Appropriate utilization of transesophageal echocardiography

Appropriateness criteria for echocardiography were recently published and classify potential procedural indications as appropriate (scores of 7 to 9), uncertain (scores of 4 to 6), or inappropriate (scores of 1 to 3). The rate of the appropriate utilization of transesophageal echocardiography (TEE) in clinical practice is unknown. The aim of this study was to determine the appropriate utilization rate of TEE in a large consecutive patient series. A retrospective review of consecutive patients referred for TEE within Saint Luke's Health System (Kansas City, Missouri) was performed. The clinical indication for TEE was determined on the basis of a detailed review of preprocedural clinical documentation. These indications were then further classified into 1 of the 59 indications specified in the appropriateness criteria publication. From January 2006 to August 2007, 1,260 patients (mean age 61 years) underwent TEE for clinically indicated reasons. Among the final study group of 1,235 patients, the procedures were appropriate in 1,156 (93.6%). Appropriateness was uncertain in 43 patients (3.5%), and the procedures were inappropriate in 36 patients (2.9%). The most common "appropriate" use of TEE was to inform clinical decision making for atrial fibrillation or flutter. All the "uncertain" cases were for the evaluation of cerebrovascular accidents in patients with normal findings on transthoracic echocardiography, no history of atrial fibrillation, and normal electrocardiographic results. The most common "inappropriate" indication for TEE was evaluation for endocarditis in patients with transient fever but no bacteremia or new murmurs. In conclusion, most transesophageal echocardiographic studies in our health system were performed for appropriate indications.