Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review

Abstract

Background: Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) - lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE.

Methods: MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31^st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate.

Results: Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported.

Conclusions: The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.

Keywords: cardiac arrest; critical care; diagnostic imaging; echocardiography; resuscitation; shock; ultrasound.

Figure 1.

Flow Diagram.

Figure 2.

Resuscitative ccTEE views used for phenotyping of shock in the unstable patient Legend. Abbreviations: ME4, Mid-esophageal 4 chamber; MEBC, Mid-esophageal bicaval; MELAX, mid-esophageal long axis; TG SAX, Transgastric short axis; LA, Left Atrium; RA, Right Atrium; MV, Mitral Valve; TV, Tricuspid Valve; AV, aortic valve; LVOT, Left Ventricular Outflow Tract; LV, Left Ventricle; RV, Right Ventricle; RWMA, Regional Wall Motion Abnormalities; CPR, Cardiopulmonary Resuscitation.