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Submitted by Dr. Yasser Mokhtar, MD. Dept. of internal
medicine. School of medicine, University of South Dakota.
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TEE improves diagnostic information in various cardiovascular diseases compared to conventional echo.
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Complications of TEE
Complications can be related to the probe, the
procedure or the medications used during the procedure.
I. Probe related complication
A. Failure of probe introduction
In the cooperative European experience involving
10,419 patients, the incidence of unsuccessful probe introductions was
1.9% whereas 0.9% of examinations were interrupted before completion
because of patient intolerance (Daniel et al.,
1991).
A small proportion of patients can not tolerate
the study and either gag so much that the probe can not be inserted
or remove the probe forcibly before the study is completed (Fraser
and Anderson 1991).
B. Thermal injuries:
In order to minimize any possible thermal injury
to the esophagus, most of the commercially available TEE probes monitor
temperature at their tips and if the temperature rises above a preset
cut off level (usually 39oC) the probe is either automatically switched
off or the operator is warned.
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C. Pressure injuries:
The tip of the probe should never be maintained
in imaging position with extreme force since contact pressures of 60
mmHg can be produced and these might damage the esophageal or gastric
mucosa (Urbanowicz et al., 1990).
II. Procedure related complications
A. Respiratory compromise
B. Cardiovascular complications:
Arrhythmias:
C. Others:
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Minor pharyngeal bleeding.
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Nausea and
vomiting.
-
Bacteremia:
It has been associated with TEE in 3.2% to
12% of patients (Pongratz et al., 1993).
The organisms responsible for bacteremia after
TEE intubation include
Staphylococcus aureus, Staphylococcus epidermidis and
a-hemolytic
streptococci (Saltissi et al., 1994).
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Deaths: Two deaths were reported:
The first was a patient who had a malignant
lung tumor that invaded the esophagus and during introduction of the
probe, laceration of the tumor occurred resulting in massive
hematemesis and death of the patient.
The second was a
diabetic female who died of
cardiopulmonary arrest ten minutes after an uneventful procedure.
Safety of TEE
TEE is a low risk procedure that yields an enormous
amount of clinically relevant information when used appropriately. Although
it is semi invasive, TEE is generally very safe. In two large studies,
major complications were unusual (0.18% to 0.5%) and two deaths were reported
(Daniel et al., 1991 and Khandheria et al., 1992).
TEE has been performed for many years and thousands
of studies have been done, virtually, all of them without significant
complications (Sreeram et al., 1990).
Advantages of TEE over TTE
Schl?er et al. in 1984 and later Matsuzaki et
al. in 1990 postulated that imaging the heart via the esophagus provides
information about the cardiac structure and the great vessels and allows
the use of higher frequency transducers which results in improved image
quality. TEE improves diagnostic information in various cardiovascular
diseases compared to conventional
TTE (Schl?er
et al., 1984 and Matsuzaki et al., 1990).
TTE
does not provide complete or adequately detailed
information. This is especially true in evaluation of posterior cardiac
structures (e.g. left atrium, left atrial appendage, interatrial septum,
the aorta distal to the root), in the assessment of prosthetic cardiac
valves and in the delineation of cardiac structures less than 3 mm in
size (e.g. small vegetations or thrombi). Ultrasound imaging from the
esophagus is uniquely suited to these situations as the esophagus is adjacent
to the left atrium and the thoracic aorta for much of its course (Dittrich
et al., 1992 and Blanchard et al., 1994).
In many patients, image quality with
TTE
is significantly
limited by ultrasound interference by chest wall and lung especially in
obese and elderly patients and in patients with chronic obstructive pulmonary
disease. This limitation is overcome with TEE, for consistent high quality
imaging is obtainable in all patients.
TEE is particularly advantageous in imaging the
interatrial septum since an esophageal probe faces this cardiac structure
nearly perpendicularly at a relatively short distance. The image quality
is superior to transthoracic recordings and echo dropouts are virtually
non-existent. By manipulation of the transducer, the total length of the
interatrial septum can be imaged and scanned for defects (Hanrath
et al., 1983).
TEE has become a valuable addition to the cardiovascular
ultrasound imaging and hemodynamic laboratory because the more proximate
and unobstructed esophageal window markedly improves visualization of
cardiovascular anatomy and a broad spectrum of lesion (Seward et al.,
1988).
TEE is conclusive in many cardiac diseases so that
it can diagnose 95% of cases versus 48% using
TTE
(Pavlides
et al., 1990).
TEE has become a logistical extension of comprehensive
echocardiographic examination. If a precordial (transthoracic) examination
is incomplete, TEE can be complementary in most cases (Seward
et al., 1988 and Seward et al., 1990).
TEE in critically ill patients
Utility of transesophageal echocardiography in
critically ill patients is now well recognized. TEE can be performed safely
in such patients who are often too unstable or encumbered with life support
devices to permit other means of expeditious evaluation and immediately
provides a wealth of information for management (Oh
et al., 1990).
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