Visual guidance improves first-attempt TEE probe insertion success in cardiac surgery patients

OBJECTIVES: The objective of this study was to compare visually assisted techniques (flexible bronchoscope and video laryngoscope) versus blind insertion of the transesophageal echocardiography (TEE) probe. The primary objective was to evaluate the first-attempt success rate of probe insertion. Secondary objectives were to evaluate the time required for probe insertion, the number of attempts required for successful insertion, hemodynamic perturbation immediately after and at 3 minutes after probe insertion, operator satisfaction, and the incidence of complications related to probe insertion. DESIGN: A randomized controlled study. SETTING: A single-institution tertiary center. PARTICIPANTS: One hundred thirty-five adult patients undergoing elective cardiac surgery. INTERVENTIONS: Patients were randomized into 3 equal groups of 45 patients each: blind insertion of the TEE probe (group B), video laryngoscopy-assisted insertion of the TEE probe (group VL), and flexible bronchoscopy-assisted insertion of the TEE probe (group FB). MEASUREMENTS AND MAIN RESULTS: One hundred twenty-four patients completed the study (group B, n = 42; group VL, n = 41; group FB, n = 41). The first-attempt success rate was significantly better with visually assisted techniques: 92.7% in group VL and 95.1% in group FB versus 78.6% in group B (p = 0.042). Time to probe insertion was significantly longer in group FB versus both groups VL and B (p = 0.001). The number of attempts required for successful probe insertion was significantly lower in the visually assisted groups (p = 0.01). The increases in heart rate and mean arterial pressure were significantly lower in group FB versus groups VL and B immediately following probe insertion and at 3 minutes. However, there was no difference in hemodynamics between groups VL and B. Operator satisfaction was comparable among the groups. The incidence of complications such as blood at the tip of the probe was significantly lower with visually guided techniques (p = 0.005), whereas the incidence of probe-related injuries was comparable across the groups (p = 0.09). CONCLUSIONS: Flexible bronchoscopy-assisted TEE probe insertion provides similar performance characteristics to video laryngoscopy-assisted insertion albeit with less hemodynamic perturbation and is superior to blind insertion of the TEE probe.