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Introduction to Transesophageal Echocardiography: Indications, Risks, Complications, and Protocol
Acknowledgment
The author would like to acknowledge the contributions of Drs. Elyse Foster and Atif Qasim, who were the authors of this chapter in previous edition.
The field of transesophageal echocardiography (TEE) has evolved significantly since its initial development. The esophageal transducer was developed to obtain ultrasound images from the esophagus, an ideal location because of its direct location behind the heart and associated structures. This allowed for the improvement of image resolution and avoidance of the standard artifacts of transthoracic imaging. The contemporary TEE transducer is a flexible transducer, housing a phased matrix array at the distal end, controlled by proximal knobs and manual movements.
Preprocedural Assessment
Before performance of TEE, a detailed review of indications and contraindications to procedure is required. The indications for TEE are listed in Table 12.1 and are classified into four general categories. The contraindications for TEE are listed in Table 12.2 and are divided into absolute and relative contraindications. Caution should be given to patients on chronic steroid therapy; those with a history of prior radiation to the oropharynx, scleroderma, or achalasia; or when the procedure time is expected to be prolonged. Recent data suggest that TEE can be safely performed in appropriately selected patients with esophageal varices and thrombocytopenia. , Consultation with gastroenterology may be helpful in evaluating specific contraindications.
Table 12.1
General Indications for Transesophageal Echocardiography
Adapted with permission from Hahn RT, et al: Guidelines for performing a comprehensive transesophageal echocardiographic examination, J Am Soc Echocardiogr 26:921–964, 2013.
| Evaluation of cardiac structures when TTE is nondiagnostic or would be inadequate | Detailed evaluation of left atrial appendage, aorta, prosthetic valves, paravalvular spaces for abscess or leaks; chest wall injuries; poor imaging windows on TTE |
| Intraoperative guidance | All open-heart procedures involving valves and thoracic aorta; some coronary artery bypass surgeries; noncardiac surgery if knowledge of cardiovascular structures is needed |
| Transcatheter procedure guidance | Transcatheter valve procedures, left atrial appendage occlusion, atrial or ventricular septal defect closures |
| Critically ill patients | Ventilated patients with possible cardiovascular pathology that will impact ICU management |
ICU, Intensive care unit; TTE, transthoracic echocardiography.
Table 12.2
Contraindications to Transesophageal Echocardiography
Adapted with permission from Hahn RT, et al: Guidelines for performing a comprehensive transesophageal echocardiographic examination, J Am Soc Echocardiogr 26:921–964, 2013.
| Absolute Contraindications | Relative Contraindications |
|---|---|
| Esophageal related: esophageal tumor, stricture, fistula, or perforation | Barrett esophagus History of dysphagia (may require gastroenterology consultation) |
| Active upper GI bleed | Active esophagitis |
| Perforated bowel or bowel obstruction | High-grade esophageal varices Active peptic ulcer disease |
| Unstable cervical spine | Neck immobility (severe cervical arthritis, atlantoaxial joint disease) |
| Uncooperative patient | Severe hiatal hernia |
| Severe coagulopathy or thrombocytopenia | |
| Prior neck or chest radiation | |
| Prior GI surgery | |
| Esophageal diverticulum Loose teeth (may require dental consultation) |
GI, Gastrointestinal.
The risk of TEE derives from two sources: (1) the risk of sedation and (2) injury to the gastrointestinal (GI) tract from probe insertion and manipulation. Sedation used for TEE can lead to respiratory depression, altered mental status, and hypotension; consultation with anesthesiology may be helpful when assessing the preprocedure risk. Mallampati airway score and American Society of Anesthesiologist Physical Status (ASA) classification are useful guides in determining patients at higher risk for complications. Injuries to the gastric tract can be minor or major; the most serious complication is esophageal perforation, which does not always present with the classic Meckel’s triad of vomiting, pain, and subcutaneous emphysema. Pharyngeal or cervical perforations occur more typically in patients under moderate sedation, usually as a complication of TEE insertion ; in operative settings, perforations occur more frequently in the thoracic or abdominal esophagus. The risks and complications of TEE are listed in Table 12.3 along with their overall incidence. Detailed assessment of the risk-to-benefit ratio should be reviewed with patients as part of the informed consent.
Table 12.3
Risks and Complications of Transesophageal Echocardiography
Adapted with permission from Hahn RT, et al: Guidelines for performing a comprehensive transesophageal echocardiographic examination, J Am Soc Echocardiogr 26:921–964, 2013.
| Complications | Incidence for Diagnostic TEE (%) |
|---|---|
| Mortality | <0.01–0.02 |
| Major bleeding | <0.01 |
| Major morbidity | 0.2 |
| Esophageal perforation | <0.01 |
| Dysphagia | 1.8 |
| Hoarseness | 12 |
| Bronchospasm | 0.06–0.07 |
| Laryngospasm | 0.14 |
| Minor pharyngeal bleeding | 0.01–0.2 |
| Dental injury | 0.1 |
| Lip injury | 13 |
| Heart failure | 0.05 |
| Arrhythmia | 0.06–0.3 |
TEE, Transesophageal echocardiography.
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