Difficult TEE Probe Placement: The Evidence,Troubleshooting Techniques,and a Guide to Alternative Monitoring Options for Intraoperative Physicians

Abstract

Transesophageal echocardiography (TEE) imaging has become an essential component of many open and interventional cardiac procedures and has increasing use in monitoring for noncardiac procedures, partly because of an aging population. Whether expected or not, encountering difficulty when inserting the TEE probe presents the anesthesiologist with a conundrum. Repeated insertion attempts increase the risk of a serious complication; however, proceeding without TEE may be unacceptable to the proceduralist or surgeon. The aim of this review is to present the spectrum of complications possible with TEE, propose several evidence-based insertion tips, examine potential alternative cardiac imaging options, and finally, propose a roadmap for providers who encounter difficulty when placing a TEE probe.

Keywords

transesophageal echocardiography complications intraoperative transesophageal echocardiography intracardiac echocardiography transthoracic echocardiography epicardial echocardiography epiaortic echocardiography

Introduction

Transesophageal echocardiography (TEE) has become an invaluable tool for intraoperative and periprocedural patient evaluation since its introduction in the 1970s. Its ability to provide real-time information on hemodynamics and structural data about the heart and major vessels has greatly improved the care provided by surgeons, cardiologists, and anesthesiologists. A recent multinational survey of 200 academic and nonacademic institutions found routine use of TEE in more than 90% of non–coronary artery bypass graft (CABG) cardiac surgeries and greater than 60% of CABG surgeries.¹ The feedback provided from intraoperative TEE has been found to influence surgical decision making in 5.8% to 22% of cardiac surgical cases.^2,3 Unfortunately, TEE, as a semi-invasive procedure, is not without risks, and a variety of intraoperative complications have been reported.¹ Several of these complications are related to insertion of the TEE probe, and case reports have described injury to patients after misplacement or excessive force during probe intubation.^4-8

Our institution encountered a recent case of difficult probe placement in a patient presenting for transcatheter mitral valve repair evaluation where the diagnostic utility of TEE was considered to be essential, both preoperatively and intraoperatively. Despite not having a history of esophageal disease or swallowing dysfunction, cardiologists were unable to pass the TEE probe because of “excessive resistance.” The patient then had a normal swallow study and returned for a second TEE probe insertion attempt under general anesthesia (GA) with the same unsuccessful outcome. Situations such as this are relatively common and demonstrate the importance of having a safe and logical approach to probe insertion as well as finding effective alternatives to TEE. This review will highlight contraindications to TEE probe placement, potential complications related to placement, possible strategies to improve ability and ease of probe insertion, and alternative modalities when TEE is contraindicated or impossible. Finally, we will provide a “roadmap” for clinicians to use in a case of difficult TEE insertion.

Complications/Contraindications

TEE is generally considered a low-risk procedure despite its semi-invasive nature. However, it has the potential to cause significant morbidity and even mortality, especially in anesthetized patients who are unable to provide feedback during probe placement and manipulation. Complications during intraoperative TEE range from relatively minor such as transient dysphagia and pharyngitis to serious life-threatening injury including GI tract perforation and hemorrhage.⁹ Complications specifically reported after difficult TEE placement include soft-tissue infection,⁶ pulmonary hemorrhage,⁸ and oropharyngeal hemorrhage requiring transfusion and surgical ligation.⁷ These findings highlight the importance of a thorough preoperative assessment by the echocardiographer and a careful weighing of the risks and benefits of intraoperative TEE. Several retrospective studies have found a complication rate of 0.2% to 1.4% after intraoperative TEE in cardiac surgery patients.^5,10-13 These studies list an overall rate of complications discovered postoperatively that can be attributed to TEE but do not specify whether probe placement was difficult or required multiple attempts. Whether related to difficult placement or not, the low incidence of complications does confirm the overall safety of intraoperative TEE.

Recognizing these potential risks, the American Society of Anesthesiologists (ASA) Task Force on Perioperative Transesophageal Echocardiography surveyed ASA members and 13 “expert consultants” regarding the indications and contraindications for TEE. Using these responses, Hilberath et al⁴ developed a list of recommended absolute and relative contraindications,⁴ which has since been adopted by the American Society of Echocardiography (ASE) and the Society of Cardiovascular Anesthesiologists (SCA; Table 1).⁹

Table 1.

Contraindications to TEE.^a

Absolute Contraindications	Relative Contraindications
Perforated viscus	History of radiation to the neck and mediastinum
Esophageal trauma (perforation, laceration, tear)	Restriction of neck mobility
Esophageal tumor	History of GI surgery
Esophageal stricture	Recent upper GI bleed
Esophageal diverticulum	Esophageal varices
Active upper GI bleed	Coagulopathy
Esophagectomy, esophagogastrectomy	History of dysphagia
	Barrett’s esophagus
	Symptomatic hiatal hernia
	Active esophagitis
	Active peptic ulcer disease
	Thoracoabdominal aneurysm

Abbreviations: TEE, transesophageal echocardiography; GI, gastrointestinal.

Adapted from Hilberath et al⁴ and Hahn et al.⁹

Most of the contraindications for TEE placement are related to either bleeding concerns or anatomical changes to the GI tract that would make insertion more difficult or more likely to result in a complication. Structural abnormalities associated with challenging placement of a TEE probe include extrinsic compression of the esophagus, gastritis, tortuous distal esophagus, retained food in the esophagus, gastric ulcer, esophageal erosion,¹³ esophageal stricture,¹⁴ esophageal fistula, esophageal atresia,⁴ hypopharyngeal diverticula,¹⁵ cardiomegaly,¹⁶ fibrosis after radiation, and hiatal hernia.¹⁷ Additionally, anecdotal reports have found difficult tracheal intubation to be a predictor of difficult esophageal intubation; therefore, some experts advocate placement of TEE probes under direct visualization in this situation.⁷ Attempted placement of the TEE probe in patients with the above abnormalities may expose the patient to additional risk for complications, so the benefits of TEE imaging must be weighed against the risk of harm to the patient.

Given that many serious, though rare, complications of TEE placement are related to active gastrointestinal symptoms or prior gastrointestinal disease, it is prudent to consider esophagogastroduodenoscopy (EGD) for further evaluation prior to performing TEE. EGD is especially useful in determining the potential cause for an unsuccessful or difficult placement of the TEE probe. Unfortunately, no prospective study on the efficacy of EGD for evaluation of difficult TEE placement has been published. A small single-center retrospective study of 134 cardiology patients receiving EGD prior to TEE concluded that it was appropriate to first perform an EGD in patients with upper GI symptoms or a history of GI disease.¹³ The most common reason for referral for EGD was upper GI symptoms such as dysphagia and hematemesis. Of the patients studied, 19 were referred for further evaluation after an unsuccessful TEE probe insertion; after EGD, only 1 patient was not cleared for further attempts. Overall, 84% of patients referred were found to have abnormal findings; of these, only 20 patients (15%) were not cleared for TEE. In the group not cleared for TEE, only 1 patient had been referred for EGD evaluation because of inability to pass the TEE probe. Cirrhosis was the most common initial GI diagnosis in the group not cleared for TEE. Of the patients cleared for TEE in which passing the probe was subsequently attempted, only 3 of 99 had inability to successfully pass the TEE probe. All 3 of these patients had abnormal GI findings but no overt reason for placement should have been avoided or difficult. The authors concluded that abnormal EGD findings did not clearly correlate with difficult TEE placement because the vast majority of patients had abnormalities; however, subsequent probe placement was still successful.¹³

Although EGD is useful in evaluation of patients where TEE placement was unable to be performed, many circumstances exist where the use of TEE or another imaging modality is required for a procedure or surgery. Although postponing the case to allow for evaluation is sometimes feasible, it can be impractical or impossible in some urgent/emergent situations. Thus, in the following sections, troubleshooting techniques and alternatives to TEE will be discussed.

Techniques to Assist With Placement

Many practitioners default to “blind” placement of the TEE probe where the probe is placed into the hypopharynx and then anteflexed and passed into the esophagus without any assistance or visualization. Although blind placement can often be successful, it is not without the potential for complications, as demonstrated earlier. Fortunately for the modern TEE practitioner, there exist a number of techniques and adjuncts that can be utilized to help with placement.

Although many complications and contraindications to TEE placement are esophageal in origin, the first site of potential obstruction is obviously proximal to the esophagus. A study investigating the location in which orogastric and nasogastric tubes typically encounter obstruction provides insight into potential reasons why TEE probes are difficult to pass.¹⁸ They found that in intubated patients, gastric tubes are usually impeded by either the arytenoid cartilage or the piriform sinus. In 85% of cases, they were able to successfully pass the tube after lateral neck pressure was applied. The concept behind the utility of lateral neck pressure is that the piriform sinus is compressed and the arytenoid cartilage is displaced medially, which directs a laterally placed probe medially into the esophageal inlet. Case reports have noted success with TEE placement utilizing this technique in addition to anterior displacement of the cricoid cartilage to widen the esophageal opening.¹⁹

Several other safe and easy to perform techniques are commonly used to help direct the TEE probe into the esophagus. One of the most common is direct laryngoscopy (DL). Laryngoscopy often allows direct visualization of the esophageal inlet as well as observation of potential misdirection of the probe into at-risk structures such as the diverticulum, arytenoid cartilage, and the vocal folds. Although anesthesiologists often turn to DL only as a rescue technique following difficult or impossible probe placement, there is some evidence of its benefit when used at the first attempt. Na et al²⁰ reported a small, 80 patient study where a single anesthesiologist placed a TEE probe either blindly or with DL visualization. A blinded observer then examined the oropharynx with a fiberscope, and patients were interviewed afterward to assess for odynophagia and oropharyngeal pain. Patients who had the TEE probe placed under DL, compared with blindly, required fewer attempts at probe placement (1.4 vs 1.1, P = .012) and had a lower incidence of blood on the probe tip (37.5% vs 2.5%, P < .001), oropharyngeal trauma (55% vs 5%, P < .001), and odynophagia (32.5% vs 2.5%, P < .001).²⁰ Although this is a small study, it does demonstrate the safety of DL for TEE probe placement and highlights the need for more studies on this commonly performed procedure.

If DL can be used to improve the ease and sequelae of TEE probe placement, it seems logical that video laryngoscopy (VL) would have a similar effect. There are numerous case reports of practitioners using VL to successfully place a TEE probe after previous attempts, both blind and with DL, had failed.²¹ Ishida et al²² compared TEE probe placement under DL and VL in 2013 and found several advantages to the latter. A total of 100 patients undergoing cardiac surgery at a single institution were randomized to first attempt with DL versus VL. Results showed that patients randomized to the latter group had a greater chance of visualizing the esophageal inlet (41% vs 88%), higher likelihood of probe placement on the first attempt (76% vs 92%), and a lower incidence of pharyngeal injury (16% vs 4%).²²

In patients with certain pathologies, oral placement of the TEE probe may be challenging. For example, it may be difficult to pass the probe orally in patients with severe cervical kyphoscoliosis. Attempting to place the probe via the nasal route has been described as a viable alternative in the literature, including for visualization of Amplatzer closure of a patent foramen ovale.²³ A potential advantage of nasal placement is that it may be better tolerated in an awake or lightly sedated patient. Unfortunately, the nasal approach typically requires use of a smaller TEE probe, which often sacrifices multiplane imaging and results in limited views compared with traditional TEE, although this may be sufficient in certain circumstances. Zimmerman et al²⁴ described successful transnasal TEE placement for monitoring of 45 patients at risk of cardiac decompensation prior to induction of anesthesia. Importantly, the image quality was deemed acceptable in 95% of these patients despite the use of a smaller probe.²⁴

A novel approach to overcoming difficult TEE placement involves the use of an esophageal overtube (Figure 1). The technique was initially reported in a series of 4 patients undergoing diagnostic TEE in whom placement of the probe was initially unsuccessful.¹⁷ In each case, an EGD was utilized to place an esophageal overtube through which the TEE probe could then be advanced. Overtubes are sleeve-like devices typically used for removal of sharp or toxic foreign objects, certain variceal procedures, and in situations in which the EGD scope will need to be repeatedly inserted and removed. Whereas use of esophageal overtubes is a viable alternative, it requires coordination with a gastroenterologist experienced in their use.

Unfortunately, the patient is often already in the operating room when it is determined that placement of the probe is difficult, at which point obtaining an endoscope and required personnel is often arduous. Therefore, this option seems most practical in situations where TEE is imperative and it is known beforehand that the patient is at high risk for difficult placement or has failed prior insertion attempts. Once placed, if visualization of the upper esophageal structures such as the proximal aortic arch is obstructed by the overtube, it can easily be withdrawn onto the TEE probe.

There are fewer options if the probe encounters significant resistance after entering the esophagus. Several case reports exist describing intraoperative esophageal dilation to facilitate TEE probe placement. In one instance, a patient presented for urgent open repair of a ventricular septal defect after a myocardial infarction.¹⁴ After initial attempts to pass the probe were unsuccessful, otolaryngology was asked to evaluate the patient intraoperatively given that TEE imaging was considered vital for assessing the evolving ventricular septal defect and its repair. They were unable to visualize any structural abnormalities and proceeded to perform serial dilation of the esophagus. Once dilated to a 46 French probe, the TEE probe was passed without resistance.¹⁴ Although rare, dilation does come with the risk of esophageal perforation. As with many of the various techniques mentioned, a careful assessment of the risks and benefits must be made, and a determination of the absolute need for TEE is critical. Table 2 summarizes the techniques and adjuncts that may be useful to assist with TEE placement.

Table 2.

Techniques to Assist With Placement of a TEE Probe.

Physical manipulations

Lateral neck pressure

Anterior cricoid displacement

Insertion aids

Direct laryngoscopy

Video laryngoscopy

Insertion alternatives/adjuncts

Nasal approach

Esophageal overtube

Intraoperative esophageal dilation

Abbreviation: TEE, transesophageal echocardiography.

Alternatives to TEE

Hemodynamic TEE

In patients with oropharyngeal or esophageal narrowing, a smaller TEE probe may pass easier than a standard sized adult probe. One such option is the ClariTEE hemodynamic TEE (hTEE) probe created by ImaCor (Garden City, NY), which has a probe diameter less than half the size of the typical adult probe (5.5 mm compared with 13 mm; Figure 2). It only provides monoplane imaging and was designed to show 3 specific views: midesophageal 4 chamber, midesophageal bicaval, and transgastric short axis. The studies that have been conducted in patients in the ICU are generally positive; however, the majority of studies published on its efficacy looked at continuous monitoring in ICU patients, and there is little published data regarding its efficacy in the operating room. Although the image quality should presumably be similar to that seen in the ICU, the diagnostic needs are often more advanced.

A study by Sarosiek et al²⁵ showed the device to be effective in the management of extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD) patients. Imaging quality was deemed sufficient to appropriately manage volume and titrate inotropes. hTEE was also helpful in guiding weaning from ECMO and appropriate timing for VAD implantation. They also reported multiple instances when it guided decision making regarding surgical exploration versus medical management. These included identifying a left ventricular (LV) thrombus in a VAD patient that was able to be treated medically, ruling out a perivalvular leak, avoiding surgical intervention, and identifying cardiac tamponade requiring operative intervention. Overall, the authors felt that they could accurately appraise both LV and right ventricular (RV) function, volume status, and other key factors in cardiac surgical patients.²⁵

A small study out of France attempted to determine the effectiveness of intraoperative hTEE in cardiac surgical patients.²⁶ The study included a list of parameters the authors attempted to assess: LV and RV function and dilation, septal positioning, aortic valve function, LVAD inflow cannula placement, aortic root thrombosis, and pericardial effusion. They used the device in 7 patients and were successful in 6; the one patient in whom conventional TEE was required had a mechanical mitral valve prosthesis that caused significant artifact. There were no reported complications related to the device itself.²⁶

If available, it appears that hTEE has the potential to provide an intraoperative alternative to conventional TEE in situations in which placing a standard-sized probe proves difficult. Although it does not have the analytical options and views that a multiplane device provides, it is able to provide important information about ventricular size and function, aortic valve function, pericardial complications, and device positioning.

Pediatric TEE Probes

A pediatric TEE probe provides an additional small-diameter alternative in adults with difficult standard-sized TEE probe insertion. This option may be particularly useful in patients with known esophageal or oropharyngeal narrowing that absolutely require intraoperative TEE monitoring. As with ImaCor, there is a decrease in image quality compared with the larger probe, although whether this has clinical implications is unclear. Reynolds et al²⁷ confirmed that image quality was poorer when evaluating the left ventricle, right ventricle, pericardium, left atrium, interatrial septum, mitral valve, and aortic valve. However, a study evaluating the use of pediatric TEE probes to guide septal puncture for atrial fibrillation ablation found no effect on procedural success compared with adult probes, although the smaller probes did have lower complication rates and increased patient comfort.²⁸ Table 3 lists the characteristics of common pediatric and adult-sized probes. Figure 3 displays the 3 standard-sized TEE probes as well as the ImaCor probe.

Table 3.

Common Pediatric and Adult TEE Probe Sizes.

Probe	Minimum Patient Weight	Tip Diameter	Shaft Diameter	Imaging Capabilities
Standard Adult, X8-2t (Philips); 6Tc (GE)	30 kg	17 mm	10 mm	Multiplane
Standard Peds, MiniMulti (Philips); 9t (GE)	3.5 kg	10.6 mm	7.4 mm	Multiplane
Micro TEE (Philips)	2.5 kg	7.5 mm	5.2 mm	Multiplane

Abbreviation: TEE, transesophageal echocardiography.

Intracardiac Echocardiography

Intracardiac echocardiography (ICE) is primarily used in the cardiac catheterization and electrophysiology (EP) lab for cardiac imaging during percutaneous cardiology procedures. ICE is a venous catheter-based ultrasound system typically advanced into the right atrium via the inferior vena cava following femoral vein puncture; less commonly, access is cephalad from either the internal jugular vein or the left subclavian approach. ICE is capable of providing both 2D and 3D images, M and B mode, and various Doppler options. The catheters require an 8F to 11F venous introducer sheath. Figure 4 shows a frequently used ICE probe.

ICE has a well-established role in the EP lab because it images cardiac structures, including the pulmonary veins, better than angiography; the catheter is usually in close proximity to the structures of interest, and it has a low rate of complications.²⁹ ICE has been used extensively in closure of atrial septal defects and patent foramen ovale. When used in conjunction with other imaging modalities, it has been shown to reduce both fluoroscopic and procedural times.²⁹ After proven success for these percutaneous interventions, ICE’s use has begun to expand to other procedures.

ICE is now being used for transcatheter valve deployment, particularly in minimally invasive approaches without GA and TEE. It has been used for both aortic and mitral procedures, and it is able to provide not only the critical images during deployment of the valve, but is also able to assess for potential complications.³⁰ ICE has also been utilized in placement of left atrial appendage closure devices because close-up views can be obtained if the probe is advanced through the pulmonic valve and into the pulmonary artery.³¹ There are also several case reports of ICE being used to assess and close perivalvular leaks.³⁰

One of the main benefits of ICE over TEE is the ability to perform the procedure without GA. This is valuable in patients who are poor candidates for GA or for open cardiac procedures. ICE also avoids the above-mentioned risks associated with TEE placement and can be especially useful when TEE insertion is difficult or contraindicated. Recent studies have also shown that fluoroscopic time and contrast agent administration are reduced when ICE is used. ICE often provides shorter imaging distances and higher resolution than standard TEE.²⁹

ICE has several important limitations. Images of some structures cannot be obtained because of the location of the catheter on the right side of the heart. The probe itself is relatively large and can interfere with other catheters, affecting the performance of the procedure. The introducer sheath is relatively large, and vascular complications can occur, particularly because anticoagulation is required to prevent thrombus formation. Finally, because of its intracardiac location, it can provoke arrhythmias.²⁹

Epicardial Ultrasound

Another alternative to TEE in open heart surgery is epicardial echocardiography (EE). Although TEE has largely overshadowed the use of EE because of its ability to provide continuous images without surgery interruption, its use should be considered in situations where the TEE probe cannot be placed but where ultrasound is necessary for intraoperative assessment. Because of the proximity of the heart to the ultrasound probe, EE is usually performed with higher frequency probes (5-12 MHz) similar to those used for transthoracic echocardiography (TTE). The ultrasound probe is placed into a sterile sheath with transducing gel and then is placed directly on the heart by an operator (typically the surgeon) who manipulates the probe to obtain images while the sonographer (typically the anesthesiologist) analyzes and acquires images. The mediastinum can be filled with saline to improve the echocardiographic windows. The ASE released a position paper in 2007 describing the utility of EE and the 7 imaging planes included in a comprehensive exam.³² Views obtained with EE will more closely approximate a TTE exam rather than the TEE views typically seen during cardiac surgery.

EE provides the unique capability of dexterous probe manipulation to precisely view certain areas of interest as well as different angles with which one can align the ultrasound beam with blood flow for Doppler measurement. Unlike TEE, which is somewhat restricted, in that the probe is confined to the esophagus or stomach, epicardial ultrasound has greater degrees of freedom and the potential to obtain more accurate measurements. Indeed, Taneja et al³³ demonstrated in 34 examinations across 17 patients, a significant increase in measured peak velocity when looking at epicardial ultrasound as compared with TEE. Unfortunately, left ventricular outflow tract (LVOT) velocity time integral measurements could only be obtained in 4 of the 34 epicardial examinations. The authors believe that this was related to either operator inexperience or the increased strength of the aortic valve continuous wave Doppler signal obscuring the LVOT signals; either way, they noted that this could limit its clinical utility.³³ Frenk et al³⁴ presented a case report of successful use of EE when a TEE probe could not be inserted. The patient who presented for CABG had very poor visualization of his aortic valve on preoperative TTE. After being unable to place a TEE probe despite DL, EE was performed, which revealed moderate AI and mild AS; this combined with depressed LV function resulted in the decision to replace the aortic valve. This case report shows the potential utility of epicardial ultrasound in situations where TEE probe insertion is difficult or impossible.³⁴

Epiaortic Ultrasound

Epiaortic ultrasound (EAU) should be considered in any open-heart surgery patient who has an increased risk of embolic stroke, particularly those with a history of embolic stroke or evidence of aortic atherosclerotic disease.³⁵ TEE is often used to evaluate the ascending aorta to evaluate for atheromatous disease; however, multiple studies have identified the shortcomings of this approach. The main limitation is an inability to accurately evaluate the distal ascending aorta and the proximal aortic arch because of imaging dropout caused from the air-filled right mainstem bronchus.^36,37 EAU has been shown to be superior in reducing strength rather than relying on either preoperative CT imaging or surgical palpation.³⁸ Findings of aortic disease can help guide aortic cannulation or cross-clamp site. Ikram et al³⁸ evaluated multiple studies that showed that EAU altered surgical manipulation of the aorta and resulted in lower perioperative stroke rates.

For EAU, a high resolution (>7 MHz) transducer, typically a TTE probe, is used in a similar fashion to EE. ASE and SCA recommend obtaining at least 5 views of the ascending aorta and aortic arch. These include short axis views of the proximal, mid-, and distal ascending aorta and long axis views of the ascending aorta and the aortic arch.³⁵ They recommend discussing with the surgical team areas that portend a higher risk of stroke—namely, plaques greater than 3 mm in thickness and mobile plaques. In situations where TEE cannot be performed and the aorta needs to be evaluated, EAU provides real-time imaging, which may be superior to TEE.

Transthoracic Echocardiography

TTE is a well-established imaging modality that is routinely used in a variety of clinical situations. It is an invaluable tool in the preoperative, intraoperative, and postoperative assessment and monitoring of patients. Unfortunately, surgical positioning and incision location often limit the feasibility of intraoperative TTE, particularly in open heart surgery. As percutaneous valve replacement surgery and its indications expand, there is increased interest (from both patients and providers) in utilizing monitored anesthesia care (MAC) with a transfemoral approach and TTE guidance.³⁹ With minimalist approaches becoming more prevalent, studies looking at differences in long-term outcomes with MAC and TTE versus GA and TEE are becoming available.

Paravalvular leak (PVL) is a common complication of transcatheter aortic valve replacement (TAVR) that is associated with adverse outcomes.⁴⁰ A recent retrospective study examined the rate of PVL in TTE- versus TEE-guided TAVR in more than 400 patients.⁴¹ They found no statistically significant difference in the incidence of PVL immediately postprocedure, or at 1 month or 1 year after the procedure. The rate of mild PVL was similar between the 2 groups: 33% in the TTE group and 38% in the TEE group. The incidence of major complications was also comparable; the TTE group had 1 case of annular rupture and 1 cardiac tamponade, and the TEE group had 2 patients with cardiac tamponade. Patients in the TTE cohort had fewer ICU days and shorter lengths of stay. Other studies have shown similar equivalent outcomes between TTE and TEE.^42,43 One such study of nearly 150 patients found that TTE patients had longer procedure times and higher fluoroscopy times. This was likely the cause of the increased incidence of acute kidney injury in the TTE group. Despite the small size of these studies, it appears that outcomes using TTE and TEE are relatively comparable in TAVR, so if difficult TEE probe insertion is encountered, it would be reasonable to attempt to perform the procedure under MAC with TTE imaging.

The results of the above-mentioned TAVR studies can likely be extrapolated to noncardiac procedures because the level of detail needed to assess for PVL is often more advanced than would be needed in, for example, a rescue TEE in a hypotensive patient undergoing hip surgery. In this scenario, if difficulty was encountered inserting a TEE probe, then providers should have a low threshold for using TTE if an experienced provider is available. Similarly, in the cardiothoracic surgery intensive care unit, where postoperative patients usually have mediastinal air, drains, dressing, and positioning that hinder a TTE exam, a recent study suggests that a limited TTE exam entailing parasternal, apical, and subcostal windows can provide adequate windows for diagnosis of hemodynamic state, valve disease causing hemodynamic compromise, and pericardial effusion.⁴⁴ The ability to gain adequate views varied with time from surgery. Even on postoperative day 1, about 50% of patients had at least 1 window, typically parasternal, in which a diagnosis of their hemodynamic state could be made.

Guide to Alternative Monitoring Options

When difficulty is encountered when inserting a TEE probe, we recommend that practitioners first pause and review the patient’s medical and surgical history to ensure that there are no anatomical causes or risk factors for complications because these can occasionally be overlooked particularly in urgent or emergent conditions. A few safe alternative insertion strategies should then be attempted. Lifting the head by placing your thumb on the lower palate and elevating the jaw, increasing flexion of the neck, and lateral pressure on the neck should all be attempted, ideally with the assistance of a second experienced provider. Laryngoscopy, either direct or video, should then be performed. Although there are no data favoring one over the other, we recommend using a video laryngoscope if endotracheal tube placement was challenging. Any insertion attempt that produces frank blood or results in the probe being inserted beyond 20 cm without being in the esophagus should prompt immediate cessation and evaluation for tissue perforation, which may require fiberoptic evaluation by a thoracic surgeon or otolaryngologist.

Once the above insertion techniques have been attempted without success, it is appropriate to consider how essential TEE imaging is and whether any of the other options for perioperative imaging discussed would suffice. Figure 5 depicts a suggested management strategy for this situation. Depending on resources available at your institution, the type or quality of imaging needed, and the structures being imaged, one or multiple alternatives may suffice. Many options, such as an esophageal overtube or ICE, will likely require an additional specialist, such as a gastroenterologist or cardiologist, who may not be available on short notice. Patient comorbidities should also be weighed; for example, an obese patient may be a poor candidate for ICE because venous access could be difficult. If none of the discussed alternatives is feasible or available, the scheduled procedure may need to be aborted and further evaluation undertaken.

Conclusions

Although blind TEE probe insertion is frequently accomplished without incident, complications can arise, especially in patients with abnormal gastrointestinal anatomy. In patients for whom imaging is deemed necessary, a number of troubleshooting techniques may be useful to safely and effectively insert the probe. If probe insertion remains difficult or impossible, several alternative imaging techniques are available and should be considered.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Amanda M. Kleiman

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