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Procedural TEE: Sometimes Hard to Swallow
COUNCIL ON PERIOPERATIVE ECHOCARDIOGRAPHY (COPE) COMMUNICATION Procedural TEE: Sometimes Hard to Swallow Transesophageal echocardiography (TEE) is a key imaging procedure used during multiple interventions performed in both cardiac catheterization and electrophysiology laboratories. Its use in these settings has become so common, in fact, that TEE is becoming regarded as less of an actual ‘‘procedure,’’ than simply another way to provide pictures for the interventionalist—not unlike the fluoroscopy machine. The difference, of course, is that the TEE probe must be invasively placed and then continually manipulated within the patient’s body during imaging. In this regard it bears more similarity to bronchoscopy than chest-wall echocardiography. I was recently reminded of the potential difficulties involved with TEE probe insertion during a left atrial appendage occluder device procedure. After a few unsuccessful blind attempts in my intubated and anesthetized patient, I realized something did not feel right. I picked up a nearby video laryngoscope, which revealed the findings in Figure 1. As it turns out, the patient had an undiagnosed Killian-Jamieson diverticulum, which is similar to the betterknown Zenker’s, although generally smaller and significantly less common.1 Per the 2013 comprehensive TEE guidelines,2 this was considered an absolute contraindication, and the procedure was abandoned. Anecdotal stories aside, Zuchelli et al. recently studied 134 patients who were referred for upper endoscopy prior to TEE placement due to positive symptoms (mainly dysphagia or hematemesis), or had a history of difficult probe placement.3 They found that 15% of the patients ultimately had some absolute contraindication to performing a TEE exam. When in doubt, it certainly never hurts to look. Of course the most feared complication of TEE, gastrointestinal perforation, is an extremely rare event. In fact, in the first large series examining the safety of TEE, published 25 years ago in this very journal, it was not reported at all in 1500 patients.4 However, that study was conducted in an ambulatory setting. Paralyzed and intubated patients, who can no longer complain of painful probe manipulations, have a much different risk profile. The major complication rate for intraoperative TEE has been reported as high as 1.2%,
and significant swallowing dysfunction may be present in over 5% of patients following TEE use in cardiac surgery.5,6 In anesthetized patients, excessive and/or extreme probe manipulations may contribute to gastrointestinal tract injury; the physician operating the probe must be aware of these concerns. The data on operative and non-operative TEE safety was thoroughly reviewed by HilRoman Sniecinberath et al. in the November, 2010 issue of ski, MD, FASE 7 JASE. At that time, however, ‘‘operative’’ referred almost exclusively to those TEEs performed during the course of cardiac surgery. The operating room TEE sequence generally consists of baseline, off-CPB (cardiopulmonary bypass), and chest-closed exams, each with discrete periods of image acquisition typically lasting 10-20 minutes. On the other hand, when TEE is used to help guide catheter-based procedures, there can be extended periods of time where the probe is locked onto one or two particular views while the interventionalist is working. I can remember one of my colleagues straddling the C-arm for nearly three straight hours during the learning curve phase of a particular mitral valve intervention. Unlike fluoroscopy machines, which are required by law to record radiation exposure time, there is little data collected that can be used to assess the impact that these protracted TEE exams may have on patient safety. The take-home message here is that we need to remember that just because TEE is common does not mean it is without risks. Medical judgement is required to assess those risks and weigh imaging concerns against potentially harmful probe maneuvers, including placing it altogether. It is interesting to note that the British Society of Echocardiography and the Association of Cardiac Anaesthetists have recently endorsed a safety checklist specifically for TEE.8 I commend them for formally recognizing that TEE is an invasive medical procedure, and implore our interventionalist colleagues not to forget that it is. REFERENCES
Figure 1 Video laryngoscope picture of a TEE probe being inserted into an esophageal diverticulum. The green arrow points to the esophageal inlet.
22A Journal of the American Society of Echocardiography
1. Rubesin SE, Levine MS. Killian-Jamieson diverticula: radiographic findings in 16 patients. AJR Am J Roentgenol 2001;177:85-9. 2. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64. 3. Zuchelli T, Alsheik E, Chu C, Bhandari B. Does an Upper Endoscopy Before Transesophageal Echocardiography Change Patient Management? J Clin Gastroenterol 2015;49:848-52. 4. Chan KL, Cohen GI, Sochowski RA, Baird MG. Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations. J Am Soc Echocardiogr 1991;4:577-82. 5. Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC, Yusoff IF. Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients. J Cardiothorac Vasc Anesth 2005;19:141-5.
Volume 29 Number 4
6. Hogue CW Jr, Lappas GD, Creswell LL, Ferguson TB Jr, Sample M, Pugh D, et al. Swallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg 1995;110:517-22. 7. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr 2010;23:1115-27. quiz 220-221. 8. Sharma V, Alderton S, McNamara H, Steeds R, Bradlow W, Chenzbraun A, et al. A safety checklist for transoesophageal echocardiography from the
Volume 29 Number 4
British Society of Echocardiography and the Association of Cardiothoracic Anaesthetists. Echo Res Pract 2015;2:G25-7.
Roman Sniecinski, MD, FASE is an Associate Professor of Anesthesiology in the Division of Cardiothoracic Anesthesia at Emory University School of Medicine. He is the current Chair of the Council of Perioperative Echocardiography steering committee.
Journal of the American Society of Echocardiography 23A
and significant swallowing dysfunction may be present in over 5% of patients following TEE use in cardiac surgery.5,6 In anesthetized patients, excessive and/or extreme probe manipulations may contribute to gastrointestinal tract injury; the physician operating the probe must be aware of these concerns. The data on operative and non-operative TEE safety was thoroughly reviewed by HilRoman Sniecinberath et al. in the November, 2010 issue of ski, MD, FASE 7 JASE. At that time, however, ‘‘operative’’ referred almost exclusively to those TEEs performed during the course of cardiac surgery. The operating room TEE sequence generally consists of baseline, off-CPB (cardiopulmonary bypass), and chest-closed exams, each with discrete periods of image acquisition typically lasting 10-20 minutes. On the other hand, when TEE is used to help guide catheter-based procedures, there can be extended periods of time where the probe is locked onto one or two particular views while the interventionalist is working. I can remember one of my colleagues straddling the C-arm for nearly three straight hours during the learning curve phase of a particular mitral valve intervention. Unlike fluoroscopy machines, which are required by law to record radiation exposure time, there is little data collected that can be used to assess the impact that these protracted TEE exams may have on patient safety. The take-home message here is that we need to remember that just because TEE is common does not mean it is without risks. Medical judgement is required to assess those risks and weigh imaging concerns against potentially harmful probe maneuvers, including placing it altogether. It is interesting to note that the British Society of Echocardiography and the Association of Cardiac Anaesthetists have recently endorsed a safety checklist specifically for TEE.8 I commend them for formally recognizing that TEE is an invasive medical procedure, and implore our interventionalist colleagues not to forget that it is. REFERENCES
Figure 1 Video laryngoscope picture of a TEE probe being inserted into an esophageal diverticulum. The green arrow points to the esophageal inlet.
22A Journal of the American Society of Echocardiography
1. Rubesin SE, Levine MS. Killian-Jamieson diverticula: radiographic findings in 16 patients. AJR Am J Roentgenol 2001;177:85-9. 2. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64. 3. Zuchelli T, Alsheik E, Chu C, Bhandari B. Does an Upper Endoscopy Before Transesophageal Echocardiography Change Patient Management? J Clin Gastroenterol 2015;49:848-52. 4. Chan KL, Cohen GI, Sochowski RA, Baird MG. Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations. J Am Soc Echocardiogr 1991;4:577-82. 5. Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC, Yusoff IF. Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients. J Cardiothorac Vasc Anesth 2005;19:141-5.
Volume 29 Number 4
6. Hogue CW Jr, Lappas GD, Creswell LL, Ferguson TB Jr, Sample M, Pugh D, et al. Swallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg 1995;110:517-22. 7. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr 2010;23:1115-27. quiz 220-221. 8. Sharma V, Alderton S, McNamara H, Steeds R, Bradlow W, Chenzbraun A, et al. A safety checklist for transoesophageal echocardiography from the
Volume 29 Number 4
British Society of Echocardiography and the Association of Cardiothoracic Anaesthetists. Echo Res Pract 2015;2:G25-7.
Roman Sniecinski, MD, FASE is an Associate Professor of Anesthesiology in the Division of Cardiothoracic Anesthesia at Emory University School of Medicine. He is the current Chair of the Council of Perioperative Echocardiography steering committee.
Journal of the American Society of Echocardiography 23A