Clinical and Operational Considerations for Rescue Transesophageal Echocardiography

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) is an essential tool for evaluating cardiac function and guiding management because it gives both functional and anatomical information.^1,2 Rescue TEE is a subcategory in which TEE is used in a hemodynamically unstable patient to guide diagnostic and interventional support in the periarrest setting. Compared with transthoracic echocardiography (TTE), rescue TEE provides higher-resolution imaging, better visualization of posterior cardiac structures, and the unique advantage of being usable during uninterrupted cardiopulmonary resuscitation (CPR).^3,4 Its diagnostic utility spans a wide spectrum of conditions, from ventricular standstill and valvular dysfunction to tamponade and aortic dissection, each with distinct implications for emergent management. Furthermore, rescue TEE can be used for periarrest interventional management, including, but not limited to, pericardiocentesis or guidance during institution of extracorporeal membrane oxygenation (ECMO), also known as eCPR.⁵ Despite its growing role in resuscitation, the impact of “rescue TEE” on clinical outcomes remains underexplored.⁶ One major barrier to advancing this field is the lack of standardized documentation.^7,8 While comprehensive TEE protocols exist, they are often too rigid or not dynamic enough for emergent use. As a result, many providers resort to unstructured, free-text descriptions, limiting both clinical clarity and research utility. Furthermore, the communication intra-arrest is rarely transmitted retrospectively during documentation and/or imaging review.

To address this gap, the current authors developed a rescue TEE program at the University of Pennsylvania in 2018, which averages 150+ rescue TEEs per year. Periarrest communication occurs between the code leader and echocardiographer. In addition, a structured documentation tool was designed to capture granular findings in a way that accommodates the dynamic nature of intra-arrest imaging versus postprocedure documentation of still images and short clips. Importantly, this service must avoid adding to the already substantial burden on cardiac anesthesiologists and cardiac intensivists, all while supporting research and quality improvement (Fig 1).⁹ The electronic medical record tool attempts to distill information from a continuous TEE examination and periarrest scene into what is standard for echocardiographic storage, including still images. In this report, rescue TEE is classified into findings based on two dimensions: first, whether the diagnosis is common versus uncommon, and second, whether the findings represent a direct cause of arrest versus a global or secondary abnormality. This distinction supports more precise clinical decision-making. For example, regional wall motion abnormalities may reflect global hypoperfusion in a patient with prior coronary artery disease rather than acute myocardial infarction; distinguishing between the two can guide appropriate intervention. Integrating echocardiographic findings with clinical context is essential for both the performance and reporting of rescue TEE. Similarly, while a pericardial effusion may be identified on TEE, determining whether it reflects tamponade (a direct-lethal finding) versus a secondary consequence of systemic disease (ie, cancer, renal failure) can critically impact the treatment pathway.

Fig 1.

Rescue transesophageal echocardiography matrix integrated into the electronic medical record for use during emergent imaging in periods of hemodynamic instability. Reproduced from Peev et al., J Cardiothorac Vasc Anesth 2025;39:2222–4, with permission from Elsevier.

To highlight the complex and difficult task of encoding periarrest rescue TEE, three cases are presented to demonstrate the gap between the performance of rescue TEE and documentation and to discuss the advantages and disadvantages of formalizing an anesthesiology rescue TEE team.

Methods

This case series was conducted in a 38-bed high-acuity Heart and Vascular Intensive Care Unit (ICU) at the University of Pennsylvania equipped with four dedicated TEE probes (Philips X8–2T, Andover, MA) for emergent use. The portable echocardiography machine is a series 5500 (Philips), which is readily available from the Heart and Vascular ICU and can be rapidly deployed in cases of cardiac arrest or hemodynamic instability, or when evaluating patients for eCPR. Board-certified cardiac anesthesiologists or cardiac critical care intensivist anesthesiologists are available 24 hours a day, 7 days a week in this ICU for rescue TEE deployment.

The TEE probe is retrieved and brought to the bedside, and echocardiography is initiated as soon as the team has arrived. Once the patient’s airway is secured via endotracheal intubation, a trained echocardiographer inserts the probe. This can occur prior to cardiac arrest, intra-arrest, or immediately after return of spontaneous circulation. The echocardiographer collaborates closely with the code team in a dual role: (1) to support ongoing resuscitative efforts and (2) to serve as a diagnostician, identifying reversible causes of arrest through real-time imaging. The Rescue TEE Matrix is used to guide image acquisition and streamline decision-making by prioritizing the most common and immediately lethal pathologies

Following resuscitation, a multidisciplinary debrief is conducted, during which the TEE findings are reviewed in the context of the clinical outcome. The team assesses the utility of the Rescue TEE Matrix in prioritizing diagnostic considerations and reflects on whether the initial imaging approach should be refined for future cases.

Case 1: Mitral Valve Endocarditis in Pregnancy

Rescue TEE Guidance With Clinical Management to the Cardiac Catheterization Laboratory

A 29-year-old female at 32 weeks gestation presented to the emergency department in cardiac arrest. The initial rhythm was pulseless electrical activity, and return of spontaneous circulation was achieved after 12 minutes of advanced cardiac life support (ACLS). The postarrest electrocardiogram revealed ST-segment elevations in the anterolateral leads, raising concern for acute myocardial infarction and profound cardiogenic shock. Given her pregnancy and ongoing hemodynamic instability, a rescue TEE was performed at bedside intra-arrest in the emergency department to provide diagnostic support and evaluation for possible initiation of ECMO. The rescue TEE revealed anterior and anteroseptal wall motion abnormalities and a large vegetation on the anterior mitral valve consistent with infective endocarditis, leading to leaflet destruction and severe mitral regurgitation (Fig 2; Video 1). The left ventricular ejection fraction was 35% to 40%. Given the combination of electrocardiogram findings and regional wall motion abnormalities on echocardiography, she was then taken to the cardiac catheterization laboratory, with the TEE probe remaining in place. Upon left heart catheterization, she was found to have a distal left anterior descending artery occlusion, presumably from embolization of endocarditis debris. Revascularization by percutaneous coronary intervention was performed; however, she remained in cardiogenic shock and had recurrent cardiac arrest upon arrival to the ICU. The TEE remained in place from the emergency department to the catheterization laboratory and then the ICU. With imaging guidance, she was emergently cannulated for venoarterial ECMO (VA ECMO) at the bedside to provide hemodynamic stability. Complete wire visualization was performed during cannulation, and the final venous cannula position was confirmed. An emergent cesarean section was performed, and a viable neonate was delivered to the neonatal ICU. After stabilization for 48 hours on VA ECMO, she underwent mitral valve replacement with a #36 Mitris (Edwards Lifesciences, Irving, CA) bioprosthetic valve.

Fig 2.

Rescue transesophageal echocardiography after cardiac arrest demonstrating persistent mitral valve vegetation.

Case 2: Aortic Root Abscess With Left Coronary Artery Rupture

Rescue TEE Guidance With Clinical Management to Forgo Cardiac Catheterization Laboratory and Obtain Computed Tomography Imaging

A 74-year-old male with a history of 27-mm Trifecta (Abbott Laboratories, Abbott Park, IL) bioprosthetic aortic valve replacement for aortic stenosis presented with fever, malaise, and positive blood cultures for Enterococcus faecalis. He was diagnosed with prosthetic valve endocarditis and began intravenous antibiotics, outpatient anticoagulation (apixaban and clopidogrel) was stopped, and operative intervention was planned. Despite initial improvement and an intact neurologic examination, he decompensated acutely on hospital day 4 with hypotension and altered mental status, progressing to cardiac arrest. The rescue TEE team arrived prearrest alongside the anesthesia airway team and placed a TEE probe immediately after the airway was secured. Imaging noted progression of pathology with now a completely dehisced rocking prosthetic valve. Clinically, the presenting rhythm was wide complex ventricular fibrillation. CPR and preparation for ECMO initiation were started. Wire confirmation was supported with rescue TEE, and the patient was stabilized on VA ECMO. Given the wide complex tachycardia, plans were made to go to the catheterization laboratory; however, postarrest rescue TEE imaging now documented an abscess cavity extending into the aortic root (Fig 3, A; Video 2). Notably, color Doppler demonstrated systolic flow from the left coronary cusp into the pericardial space, raising concern for contained rupture of the left coronary artery or adjacent root structures (Fig 3, B). After a multidisciplinary discussion with the interventional cardiologist and cardiac surgery team, the catheterization laboratory was bypassed, and the patient was taken directly to computed tomography imaging, which confirmed acute root and coronary rupture. Despite maximal support with ECMO and vasopressors, the patient remained profoundly unstable and was deemed a poor surgical candidate due to extensive tissue destruction and systemic sepsis. Serial TEE showed progressive left ventricular dysfunction and rising pericardial pressure. He developed worsening lactic acidosis, renal failure requiring continuous renal replacement therapy, and liver dysfunction. Multidisciplinary discussion with the family led to a consensus to withdraw life-sustaining therapies.

Fig 3.

Aortic root abscess with left coronary artery rupture. (A) Rescue transesophageal echocardiography demonstrating aortic root abscess. (B) Color Doppler demonstrating systolic flow from the left coronary cusp into the pericardial space.

Case 3: Acute Type A Aortic Dissection

Rescue TEE Demonstrating Type A Dissection With Decision to Forgo VA ECMO

A 53-year-old male with a history of hypertension and type 2 diabetes mellitus presented from home with an acute onset of altered mental status and dyspnea at work. He was hemodynamically stable at the time of EMS arrival, but during transport to the emergency department, he became progressively bradycardic to 40 beats per minute with preserved blood pressure and worsening confusion. Upon arrival to the emergency room, he rapidly deteriorated into pulseless electrical activity arrest, prompting activation of the rescue TEE team concurrent with initiation of eCPR. After securing the airway, the echocardiographer placed the TEE probe to assess for reversible causes and guide cannulation for ECMO. The TEE probe was placed prior to wire introduction. Imaging revealed an acute type A aortic dissection with extension into the proximal ascending aorta (Fig 4; Video 3). Recognizing that acute dissection is a contraindication to VA ECMO due to the risk of propagation and malperfusion, the cannulation was aborted. Due to the catastrophic presentation of the type A dissection, CPR was discontinued as no medical or surgical exit options were available.

Fig 4.

Transesophageal echocardiogram, midesophageal aortic valve long-axis view, demonstrating acute type A dissection.

Discussion

Rescue TEE, as evidenced by these cases, has an established role in cardiac critical care.⁵ Cardiac anesthesiologists and critical care intensivists can provide their expertise in this arena; however, the implementation of a dedicated service across all cardiovascular attendings in an ICU remains an institutional challenge.¹⁰ The volume of rescue TEEs at the authors’ institution has grown to well over 150 per year. The downstream effect of this has implications for clinical decision making as well as periarrest communication and postarrest documentation.^3,11 This case conference was designed to highlight and illustrate the challenges of the following issues: (1) The complexity of performing rescue TEE, communicating findings in an integrated fashion with the ACLS team, and documenting TEE in periarrest situations, which is a distinct directed examination compared with a formal comprehensive intraoperative TEE; (2) Creating a reliable service of expert echocardiographers available for complex cardiac resuscitation as well as eCPR guidance; and (3) Training of cardiovascular and ICU anesthesiology fellows and attendings in rescue TEE implementation, as well as institutional support for the operations of rescue TEE.

The first case presented highlights the role of rescue TEE in shepherding the patient between a periarrest scene in the emergency room, to the cardiac catheterization laboratory with regional wall motion abnormalities, and then to procedural guidance during ECMO cannulation in the ICU. The second case highlights the decision to forego the cardiac catheterization laboratory and proceed directly to computed tomography imaging in the setting of ventricular tachycardia/fibrillation and confirming root rupture as well as using rescue TEE for eCPR guidance. The last case underscores the critical role of rescue TEE in rapidly identifying an absolute contraindication to VA ECMO and immediately altering the resuscitation plan to avoid a futile and potentially harmful intervention.

From a systems standpoint, mandating that rescue TEE be performed by the ICU team increases the burden on an already busy cardiac anesthesiologist’s or intensivist’s clinical workload. Formalization of rescue TEE necessitates institutional awareness and the maintenance of documentation. Involvement in high-risk critical care situations naturally carries exposure to high-risk decision-making.¹² Yet this risk still warrants specific consideration as implementation of a comprehensive rescue TEE service requires clear role delineation, dedicated training, and institutional support to ensure both patient safety and provider sustainability. The language and role in communication of the rescue TEE findings comprise an ongoing area of research and clinical development. Continuing education with quality improvement, morbidity and mortality review, and fellow and attending education, is mandatory. Finally, the concerns around consent in an emergency setting are valid. In the research setting, Exception From Informed Consent processes are in place for researchers to conduct studies on topics within the therapeutic window. However, rescue TEE is not currently in the standard of care for ACLS, and therefore, careful consideration of consent is necessary prior to starting a rescue TEE program.

There is ample clinical utility for structured rescue TEE in the emergent evaluation of patients undergoing cardiac arrest. The TEE, however, is not a yes-no linear examination. In the current model, the authors emphasize how the Rescue TEE Matrix supports real-time diagnosis, guides resuscitative decision-making, and facilitates postevent analysis. Across the three cases presented, the rescue TEE uncovered both direct and secondary contributors to hemodynamic collapse, ranging from structural lesions like mitral valve endocarditis and aortic dissection to physiological sequelae such as biventricular failure and tamponade.

An organized framework like the Rescue TEE Matrix enhances the clinical utility of periarrest echocardiography by providing structure to diagnosis, decision-making, and postevent analysis.⁹ First, by systematically distinguishing primary (direct) from secondary (global) abnormalities, a codified language and documentation tool helps providers correctly triage and navigate management of an arresting patient. In Case 1, severe mitral regurgitation was identified as the proximate cause of arrest, directing urgent intervention. In Case 2, classification of root rupture as a directly lethal finding in the context of sepsis guided the decision to forego surgical salvage. In Case 3, detection of aortic dissection as a directly lethal pathology shifted the trajectory of care away from ECMO, preventing a potentially catastrophic misstep.

In summary, rescue TEE represents a pragmatic and scalable approach to improving the diagnostic yield, clarity, and consistency in clinical management during cardiac arrest. By aligning image interpretation with emergent clinical priorities, the tool enhances the utility of rescue TEE beyond image acquisition, thus shaping how teams synthesize findings, make decisions, and reflect on outcomes in some of the most challenging scenarios in critical care.

Expert Commentary

Nicolas Kumar, MD, and Adam A. Dalia, MD, MBA, FASE

The incorporation of TEE into ACLS for patients experiencing hemodynamic decompensation or cardiac arrest represents a significant technological advancement. It capitalizes on the ultrasonographic expertise and clinical judgment of cardiac anesthesiologists and intensivists. Similar to the Focused Assessment with Sonography for Trauma examination performed by trauma surgeons, rescue TEE can swiftly identify life-threatening pathology and guide, or redirect, immediate treatment strategies. Several centers, including the authors’,⁶ have established anesthesiology-led rescue TEE programs and shared their experiences.^9,13,14 While the concept of rescue TEE services is promising, measuring their success remains challenging and difficult to quantify objectively. A recent systematic review showed that the evidence supporting TEE’s role in cardiac arrest is of low certainty and is subject to a high risk of bias.¹ This indicates the need for a more nuanced evaluation of the value of institution-wide rescue TEE programs. The benefits of such programs depend heavily on specific clinical scenarios and the skill level of the echocardiographers.

The composite literature indicates that the application-outcome of rescue TEE is highly context dependent. Perioperative cardiac arrest represents the ideal environment for rescue TEE. Most anesthesiologists will be familiar with rescue TEE in the operating room (OR), where vital signs are already continuously monitored, patients have case-appropriate intravenous access, staff are ACLS-trained, and emergency resources are immediately available. Rescue TEE has demonstrated effectiveness in this environment.^{6,9,11,14–16} Continuous American Society of Anesthesiologists standard monitoring enables early detection of hemodynamic decompensation and early activation of rescue TEE teams. Though TEE examination image acquisition protocols vary, echocardiographic findings prompted changes or additions to active management in >59% of cases, and these patients had a survival-to-discharge rate consistently around 75%.^6,9,11,14 Sites that perform rescue TEE in the OR without mention of formally established programs demonstrated slightly lower management alteration and survival rates.^15,16 In contrast, rescue TEE in non-OR settings in patients who had an in-hospital or out-of-hospital cardiac arrest, TEE altered <50% of active interventions, and survival remained <10%.^17,18 While the diagnostic yield of TEE in these cases was definitive, the outcomes remained bleak.^17,18

The case series presented here demonstrates both the potential benefits and shortcomings of rescue TEE. It guided life-saving interventions for a mother and unborn child in the first, helped to avoid futile treatments in the second, and prevented the initiation of a harmful intervention in the third. While rescue TEE cannot save all patients, it can guide care and identify those most likely to benefit from additional aggressive intervention.

Standardization of rescue TEE examination protocols is essential to maximize diagnostic yield while minimizing interruptions to resuscitation efforts. A rescue TEE is distinct from an intraoperative TEE examination for elective cardiac surgery. For effective integration in resuscitation, rescue TEE must efficiently evaluate cardiac structures and function to identify or exclude causes of hemodynamic collapse. Similar to ACLS protocols, rescue TEE protocols should be standardized to ensure consistent image acquisition and clear communication of critical findings to the code team. Anesthesiologist-driven protocols typically include a sequence of 5 to 13 different views during rescue TEE.^6,14 Structured frameworks, such as the authors’ Rescue TEE Matrix (Fig 1), provide a systematic approach that helps echocardiographers distinguish between directly lethal pathology and global or secondary abnormalities, enabling more precise diagnostic and management decisions. Although no studies directly compare rescue TEE protocols with postresuscitation outcomes, this variation underscores the need for consensus guidelines that balance thorough assessment with the urgency of emergency situations. While rescue TEE examinations should be efficient, they must be comprehensive. Although the large vegetation on a severely regurgitant mitral valve in the first case was perhaps a more noticeable finding, it was the detection of subtler regional wall motion abnormalities consistent with an embolic myocardial infarction that prompted activation of the cardiac catheterization laboratory. In practice, after examining the heart and great vessels, the echocardiographer should continue monitoring overall cardiac function and assist in resuscitation efforts, including wire visualization for central venous line placement or ECMO cannulation. Once stability is achieved, TEE should shift focus to a detailed evaluation of cardiac and valvular functions and regional wall motion abnormalities to guide ongoing care and identify any underlying causes of the arrest. In addition to standardizing image sequences, education on rescue TEE should address the technical challenges specific to emergent probe insertion. Unlike elective cases, in which patients undergo thorough airway and upper gastrointestinal assessments, rescue TEE is often performed with limited patient history, during active chest compressions, or in patients with unknown contraindications such as esophageal pathology or cervical spine instability.⁸ These circumstances raise the risk of iatrogenic injury during probe insertion compared with controlled settings. This risk must be recognized, and rescue TEE protocols should include rapid screening for contraindications prior to attempted probe placement.

Certainly, the most important factor in determining the value of a rescue TEE program is the echocardiography team’s proficiency. In all published discussions of rescue TEE, it is widely recognized that the quality of a rescue TEE depends on the echocardiographer. A major risk of rescue TEE is the possibility of misdiagnosis of pathology. Therefore, as the authors note, the responsibility for rescue TEE has fallen on cardiac anesthesiologists and intensivists certified in Advanced Perioperative TEE. However, anesthesiologists with the Basic Perioperative TEE certification may be sufficiently suited to perform rescue TEE. The streamlined nature of rescue TEE protocols aligns well with the Basic certification’s emphasis on acquiring basic views and recognizing common pathologies. Most cardiac etiologies of acute hemodynamic collapse are quickly recognizable once the echocardiographic view is obtained and do not require performing sophisticated measurements. Nevertheless, the interpretation and dual diagnosis of severe vegetative mitral regurgitation with wall motion abnormalities as consistent with an embolic myocardial infarction in the first case; advanced interrogation of a dehisced prosthetic aortic valve, aortic root, and coronary ostia in the second; and the recognition of a type A aortic dissection coupled with the knowledge that this finding contraindicates VA ECMO in the third, likely represent the acumen of advanced echocardiographers.

Responding to rescue TEE calls and potentially expanding the pool of Advanced- and Basic-certified clinicians requires not only buy-in from these physicians but also substantial investment from institutions. Shillcutt et al.’s group at The Nebraska Medical Center estimated the total training costs of 10 advanced echocardiographers between 2008 and 2012 to be $675,630, unadjusted for inflation.¹¹ The group additionally trained 7 faculty in basic echocardiography for $93,100 in 2013, unadjusted for inflation.¹¹ Moreover, The Nebraska Medical Center’s Department of Anesthesiology took on approximately $115,000 in annual equipment procurement and maintenance costs during this period.¹¹ The authors and the University of Pennsylvania presumably made similar personal and financial investments to dedicate four TEE probes and a machine for 24 hours a day, 7 days a week rescue TEE deployment. This level of upfront investment must be coupled with institutional efforts to retain and grow trained staff as the TEE volume expands. As some centers, including the authors’, now perform over 150 rescue TEE examinations annually, the field of rescue TEE is transitioning from novel intervention to established practice at advanced cardiac centers, heightening the need for standardized protocols, systematic outcome reporting, and sustainable workforce models. Beyond initial capital and training costs, maintaining a rescue TEE program requires addressing the increased clinical workload on cardiac anesthesiologists and intensivists, considering the role of anesthesiologists certified in Basic Perioperative TEE, establishing clear role delineation and communication channels with resuscitation teams, continuously improving quality through reviews of morbidity and mortality, and creating institutional frameworks that support critical clinical decisions while managing medico-legal considerations inherent in emergency care.

In conclusion, rescue TEE is an effective diagnostic and interventional tool that can greatly influence management during cardiac arrest when properly utilized. The presented case series illustrates both the potential benefits and challenges of rescue TEE: guiding life-saving interventions in one patient, avoiding futile treatments in another, and preventing harmful procedures in a third. However, to realize this potential, technical expertise is crucial but not sufficient. Strong institutional backing, sustainable staffing strategies, and standardized protocols for real-time decision-making and later review are also essential.

Expert Commentary

Steven C. Eastlack, MD, and Rohesh J. Fernando, MD, FASE, FASA

Rescue TEE is an invaluable technique during perioperative emergencies such as cardiac collapse, hypoxemia, and electrocardiographic abnormalities concerning for ischemia.¹⁹ In addition to the ability to make a diagnosis, it can also allow for the evaluation of treatment efficacy. While it may be traditionally thought of as used in emergencies during noncardiac surgery, rescue TEE is also often used by teams that facilitate ECMO, and by specialized rapid-response teams known as “shock” teams.¹⁹ In this case conference, the authors discuss three specific clinical scenarios in which rescue TEE was integral to patient management.

While the ability to perform rescue TEE is helpful, institutions must address several considerations to effectively make this resource available in a timely fashion. First, there should be an existing pathway already in place. At the Hospital of the University of Pennsylvania (the case report authors’ institution), their model is to take advantage of having echocardiographers in both the ICU and the OR. The intensivists include those who are dual-trained in both critical care and cardiac anesthesiology, as well as some noncardiac anesthesiology-trained intensivists who have developed sufficient echocardiography skills. The echocardiographers in the OR are presumably cardiac anesthesiologists. Overall, this is similar to the model the current authors use at their institution. This strategy has the advantage of drawing from a pool of providers and allows for some flexibility when some are unable to assist due to their primary clinical duties. However, when cardiac anesthesiologists from the OR need to assist, this can be particularly challenging if they are already engaged in a critical portion of the surgery, such as separation from cardiopulmonary bypass or echocardiographic guidance of a procedure. Unfortunately, there is not necessarily an easy solution, as assigning a dedicated echocardiographer for this purpose can be logistically challenging, depending on the staffing model. Thus, institutions may need to get creative in developing solutions to make a rescue TEE service possible, while taking into account the resources available to them.

When a team is called to perform a rescue TEE, the patient must be quickly but carefully assessed to ensure there are no contraindications to TEE. As the patient may already be under general anesthesia when a rescue examination is requested, this information must be obtained from the anesthesiology and/or surgery teams in the room. There are several contraindications to consider before placing the TEE probe (Table 1).²⁰ If the patient is in extremis but their history includes a relative contraindication, the echocardiographer must quickly balance the value of proceeding with the TEE and the risks it poses.

Table 1.

Contraindications for Rescue TEE

Absolute Contraindications	Relative Contraindications
Esophagectomy	Esophageal varices
Perforated viscus	Upper GI malignancy
Esophageal stricture	Coagulopathy
Tracheoesophageal fistula	Mallory-Weiss tear
Upper GI bleed (active)	Recent upper GI bleed
Absence of definitive airway	Atlanto-axial disease and/or cervical immobility

NOTE. Reproduced from Efrimescu et al., J Cardiothorac Vasc Anesth. 2023;37:584–600, with permission from Elsevier.

Abbreviation: GI, gastrointestinal.

When a rescue TEE is performed, there may not be time to perform a full, comprehensive examination. Although an examination may need to be focused, it must also investigate a variety of conditions to determine the cause of clinical decompensation. These include ventricular and valve dysfunction, cardiac ischemia, left ventricular outflow obstruction, cardiac tamponade, aortic dissection, pulmonary embolism, intracardiac shunt, and pleural effusion or consolidation.¹⁹ While there is no universal rescue TEE protocol, Staudt et al. proposed a sequence of five different views: midesophageal (ME) four-chamber view, ME aortic valve long-axis view, ME bicaval view, transgastric short-axis view, and a view of the descending aorta.⁶ Notably, almost three out of four patients in their retrospective study had a change in management, despite the fact that almost half of the examinations were either normal or demonstrated findings that were already known.

There are at least six other rescue TEE protocols in addition to the one mentioned, as well as a practice guideline published by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists task force on TEE.^20,21 While they all have their unique differences, there are four views shared by all seven protocols. These include the ME four-chamber view, the ME aortic valve long-axis view, the ME bicaval view, and the transgastric short-axis view.²⁰ The commonality of these views across all proposed protocols suggests that they play an integral role in rescue TEE. Views should be chosen based on their ability to quickly provide accurate information on the structures that most commonly contribute to cardiovascular compromise. While there is no specified order, it may be beneficial to follow one that facilitates timely image acquisition. Furthermore, echocardiographers should recognize that they may need to tailor each examination to the individual patient. For example, evaluation of the gradient in a patient with dynamic left ventricular outflow tract obstruction may require a different view, such as the deep transgastric five-chamber view, or evaluation of the extent of an aortic dissection may require obtaining the ME ascending aortic short-axis view. Thus, while a structured protocol can be helpful, echocardiographers should also be able to adjust their examination to best meet the needs of each individual patient.²⁰

The utility of rescue TEE has been previously documented in several studies. In 2006, Memtsoudis et al. reported the results of their retrospective analysis of 22 patients.¹⁶ While a diagnosis could not be made for three patients, a preliminary diagnosis was made in the remaining patients. Examples of treatments administered included emergency coronary artery bypass graft surgery, pulmonary embolectomy, placement of an intra-aortic balloon pump, and pericardiotomy. Overall, 14 of 22 patients left the OR alive, but there was a 50% in-hospital mortality afterward.¹⁶

Another study on rescue echocardiography was conducted by the group at the University of Nebraska, led by Shillcutt et al. in 2012, describing a “modified” rescue TEE examination.¹³ Notably, they included not only patients who received rescue TEE (n = 22), but also rescue TTE (n = 9). In 9 of 31 cases, the anesthesia staff caring for the patient performed the echocardiographic evaluation, whereas consultation with another echocardiographer was done in the remaining cases, which could have been an anesthesiologist or cardiologist. Although the most common diagnoses were related to ventricular dysfunction, other pathologies, such as pulmonary embolism, were also documented. Overall, this study was notable for using TTE as a rescue method.

A few years later, Markin et al. published a similar retrospective study involving rescue echocardiography in 364 patients¹⁴ As in the study by Shillcutt et al., a small proportion of these patients received rescue TTE (n = 15). Overall, echocardiographic examination resulted in changes in 214 cases. The most common diagnoses were hypovolemia (24.5%), moderate or severe right or left ventricular dysfunction (16.2% and 16.5%, respectively), left ventricular segment wall motion abnormality (13.5%), and moderate or severe valvular lesion (11.3%). Of note, 80% of the rescue TTE examinations were done postoperatively, either in the postanesthesia care unit or the ICU.¹⁴ This is not necessarily surprising given that TTE requires access to the chest and/or abdomen, which may be challenging intraoperatively depending on the site of surgery; furthermore, patients may have been extubated when the rescue examinations were done in the postoperative period, making TTE a potentially more appealing option due to it being less invasive than TEE.

In the current era, rescue point-of-care ultrasound (POCUS) has also emerged as an option.²² Chest wall imaging should be considered whenever the patient has a serious relative contraindication to TEE, especially when the echocardiographer has expertise in performing a surface examination. A 2020 retrospective observational study by Lu et al. investigated the role of rescue cardiac POCUS in the ICU setting.²³ Their study analyzed 141 patients for whom 189 surface cardiac POCUS examinations were performed and concluded that the ability to rapidly acquire hemodynamic information led to more time-sensitive interventions. A noteworthy aspect of their findings was that in 13 examinations, no abnormalities were identified, which prompted the echocardiographers to expand their differential diagnosis beyond a cardiogenic etiology more quickly. Examples such as this study illustrate the value of rescue cardiac POCUS examinations despite the significant barriers to high-quality image acquisition in patients in the ICU, particularly postsurgical patients (eg, due to incision sites, dressings, drains, or chest tubes).

In summary, rescue echocardiography is a powerful tool to aid clinicians during periods of unexplained hemodynamic instability. While TEE has traditionally been considered the technique of choice for rescue echocardiography in the perioperative arena, TTE or cardiac POCUS is emerging as a potential alternative. Clinicians should consider factors such as the specific questions to be answered, the technical feasibility based on access to the patient, potential contraindications to probe placement, and the echocardiographer’s expertise when choosing between modalities. While it does offer significant potential benefits for making a diagnosis and monitoring treatment, the logistics of implementing such a program may be challenging and require investment from the clinicians and the institution. However, institutions that can provide this service may find the reward well worth the investment, as it streamlines patient care when the cause of cardiovascular or respiratory collapse is unknown.

Supplementary Material

Supplementary material associated with this article can be found in the online version at doi:10.1053/j.jvca.2026.02.018.