Feasibility, Safety, and Utility of Advanced Critical Care Transesophageal Echocardiography Performed by Pulmonary/Critical Care Fellows in a Medical ICU

      Background

      Competence in advanced critical care transesophageal echocardiography allows the intensivist to diagnose and manage cardiopulmonary failure when transthoracic echocardiography is not sufficient to answer the clinical question. This report describes the feasibility, safety, and utility of transesophageal echocardiography performed by pulmonary and critical care fellows in a medical ICU in critically ill patients who were mechanically ventilated.

      Methods

      This longitudinal descriptive study of advanced transesophageal echocardiography was performed in patients who were mechanically ventilated. The complications and clinical utility of the examinations were abstracted from review of the image set, the written report, and the patient chart. Influence on diagnosis was classified as confirming the initial clinical diagnosis or identification of a new or unanticipated finding. Therapeutic impact was categorized as no change in therapy resulting from the study findings or as change in therapy resulting from the study findings.

      Results

      The examination was feasible in all patients in whom it was attempted, and there were no complications of the procedure. New or actionable findings were identified in 43 (28%) studies, and 109 (72%) studies confirmed the initial clinical diagnosis. The findings resulted in a change in clinical management in 58 (38%) patients.

      Conclusions

      Critical care transesophageal echocardiography is feasible, safe, and has clinical utility. It can be safely and effectively performed by fellows within the context of their critical care training with faculty supervision. Pulmonary critical care fellowship training programs should consider introducing critical care transesophageal echocardiography as a useful clinical tool.

      Key Words

      Abbreviations:

      MICU ( medical ICU), PCCM ( pulmonary/critical care), TEE ( transesophageal echocardiography), TTE ( transthoracic echocardiography)
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      References

        • Mayo P.H.
        • Narasimhan M.
        • Koenig S.
        Critical care transesophageal echocardiography.
        Chest. 2016; 148: 1323-1332
        • Expert Round Table on Echocardiography in ICU
        International consensus statement on training standards for advanced critical care echocardiography.
        Intensive Care Med. 2014; 40: 654-666
        • Charron C.
        • Prat G.
        • Caille V.
        • et al.
        Validation of a skills assessment scoring system for transesophageal echocardiography monitoring of hemodynamics.
        Intensive Care Med. 2007; 33: 1712-1718
        • Huttemann E.
        • Schelenz C.
        • Kara F.
        • Chatzinikolaou K.
        • Rain-Hart K.
        The use and safety of transesophageal echocardiography in the general ICU—a mini review.
        Acta Anaesthesiol Scand. 2004; 48: 827-836
        • Hirabayashi Y.
        GlideScope-assisted insertion of a transesophageal echocardiography probe.
        J Cardiothorac Vasc Anesth. 2007; 21: 628
        • Hahn R.T.
        • Abraham T.
        • Adams M.S.
        • et al.
        Guidelines for performing a comprehensive transesophageal echocardiography examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologist.
        J Am Soc Echocardiogr. 2013; 26: 921-964
        • Hwang J.J.
        • Shyu K.G.
        • Chen J.J.
        • Tseng Y.Z.
        • Kuan P.
        • Lien W.P.
        Usefulness of transesophageal echocardiogaphy in the treatment of critically ill patients.
        Chest. 1993; 104: 861-866
        • Heidenreich P.A.
        • Stainback R.F.
        • Redberg R.F.
        • Schiller N.B.
        • Cohen N.H.
        • Foster E.
        Transesophageal echocardiography predicts mortality in critically ill patients with unexplained hypotension.
        J Am Coll Cardiol. 1995; 26: 152-158
        • Colreavy F.B.
        • Donovan K.
        • Lee K.Y.
        • Weekes J.
        Transesophageal echocardiography in critically ill patients.
        Crit Care Med. 2002; 30: 989-996
        • Van der Wouw P.A.
        • Koster R.W.
        • Delemarre B.J.
        • De Vos R.
        • Lampe-Schoenmaeckers A.J.
        • Lie K.I.
        Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation.
        J Am Coll Cardiol. 1997; 30: 780-783
        • Arntfield R.
        • Pace J.
        • Hewak M.
        • Thompson D.
        Focused transesophageal echocardiography by emergency physicians is feasible and clinically influential: observational results from a novel ultrasound program.
        J Emerg Med. 2016; 50: 286-294
        • Vieillard-Baron A.
        • Schmitt J.M.
        • Augarde R.
        • et al.
        Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications and prognosis.
        Crit Care Med. 2001; 29: 1551-1555
        • Benjamin E.
        • Griffin K.
        • Leibowitz A.B.
        • et al.
        Goal-directed transesophageal echocardiography performed by intensivists to assess left ventricular function: comparison with pulmonary artery catheterization.
        J Cardiothorac Vasc Anesth. 1998; 12: 10-15
        • Arntfield R.
        • Pace J.
        • McLeod S.
        • Granton J.
        • Hegazy A.
        • Lingard L.
        Focused transesophageal echocardiography for emergency physicians—description and results from simulation training of a structured four-view examination.
        Crit Ultrasound J. 2015; 7: 10
        • Prat G.
        • Charron C.
        • Repesse X.
        • et al.
        The use of computerized echocardiography simulation improves the learning curve for transesophageal hemodynamic assessment in critically ill patients.
        Ann Intensive Care. 2016; 6: 27

      Linked Article

      • Critical Care Echocardiography
        CHESTVol. 153Issue 2
        • In Brief
          We read with enthusiasm the study by Garcia et al1 published in CHEST (October 2017) describing the safety, feasibility, and clinical decisions made from advanced transesophageal echocardiographic studies performed by pulmonary and critical care fellows. We agree that both transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) are important tools in the intensivist’s armamentarium.2 However, we worry that trainees and advocates for critical care echocardiography could be misled by the findings, particularly with respect to TEE’s clinical utility.
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      • Response
        CHESTVol. 153Issue 2
        • In Brief
          We thank Bergl et al for their interesting commentary. Their perspective highlights some very important points. In response to the lack of inclusion criteria, our inclusion criteria were very simple: If we could not get adequate transthoracic echocardiographic (TTE) windows to determine the cause of the shock state or to guide our treatment, we chose to perform transesophageal echocardiography (TEE). This was our only inclusion criterion. In each patient, the view or views we were unable to acquire were different, but we were unable to answer the clinical questions needed to treat the patient.
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