Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review

Abstract

Background Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) – lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE. Methods MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate. Results Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported. Conclusions The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.

Hemodialysis Catheter-Associated Right Atrial Thrombus Diagnosed via Point of Care Transesophageal Echocardiogram

“…Compared to TTE, TEE has consistently demonstrated its diagnostic superiority with enhanced resolution, multiplane imaging capabilities, and improved visualization of the RA and its contents 11 , 12 , 13 . In the past decade, there has been a noticeable paradigm shift in the application of TEE 14 , 15 , 16 .…”

Blood Pressure Goals in Critically Ill Patients

“…40 In an extensive review of the literature, Prager et al noted that utilization of TEE in the critical care setting resulted in a change of diagnosis in 52% to 78% of patients and a change in management in 32% to 79% of patients examined. 41 They additionally showed that TEE was able to successfully distinguish the etiology of cardiac arrest in 25% to 35% of cases when it was used for this purpose. 41 As shown in Figures 4 A and B, minimal changes occur in the LV dimension in both systole and diastole, respectively, which is indicative of decreased LV function that can be further assessed and quantified using other 2D and 3D echocardiographic measurements.…”

“…41 They additionally showed that TEE was able to successfully distinguish the etiology of cardiac arrest in 25% to 35% of cases when it was used for this purpose. 41 As shown in Figures 4 A and B, minimal changes occur in the LV dimension in both systole and diastole, respectively, which is indicative of decreased LV function that can be further assessed and quantified using other 2D and 3D echocardiographic measurements. This patient responded to inotropes to increase cardiac contractility and output.…”

Point-of-Care Echocardiography in the Difficult-to-Image Patient in the ICU: A Narrative Review

“…Given some of the limitations of TTE and additional benefits of TEE, there is increasing demand for training in TEE competency amongst general intensivists. Evidence suggests that point-of-care TEE in the ICU improves diagnostic yield beyond TTE, often changes management, and basic midesophageal and transgastric views are readily learned by trainees (52, 57). However, TEE does not come without risks.…”

“…Contraindications include significant esophageal disease such as stricture or recent esophageal or gastric surgery. Severe complications may include oropharyngeal bleeding, esophageal bleeding, and esophageal perforation, although these are rare complications and occur in roughly 0.01–0.5% of cases (57, 58).…”