The presentation of the critically ill patient encompasses numerous idiosyncrasies and complexities. The correct diagnosis is crucial and must be made in an expeditious fashion to avert an ever-pressing morbidity or mortality. Current technology is not always helpful and can be misleading for the correct diagnosis (e.g., information from the pulmonary artery catheter [PAC]) and monitoring of these critically ill patients.<sup>250References 3, 16, 17, 61, 80, 89, 91, 115, 122, 150, 151, 220, 224, 225, 234, 236–239, 266, 289, 327, 339.

Cliquez ici pour aller à la section Références</sup> Transesophageal echocardiography (TEE) is not a new technology but an evolving and explosive one, and it should be one of the diagnostic tools for the intensivist.^{*References 3, 16, 17, 61, 80, 89, 91, 115, 122, 150, 151, 220, 224, 225, 234, 236–239, 266, 289, 327, 339.} As the proportion of in-house acutely ill patients increases in an environment of health-care reform, the multidisciplinary critical care physician continues to play a major role in the total care of these patients. The use of TEE is part of the physician's armamentarium and should complement the role of transthoracic echocardiography (TTE).<sup>83References 3, 16, 17, 61, 80, 89, 91, 115, 122, 150, 151, 220, 224, 225, 234, 236–239, 266, 289, 327, 339.

Cliquez ici pour aller à la section Références, 335References 3, 16, 17, 61, 80, 89, 91, 115, 122, 150, 151, 220, 224, 225, 234, 236–239, 266, 289, 327, 339.

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The benefits of TEE over TTE comprise several major advantages. Because the placement of the probe is retrocardiac via the esophagus, adjacent cardiac and extracardiac structures are easily visualized with excellent resolution (higher frequency). Typically, in the intensive care patient, inadequate imaging via the TTE approach is common (e.g., obesity or underlying pulmonary disease or mechanical interference by dressings, tapes, or thoracostomy tubes). In addition, the position of the TEE probe can be manipulated or maintained easily in one position depending on the condition in question (diagnosis versus monitoring). It is not infrequent in our practice to initiate the evaluation from the esophageal approach. For complete appreciation of the detailed anatomic correlates of the images, the author defers to other texts (Figure 1, Figure 4, Figure 5, Figure 6).<sup>17 Bansal R.C., Shakudo M., Shah P.M. , et al. Biplane transesophageal echocardiography: Technique, image orientation, and preliminary experience in 131 patients J Am Soc Echocardiogr 1990 ;  3 : 348

Cliquez ici pour aller à la section Références, 80 Erbel R., Khandheria B.K., Brennecke R. , et al.   Transesophageal: A New Window to the Heart Heidelberg: Springer-Verlag (1989). 

Cliquez ici pour aller à la section Références, 91 Freeman W.K., Seward J.B., Khandheria B.K. , et al.   Transesophageal Echocardiography Boston: Little Brown (1994). 

Cliquez ici pour aller à la section Références, 150 Khandheria B.K., Seward J.B., Tajik A.J. Transesophageal echocardiography Transesophageal Echocardiography, Heart Disease: A Textbook of Cardiovascular Medicine Philadelphia: WB Saunders (1991). 

Cliquez ici pour aller à la section Références, 238 Porembka D.T. Transesophageal echocardiography and innovative echocardiographic technology Crit Care Clin 1996 ;  12 : 203

Cliquez ici pour aller à la section Références, 266 Seward J.B., Khandheria B.K., Edwards W.D. , et al. Biplanar transesophageal echocardiography: Anatomic correlations, image orientation, and clinical applications Mayo Clin Proc 1990 ;  65 : 1193

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The indications for the use of TEE in the intensive care setting are not that indifferent for the cardiologist, rather than the proportion and prime indicators. In the intensive care setting, the indications are ventricular function, including ventricular performance, right and left heart interactions, preload assessment, ischemic heart disease and its complications; aortic pathology—aortic dissection and aneurysm, aortic trauma-periaortic hematoma or transection or tear, and aortic debris (as a source for emboli); valvular heart disease (native or prosthetic); intracardiac or extracardiac masses (either vegetations or thrombi), including pulmonary embolism; and intracardiac shunts—patent foramen ovale (as a conduit for emboli or contributor for refractory hypoxia) and congenital or acquired defects (following penetrating trauma).<sup>89 Foster E., Schiller N.B. The role of transesophageal echocardiography in critical care: USCF experience J Am Soc Echocardiogr 1992 ;  5 : 368

Cliquez ici pour aller à la section Références, 122 Hwang J., Shyu K., Chen J. , et al. Usefulness of transesophageal echocardiography in the treatment of critically ill patients Chest 1993 ;  104 : 861  [cross-ref]

Cliquez ici pour aller à la section Références, 151 Khoury A.F., Afridi I., Quinones M.A. , et al. Transesophageal echocardiography in critically ill patients: Feasibility, safety, and impact on management Am Heart J 1994 ;  127 : 1363  [cross-ref]

Cliquez ici pour aller à la section Références, 220 Oh J.K., Seward J.B., Khandheria B.K. , et al. Transesophageal echocardiography in critically ill patients Am J Cardiol 1990 ;  66 : 1492  [cross-ref]

Cliquez ici pour aller à la section Références, 224 Pavlides G.S., Hause A.M., Stewart J.R. , et al. Contribution of transesophageal echocardiography to patient diagnosis and treatment: A prospective analysis Am Heart J 1990 ;  120 : 910  [cross-ref]

Cliquez ici pour aller à la section Références, 225 Pearson A.C., Castello R., Labovitz A.J. , et al. Safety and utility of transesophageal echocardiography in the critically ill patient Am Heart J 1990 ;  119 : 1083  [cross-ref]

Cliquez ici pour aller à la section Références, 234 Poelaert J.I., Trouerbach J., De Buyzere M. , et al. Evaluation of transesophageal echocardiography as a diagnostic and therapeutic aid in critical care setting Chest 1995 ;  107 : 774  [cross-ref]

Cliquez ici pour aller à la section Références, 237 Porembka D.T. Transesophageal echocardiography in the critically ill Critical Care: State of the Art 1995 ;  15 : 269

Cliquez ici pour aller à la section Références, 239 Porembka D.T., Hoit D.B. Transesophageal echocardiography in the intensive care patient Crit Care Med 1991 ;  19 : 826  [cross-ref]

Cliquez ici pour aller à la section Références, 339 Wolfe L.T., Rossi A., Ritter S.B. Transesophageal echocardiography in infants and children: Use and importance in the cardiac intensive care unit J Am Soc Echocardiogr 1993 ;  6 : 286

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The contraindications are few but must be appreciated with any procedure. The absolute contraindications are any esophageal pathologic condition such as strictures, recent esophageal or gastric surgery, esophageal hemorrhage or bleeding varices, neoplasm, or recent penetrating trauma. Relative contraindications are systemic sclerosis, chest wall radiation, esophageal varices (TEE is increasingly used during orthotopic liver transplantation), or an uncooperative patient. After review of history and physical, a gastroenterologist should be consulted if suspect esophageal pathology exists.^{*References 3, 16, 17, 61, 80, 89, 91, 115, 122, 150, 151, 220, 224, 225, 234, 236–239, 266, 289, 327, 339.}

There are some risks in the TEE examination, ranging from esophageal bleeding, tears, laryngospasm, aspiration, hypoxia, bronchospasm, congestive heart failure, and dysrhythmias to mechanical difficulties (in children) such as

The future of echocardiography encompasses miniaturization of probes, even the development of intracardiac echocardiography and PAC technology. In addition, software advancements will incorporate algorithms for regional wall motion analysis, three-dimensional volume reconstruction, pressure/volume relationships, and tissue characterization for perfusion. All of these improvements will affect the intensivist and the care of their patients for accurate, real-time diagnosis and monitoring. This article discusses the benefits and the efficacy of TEE for the intensivist and the perioperative physician. Some of the discussion reviews the evolving technology and its impact, keeping in mind the multidisciplinary team approach.