Transesophageal echocardiography (TEE)
(Redirected from TEE)
Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Eli V. Gelfand, M.D.; Anne B. Riley, M.D. Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD[2]
Overview
Transesophageal echocardiogram, or TEE is a type of echocardiogram that uses a endoscopic probe with an ultrasound transducer to assess, visualize and take images of cardiac structures and great vessels.
Procedure
TEE is performed by passing a probe with an ultrasound transducer into the esophagus, resulting in clear visualization and high-quality images of posterior cardiac structures, thoracic aorta, pulmonary veins and left coronary artery.[1] This is because of the proximity of the esophagus and these structures which reduces the attenuation of ultrasound signal, whereas in transthoracic echocardiogram (TTE), ultrasound signal passes through the chest wall and lungs resulting in degraded image quality.
TEE performance requires trained physicians and personnel.[1]
Preparation, Sedation and Anesthesia
- Patients must abstain from all oral intake of food or water for at least 4 hours before TEE procedure.[1]
- Patient medical history must be checked for contraindications and medication allergies.[1][2]
- Dentures must be removed.[1]
- Intravenous access is required in all patients.[2][1]
- Oxygen delivery and suction devices, endotracheal tubes, and laryngoscopes should be available (in case of respiratory complications).[2]
- Methylene blue (in case of methemoglobinemia caused by the topical use of benzocaine), flumazenil (reversal agent for benzodiazepines), and naloxone (reversal agent for opioids) should be available.[2]
- Continuous monitoring of the patients's hemodynamic stability, vital signs (heart rate, blood pressure, respiratory rate) and oxygen saturation should be assessed during TEE performance.[2]
- Topical anesthesia of the oropharynx is acheived by a local anesthetic (benzocaine or lidocaine), [1][2] which will reduce the gag reflex and eliminate laryngospasm.[1]
- For sedation, benzodiazepines (midozolam is the best choice) are most commonly used.[2]
- Opioids (fentanyl and meperidine are the most commonly used) are used as additional sedatives to decrease the discomfort of TEE procedure.[2]
- A bite block is placed in the patient’s mouth (after topical anesthesia and before sedation). [2]
- The procedure is performed with the patient being in the left lateral decubitus position.[1][2]
- Patients in the intensive care unit or in the operating room are placed in the supine position.[1][2]
- Patients undergoing surgery with TEE are generally anesthetized and intubated.[2]
- Most pediatric patients are generally anesthetized and intubated. [3]
Tomography of Transesophageal echocardiography (TEE)
- M-mode echocardiography
- 2D echocardiography
- 3D echocardiography
- Doppler echocardiography
Standard Views of Transesophageal echocardiography (TEE)
| Standard Views of Transesophageal echocardiography (TEE)
(Modified table from "Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists")[2] | ||||
|---|---|---|---|---|
| View | Imaging Plane| | Aquisition Protocol | Structures Imaged | |
| Midesophageal (ME) | 1 | ME five-chamber view |
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| 2 | ME four-chamber view |
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| 3 | ME Mitral Commissural View |
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| 4 | ME Two-Chamber View |
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| 5 | ME Long Axis (LAX) View |
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| 6 | ME AV LAX View |
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| 7 | ME Ascending Aorta LAX View |
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| 8 | ME Ascending Aorta Short Axis (SAX) View |
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| 9 | ME Right Pulmonary Vein View |
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| 10 | ME AV SAX View |
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| 11 | ME RV Inflow-Outflow View |
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| 12 | ME Modified Bicaval TV View |
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| 13 | ME Bicaval View |
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| |
| 14 | ME Right and Left Pulmonary Vein View |
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| |
| 15 | ME LA Appendage View |
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| |
| Transgastric (TG) | 16 | TG Basal SAX View |
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| 17 | TG Midpapillary SAX View |
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| 18 | TG Apical SAX View |
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| 19 | TG RV Basal View |
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| 20 | TG RV Inflow-Outflow View |
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| 21 | Deep TG Five-Chamber |
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| 22 | TG Two-Chamber View |
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| 23 | TG RV Inflow View |
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| 24 | TG LAX View |
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| Aortic | 25 | Descending Aorta SAX View |
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| 26 | Descending Aorta LAX View |
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| 27 | UE Aortic Arch to LAX View |
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| 28 | UE Aortic Arch SAX View |
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| |
Clinical Applications
| Indications for Transesophageal echocardiography (TEE)
(Modified table from "Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography")[4] | |
|---|---|
| Cardiac and Thoracic Aortic Surgery |
or
|
| Transcatheter intracardiac procedures |
|
| Noncardiac Surgery |
|
| Critical Care |
|
Contraindications
Contraindications include:[4][5][6][7][2][8]
- Perforated viscus
- Esophegeal stricture, tumor, perforation, laceration, diverticulum, varices
- Mallory-Weiss tears [6]
- Active upper gastrointestinal (GI) bleeding
- Large descending aortic aneurysm[4], thoracic aortic aneurysm[9]
- Zenker diverticulum[4]
- Prior esophagectomy or esophagogastrectomy[4]
- Prior GI surgery
- Resent upper GI bleeding
- Barrett's esophagus
- Dysphagia
- Restricted neck mobility (severe cervical arthritis, atlantoaxial joint disease)
- Prior radiation to neck and chest
- Symptomatic hiatal hernia
- Active esophagitis or active peptic ulcer disease
- Coagulopathy, thrombocytopenia
Complications
- Majority of the complications are caused by injury or trauma[9]
- Dental injury (eg. loosened tooth) [9] [4]
- Tongue necrosis (caused by prolonged placement of TEE probe)[10]
- Sore throat[1]
- Odynophagia[9][6]
- Dysphagia[9][4]
- Profound gag[1]
- Laryngeal palsy[4]
- Hoarsness[1]
- Methemoglobinemia (caused by the topical use of benzocaine in the preparation of TEE procedure)[11]
- Hypoxia[5][12][1][6]
- Laryngospasm[12][1]
- Bronchospasm[5][7]
- Airway obstruction[13][14][15]
- Accidental tracheal intubation[7][13]
- Endotracheal tube malposition[9]
- Congestive heart failure[12][1]
- Dysrhythmias (eg. atrial fibrillation, supraventricular tachycardia, atrioventricular block, premature ventricular beats, nonsustained ventricular tachycardia, ventricular tachycardia)[7][5][12][1]
- Transient hypotention or hypertension[12][1]
- Transient changes in heart rate[16]
- Oroharyngeal,hypopharyngeal, esohageal or gastric abrasion[9] or perforation [17][5][9][7][6][4]
- Hemorrhage
- Upper GI bleeding[5][6][9]
- Hemoptysis[6][5]
- Blood-tinged sputum[12][1]
- Cardiac tamponade (due to rupture of aortic dissection or aortic aneurysm)[18] [19][20]
- Splenic rupture[21]
- Hematoma[4][6]
- Pressure necrosis (in patients with severe atherosclerosis)[22]
- Death(rare)[6][5][12][1]
Advantages and Disadvantages of Transesophageal echocardiography (TEE)
| Advantages and Disadvantages of Transesophageal echocardiography (TEE) | |
|---|---|
| Advantages | Disadvantages |
| |
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 Khandheria BK, Seward JB, Tajik AJ (1994). "Transesophageal echocardiography". Mayo Clin Proc. 69 (9): 856–63. doi:10.1016/s0025-6196(12)61788-1. PMID 8065188.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM; et al. (2013). "Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists". J Am Soc Echocardiogr. 26 (9): 921–64. doi:10.1016/j.echo.2013.07.009. PMID 23998692.
- ↑ Fyfe DA, Ritter SB, Snider AR, Silverman NH, Stevenson JG, Sorensen G; et al. (1992). "Guidelines for transesophageal echocardiography in children". J Am Soc Echocardiogr. 5 (6): 640–4. doi:10.1016/s0894-7317(14)80332-5. PMID 1344706.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography (2010). "Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography". Anesthesiology. 112 (5): 1084–96. doi:10.1097/ALN.0b013e3181c51e90. PMID 20418689.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Daniel WG, Erbel R, Kasper W, Visser CA, Engberding R, Sutherland GR; et al. (1991). "Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations". Circulation. 83 (3): 817–21. doi:10.1161/01.cir.83.3.817. PMID 1999032.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP; et al. (2005). "Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations". J Am Soc Echocardiogr. 18 (9): 925–9. doi:10.1016/j.echo.2005.01.034. PMID 16153515.
- ↑ 7.0 7.1 7.2 7.3 7.4 Chan KL, Cohen GI, Sochowski RA, Baird MG (1991). "Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations". J Am Soc Echocardiogr. 4 (6): 577–82. doi:10.1016/s0894-7317(14)80216-2. PMID 1760179.
- ↑ 8.0 8.1 Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK (2010). "Safety of transesophageal echocardiography". J Am Soc Echocardiogr. 23 (11): 1115–27, quiz 1220-1. doi:10.1016/j.echo.2010.08.013. PMID 20864313.
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK (2001). "The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients". Anesth Analg. 92 (5): 1126–30. doi:10.1097/00000539-200105000-00009. PMID 11323333.
- ↑ Sriram K, Khorasani A, Mbekeani KE, Patel S (2006). "Tongue necrosis and cleft after prolonged transesophageal echocardiography probe placement". Anesthesiology. 105 (3): 635. doi:10.1097/00000542-200609000-00043. PMID 16932012.
- ↑ Jacka MJ, Kruger M, Glick N (2006). "Methemoglobinemia after transesophageal echocardiography: a life-threatening complication". J Clin Anesth. 18 (1): 52–4. doi:10.1016/j.jclinane.2005.04.008. PMID 16517334.
- ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Seward JB, Khandheria BK, Oh JK, Freeman WK, Tajik AJ (1992). "Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications". J Am Soc Echocardiogr. 5 (3): 288–305. doi:10.1016/s0894-7317(14)80352-0. PMID 1622623.
- ↑ 13.0 13.1 Stevenson JG (1999). "Incidence of complications in pediatric transesophageal echocardiography: experience in 1650 cases". J Am Soc Echocardiogr. 12 (6): 527–32. doi:10.1016/s0894-7317(99)70090-8. PMID 10359925.
- ↑ Arima H, Sobue K, Tanaka S, Morishima T, Ando H, Katsuya H (2002). "Airway obstruction associated with transesophageal echocardiography in a patient with a giant aortic pseudoaneurysm". Anesth Analg. 95 (3): 558–60, table of contents. doi:10.1097/00000539-200209000-00010. PMID 12198035.
- ↑ Nakao S, Eguchi T, Ikeda S, Nagata A, Nishizawa N, Shingu K (2000). "Airway obstruction by a transesophageal echocardiography probe in an adult patient with a dissecting aneurysm of the ascending aorta and arch". J Cardiothorac Vasc Anesth. 14 (2): 186–7. doi:10.1016/s1053-0770(00)90016-8. PMID 10794340.
- ↑ Geibel A, Kasper W, Behroz A, Przewolka U, Meinertz T, Just H (1988). "Risk of transesophageal echocardiography in awake patients with cardiac diseases". Am J Cardiol. 62 (4): 337–9. doi:10.1016/0002-9149(88)90244-5. PMID 3400617.
- ↑ Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC, Yusoff IF (2005). "Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients". J Cardiothorac Vasc Anesth. 19 (2): 141–5. doi:10.1053/j.jvca.2005.01.020. PMID 15868517.
- ↑ Kim CM, Yu SC, Hong SJ (1997). "Cardiac tamponade during transesophageal echocardiography in the patient of circumferential aortic dissection". J Korean Med Sci. 12 (3): 266–8. doi:10.3346/jkms.1997.12.3.266. PMC 3054279. PMID 9250927.
- ↑ Dalby Kristensen S, Ramlov Ivarsen H, Egeblad H (1996). "Rupture of Aortic Dissection During Attempted Transesophageal Echocardiography". Echocardiography. 13 (4): 405–406. doi:10.1111/j.1540-8175.1996.tb00912.x. PMID 11442947.
- ↑ Silvey SV, Stoughton TL, Pearl W, Collazo WA, Belbel RJ (1991). "Rupture of the outer partition of aortic dissection during transesophageal echocardiography". Am J Cardiol. 68 (2): 286–7. doi:10.1016/0002-9149(91)90769-h. PMID 2063804.
- ↑ Chow MS, Taylor MA, Hanson CW (1998). "Splenic laceration associated with transesophageal echocardiography". J Cardiothorac Vasc Anesth. 12 (3): 314–6. doi:10.1016/s1053-0770(98)90013-1. PMID 9636915.
- ↑ Kharasch ED, Sivarajan M (1996). "Gastroesophageal perforation after intraoperative transesophageal echocardiography". Anesthesiology. 85 (2): 426–8. doi:10.1097/00000542-199608000-00027. PMID 8712461.