTE findings 1
• TEE is the most sensitive and specific technique to detect sources and potential mechanisms for cardiogenic embolism, with sensitivity approaching 100% for endocarditis diagnosis compared to TTE's more limited sensitivity 1
• The European Society of Cardiology explicitly states that TEE should be performed when good-quality TTE is negative but clinical suspicion of infective endocarditis remains high, and if initial TEE is negative but suspicion persists, repeat TEE within 7-10 days 1

When TEE Is Appropriate as Follow-Up to Normal TTE

Multiple guideline bodies support TEE escalation in specific clinical scenarios despite normal initial imaging:

• TEE is appropriately used as an adjunct or subsequent test to TTE when the clinical question remains unanswered, particularly for conditions with high morbidity/mortality if overlooked 1
• In the emergency setting, TEE should be used after TTE when TTE is non-diagnostic and when visualization of certain cardiac structures is necessary to confirm or reject a suspected diagnosis which, if overlooked, is associated with high morbidity and mortality 1
• The European Association of Cardiovascular Imaging specifically lists acute valvular regurgitation and acute prosthetic valve dysfunction as scenarios where TEE can be first choice, but by extension, when these are suspected but not confirmed on TTE, TEE becomes mandatory 1

Specific Advantages of TEE in This Clinical Scenario

TEE provides critical diagnostic information that TTE cannot reliably exclude:

• TEE places a high-frequency ultrasound transducer close to the heart, providing superior image quality for detecting small vegetations, perivalvular abscesses, valve perforations, and fistulas that may not be visible on TTE 1
• Research demonstrates that TEE is superior to TTE in evaluating cardiac masses and tumors, with TEE providing additional findings not seen on TTE in the majority of cases, which is directly applicable to detecting vegetations 2
• In mechanically ventilated or critically ill patients, TEE has markedly superior diagnostic accuracy (95/98 vs 60/158 problems solved) compared to TTE, and this principle extends to any patient where TTE windows are suboptimal 3

Risk-Benefit Analysis Favoring TEE

The risks of TEE are minimal compared to the potential consequences of missed diagnosis:

• TEE is well-tolerated with no complications reported in large case series, with a mortality rate of only 0.0098% and complication rate of 0.88% 4, 3
• The examination may be unsuccessful in only 3-5% of patients due to inability to tolerate the probe 4
• Missing infective endocarditis carries devastating consequences including valve destruction, heart failure, systemic embolization, and death, far outweighing the minimal risks of TEE 1

Clinical Algorithm for Decision-Making

Proceed with TEE if any of the following apply:

1. Persistent fever with cardiac symptoms despite negative TTE (this patient qualifies) 1
2. High clinical suspicion for endocarditis based on Duke criteria, even with negative TTE 1
3. Unexplained constitutional symptoms (fevers, chills, fatigue) in the setting of cardiac complaints 1
4. Any concern for complications such as abscess, perforation, or fistula that TTE cannot adequately exclude 1

Common Pitfalls to Avoid

• Do not rely solely on negative TTE to exclude endocarditis when clinical suspicion is high—TTE has lower sensitivity and may miss small vegetations, particularly on the mitral valve, atrial structures, and prosthetic valves 1
• Do not delay TEE if the clinical picture suggests possible endocarditis, as early detection dramatically improves outcomes and prevents complications 1
• Do not assume normal valves on TTE exclude all pathology—TEE can detect perivalvular abscesses, valve perforations, and early vegetations not visible on TTE 1