Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic

Abstract

Background: The COVID-19 pandemic has placed an extraordinary strain on healthcare systems across North America. Defining the optimal approach for managing a critically ill COVID-19 patient is rapidly changing. Goal-directed transesophageal echocardiography (TEE) is frequently used by physicians caring for intubated critically ill patients as a reliable imaging modality that is well suited to answer questions at bedside.

Methods: A multidisciplinary (intensive care, critical care cardiology, and emergency medicine) group of experts in point-of-care echocardiography and TEE from the United States and Canada convened to review the available evidence, share experiences, and produce a consensus statement aiming to provide clinicians with a framework to maximize the safety of patients and healthcare providers when considering focused point-of-care TEE in critically ill patients during the COVID-19 pandemic.

Results: Although transthoracic echocardiography can provide the information needed in most patients, there are specific scenarios in which TEE represents the modality of choice. TEE provides acute care clinicians with a goal-directed framework to guide clinical care and represents an ideal modality to evaluate hemodynamic instability during prone ventilation, perform serial evaluations of the lungs, support cardiac arrest resuscitation, and guide veno-venous ECMO cannulation. To aid other clinicians in performing TEE during the COVID-19 pandemic, we describe a set of principles and practical aspects for performing examinations with a focus on the logistics, personnel, and equipment required before, during, and after an examination.

Conclusions: In the right clinical scenario, TEE is a tool that can provide the information needed to deliver the best and safest possible care for the critically ill patients.

Keywords: Acute respiratory syndrome associated with COVID-19; COVID-19; Novel coronavirus; Point-of-care ultrasound; SARS-CoV-2; Transesophageal echocardiography.

Figure 1

TEE during cardiac arrest resuscitation in a patient with COVID-19. Right atrial thrombus (asterisk) visualized in an off-axis bicaval (A) and a midesophageal four-chamber (B) view, both obtained during ongoing cardiopulmonary resuscitation (CPR). Another midesophageal four-chamber view (C) of same patient shows a dilated right ventricle (RV) and septal deviation during CPR pause, suggesting pulmonary embolism. LA, Left atrium; LV, left ventricle; RA, right atrium.

Figure 2

TELUS of patients with hypoxemia in the intensive care unit (A,B) and emergency department (C,D). (A) Sagittal plane view of the left lung shows B-lines (asterisk) suggesting increased extravascular lung water. Panels (B) and (C) correspond to sagittal-plane views of the right costophrenic angle showing consolidation pattern (asterisk) suggestive of atelectasis versus pneumonia. In (D), an axial-plane view of the left lung shows an atelectatic lung (left asterisk) and pleural effusion (right asterisk). DTA, Descending thoracic aorta.

Figure 3

Performance of point-of-care TEE with patient in the prone position.