Skip to main content
Download PDF

Transoesophageal echocardiography (TOE): contra-indications, complications and safety of perioperative TOE

Echo Research & Practice volume 5, pages R101–R113 (2018)Cite this article

Abstract

Transoesophageal echocardiography (TOE) has, in certain clinical situations, become an almost universal monitor and diagnostic tool. In the perioperative environment, TOE is frequently used to guide anaesthetic management and assist with surgical decision making for, but not limited to, cardiothoracic, major vascular and transplant operations. The use of TOE is not limited to the theatre environment being frequently used in outpatient clinics, emergency departments and intensive care settings. Two case reports, one of oesophageal perforation and another of TOE utilization in a patient having previously undergone an oesophagectomy, introduce the need for care while using TOE and highlight the need for vigilance. The safe use of TOE, the potential complications and the suggested contraindications are then considered together with suggestions for improving the safety of TOE in adult and paediatric patients.

References

  1. Click RL, Abel MD & Schaff HV. Intraoperative transesophageal echocardiography: 5-year prospective review of impact on surgical management. Mayo Clinic Proceeding 2000 75 241–247. (https://doi.org/10.1016/S0025-6196(11)65027-1)

    CAS  Google Scholar 

  2. Mishra M, Chauhan R, Sharma KK, Dhar A, Bhise M, Dhole S, Omar A, Kasliwal RR & Trehan N. Real-time intraoperative transesophageal echocardiography - how useful? Experience of 5016 cases. Journal of Cardiothoracic and Vascular Anesthesia 1998 12 625–632. (https://doi.org/10.1016/S1053-0770(98)90232-4)

    CAS  PubMed  Google Scholar 

  3. Eltzschig HK, Shernan SK & Rosenberger P. Ischemic mitral regurgitation during temporary coronary artery ligation. New England Journal of Medicine 2004 350 2424–2425. (https://doi.org/10.1056/NEJM200406033502323)

    CAS  Google Scholar 

  4. Eltzschig HK, Rosenberger P, Loffler M, Fox JA, Aranki SF & Shernan SK. Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery. Annals of Thoracic Surgery 2008 85 845–852. (https://doi.org/10.1016/j.athoracsur.2007.11.015)

    Google Scholar 

  5. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN & Eltzschig HK. Safety of transesophageal echocardiography. Journal of the American Society of Echocardiography 2010 23 1115–1127. (https://doi.org/10.1016/j.echo.2010.08.013)

    Google Scholar 

  6. Heidenreich PA. Transesophageal echocardiography (TEE) in the critical care patient. Clinical Cardiology 2000 18 789–805. (https://doi.org/10.1016/S0733-8651(05)70180-6)

    CAS  Google Scholar 

  7. Yong Y, Wu D, Fernandes V, Kopelen HA, Shimoni S, Nagueh SF, Callahan JD, Bruns DE, Shaw LJ, Quinones MA, et al. Diagnostic accuracy and cost-effectiveness of contrast echocardiography on evaluation of cardiac function in technically very difficult patients in the intensive care unit. American Journal of Cardiology 2002 89 711–718. (https://doi.org/10.1016/S0002-9149(01)02344-X)

    Google Scholar 

  8. Schmidlin D, Schuepbach R, Bernard E, Ecknauer E, Jenni R & Schmid ER. Indications and impact of postoperative transesophageal echocardiography in cardiac surgical patients. Critical Care Medicine 2001 29 2143–2148. (https://doi.org/10.1097/00003246-200111000-00016)

    CAS  PubMed  Google Scholar 

  9. Tousignant CP, Walsh F & Mazer CD. The use of transesophageal echocardiography for preload assessment in critically ill patients. Anesthesia and Analgesia 2000 90 351–355.

    CAS  PubMed  Google Scholar 

  10. Yvorchuk KJ & Chan KL. Application of transthoracic and transesophageal echocardiography in the diagnosis and management of infective endocarditis. Journal of the American Society of Echocardiography 1994 7 294–298. (https://doi.org/10.1016/S0894-7317(14)80400-8)

    CAS  PubMed  Google Scholar 

  11. Michelena HI, Abel MD, Suri RM, Freeman WK, Click RL, Sundt TM, Schaff HV, Enriquez-Sarano M: Intraoperative echocardiography in valvular heart disease: an evidence-based appraisal. Mayo Clinic Proceeding 2010 85 646–655. (https://doi.org/10.4065/mcp.2009.0629)

    Google Scholar 

  12. Klein AL, Obarski TP, Stewart WJ, Casale PN, Pearce GL, Husbands K, Cosgrove DM & Salcedo EE. Transesophageal Doppler echocardiography of pulmonary venous flow: a new marker of mitral regurgitation severity. Journal of the American College of Cardiology 1991 18 518–526. (https://doi.org/10.1016/0735-1097(91)90609-D)

    CAS  PubMed  Google Scholar 

  13. Yalcin F, Thomas JD, Homa D & Flachskampf FA. Transesophageal echocardiography: first-line imaging for aortic diseases. Cleveland Clinic Journal of Medicine 2000 67 417–418, 421-428. (https://doi.org/10.3949/ccjm.67.6.417)

    CAS  PubMed  Google Scholar 

  14. Manning WJ, Weintraub RM, Waksmonski CA, Haering JM, Rooney PS, Maslow AD, Johnson RG & Douglas PS. Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. American College of Physicians 1995 123 817–822. (https://doi.org/10.7326/0003-4819-123-11-199512010-00001)

    CAS  Google Scholar 

  15. Practice Guidelines for Perioperative Transesophageal Echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010 112 1084–1096.

    Google Scholar 

  16. Kallmeyer IJ, Collard CD, Fox JA, Body SC & Shernan SK. The safety of transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesthesia and Analgesia 2001 92 1126–1130. (https://doi.org/10.1097/00000539-200105000-00009)

    CAS  PubMed  Google Scholar 

  17. Bavalia N, Anis A, Benz M, Maldjian P, Bolanowski PJ & Saric M. Esophageal perforation, the most feared complication of TEE: early recognition by multimodality imaging. Echocardiography 2011 28 E56–E59. (https://doi.org/10.1111/j.1540-8175.2010.01291.x)

    PubMed  Google Scholar 

  18. Min JK, Spencer KT, Furlong KT, DeCara JM, Sugeng L, Ward RP & Lang RM. Clinical features of complications from transesophageal echocardiography: a single-center case series of 10,000 consecutive examinations. Journal of the American Society of Echocardiography 2005 18 925–929. (https://doi.org/10.1016/j.echo.2005.01.034)

    PubMed  Google Scholar 

  19. Daniel WG, Erbel R, Kasper W, Visser CA, Engberding R, Sutherland GR, Grube E, Hanrath P, Maisch B, Dennig K, et al. Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation 1991 83 817–821. (https://doi.org/10.1161/01.CIR.83.3.817)

    CAS  PubMed  Google Scholar 

  20. Silvis SE, Nebel O, Rogers G, Sugawa C & Mandelstam P. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy survey. JAMA 1976 235 928–930. (https://doi.org/10.1001/jama.1976.03260350032023)

    CAS  PubMed  Google Scholar 

  21. Miller G. Complications of endoscopy of the upper gastrointestinal tract [article in German]. Leber, Magen, Darm 1987 17 299–304.

    CAS  PubMed  Google Scholar 

  22. Kharasch ED & Sivarajan M. Gastroesophageal perforation after intraoperative transesophageal echocardiography. Anesthesiology 1996 85 426–428. (https://doi.org/10.1097/00000542-199608000-00027)

    CAS  PubMed  Google Scholar 

  23. Piercy M, McNicol L, Dinh DT, Story DA & Smith JA. Major complications related to the use of transesophageal echocardiography in cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia 2009 23 62–65. (https://doi.org/10.1053/j.jvca.2008.09.014)

    PubMed  Google Scholar 

  24. Jougon JB, Gallon P, MacBride T, Dubrez J & Velly JF. Esophageal perforation after transesophageal echocardiography. European Journal of Cardio-Thoracic Surgery 1999 16 686–687. (https://doi.org/10.1016/S1010-7940(99)00322-X)

    CAS  PubMed  Google Scholar 

  25. Spahn DR, Schmid S, Carrel T, Pasch T & Schmid ER. Hypopharynx perforation by a transesophageal echocardiography probe. Anesthesiology 1995 82 581–583. (https://doi.org/10.1097/00000542-199502000-00029)

    CAS  PubMed  Google Scholar 

  26. Massey SR, Pitsis A, Mehta D & Callaway M. Oesophageal perforation following perioperative transoesophageal echocardiography. British Journal of Anaesthesia 2000 84 643–646. (https://doi.org/10.1093/bja/84.5.643)

    CAS  PubMed  Google Scholar 

  27. Sainathan S & Andaz S. A systemic review of transesophageal echocardiography-induced esophageal perforation. Echocardiography 2013 30 977–983. (https://doi.org/10.1111/echo.12290)

    PubMed  Google Scholar 

  28. Zuchelli T, Alsheik E, Chu C & Bhandari B. Does an upper endoscopy before transesophageal echocardiography change management? Journal of Clinical Gastroenterology 2015 49 848–852. (https://doi.org/10.1097/MCG.0000000000000332)

    PubMed  Google Scholar 

  29. Savino JS, Hanson CW III, Bigelow DC, Cheung AT & Weiss SJ. Oropharyngeal injury after transesophageal echocardiography. Journal of Cardiothoracic and Vascular Anesthesia 1994 8 76–78. (https://doi.org/10.1016/1053-0770(94)90017-5)

    CAS  PubMed  Google Scholar 

  30. Urbanowicz JH, Kernoff RS, Oppenheim G, Parnagian E, Billingham ME & Popp RL. Transesophageal echocardiography and its potential for esophageal damage. Anesthesiology 1990 72 40–43. (https://doi.org/10.1097/00000542-199001000-00008)

    CAS  PubMed  Google Scholar 

  31. O’Shea JP, Southern JF, D’Ambra MN, Magro C, Geurrero JL, Marshall JE, Vlahakes GV, Levine RA & Weyman AE. Effects of prolonged transesophageal echocardiographic imaging and probe manipulation on the esophagus-an echocardiographic-pathologic study. Journal of the American College of Cardiology 1991 17 1426–1429.

    PubMed  Google Scholar 

  32. Lennon MJ, Gibbs NM, Weightman WM, Leber J, Ee HC & Yusoff IF. Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients. Journal of Cardiothoracic and Vascular Anesthesia 2005 19 141–145. (https://doi.org/10.1053/j.jvca.2005.01.020)

    PubMed  Google Scholar 

  33. Kasper J, Bolliger D, Skarvan K, Buser P, Filipovic M & Seeberger MD. Additional cross sectional transesophageal echocardiography views improve perioperative right heart assessment. Anesthesiology 2012 117 726–734. (https://doi.org/10.1097/ALN.0b013e318269054b)

    PubMed  Google Scholar 

  34. Bufkin BL, Miller JI & Mansour KA. Esophageal perforation: emphasis on management. Annals of Thoracic Surgery 1996 61 1447–1451; discussion 1451-1442. (https://doi.org/10.1016/0003-4975(96)00053-7)

    CAS  Google Scholar 

  35. Ohri SK, Liakakos TA, Pathi V, Townsend ER & Fountain SW. Primary repair of iatrogenic thoracic esophageal perforation and Boerhaave’s syndrome. Annals of Thoracic Surgery 1993 55 603–606. (https://doi.org/10.1016/0003-4975(93)90261-F)

    CAS  Google Scholar 

  36. Nesbitt JC & Sawyers JL. Surgical management of esophageal perforation. American Surgeon 1987 53 183–191.

    CAS  Google Scholar 

  37. Whyte RI, Iannettoni MD & Orringer MB. Intrathoracic esophageal perforation. The merit of primary repair. Journal of Thoracic and Cardiovascular Surgery 1995 109 140–144; discussion 144-146. (https://doi.org/10.1016/S0022-5223(95)70429-9)

    CAS  Google Scholar 

  38. Spier BJ, Larue SJ, Teelin TC, Leff JA, Swize LR, Borkan SH, Satyapriya A, Rhako PS & Pfau PR. Review of complications in a series of patients with known gastroesophageal varices undergoing transesophageal echocardiography. Journal of the American Society of Echocardiography 2009 22 396–400. (https://doi.org/10.1016/j.echo.2009.01.002)

    PubMed  Google Scholar 

  39. St-Pierre J, Fortier LP, Couture P & Hebert Y. Massive gastrointestinal hemorrhage after transoesophageal echocardiography probe insertion. Canadian Journal of Anesthesia 1998 45 1196–1199. (https://doi.org/10.1007/BF03012463)

    CAS  PubMed  Google Scholar 

  40. Hulyalkar AR & Ayd JD. Low risk of gastroesophageal injury associated with transesophageal echocardiography during cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia 1993 7 175–177. (https://doi.org/10.1016/1053-0770(93)90212-4)

    CAS  PubMed  Google Scholar 

  41. McSweeney ME, Garwood S, Levin J, Marino MR, Wang SX, Kardatzke D, Mangano DT & Wolman RL. Adverse gastrointestinal complications after cardiopulmonary bypass: can outcome be predicted from preoperative risk factors? Anesthesia and Analgesia 2004 98 1610–1617. (https://doi.org/10.1213/01.ANE.0000113556.40345.2E)

    PubMed  Google Scholar 

  42. Hogue CW, Lappas GD, Creswell LL, Fergusen TB Jr, Sample M, Pugh D, Balfe D, Cox JL & Lappas DG. Swallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. Journal of Thoracic and Cardiovascular Surgery 1995 110 517–522. (https://doi.org/10.1016/S0022-5223(95)70249-0)

    Google Scholar 

  43. Rousou JA, Tighe DA, Garb JL, Krasner K, Engelman RM, Flack JE & Deaton DW. Risk of dysphagia after transesophageal echocardiography during cardiac operations. Annals of Thoracic Surgery 2000 69 486–490.

    CAS  Google Scholar 

  44. Messina AG, Paranicas M, Fiamengo S, Yao F-S, Krieger K, Isom OW & Devereux RB. Risk of dysphagia after transesophageal echocardiography. American Journal of Cardiology 1991 67 313–314. (https://doi.org/10.1016/0002-9149(91)90567-5)

    CAS  Google Scholar 

  45. Khandheria BK & Oh J. Transesophageal echocardiography: state-of-the art and future directions. American Journal of Cardiology 1992 69 (Supplement 1) 61H–75H. (https://doi.org/10.1016/0002-9149(92)90648-I)

    CAS  Google Scholar 

  46. Kallmeyer I, Morse DS, Body SC & Collard CD. Case 2-2000. Transesophageal echocardiography-associated gastrointestinal trauma. Journal of Cardiothoracic and Vascular Anesthesia 2000 14 212–216. (https://doi.org/10.1016/S1053-0770(00)90022-3)

    CAS  PubMed  Google Scholar 

  47. Sharma V, Alderton S, McNamara H, Steeds R, Bradlow W, Chenzbraun A, Oxborough D, Mathew T, Jones R, Wheeler R, et al. A safety checklist for transesophageal echocardiography from the British Society of Echocardiography and the Association of Cardiothoracic Anaesthetists. Echo Research and Practice 2015 2 G25–G27. (https://doi.org/10.1530/ERP-15-0035)

    PubMed  PubMed Central  Google Scholar 

  48. Kako H, Alkhatib O, Krishna SG, Khan S, Naguib A & Tobias JD. Changes in intracuff pressure of a cuffed endotracheal tube during surgery for congenital heart disease using cardiopulmonary bypass. Pediatric Anaesthesia 2015 25 705–710. (https://doi.org/10.1111/pan.12631)

    Google Scholar 

  49. Inada T, Kawachi S & Kuroda M. Tracheal tube cuff pressure during cardiac surgery using cardiopulmonary bypass. British Journal of Anaesthesia 1995 74 283–286. (https://doi.org/10.1093/bja/74.3.283)

    CAS  PubMed  Google Scholar 

  50. Souza Neto EP, Piriou V, Durand PG, George M, Evans R, Obadia JF & Lehot JJ. Influence of temperature on tracheal tube cuff pressure during cardiac surgery. Acta Anaesthesiologica Scandinavica 1999 43 333–337. (https://doi.org/10.1034/j.1399-6576.1999.430315.x)

    CAS  PubMed  Google Scholar 

  51. Mishra M, Chauhan R, Sharma KK, Dhar A, Bhise M, Dhole S, Omar A, Kasliwal RR & Trehan N. Real-time intraoperative transesophageal echocardiography - how useful? Experience of 5016 cases. Journal of Cardiothoracic and Vascular Anesthesia 1998 12 625–632. (https://doi.org/10.1016/S1053-0770(98)90232-4)

    CAS  PubMed  Google Scholar 

  52. Couture P, Denault AY, McKenty S, Boudreault D, Plante F, Perron R, Babin D, Normandin L & Poirier N. Impact of routine use of intraoperative transesophageal echocardiography during cardiac surgery. Canadian Journal of Anesthesia 2000 47 20–26. (https://doi.org/10.1007/BF03020726)

    CAS  PubMed  Google Scholar 

  53. Comunale ME, Body SC, Ley C, Koch C, Roach G, Mathew J, Herskowitz A & Mangano T. The concordance of intraoperative left ventricular wall-motion abnormalities and electrocardiographic S-T segment changes: association with outcome after coronary revascularization. Anesthesiology 1998 88 945–954. (https://doi.org/10.1097/00000542-199804000-00014)

    CAS  PubMed  Google Scholar 

  54. Denault AY, Couture P, McKenty S, Boudreault D, Plante F, Perron R, Babin D & Buithieu J. Perioperative use of transesophageal echocardiography by anesthesiologists: impact in noncardiac surgery and in the intensive care unit. Canadian Journal of Anesthesia 2002 49 287–293. (https://doi.org/10.1007/BF03020529)

    PubMed  Google Scholar 

  55. Memtsoudis SG, Rosenberger P, Loffler M, Eltzschig HK, Mizuguchi A, Shernan SK & Fox JA. The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery. Anesthesia and Analgesia 2006 102 1653–1657. (https://doi.org/10.1213/01.ane.0000216412.83790.29)

    PubMed  Google Scholar 

  56. Rapezzi C, Rocchi G, Fattori R, Calderera I, Ferlito M, Napoli G, Pierangeli A & Branzi A. Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysms. American Journal of Cardiology 2001 87 315–319. (https://doi.org/10.1016/S0002-9149(00)01365-5)

    CAS  Google Scholar 

  57. Greene MA, Alexander JA, Knauf DG, Talbert J, Langham M, Kays D & Ledbetter D. Endoscopic evaluation of the esophagus in infants and children immediately following intraoperative use of transesophageal echocardiography. Chest 1999 116 1247–1250. (https://doi.org/10.1378/chest.116.5.1247)

    CAS  PubMed  Google Scholar 

  58. Tsai SK, Chang CI, Wang MJ, Chen SJ, Chiu IS, Chen YS & Lue HC. The assessment of the proximal left pulmonary artery by transesophageal echocardiography and computed tomography in neonates and infants: a case series. Anesthesia and Analgesia 2001 93 594–597. (https://doi.org/10.1097/00000539-200109000-00013)

    CAS  PubMed  Google Scholar 

  59. Andropoulos DB, Ayres NA, Stayer SA, Bent ST, Campos CJ & Fraser CD. The effect of transesophageal echocardiography on ventilation in small infants undergoing cardiac surgery. Anesthesia and Analgesia 2000 90 47–49. (https://doi.org/10.1097/00000539-200001000-00011)

    CAS  PubMed  Google Scholar 

  60. Laporta D, Kleiman S, Begin L, De Marchie M & Spanier AH. Traumatic perforation of the cervical esophagus: a complication of endotracheal intubation. Intensive Care Medicine 1993 19 59–60. (https://doi.org/10.1007/BF01709282)

    CAS  PubMed  Google Scholar 

  61. Stevenson JG. Incidence of complications in pediatric transesophageal echocardiography: experience in 1650 cases. Journal of the American Society of Echocardiography 1999 12 527–532. (https://doi.org/10.1016/S0894-7317(99)70090-8)

    CAS  PubMed  Google Scholar 

Download references

Funding

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Author information

Authors and Affiliations

  1. Department of Anaesthesia & Perioperative Medicine Groote Schuur & Red Cross Children’s Hospitals, University of Cape Town, Cape Town, South Africa

    Neil David Hauser MBChB DA(SA) MMed(Anaes) FCA(SA) FANZCA & Justiaan Swanevelder MBChB MMed(Anes) FCA(SA) FRCA

Authors
  1. Neil David Hauser MBChB DA(SA) MMed(Anaes) FCA(SA) FANZCA
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Justiaan Swanevelder MBChB MMed(Anes) FCA(SA) FRCA
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Neil David Hauser MBChB DA(SA) MMed(Anaes) FCA(SA) FANZCA.

Rights and permissions

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.(http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hauser, N.D., Swanevelder, J. Transoesophageal echocardiography (TOE): contra-indications, complications and safety of perioperative TOE. Echo Res Pract 5, R101–R113 (2018). https://doi.org/10.1530/ERP-18-0047

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-18-0047

Key Words

Echo Research & Practice

ISSN: 2055-0464

Contact us