Echocardiography, Transesophageal


Echocardiography, Transesophageal

Synonym/acronym: Echo, TEE.

Common use

To assess and visualize cardiovascular structures toward diagnosing disorders such as tumors, congenital defects, valve disorders, chamber disorders, and bleeding.

Area of application

Chest/thorax.

Contrast

Can be done with or without noniodinated contrast medium (lipid microspheres).

Description

Transesophageal echocardiography (TEE) is performed to assist in the diagnosis of cardiovascular disorders when noninvasive echocardiography is contraindicated or does not reveal enough information to confirm a diagnosis. Noninvasive echocardiography may be an inadequate procedure for patients who are obese, have chest wall structure abnormalities, or have chronic obstructive pulmonary disease (COPD). TEE provides a better view of the posterior aspect of the heart, including the atrium and aorta. It is done with a transducer attached to a gastroscope that is inserted into the esophagus. The transducer and the ultrasound (US) instrument allow the beam to be directed to the back of the heart. The echoes are amplified and recorded on a screen for visualization and recorded on graph paper or videotape. The depth of the endoscope and movement of the transducer is controlled to obtain various images of the heart structures. TEE is usually performed during surgery; it is also used on patients who are in the intensive care unit, in whom the transmission of waves to and from the chest has been compromised and more definitive information is needed. The images obtained by TEE have better resolution than those obtained by routine transthoracic echocardiography because TEE uses higher frequency sound waves and offers closer proximity of the transducer to the cardiac structures. Cardiac contrast medium such as DEFINITY or Optison, is used to improve the visualization of viable myocardial tissue within the heart.

This procedure is contraindicated for

    N/A

  • high alertA variety of circumstances that may be considered absolute or relative depending on the facility’s providers:

  • Barrett esophagus
  • Bleeding disorders
  • Esophageal obstruction (e.g., spasm, stricture, tumor)
  • Esophageal trauma (e.g., laceration, perforation)
  • Esophageal varices
  • Known upper esophagus disease
  • Tracheoesophageal fistula
  • Recent esophageal surgery (e.g., esophagectomy or esophagogastrectomy)
  • Unstable cardiac or respiratory status
  • Zenker diverticulum

Indications

  • Confirm diagnosis if conventional echocardiography does not correlate with other findings
  • Detect and evaluate congenital heart disorders
  • Detect atrial tumors (myxomas)
  • Detect or determine the severity of valvular abnormalities and regurgitation
  • Detect subaortic stenosis as evidenced by displacement of the anterior atrial leaflet and reduction in aortic valve flow, depending on the obstruction
  • Detect thoracic aortic dissection and coronary artery disease (CAD)
  • Detect ventricular or atrial mural thrombi and evaluate cardiac wall motion after myocardial infarction
  • Determine the presence of pericardial effusion
  • Evaluate aneurysms and ventricular thrombus
  • Evaluate or monitor biological and prosthetic valve function
  • Evaluate septal defects
  • Measure the size of the heart’s chambers and determine if hypertrophic cardiomyopathy or congestive heart failure is present
  • Monitor cardiac function during open heart surgery (most sensitive method for monitoring ischemia)
  • Reevaluate after inadequate visualization with conventional echocardiography as a result of obesity, trauma to or deformity of the chest wall, or lung hyperinflation associated with COPD

Potential diagnosis

Normal findings

  • Normal appearance of the size, position, structure, movements of the heart valves and heart muscle walls, and chamber blood filling; no evidence of valvular stenosis or insufficiency, cardiac tumor, foreign bodies, or CAD. The established values for the measurement of heart activities obtained by the study may vary by health-care provider (HCP) and institution.

Abnormal findings related to

  • Aortic aneurysm
  • Aortic valve abnormalities
  • CAD
  • Cardiomyopathy
  • Congenital heart defects
  • Congestive heart failure
  • Mitral valve abnormalities
  • Myocardial infarction
  • Myxoma
  • Pericardial effusion
  • Pulmonary hypertension
  • Pulmonary valve abnormalities
  • Septal defects
  • Shunting of blood flow
  • Thrombus
  • Ventricular hypertrophy
  • Ventricular or atrial mural thrombi

Critical findings

  • Aortic aneurysm
  • Aortic dissection

  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Factors that may impair clear imaging

    • Incorrect placement of the transducer over the desired test site.
    • Retained barium from a previous radiological procedure.
    • Patients who are dehydrated, resulting in failure to demonstrate the boundaries between organs and tissue structures.
    • Large diaphragmatic hernia.
    • Unknown upper esophageal pathology.
    • Conditions such as esophageal dysphagia and irradiation of the mediastinum related to difficulty manipulating the US probe once it has been inserted in the esophagus.
    • The presence of COPD or use of mechanical ventilation, which increases the air between the heart and chest wall (hyperinflation) and can attenuate the US waves.
    • Obese patients due to the enlarged space between the transducer and the heart.
    • The presence of arrhythmias.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.

  • Other considerations

    • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing cardiac (heart) function.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
  • Obtain a history of the patient’s cardiovascular system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent procedures that can interfere with test results (i.e., barium procedures, surgery, or biopsy). Ensure that barium studies were performed at least 24 hr before this test.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Note the last time and dose of medication taken.
  • Review the procedure with the patient. Address concerns about pain related to the procedure. Explain that some pain may be experienced during the test, and there may be moments of discomfort during insertion of the scope. Lidocaine is sprayed in the patient’s throat to reduce discomfort caused by the presence of the endoscope. Inform the patient that the procedure is performed in a US or cardiology department, usually by an HCP, and takes approximately 30 to 60 min.
  • Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined.
  • Instruct the patient to fast and restrict fluids for 8 hr prior to the procedure. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • While complications are rare, trauma to the upper GI tract (e.g., esophageal bleeding, perforation, or rupture) may occur. Other potential complications include undiagnosed esophageal pathology, laryngospasm, or bronchospasm.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient has complied with dietary and fluid restriction for at least 8 hr prior to the procedure.
  • Ensure the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Obtain and record the patient’s vital signs.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Ask the patient, as appropriate, to remove his or her dentures.
  • Monitor pulse oximetry to determine oxygen saturation in sedated patients.
  • Establish an IV fluid line for the injection of saline, sedatives, contrast medium, or emergency medications.
  • Expose the chest, and attach electrocardiogram leads for simultaneous tracings, if desired.
  • Spray or swab the patient’s throat with a local anesthetic, and place the oral bridge device in the mouth to prevent biting of the endoscope.
  • Place the patient in a left side-lying position on a flat table with foam wedges to help maintain position and immobilization. The pharyngeal area is anesthetized, and the endoscope with the ultrasound device attached to its tip is inserted 30 to 50 cm to the posterior area of the heart, as in any esophagogastroduodenoscopy procedure.
  • Ask the patient to swallow as the scope is inserted. When the transducer is in place, the scope is manipulated by controls on the handle to obtain scanning that provides real-time images of the heart motion and recordings of the images for viewing. Actual scanning is usually limited to 15 min or until the desired number of image planes is obtained at different depths of the scope.
  • Administer contrast medium, if ordered. A second series of images is obtained.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and as ordered. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Instruct the patient to resume usual diet and activity 4 to 6 hr after the test, as directed by the HCP.
  • Instruct the patient to treat throat discomfort with lozenges and warm gargles when the gag reflex returns.
  • Recognize anxiety related to test results, and offer support. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Nutritional Considerations: Abnormal findings may be associated with cardiovascular disease. Nutritional therapy is recommended for the patient identified to be at risk for developing CAD or for individuals who have specific risk factors and/or existing medical conditions (e.g., elevated LDL cholesterol levels, other lipid disorders, insulin-dependent diabetes, insulin resistance, or metabolic syndrome). Other changeable risk factors warranting patient education include strategies to encourage patients, especially those who are overweight and with high blood pressure, to safely decrease sodium intake, achieve a normal weight, ensure regular participation in moderate aerobic physical activity three to four times per week, eliminate tobacco use, and adhere to a heart-healthy diet. If triglycerides also are elevated, the patient should be advised to eliminate or reduce alcohol. The 2013 Guideline on Lifestyle Management to Reduce Cardiovascular Risk published by the American College of Cardiology (ACC) and the American Heart Association (AHA) in conjunction with the National Heart, Lung, and Blood Institute (NHLBI) recommends a “Mediterranean”-style diet rather than a low-fat diet. The new guideline emphasizes inclusion of vegetables, whole grains, fruits, low-fat dairy, nuts, legumes, and nontropical vegetable oils (e.g., olive, canola, peanut, sunflower, flaxseed) along with fish and lean poultry. A similar dietary pattern known as the Dietary Approach to Stop Hypertension (DASH) makes additional recommendations for the reduction of dietary sodium. Both dietary styles emphasize a reduction in consumption of red meats, which are high in saturated fats and cholesterol, and other foods containing sugar, saturated fats, trans fats, and sodium.
  • Social and Cultural Considerations: Numerous studies point to the prevalence of excess body weight in American children and adolescents. Experts estimate that obesity is present in 25% of the population ages 6 to 11 yr. The medical, social, and emotional consequences of excess body weight are significant. Special attention should be given to instructing the child and caregiver regarding health risks and weight control education.
  • Recognize anxiety related to test results, and be supportive of fear of shortened life expectancy. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services. Provide contact information, if desired, for the American Heart Association (www.americanheart.org) or the NHLBI (www.nhlbi.nih.gov).
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include antiarrhythmic drugs, apolipoprotein A and B, AST, atrial natriuretic peptide, BNP, blood gases, blood pool imaging, calcium, chest x-ray, cholesterol (total, HDL, LDL), CT cardiac scoring, CT thorax, CRP, CK and isoenzymes, echocardiography, electrocardiogram, exercise stress test, glucose, glycated hemoglobin, Holter monitor, homocysteine, ketones, LDH and isos, lipoprotein electrophoresis, lung perfusion scan, magnesium, MRI chest, MI infarct scan, myocardial perfusion heart scan, myoglobin, PET heart, potassium, pulse oximetry, sodium, triglycerides, and troponin.
  • Refer to the Cardiovascular System table at the end of the book for related tests by body system.