Transesophageal echocardiography during cardiac arrest: integrating emerging prehospital evidence with practical boundaries for clinical application

To the Editor:

Vetrugno et al. recently provided a comprehensive review of the role of transesophageal echocardiography (TEE) during cardiac arrest [1]. The authors outline the technical advantages of resuscitative TEE, particularly its ability to deliver continuous cardiac imaging without interrupting chest compressions and its potential to support real-time decision-making. This review offers a timely conceptual framework for anesthesiologists and intensivists who are increasingly involved in advanced resuscitation care.

Since publication of this review, new clinical evidence has emerged that further informs this discussion. A randomized controlled pilot trial evaluated the feasibility of prehospital TEE during out-of-hospital cardiac arrest and demonstrated that TEE could be implemented without prolonging hands-off time or reducing chest compression fraction in a highly resourced, physician-staffed emergency medical service system [2]. These findings provide empirical support for the feasibility assumptions outlined in the review and represent an important step toward extending resuscitative TEE beyond the emergency department and intensive care unit.

At the same time, this pilot experience highlights practical considerations that are particularly relevant for anesthesiologists responsible for airway management, task prioritization, and team coordination during cardiac arrest. Improvements in cardiopulmonary resuscitation (CPR) process measures observed in technologically augmented resuscitation settings may be highly sensitive to system-level factors, including staffing, timing of intervention, and the ability to execute truly parallel tasks. Prior experience with ultrasound during cardiac arrest has shown that even well-intentioned imaging can introduce workflow disruption and cognitive load if not carefully integrated [3, 4]. In early or prehospital phases of resuscitation, compelling real-time cardiac images may unintentionally compete with core resuscitation priorities if not embedded within a clearly defined and disciplined workflow.

From a practical standpoint, these observations support viewing TEE not as a time-critical intervention, but as a conditional adjunct whose value depends on context. Safe and effective use requires prerequisites that anesthesiologists readily recognize: a secured airway, sufficient personnel to allow parallel task execution, and operators experienced in both image acquisition and interpretation. Within such boundaries, TEE may meaningfully inform decisions such as compression optimization or identification of reversible mechanical pathology, as suggested by prior resuscitative TEE studies [5]. Outside these conditions, restraint may be equally important to preserve the fundamentals of high-quality resuscitation emphasized in current guidelines [6].

Integrating emerging randomized feasibility evidence with the conceptual framework provided by the present review may help refine not only what TEE can offer during cardiac arrest, but also when and under what conditions it should be applied in clinical practice, particularly with respect to workflow prioritization and interpretation discipline [7]. For the anesthesia and critical care community, this balanced perspective may facilitate responsible adoption of resuscitative TEE while safeguarding the resuscitation fundamentals that ultimately determine patient outcomes.

Authors’ contributions

All authors contributed to the conception, drafting and final approval of the letter.

Funding

The author (MH Hung) was supported by a grant (No. 107-N01) from National Taiwan University Hospital.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.