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To evaluate the feasibility, safety, indications, and utility of transesophageal echocardiogram (TEE) in mechanically ventilated critically ill patients performed by pulmonary and critical care (PCCM) fellows in a medical intensive care unit (MICU). METHODS: This is a longitudinal descriptive study of TEE performed in mechanically ventilated patients in the MICU by PCCM fellows. 100 TEE studies were stored in a unit data base (QPath) that included a standard report with the indications for the study, description of hemodynamic parameters, and clinical application of the results. Examinations were performed by PCCM fellows under direct supervision of intensivists trained in advanced critical care echocardiography. TEE examinations included a standard image set. Therapeutic impact was described as the percentage of cases where TEE findings changed the therapy such as fluid resuscitation, inotropic/pressor use, antibiotic therapy, anticoagulation, and/or surgery. Complications and safety of TEE were documented. The therapeutic impact of the TEE was assessed based on review of medical chart and TEE final report. RESULTS: 100 TEE studies were performed in intubated patients with shock, respiratory failure, and inadequate transthoracic echocardiography views. In 36% of cases the TEE findings led to a change in therapy. Severe left and right ventricular dysfunction, endocarditis with surgical indication, severe valvulopathies, left atrial thrombus, and aortic dissection were identified in a timely manner. These findings led to a variety of therapeutic interventions which included inotropic support, right ventricular protective ventilator strategies, antibiotics for endocarditis, onset of anticoagulation, and valvular surgery. There were no complications related to the performance of TEE with fellows being the primary scanner. CONCLUSIONS: Assessment of shock for diagnosis or to guide therapy was the main reason for TEE evaluation followed by the evaluation of hypoxemic and/or hypercapnic respiratory failure in patients under mechanical ventilation. In 36% of cases the TEE findings led to a change in therapy, and there were no complications with the fellow assigned as the primary scanner. CLINICAL IMPLICATIONS: The use of TEE performed by PCCM fellows is feasible and safe in the MICU. TEE led to the identification of new clinically relevant information that resulted in a change of therapy in one third of the patients studied and led to confirmation of managment strategy in the balance of the patients. These results may encourage the incorporation of TEE training into PCCM fellowship training.

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