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PurposeMortality in circulatory shock is high. Enhanced resolution of shock may improve outcomes. We aim to determine whether adding hemodynamic monitoring with continual transesophageal echocardiography (hTEE) to usual care accelerates resolution of hemodynamic instability.Methods550 patients with circulatory shock were randomly assigned to four groups stratified using hTEE (hTEE vs usual care) and assessment frequency (minimum every 4 h vs 8 h). Primary outcome was time to resolution of hemodynamic instability, analyzed as intention-to-treat (ITT) analysis at day 6 and in a predefined secondary analysis at days 3 and 28.ResultsOf 550 randomized patients, 271 with hTEE and 274 patients with usual care were eligible and included in the ITT analysis. Time to resolution of hemodynamic instability did not differ within the first 6 days [hTEE vs usual care adjusted sub-hazard ratio (SHR) 1.20, 95% confidence interval (CI) 0.98–1.46, p = 0.067]. Time to resolution of hemodynamic instability during the 72 h of hTEE monitoring was shorter in patients with TEE (hTEE vs usual care SHR 1.26, 95% CI 1.02–1.55, p = 0.034). Assessment frequency had no influence. Time to resolution of clinical signs of hypoperfusion, duration of organ support, length of stay and mortality in the intensive care unit and hospital, and mortality at 28 days did not differ between groups.ConclusionsIn critically ill patients with shock, hTEE monitoring or hemodynamic assessment frequency did not influence resolution of hemodynamic instability or mortality within the first 6 days.Trial registration and statistical analysis planClinicalTrials.gov Identifier: NCT02048566.

This meta-analysis aimed to compare videolaryngoscope (VL)-assisted transesophageal echocardiography (TEE) probe insertion with conventional methods in terms of efficacy and safety. Several major databases such as Medline and Embase were systematically searched to identified relevant studies from inception to June 2024. The primary outcome was complication rate, defined as the proportion of patients experiencing complications related to TEE probe insertion. Injuries at specific sites (e.g., posterior hypopharyngeal wall) from both groups were also analyzed. The secondary outcomes included the first-attempt success rate and total insertion time of VL and conventional methods. Seven trials involving 716 participants were identified. The use of VL was found to significantly reduce the complication rate (risk ratio[RR]:0.28, 95% confidence interval[CI]:0.17-0.46, P < 0.00001) and increased the first-attempt success rate [FASR] (RR:1.33, 95%CI: 1.10-1.60, P = 0.003) compared with conventional methods. These findings were confirmed by trial sequential analysis. No significant difference was found in the TEE insertion time among the two techniques (mean difference: -2.94s, 95%CI: -10.28-4.4, P = 0.43). VL significantly reduced the risk of trauma to the hypopharyngeal wall but showed no significant benefits in other areas (e.g., pyriform sinus). The certainty of evidence was moderate for the complication rate, very low for the FAS rate, and low for the TEE insertion time. The use of VL for TEE probe insertion is associated with a significantly lower complication rate and higher FAS rate than conventional methods. These findings suggest that VL enhances patient safety and improves the efficiency of TEE probe insertion.

Background Transesophageal echocardiography during out-of-hospital cardiac arrest can be performed during ongoing chest compressions and may improve resuscitation quality, but its prehospital use has not been systematically evaluated. To assess the feasibility, diagnostic yield, and impact of prehospital TEE on resuscitation metrics and advanced life support (ALS) interventions during OHCA. Methods We conducted a randomized controlled trial in a physician-staffed two-tiered emergency medical service (EMS). Adults with ongoing non-traumatic OHCA were randomized 1:1 to standard ALS or ALS plus TEE. The primary endpoints were hands-off time and chest compression fraction (CCF) from EMS arrival to return of spontaneous circulation (ROSC) or resuscitation termination. Secondary endpoints included ROSC at hospital admission, survival to hospital discharge, neurological status at hospital discharge, and TEE findings. Analyses followed the intention-to-treat principle. Results Of 249 screened patients, 35 were randomized and 32 analyzed (TEE n  = 15; control n  = 17). Median hands-off time was 4 s in both groups. Mean CCF was higher in the TEE group (96.2%) than the control group (91.6%), with a mean difference of 4.6% (95% confidence interval 2.5–6.7; p  < 0.001). Sustained ROSC occurred in 40% (TEE) versus 71% (control; p  = 0.083). The control group had an eCPR rate of 41%, compared to 20% in the TEE group. Using TEE, an incorrect area of maximal compression or inadequate depth was identified in 23% and 14%, respectively. Conclusion Prehospital TEE during OHCA was feasible without negatively interfering with CPR metrics, and provided clinically relevant diagnostic information and procedural guidance, warranting further evaluation in larger trials. Trial registration German Clinical Trials Register DRKS00028695 registered on 28 April 2022.

Background Transesophageal echocardiography (TEE) is a vital diagnostic procedure, but retching can be provoked during TEE examination, potentially resulting in severe complications. The internal branch of the superior laryngeal nerve (iSLN) block has potential to attenuate supraglottic discomfort and inhibit the retching caused by foreign body stimulation in the larynx and glottis. Therefore, the objective of this study was to evaluate the efficacy of iSLN block in mitigating complications associated with TEE examinations and improving patient comfort. Methods One hundred forty-eight patients scheduled for TEE were randomized to either Group C: tetracaine syrup (1%) for oropharyngeal surface anesthesia ( n  = 74) or Group S: tetracaine syrup (1%) for oropharyngeal surface anesthesia and followed by bilateral iSLN block (lidocaine, 2%, 2 ml for each side) ( n  = 74). Under ultrasound guidance, the iSLN was identified and exposed below the thyrohyoid membrane. The primary outcome was the incidence of the retching. Secondary outcomes included the incidence of oropharyngeal mucosal bleeding, rapid TEE probe insertion rate, patient comfort, and hemodynamic response. Results The incidence of retching was significantly lower in Group S compared with Group C (12.16% vs. 39.19%, P  < 0.001). Group S also showed significantly lower incidences of oropharyngeal mucosal bleeding (8.11% vs. 27.02%, P  < 0.001) and higher rapid probe insertion rate (93.24% vs. 82.43%, P  = 0.044), as well as improved patient comfort scores ( P  < 0.001). The absolute changes in mean arterial pressure during TEE examination were smaller in Group S ( P  = 0.001). Multivariate analysis identified low body mass index and high Mallampati classification as independent risk factors for retching. Conclusions Bilateral iSLN block significantly reduces the incidence of retching and oropharyngeal mucosal bleeding, while improving patient comfort, increasing the rapid TEE probe insertion rate, and stabilizing MAP during TEE examination. This technique can significantly improve patient experience and safety during TEE procedures. Trial registration The study was registered at Chictr.org.cn with the number ChiCTR2300076359 on 07/10/2023.

With the growing complexity of structural heart disease procedures, the need for advanced intraprocedural imaging has become increasingly critical. Transesophageal echocardiography remains the gold standard for procedural guidance but is associated with risks such as upper gastrointestinal tract injury and the need for general anesthesia for patient comfort and safety. Miniaturized three-dimensional transesophageal echocardiography (miniTEE) probes offer a promising solution by providing high-resolution imaging which could be performed under conscious sedation. Studies evaluating the miniTEE probe for safety, image quality, and ability to guide specific structural and non-structural heart disease procedures will be reviewed. The limitations and future developments will be discussed. Graphical abstract: smaller transesophageal echocardiography probes have a number of advantages and limitations. As the technology improves, the utilization of these probes will likely increase

Purpose To assess the feasibility, image quality, diagnostic accuracy, therapeutic impact and tolerance of diagnostic and hemodynamic assessment using a novel miniaturized multiplane transesophageal echocardiography (TEE) probe in ventilated ICU patients with cardiopulmonary compromise. Study design Prospective, descriptive, single-center study. Methods Fifty-seven ventilated patients with acute circulatory or respiratory failure were assessed, using a miniaturized multiplane TEE probe and a standard TEE probe used as reference, randomly by two independent experienced operators. Measurements of hemodynamic parameters were independently performed off-line by a third expert. Diagnostic groups of acute circulatory failure ( n  = 5) and of acute respiratory failure ( n  = 3) were distinguished. Hemodynamic monitoring was performed in 9 patients using the miniaturized TEE probe. TEE tolerance and therapeutic impact were reported. Results The miniaturized TEE probe was easier to insert than the standard TEE probe. Despite lower imaging quality of the miniaturized TEE probe, the two probes had excellent diagnostic agreement in patients with acute circulatory failure (Kappa: 0.95; 95 % CI: 0.85–1) and with acute respiratory failure (Kappa: 1; 95 % CI: 1.0–1.0). Accordingly, therapeutic strategies derived from both TEE examinations were concordant (Kappa: 0.82; 95 % CI: 0.66–0.97). The concordance between quantitative hemodynamic parameters obtained with both TEE probes was also excellent. No relevant complication secondary to TEE probes insertion occurred. Conclusions Hemodynamic assessment of ventilated ICU patients with cardiopulmonary compromise using a miniaturized multiplane TEE probe appears feasible, well-tolerated, and relevant in terms of diagnostic information and potential therapeutic impact. Further larger-scale studies are needed to confirm these preliminary results.

Background In cardiac surgical procedures, patients carrying high-risk profiles are prone to encompass complicated cardiopulmonary bypass (CPB) separation. Intraoperative transesophageal echocardiography (TEE), a readily available tool, is utilized to detect cardiac structural and functional pathologies as well as to facilitate clinical management of CPB separation, especially in the episodes of hemodynamic compromise. However, the conventional TEE examination, always performed in a liberal fashion without any restriction of view acquisition, is relatively time-consuming; there appear its flaws in the context of critically severe status. We therefore developed the perioperative rescue transesophageal echocardiography (PReTEE), a simplified three-view TEE protocol consisting of midesophageal four chamber, midesophageal left ventricular long axis, and transgastric short axis. Methods This is a single-center and randomized controlled trial which will be implemented in Peking Union Medical College Hospital, Beijing, China. A total of 46 TEE scans are schemed to be performed by 6 operators participating in and randomly assigned to either the PReTEE or the conventional TEE group. This study is purposed to investigate whether the efficiency of discriminating leading causes of difficult CPB wean-off can be significantly improved via an abbreviated sequence of TEE views. The primary outcome of interest is the difference between the groups of PReTEE and the conventional TEE in the successful discrimination of etiologies in specified 120 s. Cox proportional hazards model will be further employed to calculate the outcome difference. Discussion The estimated results of this trial are oriented at verifying whether a simplified TEE exam sequence can improve the efficiency of etiologies discrimination during CPB separation in cardiac surgery. Trial registration ClinicalTrials.gov NCT05960552. Registered on 6 July 2023.

Background An insertable cardiac monitor (ICM) and transesophageal echocardiography (TEE) are useful for investigating potential embolic sources in cryptogenic stroke, of which atrial fibrillation (AF) is a critical risk factor for stroke recurrence. The association of left atrial appendage flow velocity (LAA-FV) on TEE with ICM-detected AF is yet to be elucidated. Methods CRYPTON-ICM (CRYPTOgenic stroke evaluation in Nippon using ICM) is a multicenter registry of cryptogenic stroke with ICM implantation, and patients whose LAA-FV was evaluated on TEE were enrolled. The primary outcome was the detection of AF (> 2 min) on ICM. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off of LAA-FV, and factors associated with ICM-detected AF were assessed. Results A total of 307 patients (age 66.6 ± 12.3 years; 199 males) with median follow-up of 440 (interquartile range 169–726) days were enrolled; AF was detected in 101 patients. The lower-tertile LAA-FV group had older age, more history of congestive heart failure, and higher levels of B-type natriuretic peptide (BNP) or N-terminal proBNP (all P  < 0.05). On ROC analysis, LAA-FV < 37.5 cm/s predicted ICM-detected AF with sensitivity of 26.7% and specificity of 92.2%. After adjustment for covariates, the lower tertile of LAA-FV (hazard ratio [HR], 1.753 [1.017–3.021], P  = 0.043) and LAA-FV < 37.5 cm/s (HR 1.987 [1.240–3.184], P  = 0.004) predicted ICM-detected AF. Conclusions LAA-FV < 37.5 cm/s predicts AF. TEE is useful not only to evaluate potential embolic sources, but also for long-term detection of AF on ICM by measuring LAA-FV in cryptogenic stroke. http://www.umin.ac.jp/ctr/ (UMIN000044366).

Objective To assess the impact of pneumoperitoneum pressure on cardiac output (CO) in patients undergoing laparoscopic surgery using transesophageal echocardiography. Methods Fifty patients (26 men, 24 women; age, 55–85 years old) who scheduled for laparoscopic colorectal cancer resection under general anesthesia at the First People's Hospital of Taicang (March 2021–December 2022) were enrolled. Patients were randomly assigned to three groups based on pneumoperitoneum pressure: group A (10 mmHg), group B (12 mmHg), and group C (14 mmHg). Left ventricular outflow tract diameter (LVOT) and velocity time integral (VTI) were measured using transesophageal echocardiography to calculate CO). Results Baseline characteristics and intraoperative data were comparable among groups ( P  > 0.05). Post-anesthesia, heart rate, mean arterial pressure (MAP), systolic blood pressure (SBP), and diastolic blood pressure (DBP) showed no significant differences among groups ( P  > 0.05). However, CO in all groups was lower than normal reference values after anesthesia induction ( P  < 0.05) and further declined following pneumoperitoneum establishment ( P  < 0.05). Group C exhibited significantly lower CO than Groups A and B five minutes after pneumoperitoneum initiation ( P  < 0.05). Conclusion Pneumoperitoneum pressure significantly impacts CO during laparoscopic surgery. Transesophageal echocardiography provides an effective method for monitoring hemodynamic changes and optimizing perioperative management.

Subvalvular aortic stenosis (SAS) is a relatively uncommon cause of left ventricular outflow tract (LVOT) obstruction, constituting only 8-20% of cases. Among the etiologies, subaortic membranes (SAoM) are the most prevalent, manifesting in various anatomical forms, including thin discrete membranes, fibromuscular ridges, and diffuse tunnel-like narrowings. While transthoracic echocardiography (TTE) is the primary diagnostic tool, it often presents challenges, particularly in cases where the membrane is not readily visible, and needs further imaging with transesophageal echocardiogram (TEE) or cardiac magnetic resonance imaging (CMR). This case series explores 2 diagnostically challenging instances of SAoM, highlighting the importance of multimodal imaging and the nuances of interpreting these findings. The first case is of a 19-year-old female with congenital aortic stenosis and ESRD presented with worsening dyspnea; initial TTE, TEE, and CMR failed to identify a subaortic membrane, but intra-procedural 3D TEE revealed an oval-shaped membrane, redirecting management from balloon angioplasty to surgical excision. The second is of a 62-year-old female with prior diagnosis of hypertrophic obstructive cardiomyopathy (HOCM) and progressive dyspnea was found on TEE to have a SAoM, contradicting her prior diagnosis; medical therapy was adjusted, and she was referred for surgery. These cases underscore the diagnostic challenges of SAoM, often evading detection on initial TTE and CMR, necessitating advanced techniques like 3D TEE. Misdiagnosis, as seen with HOCM, can lead to years of inappropriate treatment. In conclusion, accurate and early differentiation through expert interpretation of multimodal imaging, particularly TEE, is crucial for guiding proper management and avoiding unnecessary interventions.