Correspondence
Transesophageal Echocardiography
N Engl J Med 1995; 333:1153-1154October 26, 1995
- Article
To the Editor:
The article on transesophageal echocardiography (TEE) (May 11 issue)1 by Daniel and Mügge is very informative. The authors point out that TEE is an invasive procedure and in most instances — all, in my experience — requires the use of sedation or general anesthesia. The authors do not discuss alternative noninvasive methods, such as magnetic resonance imaging (MRI). They cite four articles on MRI in aortic dissections but fail to mention that these studies showed MRI to be superior to TEE. TEE has the disadvantage of having less resolution than MRI and being invasive and should, in my opinion, be the last choice, after noninvasive MRI has been considered or performed. TEE is superior to MRI in showing vegetations on valvular leaflets and in evaluating prosthetic heart valves, as well as for use in critically ill patients. Overall, however, MRI is superior and should therefore be the first choice in dealing with the complications of endocarditis (such as abscess formation), cardiac tumors, aortic dissection, and the diagnosis and follow-up of some forms of congenital heart disease.2 MRI is more promising than TEE in investigations involving the coronary arteries.2
2 ReferencesHugo G. Bogren, M.D., Ph.D.
University of California, Davis, School of Medicine, Sacramento, CA 958171
Daniel WG ,Mugge A . Transesophageal echocardiography. N Engl J Med 1995;332:1268-1279
Full Text | Web of Science | Medline2
Mohiaddin RH ,Longmore DB . Functional aspects of Cardiovascular Nuclear Magnetic Resonance Imaging: Techniques and Application. Circulation 1993;88:264-281
Web of Science | Medline
To the Editor:
As a neuroanesthesiologist, I am interested in the use of TEE during neurosurgical procedures in patients in the seated position, and specifically in the diagnosis of venous air embolism and paradoxical embolism. Do the authors consider these valid applications for TEE?
Arthur M. Lam, M.D.
University of Washington School of Medicine, Seattle, WA 98104-2499To the Editor:
Daniel and Mügge did not comment on whether TEE is useful in deciding whether to undertake anticoagulation before cardioversion from atrial fibrillation. Could the authors comment briefly on this issue?
Yoshifumi Enokawa, M.D.
Yoshinori Seko, M.D.
Yoshio Yazaki, M.D.
University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113, JapanAuthor/Editor Response
The authors reply:
To the Editor: We do not agree with Dr. Bogren that a TEE study requires sedation or general anesthesia in most patients. As we pointed out in an earlier article, the issue of whether an intravenous sedating premedication is needed is handled differently in various centers.1 In our laboratories, sedating premedication is used in less than 5 percent of ambulatory patients undergoing TEE. Sedation is needed only when patients are not sufficiently cooperative and in cases of suspected aortic dissection. General anesthesia may become necessary in some children scheduled for TEE, and its risk must be carefully balanced against the potential benefits of the TEE examination.
We also do not agree that TEE “should . . . be the last choice” for the diagnosis of acute aortic dissection “after noninvasive MRI has been considered or performed.” TEE can be quickly performed at the patient's bedside and is readily available in most hospitals, whereas MRI is not available on an emergency basis in many institutions. In addition, MRI has several shortcomings,2,3 including high costs and logistic drawbacks in patients whose condition is hemodynamically unstable. Both MRI and TEE have excellent sensitivities in diagnosing aortic dissection, and the lower specificity of TEE reported by Nienaber et al.4 is not universally accepted.5 We maintain, in agreement with Cigarroa et al.,2 that TEE should be considered first in cases of suspected aortic dissection. MRI is nonetheless highly accurate and, if available, particularly useful in patients with hemodynamically stable or chronic dissections.
The issue of whether TEE-guided cardioversion from atrial fibrillation without previous prolonged anticoagulation is safe or safer than the conventional approach to management is still controversial. Recent studies, however, seem to favor TEE guidance.6 On the basis of currently available information, we believe that in patients with high-quality multiplane TEE images without thrombi or severe, spontaneous echo contrast in the atria, cardioversion without prolonged anticoagulation is justified. However, the necessity of anticoagulation after cardioversion remains unaffected by this strategy.
With respect to the question posed by Dr. Lam, various studies have documented that contrast TEE associated with the Valsalva maneuver or coughing is highly accurate in the identification of patent foramen ovale. In patients undergoing posterior craniotomy in a sitting position, there is a 30 to 40 percent risk of venous air embolism, and disastrous outcomes have been reported when paradoxical embolism through a patent foramen ovale occurs. Preoperative exclusion of patent foramen ovale by TEE and intraoperative TEE monitoring for air embolism have certainly modified individual surgical strategies and helped decrease the risk associated with these neurosurgical procedures.7
7 ReferencesWerner G. Daniel, M.D.
University Clinic, 01307 Dresden, GermanyAndreas Mügge, M.D.
Hannover Medical School, 30625 Hannover, Germany1
Daniel WG ,Erbel R ,Kasper W , et al. Safety of transesophageal echocardiography -- a multicenter survey of 10,419 examinations. Circulation 1991;83:817-821
Web of Science | Medline2
Cigarroa JE ,Isselbacher EM ,DeSanctis RW ,Eagle KA . Diagnostic imaging in the evaluation of suspected aortic dissection -- old standards and new directions. N Engl J Med 1993;328:35-43
Full Text | Web of Science | Medline3
Mohiaddin RH ,Longmore DB . Functional aspects of cardiovascular nuclear magnetic resonance imaging: techniques and application. Circulation 1993;88:264-281
Web of Science | Medline4
Nienaber CA ,von Kodolitsch Y ,Nicolas V , et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993;328:1-9
Full Text | Web of Science | Medline5
Goldstein SA ,Lindsay J Jr ,Vasan R . The diagnosis of aortic dissection by noninvasive imaging procedures. N Engl J Med 1993;328:1637-1638
Full Text | Web of Science | Medline6
Manning WJ ,Silverman DI ,Keighley CS ,Oettgen P ,Douglas PS . Transesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5-year study. J Am Coll Cardiol 1995;25:1354-1361
CrossRef | Web of Science | Medline7
Black S ,Muzzi DA ,Nishimura RA ,Cucchiara RF . Preoperative and intraoperative echocardiography to detect right-to-left shunts in patients undergoing neurosurgical procedures in the sitting position. Anesthesiology 1990;72:436-438
CrossRef | Web of Science | Medline
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