Intra-arrest transesophageal echocardiography during cardiopulmonary resuscitation

Article information

Clin Exp Emerg Med. 2022;9(4):271-280
Publication date (electronic) : 2022 December 7
doi : https://doi.org/10.15441/ceem.22.399
Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
Correspondence to: Sung Oh Hwang Department of Emergency Medicine, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea E-mail: shwang@yonsei.ac.kr
Received 2022 November 16; Accepted 2022 November 17.

Abstract

Determining the cause of cardiac arrest (CA) and the heart status during CA is crucial for its treatment. Transesophageal echocardiography (TEE) is an imaging method that facilitates close observation of the heart without interfering with cardiopulmonary resuscitation (CPR). Intra-arrest TEE is a point-of-care ultrasound technique that is used during CPR. Intra-arrest TEE is performed to diagnose the cause of CA, determine the presence of cardiac contraction, evaluate the quality of CPR, assist with catheter insertion, and explore the mechanism of blood flow during CPR. The common causes of CA diagnosed using intra-arrest TEE include cardiac tamponade, aortic dissection, pulmonary embolism, and intracardiac thrombus, which can be observed on a few simple image planes at the mid-esophageal and upper esophageal positions. To operate an intra-arrest TEE program, it is necessary to secure a physician who is capable of performing TEE, provide appropriate training, establish implementation protocols, and prepare a plan in collaboration with the CPR team.

INTRODUCTION

Transesophageal echocardiography (TEE) is a diagnostic tool that can obtain images of the heart from its nearest location. It provides numerous types of echocardiographic information, including two-dimensional or three-dimensional images, M-mode, color flow imaging, Doppler studies, and related calculations, such as transthoracic echocardiography (TTE). Compared with TTE, TEE provides excellent echocardiographic windows to the heart regardless of the patient’s body type. Despite its advantages, TEE has rarely been used in patients with cardiovascular emergencies in the emergency department (ED) when it was initially introduced into clinical practice. TEE in the ED has been used in urgent situations such as cardiac arrest (CA). Recent cardiopulmonary resuscitation (CPR) guidelines recommend or suggest the use of point-of-care ultrasound as a method to determine the reversible cause of CA during CPR, thus encouraging the use of echocardiography during the performance of advanced life support [1,2].

TTE is an easy and simple method for point-of-care ultrasound during resuscitation. However, it is not suitable for close inspection of the heart while chest compressions are being performed. By employing TEE, rescuers can continuously observe the heart without interfering with CPR because the probe is located in the esophagus. Owing to the increasing use of TEE during resuscitation (intra-arrest TEE), the American College of Emergency Physicians and the American Society of Echocardiography have jointly published guidelines for point-of-care applications in CA resuscitation [3]. Since the publication of these guidelines, considerable experience has been accumulated with TEE during CPR. Korea, one of the first countries to use TEE in the ED, began employing TEE accordingly in 1992 [4]. Recently, almost all EDs in Korea have been equipped with echocardiography machines; the remaining EDs are being prepared to support it. However, considering limitations in professional human resources and procedural time, it is unreasonable to conduct a comprehensive TEE study in the ED. By contrast, intra-arrest TEE as a point-of-care ultrasound is feasible in the ED and can be helpful in resuscitating patients who experienced CA. This review is intended to provide an overview of the practical use of intra-arrest TEE in emergency medicine.

INDICATIONS AND PREVIOUS EXPERIENCES

Intra-arrest TEE is performed to explore the mechanism of blood flow during CPR, diagnose the possible cause of CA, monitor the presence of cardiac contraction, assess the effectiveness of chest compression, guide catheter cannulation, and evaluate the complications of CPR. Table 1 summarizes the indications and objectives of intra-arrest TEE and the echocardiographic findings of intra-arrest TEE in the literature [5-47].

Indications and findings of intra-arrest TEE in the literature

PREPARATION FOR INTRA-ARREST TEE

Multiple factors should be considered when implementing intraarrest TEE in the ED. These include the cost of the equipment; equipment maintenance, including probe disinfection; the input of additional personnel and technical training; evaluation of the operation quality; and collaboration with experts from other clinical fields, including cardiology [48]. For intra-arrest TEE, the TEE probe and related software must be purchased together with the echocardiography machine. The most appropriate area to place the echocardiography machine is a room in the resuscitation area. Drugs and devices for intensive monitoring and advanced life support, including airway support, defibrillation, and emergency medications, should be available at all times during TEE. According to Spaulding’s classification for disinfection and sterilization of patient care items and equipment, the TEE probe is classified as a semi-critical instrument with an endoscope. Cleaning and disinfection after every use are required according to these guidelines [49,50].

TEE should be performed by physicians who have (1) knowledge of cardiovascular anatomy and physiology, (2) knowledge of echocardiographic imaging, (3) proficiency and experience in performing TTE and TEE procedures, (4) knowledge required for interpretation of TEE results, and (5) knowledge of the management of TEE equipment and related instruments [51]. Considering these requirements, the guidelines recommend supervised performance and interpretation of at least 50 to 100 TEE procedures prior to the independent undertaking of TEE [52-54]. The American College of Emergency Physicians recommends a minimum of 10 proctored TEE examinations on live patients and simulation models with TEE-specific continuing medical education for the use of TEE in the ED for ultrasound-guided resuscitation during or after CA [55]. Therefore, emergency physicians performing TEE in the ED should have the qualifications for performing echocardiography, skills for TEE procedures, and competent TEE experience. Echocardiography is an operator-dependent procedure; therefore, the operator should conduct the procedure only after becoming certain that he or she can perform TEE on his or her own with consideration of the patient’s safety. Lack of substantial training may result in misdiagnosis or misinterpretation of echocardiographic findings, possibly causing catastrophic outcomes.

INTRA-ARREST TEE PROCEDURE

A physician who is capable of performing TEE and is not part of the CPR team is required for the intra-arrest TEE procedure. Intraarrest TEE is usually initiated after endotracheal intubation is complete. The patient in CA is not able to swallow the TEE probe; therefore, the operator must push the TEE probe into the esophagus. Before insertion of the TEE probe into the esophagus, the operator initially checks whether the probe is located behind the endotracheal tube and then bends the probe tip (anteflexion position) and pushes it into the back of the pharynx. When the TEE probe reaches the pharynx, it is inserted into the esophagus by straightening (unlocked position) and pushing the tip of the probe. If resistance is sensed while inserting the probe, the probe tip is not inserted into the esophagus. Insertion with excessive force may cause damage to the hypopharynx or upper esophagus [56,57]. Care should be taken not to dislodge the endotracheal tube during TEE.

IMAGING PROTOCOL AND VIEWS FOR INTRA-ARREST TEE

The protocol for intra-arrest TEE includes a quick scan to assess the possible cause of CA and the presence of cardiac contraction, assessment of CPR quality, monitoring of resuscitation measures, and guidance of catheter cannulation. To perform an initial scan immediately after probe insertion, the mid-esophageal (ME) fourchamber view, ME long-axis (ME LAX) view, ME ascending aorta short-axis (SAX) view, ME ascending aorta LAX view, descending aorta SAX view, and upper esophageal aortic arch LAX view are obtained in order (Fig. 1) [40]. Transgastric views during chest compressions are not recommend because the forceful anterograde or retrograde flexion position for the transgastric views may cause injury to the esophagus or stomach [58,59]. After quick observation of the heart and great vessels, a TEE probe with a four-chamber view is placed at the ME level to monitor for cardiac movement and assist resuscitation measures. When catheterization is required for resuscitative measures, such as employing a central venous catheter, extracorporeal membrane oxygenation, or resuscitative endovascular balloon occlusion of the aorta (REBOA), ME bicaval view and the descending aorta SAX and LAX view are optimal for visualizing the vena cava or aorta. After the return of spontaneous circulation, a comprehensive examination of cardiac function, morphology, and regional-wall motion is needed.

Fig. 1.

Suggested intra-arrest transesophageal echocardiography imaging planes and the corresponding structures or pathologies imaged. ME, mid-esophageal; RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; MV, mitral valve; AV, aortic valve; TV, tricuspid valve; LVOT, left ventricular outflow tract; RVOT, right ventricular outflow tract; SVC, superior vena cava.

FINDINGS OF INTRA-ARREST TEE

The diagnostic sensitivity, specificity, and positive predictive value of TEE for the cause of CA were reported to be 93%, 50%, and 87%, respectively [17]. One-fourth of the patients who underwent intra-arrest TEE showed specific evidence associated with CA. Such evidence is associated with poor resuscitation outcome [40]. The common causes of CA confirmed by TEE are cardiac tamponade, aortic dissection, pulmonary embolism, and intracardiac thrombi. Cardiac tamponade is easily diagnosed and appears as a large amount of pericardial effusion with the collapse of the right ventricle (RV) in ME views (Fig. 2). A large pericardial effusion and/or left pleural effusion may be a sign of aortic rupture (Fig. 3). Aortic dissection can be diagnosed by the presence of an intimal flap in the ascending aorta, aortic arch, and descending aorta views (Fig. 4). High suspicion or diagnosis of pulmonary embolism is possible when thrombi are observed in the right atrium, RV, or pulmonary artery (Figs. 5, 6). Intracardiac or disseminated thrombi, observed as echogenic densities in the left-side cardiac chambers and/or the aorta without right heart thrombus, is a sequela of CA (Fig. 7). During a quick scan of the possible causes of CA, cardiac contraction and movement during chest compressions can be observed. Fibrillary or mechanical contractions of the ventricle can be observed during ventricular fibrillation or pulseless electrical activity (Supplemental Video 1). Catheterizations for interventional measures, such as REBOA or extracorporeal CPR, can be assisted by intra-arrest TEE [29,60]. Cardiac movement, including compression of the cardiac chambers and valvular motion, can be continuously monitored during TEE [7,8,14,21]. Kinetic analysis of chest compressions can be performed by measuring the excursions of the free wall of the RV [34]. An intracardiac shunt or paradoxical embolism can be detected during intra-arrest TEE [41,47].

Fig. 2.

Cardiac tamponade. The mid-esophageal view shows a large amount of pericardial effusion (PE) surrounding the left ventricle (LV).

Fig. 3.

Ruptured aortic dissection. A dissecting flap (arrow) and left pleural effusion (Pl E) are noted on the descending aorta (AO) short-axis view.

Fig. 4.

Aortic dissection. The mid-esophageal ascending aorta short-axis view shows a dissecting flap (arrow) in the ascending aorta (Ao). PA, pulmonary artery.

Fig. 5.

Thrombi (T*) in the right-sided chambers. Echogenic densities occupying the right atrium (RA) and the right ventricle (RV) on the mid-esophageal four-chamber view suggest pulmonary embolism as a possible cause of cardiac arrest. LA, left atrium; LV, left ventricle.

Fig. 6.

Thrombi (T*) in the pulmonary artery (PA). The mid-esophageal view for the PA shows echogenic densities in the main and right PA. Ao, ascending aorta.

Fig. 7.

Intracardiac thrombi (T*). Echogenic densities with variable sizes are noted in all cardiac chambers suggesting sequelae of prolonged cardiac arrest. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

SAFETY OF INTRA-ARREST TEE

TEE is relatively safe. The overall complication rate of diagnostic and intraoperative TEE ranges from 0.18% to 2.8%, and the mortality rate is less than 0.01% to 0.02% [61-63]. However, no study has reported the safety of intra-arrest TEE. From our experience (unpublished data), intra-arrest TEE was successfully performed with no complications in 179 of 183 patients (97.8%) who experienced out-of-hospital CA. Failure of TEE probe insertion into the esophagus occurred in three patients (1.6%), while vallecular injury was confirmed in one patient (0.5%) after intra-arrest TEE. The electrical safety of using TEE during transthoracic defibrillation remains controversial [64]. Operator injury or equipment failure was not reported during transthoracic defibrillation. No study has reported the harmful effects of transthoracic defibrillation on operators or patients when a TEE probe is inserted. However, the effect of defibrillation on TEE machines has not yet been evaluated.

CONCLUSION

TEE is now widely practiced not only by cardiologists, but also by doctors who manage patients with cardiovascular disorders, including emergency physicians, intensivists, and anesthesiologists. Excellent imaging windows, easy accessibility, and high portability have enabled TEE to be a point-of-care imaging modality during CA in the ED. Intra-arrest TEE facilitates the diagnosis of the CA cause, enables the evaluation of cardiac contractions and CPR quality, and aids in catheter insertion for therapeutic procedures. Trained experts, protocols, coordination, and equipment maintenance are essential for the successful application of an intra-arrest TEE program in the ED. Future research should evaluate the effect of intra-arrest TEE on resuscitation outcomes in patients with CA.

SUPPLEMENTARY MATERIAL

Supplementary material is available at https://doi.org/10.15441/ceem.22.399.

Supplemental Video 1.

Illustrative case of ventricular fibrillation observed on intra-arrest transesophageal echocardiography. The mid-esophageal four-chamber view shows fine fibrillary contraction of the left ventricle and mitral valve movement.

Notes

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

AUTHOR CONTRIBUTIONS

Conceptualization: SOH; Data curation: WJJ; Investigation: KCC; Methodology: SOH; Resources: WJJ; Supervision: SOH; Visualization: YIR; Writing–original draft: SOH; Writing–review & editing: all authors.

All authors read and approved the final manuscript.

References

1. Oh J, Cha KC, Lee JH, et al. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 4. Adult advanced life support. Clin Exp Emerg Med 2021;8(S):S26–40.
2. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132(18 Suppl 2):S444–64.
3. Fair J, Mallin M, Mallemat H, et al. Transesophageal echocardiography: guidelines for point-of-care applications in cardiac arrest resuscitation. Ann Emerg Med 2018;71:201–7.
4. Oh JH, Choo SJ, Lee CK, Lim KS, Hwang SO, Park KS. Traumatic aortic rupture using transesophageal echocardiography: a case. Korean J Thorac Cardiovasc Surg 1992;25:335–40.
5. Higano ST, Oh JK, Ewy GA, Seward JB. The mechanism of blood flow during closed chest cardiac massage in humans: transesophageal echocardiographic observations. Mayo Clin Proc 1990;65:1432–40.
6. Kuhn C, Juchems R, Frese W. Evidence for the ‘cardiac pump theory’ in cardiopulmonary resuscitation in man by transesophageal echocardiography. Resuscitation 1991;22:275–82.
7. Porter TR, Ornato JP, Guard CS, Roy VG, Burns CA, Nixon JV. Transesophageal echocardiography to assess mitral valve function and flow during cardiopulmonary resuscitation. Am J Cardiol 1992;70:1056–60.
8. Redberg RF, Tucker KJ, Cohen TJ, Dutton JP, Callaham ML, Schiller NB. Physiology of blood flow during cardiopulmonary resuscitation: a transesophageal echocardiographic study. Circulation 1993;88:534–42.
9. Tucker KJ, Redberg RF, Schiller NB, Cohen TJ; Cardiopulmonary Resuscitation Working Group. Active compression-decompression resuscitation: analysis of transmitral flow and left ventricular volume by transesophageal echocardiography in humans. J Am Coll Cardiol 1993;22:1485–93.
10. Barton CW, Eisenberg MJ, Schiller N. Transesophageal echocardiographic diagnosis of massive pulmonary embolism during cardiopulmonary resuscitation. Am Heart J 1994;127:1639–42.
11. Ma MH, Huang GT, Wang SM, et al. Aortic valve disruption and regurgitation complicating CPR detected by transesophageal echocardiography. Am J Emerg Med 1994;12:601–2.
12. Pell AC, Guly UM, Sutherland GR, Steedman DJ, Bloomfield P, Robertson C. Mechanism of closed chest cardiopulmonary resuscitation investigated by transoesophageal echocardiography. J Accid Emerg Med 1994;11:139–43.
13. Pell AC, Pringle SD, Guly UM, Steedman DJ, Robertson CE. Assessment of the active compression-decompression device (ACD) in cardiopulmonary resuscitation using transoesophageal echocardiography. Resuscitation 1994;27:137–40.
14. Ma MH, Hwang JJ, Lai LP, et al. Transesophageal echocardiographic assessment of mitral valve position and pulmonary venous flow during cardiopulmonary resuscitation in humans. Circulation 1995;92:854–61.
15. Gilon D, Geist M, Rein AJ, Gotsman MS, Hasin Y. Mechanisms of cardiopulmonary resuscitation in a patient with right ventricular dilatation: an echocardiographic contribution. Clin Cardiol 1996;19:69–70.
16. Huemer G, Kolev N, Zimpfer M. Transoesophageal echocardiographic assessment of mitral and aortic valve function during cardiopulmonary resuscitation. Eur J Anaesthesiol 1996;13:622–6.
17. van der Wouw PA, Koster RW, Delemarre BJ, de Vos R, Lampe-Schoenmaeckers AJ, Lie KI. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol 1997;30:780–3.
18. Hwang SO, Kim H, Lee KH, et al. Role of transesophageal echocardiography in differential diagnosis of the cause of cardiac arrest during the secondary survey of advanced cardiac life support. Korean Circ J 1998;28:262–8.
19. Tsai SK, Wang MJ, Ko WJ, Wang SJ. Emergent bedside transesophageal echocardiography in the resuscitation of sudden cardiac arrest after tricuspid inflow obstruction and pulmonary embolism. Anesth Analg 1999;89:1406–8.
20. Comess KA, DeRook FA, Russell ML, Tognazzi-Evans TA, Beach KW. The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity. Am J Med 2000;109:351–6.
21. Hwang SO, Lee KH, Cho JH, Yoon J, Choe KH. Changes of aortic dimensions as evidence of cardiac pump mechanism during cardiopulmonary resuscitation in humans. Resuscitation 2001;50:87–93.
22. Liu P, Gao Y, Fu X, et al. Pump models assessed by transesophageal echocardiography during cardiopulmonary resuscitation. Chin Med J (Engl) 2002;115:359–63.
23. Memtsoudis SG, Rosenberger P, Loffler M, et al. The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery. Anesth Analg 2006;102:1653–7.
24. Lin T, Chen Y, Lu C, Wang M. Use of transoesophageal echocardiography during cardiac arrest in patients undergoing elective non-cardiac surgery. Br J Anaesth 2006;96:167–70.
25. Blaivas M. Transesophageal echocardiography during cardiopulmonary arrest in the emergency department. Resuscitation 2008;78:135–40.
26. Kim H, Hwang SO, Lee CC, et al. Direction of blood flow from the left ventricle during cardiopulmonary resuscitation in humans: its implications for mechanism of blood flow. Am Heart J 2008;156:1222.
27. Hwang SO, Zhao PG, Choi HJ, et al. Compression of the left ventricular outflow tract during cardiopulmonary resuscitation. Acad Emerg Med 2009;16:928–33.
28. Weidman JL, Hilberath JN. Systemic thrombus formation in cardiac arrest: manifestation of cardiac arrest-related hypercoagulability visualized by transesophageal echocardiography. Anesthesiology 2014;120:997.
29. Fair J, Tonna J, Ockerse P, et al. Emergency physician-performed transesophageal echocardiography for extracorporeal life support vascular cannula placement. Am J Emerg Med 2016;34:1637–9.
30. Liu Y, Tian Z, Yu C, et al. Transesophageal echocardiography to assess mitral valve movement and flow during long term cardiopulmonary resuscitation: how cardiac effects fade with time. Int J Cardiol 2016;223:693–8.
31. 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;50:286–94.
32. Catena E, Ottolina D, Fossali T, et al. Association between left ventricular outflow tract opening and successful resuscitation after cardiac arrest. Resuscitation 2019;138:8–14.
33. Fair J 3rd, Mallin MP, Adler A, et al. Transesophageal echocardiography during cardiopulmonary resuscitation is associated with shorter compression pauses compared with transthoracic echocardiography. Ann Emerg Med 2019;73:610–6.
34. Kim YW, Cha KC, Kim YS, et al. Kinetic analysis of cardiac compressions during cardiopulmonary resuscitation. J Crit Care 2019;52:48–52.
35. Lee DK, Kang KS, Cha YS, et al. Acute aortic dissection developed after cardiopulmonary resuscitation: transesophageal echocardiographic observations and proposed mechanism of injury. Acute Crit Care 2019;34:228–31.
36. Teran F, Dean AJ, Centeno C, et al. Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department. Resuscitation 2019;137:140–7.
37. Giorgetti R, Chiricolo G, Melniker L, Calaf C, Gaeta T. RESCUE transesophageal echocardiography for monitoring of mechanical chest compressions and guidance for extracorporeal cardiopulmonary resuscitation cannulation in refractory cardiac arrest. J Clin Ultrasound 2020;48:184–7.
38. Long CS, Miller MR, McMullin GM, Tivey SL. Transesophageal echocardiography-guided cardiopulmonary resuscitation after rocuronium anaphylaxis. A A Pract 2020;14:e01175.
39. Merlin MA, Joseph J, Hohbein J, Ariyaprakai N, Tanis J, Tagore A. Out-of-hospital transesophageal echocardiogram for cardiac arrest resuscitation: the initial case. Prehosp Emerg Care 2020;24:90–3.
40. Jung WJ, Cha KC, Kim YW, et al. Intra-arrest transoesophageal echocardiographic findings and resuscitation outcomes. Resuscitation 2020;154:31–7.
41. Kim SJ, Kim Y, Ahn KJ, Hwang SO. Cardiopulmonary resuscitation may cause paradoxical embolism. Am J Emerg Med 2020;38:1701.
42. Orihashi K. Transesophageal echocardiography during cardiopulmonary resuscitation (CPR-TEE). Circ J 2020;84:820–4.
43. Rublee C, Yang B, Eisinger G, et al. A case for the use of transesophageal echocardiography in the ED treatment of cardiac arrest. Chest 2020;157:e173–6.
44. Kim YW, Jung WJ, Cha KC, et al. Diagnosis of aortic dissection by transesophageal echocardiography during cardiopulmonary resuscitation. Am J Emerg Med 2021;39:92–5.
45. Poppe M, Magnet I, Muller M, Janata-Schwatczek K. Thrombolysis of a massive intracardiac thrombus during resuscitation: documentation by transoesophageal echocardiography. BMJ Case Rep 2021;14:e239063.
46. Horowitz JM, Yuriditsky E, Bakker J, Magda G, Teran F, Saric M. Clot in transit in a patient with COVID-19: transesophageal echocardiographic guidance of mechanical cardiopulmonary resuscitation. CASE (Phila) 2021;5:143–6.
47. Jung WJ, Cha KC, Roh YI, et al. Right-to-left shunts occur during cardiopulmonary resuscitation: echocardiographic observations. Crit Care Med 2022;50:1486–93.
48. McGuire D, Johnson S, Mielke N, Bahl A. Transesophageal echocardiography in the emergency department: a comprehensive guide for acquisition, implementation, and quality assurance. J Am Coll Emerg Physicians Open 2022;3:e12758.
49. Rutala WA, Weber DJ, ; The Healthcare Infection Control Practices Advisory Committee (HIPAC). Guidelines for disinfection and sterilization in healthcare facilities [Internet] Atlanta, GA: Centers for Disease Control and Prevention; 2019. [cited 2022 Oct 25]. Available from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/.
50. Kanagala P, Bradley C, Hoffman P, Steeds RP; British Society of Echocardiography. Guidelines for transoesophageal echocardiographic probe cleaning and disinfection from the British Society of Echocardiography. Eur J Echocardiogr 2011;12:i17–23.
51. Hahn RT, Abraham T, Adams MS, 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.
52. Beller GA, Bonow RO, Fuste V, ; American College of Cardiology Foundation, ; American Heart Association, ; American College of Physicians Task Force on Clinical Competence and Training. ACCF 2008 recommendations for training in adult cardiovascular medicine core cardiology training (COCATS 3) (revision of the 2002 COCATS Training Statement). J Am Coll Cardiol 2008;51:335–8.
53. Cahalan MK, Stewart W, Pearlman A, et al. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. J Am Soc Echocardiogr 2002;15:647–52.
54. Flachskampf FA, Badano L, Daniel WG, et al. Recommendations for transoesophageal echocardiography: update 2010. Eur J Echocardiogr 2010;11:557–76.
55. Guidelines for the use of transesophageal echocardiography (TEE) in the ED for cardiac arrest. Ann Emerg Med 2017;70:442–5.
56. Ottaviani F, Schindler A, Mozzanica F, Peri A, Rezzonico S, Turiel M. Surgical management of a life-threatening retro-pharyngeal haematoma following trans-oesophageal echocardiography. Acta Otorhinolaryngol Ital 2011;31:39–42.
57. Onishi T, Onishi Y, Tachibana K, et al. Perforation of the hypopharynx after transesophageal echocardiography. J Echocardiogr 2014;12:71–4.
58. 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.
59. Tang MM, Fang DF, Liu B. Upper gastrointestinal bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography during successful cardiopulmonary resuscitation: a case report. World J Clin Cases 2022;10:2954–60.
60. Kelly C, Stoecklein HH, Brant-Zawadzki G, et al. TEE guided REBOA deflation following ROSC for non-traumatic cardiac arrest. Am J Emerg Med 2023;63:182.
61. Daniel WG, Erbel R, Kasper W, et al. Safety of transesophageal echocardiography: a multicenter survey of 10,419 examinations. Circulation 1991;83:817–21.
62. Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg 2001;92:1126–30.
63. Seward JB, Khandheria BK, Oh JK, et al. Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications. Mayo Clin Proc 1988;63:649–80.
64. Davis-Gomez N, Perkins GD. Safety of transoesophageal echocardiography during cardiac arrest. Resuscitation 2008;79:175.

Article information Continued

Notes

Capsule Summary

What is already known

The use of point-of-care ultrasound during cardiopulmonary resuscitation (CPR) has been suggested.

What is new in the current study

Intra-arrest transesophageal echocardiography can be used as a point-of-care ultrasound method to diagnose the cause of cardiac arrest, determine the presence of cardiac contractions, evaluate the quality of CPR, assist with catheter insertion, and explore the mechanism of blood flow during CPR.

Fig. 1.

Suggested intra-arrest transesophageal echocardiography imaging planes and the corresponding structures or pathologies imaged. ME, mid-esophageal; RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; MV, mitral valve; AV, aortic valve; TV, tricuspid valve; LVOT, left ventricular outflow tract; RVOT, right ventricular outflow tract; SVC, superior vena cava.

Fig. 2.

Cardiac tamponade. The mid-esophageal view shows a large amount of pericardial effusion (PE) surrounding the left ventricle (LV).

Fig. 3.

Ruptured aortic dissection. A dissecting flap (arrow) and left pleural effusion (Pl E) are noted on the descending aorta (AO) short-axis view.

Fig. 4.

Aortic dissection. The mid-esophageal ascending aorta short-axis view shows a dissecting flap (arrow) in the ascending aorta (Ao). PA, pulmonary artery.

Fig. 5.

Thrombi (T*) in the right-sided chambers. Echogenic densities occupying the right atrium (RA) and the right ventricle (RV) on the mid-esophageal four-chamber view suggest pulmonary embolism as a possible cause of cardiac arrest. LA, left atrium; LV, left ventricle.

Fig. 6.

Thrombi (T*) in the pulmonary artery (PA). The mid-esophageal view for the PA shows echogenic densities in the main and right PA. Ao, ascending aorta.

Fig. 7.

Intracardiac thrombi (T*). Echogenic densities with variable sizes are noted in all cardiac chambers suggesting sequelae of prolonged cardiac arrest. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Table 1.

Indications and findings of intra-arrest TEE in the literature

Study Study type No. of patientsa) Indication/objectiveb) Main echocardiographic finding
Higano et al. [5] (1990) Case report 2 Exploratory Compression of RV and LV and closure of MV during compression
Kuhn et al. [6] (1991) Case report 1 Exploratory Opening of AV during thoracic compression with simultaneous closure of mitral and tricuspid valves
Porter et al. [7] (1992) Prospective observational 17 Exploratory Closure of MV during downstroke of chest compression and absence of correlation between MV flow and LV fractional shortening
Redberg et al. [8] (1993) Prospective observational 20 Exploratory MV opening during cardiac release, reduction of ventricular cavity size with compression, and atrioventricular regurgitation supporting the cardiac pump theory
Tucker et al. [9] (1993) Prospective observational 5 Exploratory Improved transmitral flow, end-decompression LV volume, and stroke volume with ACD CPR
Barton et al. [10] (1994) Case report 1 Diagnostic Massive pulmonary embolism as a cause of PEA
Ma et al. [11] (1994) Case report 1 Complications AV disruption complicating CPR
Pell et al. [12] (1994) Prospective observational 18 Exploratory Compression of all four cardiac chambers resulting in forward flow in pulmonary and systemic circulations, retrograde pulmonary vein flow, and incomplete MV closure
Antegrade pulmonary vein flow and LV filling observed during relaxation phase
Pell et al. [13] (1994) Prospective observational 7 Exploratory Improved right heart compression, antegrade blood flow patterns, and LV filling during ACD CPR
Ma et al. [14] (1995) Prospective observational 17 Exploratory Presence of opened MV with forward mitral flow and backward pulmonary venous flow during chest compression, suggesting “LA pump”
Gilon et al. [15] (1996) Case report 1 Exploratory RV compression and tricuspid valve closure
Huemer et al. [16] (1996) Case report 1 Exploratory Closure of MV, opening of AV, and reduction of LV cross-sectional area during downstroke of chest compression
Van der Wouw et al. [17] (1997) Prospective observational 48 Diagnostic Cardiac tamponade (n = 6), myocardial infarction (n = 21), pulmonary embolism (n = 6), ruptured aorta (n = 1), aortic dissection (n = 4), papillary muscle rupture (n = 1), other diagnosis (n = 2), and absence of structural cardiac abnormalities (n = 7)
Hwang et al. [18] (1998) Prospective observational 52 Diagnostic Pericardial effusion (n = 10), aortic dissection (n = 5), occlusion of the mitral orifice by thrombus (n = 2), main pulmonary artery thrombus (n = 2), thrombotic occlusion of the prosthetic valve (n = 1), hypertrophic cardiomyopathy (n = 1), and aortic stenosis (n = 1)
Tsai et al. [19] (1999) Case report 1 Diagnostic Total tricuspid valve obstruction and massive pulmonary embolism
Comess et al. [20] (2000) Prospective observational 36 Diagnostic Pulmonary emboli in 9 of 25 patients (36%) with pulseless electrical activity as initial event
Hwang et al. [21] (2001) Prospective observational 14 Exploratory Deformation of the aorta at maximal compression site and increase in cross-sectional area of proximal aorta
Liu et al. [22] (2002) Prospective observational 6 Exploratory Closure of mitral and tricuspid valves with simultaneous opening of AV during chest compression
Memtsoudis et al. [23] (2006) Retrospective observational 22 Exploratory Thromboembolic events (n = 9), acute myocardial ischemia (n = 6), hypovolemia (n = 2), and pericardial tamponade (n = 2)
Lin et al. [24] (2006) Prospective observational 10 Diagnostic Myocardial infarction (n = 5), pulmonary embolism (n = 2), and severe hypovolemia and ventricular arrhythmia without specific pathology (n = 2)
Blaivas [25] (2008) Case report 6 Diagnostic/monitoring Identification of VF in patients with asystole on ECG
Kim et al. [26] (2008) Prospective observational 10 Exploratory Retrograde flow to LA and forward blood flow to aorta on LV contrast echocardiography during compression phase
Hwang et al. [27] (2009) Prospective observational 34 Exploratory Significant narrowing of LV outflow tract or aorta during compression phase
Weidman et al. [28] (2014) Case report 1 Exploratory Formation of multiple thrombi in heart and descending thoracic aorta during CA
Fair et al. [29] (2016) Prospective observational 10 Guiding catheter cannulation ECMO guidewire placement and cannula positioning
Liu et al. [30] (2016) Prospective observational 20 Exploratory Cardiac effect at beginning of CA, faded with time, making the thoracic pump dominant mechanism during prolonged CPR
Arntfield et al. [31] (2016) Retrospective observational 23 Diagnostic/feasibility of TEE by emergency physicians High degree of feasibility and clinical utility of ED-based TEE
Catena et al. [32] (2019) Retrospective observational 19 Outcome prediction LV outflow tract opening associated with successful CPR
Fair et al. [33] (2019) Prospective interventional 25 Efficacy of TEE on pulse check time Shorter pulse check times with TEE compared with TTE
Kim et al. [34] (2019) Retrospective observational 20 Exploratory Measurement of compression depth at RV free wall and calculation of compression velocity
Lee et al. [35] (2019) Case report 1 Complications Acute aortic dissection complicating CPR
Teran et al. [36] (2019) Prospective observational 21 Diagnostic/CPR quality Identification of pseudo-PEA and fine VF, determination of reversible pathology, and optimization of CPR quality
Giorgetti et al. [37] (2019) Case report 1 Guiding catheterization Monitoring of mechanical chest compression performance and guiding cannulation for ECPR
Long et al. [38] (2020) Case report 1 Monitoring cardiac status Monitoring of CA due to anaphylaxis
Merlin et al. [39] (2020) Case report 1 Trial of out-of-hospital TEE Report of initial case of out-of-hospital TEE
Jung et al. [40] (2020) Retrospective observational 158 Diagnostic/prediction of outcome Total of 40 patients (25.3%, TEE positive group) with specific TEE findings, including possible causes of CA (n = 31, 19.6%) and sequelae of CA (n = 9, 5.7%)
Positive TEE findings were associated with poor resuscitation outcomes
Kim et al. [41] (2020) Case report 1 Diagnostic Paradoxical embolism of right heart thrombi visualized on TEE during CPR
Orihashi [42] (2020) Case report 4 Guiding catheterization Monitoring chest compressions, guiding catheter insertion, and assisting pericardiocentesis
Rublee et al. [43] (2020) Case report 1 Diagnostic Cardiac tamponade and type A aortic dissection
Kim et al. [44] (2021) Retrospective observational 45 Diagnostic Diagnosing aortic dissection as cause of CA
Poppe et al. [45] (2021) Case report 1 Diagnostic Massive intracardiac thrombus and subsequent thrombolysis
Horowitz et al. [46] (2021) Case report 1 Diagnostic Clot in transit in RA and thrombolysis
Jung et al. [47] (2022) Retrospective observational 97 Evaluation of intracardiac shunt Assessment for presence of right-to-left shunt during CPR

TEE, transesophageal echocardiography; RV, right ventricle; LV, left ventricle; MV, mitral valve; AV, aortic valve; ACD, active compression decompression; CPR, cardiopulmonary resuscitation; PEA, pulseless electrical activities; LA, left atrium; VF, ventricular fibrillation; ECG, electrocardiogram; CA, cardiac arrest; ECMO, extracorporeal membrane oxygenation; ED, emergency department; TTE, transthoracic echocardiography; ECPR, extracorporeal cardiopulmonary resuscitation; RA, right atrium.

a)

Number of patients only includes those who underwent TEE during CA.

b)

Exploratory, determination of mechanism of blood flow during cardiopulmonary resuscitation; Diagnostic, diagnosis of cause of CA.