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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

  • Laryngospasm: may occur due to instillation and aspiration of topical anesthetic spray or inadverent endotracheal intubation.

  • Hypoxia.

  • Bronchospasm.

B. Cardiovascular complications:

Arrhythmias:

C. Others:

  • Minor pharyngeal bleeding.

  • 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).

  • 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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