Elsevier

Mayo Clinic Proceedings

Volume 69, Issue 9, September 1994, Pages 856-863
Mayo Clinic Proceedings

Transesophageal Echocardiography

https://doi.org/10.1016/S0025-6196(12)61788-1Get rights and content

To describe the role of transesophageal echocardiography (TEE) in the diagnosis of various cardiac pathologic conditions, we reviewed the currently accepted clinical applications, the contraindications to the procedure, and the potential complications. The Mayo Clinic experience with 7,134 TEE examinations during a 6-year period (1988 through 1993) was summarized, and TEE results reported in the literature were reviewed. TEE has a substantially higher yield than transthoracic echocardiography (TTE) for diagnosis of direct and indirect sources of cardioembolism. Moreover, TEE is highly sensitive for detecting abnormalities of mitral prostheses and endocarditis-related complications of aortic prostheses. TEE is superior to TTE for localization and characterization of cardiac and paracardiac masses. In addition to establishing the diagnosis of aortic dissection, TEE can readily show the site, type, and extent of the tear. Ventilated, critically ill patients can safely undergo TEE. TEE has a limited role in the assessment of neonates, infants, and children with congenital heart disease because TTE can provide almost all the necessary information in such patients. Intraoperatively, TEE is useful for managing patients undergoing mitral valve repair and for monitoring for air and fat embolism in those undergoing neurosurgical procedures or hip replacement. Absolute contraindications to the performance of TEE include a history of dysphagia, current pathologic conditions of the esophagus, and recent esophageal operations. In patients with relative contraindications, such as esophageal varices or active upper gastrointestinal bleeding, the risk-to-benefit ratio must be assessed before TEE is performed. Complications associated with TEE can be related to the probe, to the procedure, or to drugs used during the examination. TEE is relatively safe; in the Mayo experience, the incidence of complications during a 6-year period was 2.8%. Thus, TEE is a low-risk procedure that provides useful information for the management of cardiology patients.

Section snippets

INSTRUMENTATION

The TEE transducer is a modified endoscope with a set of crystals at the tip, which are activated to produce the ultrasound beam. In 1994, the highest evolved TEE technology is a multiplane (capable of ultrasonically sectioning the heart in multiple planes) or biplane (a device with horizontal and longitudinal plane arrays), multifrequency (can electronically change the frequency from 3.5 MHz to 7.0 MHz) transducer equipped with Doppler and color flow imaging capabilities (Fig. 3).

PREPARATION AND EXAMINATION OF PATIENTS

For prescheduled outpatient or inpatient TEE, the patient must refrain from oral intake of food or water for at least 4 hours before the examination. The procedure should be explained in detail to the patient. The history should be elicited, with emphasis on gastrointestinal tract-related symptoms such as dysphagia, odynophagia, hematemesis, esophageal varices, prior endoscopic examination, upper gastrointestinal surgical procedures, and drug-associated allergies. Any dentures or oral

PREMEDICATION

Awake patients scheduled to undergo TEE receive premedication for the following reasons: (1) topical anesthesia (with an aerosol local anesthetic solution such as 10% lidocaine) of the oropharynx and the hard and soft palate to diminish the gag reflex and to eliminate retching and laryngospasm; (2) a drying agent (glycopyrollate, 0.2 mg intravenously) to minimize salivary and gastrointestinal secretions and reduce the risk of aspiration; (3) sedative and analgesic agents (midazolam

CLINICAL APPLICATIONS

The indications for performing a TEE examination encompass all cardiac pathologic conditions, as reflected in the Mayo Clinic experience with 7,134 procedures during a 6-year period (Fig. 4). The indications for TEE continue to be refined; the following discussion emphasizes areas in which the role of TEE is well established.

Training Requirements.

Errors caused by misdiagnosis can be minimized if the procedure is performed by properly trained personnel. Only specially trained echocardiologists should perform TEE. At some institutions, esophageal intubation is performed by a gastroenterologist, and the TEE examination is done by an echocardiologist. Physicians who wish to learn TEE should have attained at least level II training in echocardiography. In 1987, the American Society of Echocardiography published recommendations for the

COST

The best assessment of cost for TEE and other cardiac imaging modalities is to compare the relative value units assigned by the Health Care Financing Administration (Table 1). A note of caution is warranted when such cost comparisons are analyzed; a combination of technologies may be necessary when one study is nondiagnostic. In all circumstances, the well-being of the patient overrides cost considerations. Quality of care cannot and should not be jeopardized for cost-containment.

The

CONCLUSION

TEE is a low-risk procedure that provides highly relevant information for clinical decision making. TEE studies should be performed by appropriately trained physicians, and in patients with relative contraindications, the risk-to-benefit ratio must be considered before the examination is performed. Future considerations include smaller transducers and three-dimensional reconstruction of the cardiac anatomy.

Cited by (94)

  • Complications of Transesophageal Echocardiography: A Review of Injuries, Risk Factors, and Management

    2022, Journal of Cardiothoracic and Vascular Anesthesia
    Citation Excerpt :

    Gastroesophageal bleeding caused by trauma from TEE probe placement or manipulation can vary in severity from mild and self-limiting to copious and life-threatening. Minor trauma to the mucosal tissue can result in bleeding that presents as blood on the tip of the TEE probe at removal, blood visible in orogastric secretions, or postoperative hematemesis.43 Daniel et al reported minor pharyngeal bleeding in 0.01% of their cohort (1 in 10,218) in a series of ambulatory patients undergoing TEE.

  • Propofol sedation administered by cardiologists in echocardiography studies

    2022, REC: CardioClinics
    Citation Excerpt :

    Transesophageal echocardiography (TEE) is an essential diagnostic procedure in cardiology with a low complication rate in the adult population.1 However, the poor tolerance of the procedure in non-sedated patients made it necessary to carry out studies that were very focused on the pathology being sought, especially when the indications were sources of systemic embolism and suspected endocarditis.2,3 In the last decade, the clinical profile of patients and the complexity of procedures seem to have changed.

View all citing articles on Scopus
View full text