Resuscitative transesophageal echocardiography

Abstract

Background: Resuscitative transesophageal echocardiography (rTEE) has emerged as a transformative point-of-care imaging modality that integrates diagnostic and procedural guidance into real-time resuscitation. Unlike transthoracic echocardiography (TTE), rTEE provides continuous, high-resolution cardiac imaging without interrupting chest compressions, overcoming traditional limitations in patients with undifferentiated shock or cardiac arrest. Content: This review summarizes the evolution, technical foundations, and clinical applications of rTEE across resuscitation, extracorporeal membrane oxygenation (ECMO), and peri-arrest care. We discuss the development of focused scanning protocols—such as the ACEP 3-view, Resuscitative TEE 4-view, and 3 + 2 frameworks—that enable rapid qualitative assessment of cardiac activity, ventricular function, volume status, and reversible causes of arrest. Diagnostic advantages include superior rhythm classification (distinguishing pulseless electrical activity (PEA), pseudo-PEA, fine VF, and standstill), improved pulse-check accuracy, and identification of the area of maximal compression (AMC) to optimize CPR quality. Procedurally, rTEE supports real-time ECMO cannulation, monitoring, and decannulation, complementing ELSO recommendations for both V-A and V–V configurations. Evidence-based echocardiographic parameters—such as LVOT velocity time integral (VTI), MAPSE, TAPSE, and t-IVT—inform readiness for ECMO liberation and predict recovery or need for durable mechanical support. Outlook: Focused rTEE training pathways and credentialing frameworks are now available for anesthesiologists, intensivists, and emergency physicians, expanding its accessibility in perioperative and critical care environments. As the technology becomes more widespread, future research should standardize rTEE competency assessment, validate outcome-based protocols, and further integrate rTEE into precision-guided resuscitation algorithms.