Transesophageal Echocardiography (TEE) for Resuscitation
Disclaimer: TEE examinations carry risks of complications and should only be performed in the appropriate clinical situation by a trained provider. This section does not provide a comprehensive overview of TEE but highlights the most useful views for resuscitation and diagnostic assistance in critically ill patients. It should be noted that TEE is complimentary to TTE, and for certain clinical questions TTE may be preferable (RV assessment, pericardium, cardiac output).
Common Indications
- Shock assessment in patients with inadequate transthoracic windows
- Cardiac arrest
- Extracorporeal life support procedural guidance
- Suspected acute aortic disease and shock/cardiac arrest
Absolute Contraindications*
- Esophageal tumour/stricture/diverticulum
- Esophageal/viscous perforation
- Active UGIB
*Resuscitative TEE is not recommended in not intubated patients due to increased risk of complications
Relative Contraindications
- Recent UGIB
- Varices
- Coagulopathy/thrombocytopenia
- Hx of radiation to neck/mediastinum
- Hx of GI surgery
- Hx dysphagia
- Barrett’s esophagus
- Active esophagitis, peptic ulcer disease
- Restricted neck mobility
- Symptomatic hiatal hernia
J Am Soc Echocardiogr. 2013;26:921-64
- Appropriately sedate patient; consider neuromuscular blockade.
- Insert bite block add gel/lubricant.
- Position patient’s head midline and apply jaw thrust.
- Ensure probe wheels are not locked, gently insert probe midline with flat surface facing floor of mouth, consider slight ante-flexion if resistance felt.
- At ~15cm depth there may be slight resistance followed by release and passage of probe past hypopharynx and into upper esophagus. Do not use excessive force during insertion. Consider video or direct laryngoscopy for guided insertion if initial attempt unsuccessful.
- Rotation – probe can be rotated clockwise/counterclockwise in its long axis. Use both hands simultaneously, one at the patient’s mouth and the other on the probe handle.
- Big wheel: -clockwise -> anteflexion
-counterclockwise -> retroflexion
- Small wheel:
- Clockwise -> rightward flexion
- counterclockwise -> leftward flexion
- Omniplane (0-180°):
- Button furthest from probe tip -> increases angle
- Button closest to probe tip -> decreases angle
*do not advance/withdraw probe when ante/retroflexed or if wheel(s) locked to minimize risk of luminal injury
Optimization: advance/withdraw probe to use LA as acoustic window, consider ante/retroflexion to align with long axis of LV/RV
Utility: LV/RV size and function, assess for MR and TR, easy to obtain view to use as starting point for other views
*use ME4C view as a starting point from which to obtain other views and to reorient oneself if bearings lost
| Sample Image | How To Obtain from ME4C | Optimization | Clinical Utility | |
|---|---|---|---|---|
| Midesophageal 2 Chamber | Change omniplane to 90° | Rotate left/right to maximize LV cavity | LV function with focus on anterior and inferior wall, assess for MR | |
| Midesophageal Long Axis | Change omniplane to 120° | Advance/withdraw probe to center LVOT/AoV or MV | LV function, assess for MR and AR, may be used in cardiac arrest to guide compressions so as to avoid compression of LVOT | |
| Bicaval | Change omniplane to 90° Rotate probe clockwise to visualize RA in center of screen | Advance/withdraw probe to center SVC or IVC, rotate to avoid cylinder effect on SVC | Fluid responsiveness likely if SVC collapsibility in paralyzed pts 36%* Caveat: patients must be synchronous with ventilator with no spontaneous efforts, in regular cardiac rhythm, and with tidal volume ~8ml/kg (max diameter on expiration-minimum diameter on inspiration)/(max diameter on expiration) Procedural guidance to confirm appropriate Placement of wire/cannulae in SVC/IVC | |
| Midesophageal Ascending Aorta | Withdraw probe past visualization of AoV | Change omniplane to 90° for long axis view | Aortic dissection/aneurysm | |
| Midesophageal Arch and Descending Aorta | Rotate probe completely 180° so that probe is facing posteriorly (towards spine/descending thoracic aorta) | Change omniplane to 90° for long axis view, advance/withdraw probe to visualize entire aorta | Aortic dissection/aneurysm | |
| Transgastric Short Axis | Advance probe into stomach (past LA window and coronary sinus) and once rugae or liver visualized anteflex probe | Rotate probe to center LV cavity on screen, considerable anteflexion typically needed | LV/RV function, assess interventricular septal kinetics |
J Am Soc Echocardiogr. 2013;26:921-64
*Intensive Care Medicine. 2004,30(9), 1734-1739
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