Critical Care Transesophageal Echocardiography in Patients during the COVID-19 Pandemic

Felipe Teran, Katharine M Burns, Mangala Narasimhan, Alberto Goffi, Paul Mohabir, James M Horowitz, Eugene Yuriditsky, Arun Nagdev, Nova Panebianco, Eric J Chin, Michael Gottlieb, Seth Koenig, Robert Arntfield, Felipe Teran, Katharine M Burns, Mangala Narasimhan, Alberto Goffi, Paul Mohabir, James M Horowitz, Eugene Yuriditsky, Arun Nagdev, Nova Panebianco, Eric J Chin, Michael Gottlieb, Seth Koenig, Robert Arntfield

Abstract

Background: The COVID-19 pandemic has placed an extraordinary strain on healthcare systems across North America. Defining the optimal approach for managing a critically ill COVID-19 patient is rapidly changing. Goal-directed transesophageal echocardiography (TEE) is frequently used by physicians caring for intubated critically ill patients as a reliable imaging modality that is well suited to answer questions at bedside.

Methods: A multidisciplinary (intensive care, critical care cardiology, and emergency medicine) group of experts in point-of-care echocardiography and TEE from the United States and Canada convened to review the available evidence, share experiences, and produce a consensus statement aiming to provide clinicians with a framework to maximize the safety of patients and healthcare providers when considering focused point-of-care TEE in critically ill patients during the COVID-19 pandemic.

Results: Although transthoracic echocardiography can provide the information needed in most patients, there are specific scenarios in which TEE represents the modality of choice. TEE provides acute care clinicians with a goal-directed framework to guide clinical care and represents an ideal modality to evaluate hemodynamic instability during prone ventilation, perform serial evaluations of the lungs, support cardiac arrest resuscitation, and guide veno-venous ECMO cannulation. To aid other clinicians in performing TEE during the COVID-19 pandemic, we describe a set of principles and practical aspects for performing examinations with a focus on the logistics, personnel, and equipment required before, during, and after an examination.

Conclusions: In the right clinical scenario, TEE is a tool that can provide the information needed to deliver the best and safest possible care for the critically ill patients.

Keywords: Acute respiratory syndrome associated with COVID-19; COVID-19; Novel coronavirus; Point-of-care ultrasound; SARS-CoV-2; Transesophageal echocardiography.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
TEE during cardiac arrest resuscitation in a patient with COVID-19. Right atrial thrombus (asterisk) visualized in an off-axis bicaval (A) and a midesophageal four-chamber (B) view, both obtained during ongoing cardiopulmonary resuscitation (CPR). Another midesophageal four-chamber view (C) of same patient shows a dilated right ventricle (RV) and septal deviation during CPR pause, suggesting pulmonary embolism. LA, Left atrium; LV, left ventricle; RA, right atrium.
Figure 2
Figure 2
TELUS of patients with hypoxemia in the intensive care unit (A,B) and emergency department (C,D). (A) Sagittal plane view of the left lung shows B-lines (asterisk) suggesting increased extravascular lung water. Panels (B) and (C) correspond to sagittal-plane views of the right costophrenic angle showing consolidation pattern (asterisk) suggestive of atelectasis versus pneumonia. In (D), an axial-plane view of the left lung shows an atelectatic lung (left asterisk) and pleural effusion (right asterisk). DTA, Descending thoracic aorta.
Figure 3
Figure 3
Performance of point-of-care TEE with patient in the prone position.

References

    1. Guan W.J., Ni Z.Y., Hu Y., Liang W.H., Ou C.Q., He J.X. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708–1720.
    1. World Health Organization Coronavirus disease 2019 (COVID-19): situation report—69. Available at:
    1. Grasselli G., Pesenti A., Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. JAMA. Available at:
    1. Remuzzi A., Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395:1225–1228.
    1. Wang D., Hu B., Hu C., Zhu F., Liu X., Zhang J. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323:1061–1069.
    1. Huang C., Wang Y., Li X., Ren L., Zhao J., Hu Y. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506.
    1. Yang X., Yu Y., Xu J., Shu H., Xia J., Liu H. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8:P475–P481.
    1. Arentz M., Eric Y., Lindy K., Lokhandwala S., Riedo F., Chong M. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA. 2020;323:1612–1614.
    1. Chen N., Zhou M., Dong X., Qu J., Gong F., Han Y. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395:507–513.
    1. Spencer K.T., Kimura B.J., Korcarz C.E., Pellikka P.A., Rahko P.S., Siegel R.J. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567–581.
    1. Narasimhan M., Koenig S.J., Mayo P.H. Advanced echocardiography for the critical care physician: part 2. Chest. 2014;145:135–142.
    1. Kirkpatrick J.N., Mitchell C., Taub C., Kort S., Hung J., Swaminathan M. ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. J Am Soc Echocardiogr. 2020;00 000-000.
    1. Mayo P.H., Narasimhan M., Koenig S. Critical care transesophageal echocardiography. Chest. 2015;148:1323–1332.
    1. Arntfield R., Lau V., Landry Y., Priestap F., Ball I. Impact of critical care transesophageal echocardiography in medical–surgical ICU patients: characteristics and results from 274 consecutive examinations. J Intensive Care Med. 2020 In press.
    1. Teran F., Dean A.J., Centeno C., Panebianco N.L., Zeidan A.J., Chan W. Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department. Resuscitation. 2019;137:140–147.
    1. Long B., Brady W.J., Koyfman A., Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med. Available at:
    1. Xie Y., Wang X., Yang P., Zhang S. COVID-19 complicated by acute pulmonary embolism. Radiol Cardiothorac Imaging. 2020;2:e200067.
    1. Danzi G.B., Loffi M., Galeazzi G., Gherbesi E. Acute pulmonary embolism and COVID-19 pneumonia: a random association? Eur Heart J. 2020;41:1858.
    1. Nicoara A., Maldonado Y., Kort S., Swaminathan M., Mackensen G.B. Specific considerations for the protection of patients and echocardiography service providers when performing perioperative or periprocedural transesophageal echocardiography during the 2019 novel coronavirus outbreak: Council on Perioperative Echocardiography supplement to the statement of the American Society of Echocardiography. J Am Soc Echocardiogr. 2020;00 000-000.
    1. Gralnek I.M., Hassan C., Beilenhoff U., Antonelli G., Ebigbo A., Pellisè M. ESGE and ESGENA position statement on gastrointestinal endoscopy and the COVID-19 pandemic. Endoscopy. 2020. 52. 2020. Available at:
    1. Soetikno R., Teoh A.Y., Kaltenbach T., Lau J.Y., Asokkumar R., Cabral-Prodigalidad P. Considerations in performing endoscopy during the COVID-19 pandemic. Gastrointest Endosc. Available at:
    1. Lui R.N., Wong S.H., Sánchez-Luna S.A., Pellino G., Bollipo S., Wong M.-Y. Overview of guidance for endoscopy during the coronavirus disease 2019 pandemic. J Gastroenterol Hepatol. 2020;35:749–759.
    1. Johnston E.R., Habib-Bein N., Dueker J.M., Quiroz B., Corsaro E., Ambrogio M. Risk of bacterial exposure to the endoscopist’s face during endoscopy. Gastrointest Endosc. 2019;89:818–824.
    1. Nolan J., Ornato J., Parr M., Perkins G., Soar J. Resuscitation highlights in 2014. Resuscitation. 2015;89:A1–A6.
    1. Kleinman M.E., Goldberger Z.D., Rea T., Swor R.A., Bobrow B.J., Brennan E.E. 2017 American Heart Association focused update on adult basic life support and cardiopulmonary resuscitation quality: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2018;137:e7–e13.
    1. Couper K., Taylor-Phillips S., Grove A., Freeman K., Osokogu O., Court R. International Liaison Committee on Resuscitation; Brussels, Belgium: 2020. COVID-19 infection risk to rescuers from patients in cardiac arrest. Consensus on science with treatment recommendations.
    1. Catena E., Ottolina D., Fossali T., Rech R., Borghi B., Perotti A. Association between left ventricular outflow tract opening and successful resuscitation after cardiac arrest. Resuscitation. 2019;138:8–14.
    1. Fair J., Mallin M.P., Adler A., Ockerse P., Steenblick J., Tonna J. Transesophageal echocardiography during cardiopulmonary resuscitation is associated with shorter compression pauses compared with transthoracic echocardiography. Ann Emerg Med. 2019;73:610–616.
    1. 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;7:27.
    1. Fair J., Tonna J., Ockerse P., Galovic B., Youngquist S., McKellar S. Emergency physician-performed transesophageal echocardiography for extracorporeal life support vascular cannula placement. Am J Emerg Med. 2016;34:1637–1639.
    1. van Doremalen N., Bushmaker T., Morris D.H., Holbrook M.G., Gamble A., Williamson B.N. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020;382:1564–1567.
    1. World Health Organization WHO interim guidelines. Vol. 6, infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. Available at:
    1. Vignon P., Merz T.M., Vieillard-Baron A. Ten reasons for performing hemodynamic monitoring using transesophageal echocardiography. Intensive Care Med. 2017;43:1048–1051.
    1. Vignon P., Mentec H., Terre S., Gastinne H., Gueret P., Lemaire F. Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU. Chest. 1994;106:1829–1834.
    1. Hendren N.S., Drazner M.H., Bozkurt B., Cooper L.T., Jr. Description and proposed management of the acute COVID-19 cardiovascular syndrome. Circulation. Available at:
    1. Vieillard-Baron A., Price L.C., Matthay M.A. Acute cor pulmonale in ARDS. Intensive Care Med. 2013;39:1836–1838.
    1. Douflé G., Roscoe A., Billia F., Fan E. Echocardiography for adult patients supported with extracorporeal membrane oxygenation. Crit Care. 2015;19:1–10.
    1. Cronin B., Robbins R., Maus T. Pulmonary artery catheter placement using transesophageal echocardiography. J Cardiothorac Vasc Anesth. 2017;31:178–183.
    1. Lerner R.P., Haaland A., Lin J. Temporary transvenous pacer placement under transesophageal echocardiogram guidance in the emergency department. Am J Emerg Med. 2020 In press.
    1. Nishioka T., Friedman A., Cercek B., Chaux A., Luo H., Berglund H. Usefulness of transesophageal echocardiography for positioning the intraaortic balloon pump in the operating room. Am J Cardiol. 1996;77:105–106.
    1. Klopman M.A., Chen E.P., Sniecinski R.M. Positioning an intraaortic balloon pump using intraoperative transesophageal echocardiogram guidance. Anesth Analg. 2011;113:40–43.
    1. Miller S.D., Lee D.C., Dollar B.T., Schepel S.R., Shestopalov A., Culp W.C. Transesophageal echocardiography guidance for atrial-caval thrombus removal with the AngioVac system. Baylor Univ Med Cent Proc. 2020;33:85–86.
    1. Extracorporeal Life Support Organization ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure. Available at:
    1. Extracorporeal Life Support Organization COVID-19 cases on ECMO in the ELSO registry. Available at:
    1. Platts D.G., Sedgwick J.F., Burstow D.J., Mullany D.V., Fraser J.F. The role of echocardiography in the management of patients supported by extracorporeal membrane oxygenation. J Am Soc Echocardiogr. 2012;25:131–141.
    1. Griffee M.J., Zimmerman J.M., McKellar S.H., Tonna J.E. Echocardiography-guided dual-lumen venovenous extracorporeal membrane oxygenation cannula placement in the ICU—a retrospective review. J Cardiothorac Vasc Anesth. 2020;34:698–705.
    1. Cianchi G., Lazzeri C., Bonizzoli M., Batacchi S., Peris A. Echo-guided insertion of a dual-lumen cannula for venovenous extracorporeal membrane oxygenation. ASAIO J. 2019;65:414–416.
    1. Banfi C., Pozzi M., Siegenthaler N., Brunner M.E., Tassaux D., Obadia J.F. Veno-venous extracorporeal membrane oxygenation: cannulation techniques. J Thorac Dis. 2016;8:3762–3773.
    1. Cavayas Y.A., Girard M., Desjardins G., Denault A.Y. Transesophageal lung ultrasonography: a novel technique for investigating hypoxemia. Can J Anesth. 2016;63:1266–1276.
    1. Cavalcanti A.B., Suzumura É.A., Laranjeira L.N., de Moraes Paisani D., Damiani L.P., Guimaraes H.P. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 2017;318:1335–1345.
    1. Guérin C., Reignier J., Richard J.C., Beuret P., Gacouin A., Boulain T. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159–2168.
    1. Alhazzani W., Møller M.H., Arabi Y.M., Loeb M., Gong M.N., Fan E. Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19) Intensive Care Med. 2020;46:854–887.
    1. Mekontso Dessap A., Proost O., Boissier F., Louis B., Roche Campo F., Brochard L. Transesophageal echocardiography in prone position during severe acute respiratory distress syndrome. Intensive Care Med. 2011;37:430–434.
    1. Guarracino F. Transoesophageal echocardiography during prone positioning for ARDS: watching the heart to care for the lung. Intensive Care Med. 2011;37:380–381.
    1. Rutala W.A., Weber D.J. Guideline for disinfection and sterilization in healthcare facilities. Available at:
    1. US Environmental Protection Agency List N: disinfectants for use against SARS-CoV-2. Available at:

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться