Practice Variation and Consensus in Resuscitative Transesophageal Echocardiography: Insights for Standardization

Despite increasing use of resuscitative transesophageal echocardiography (rTEE) during cardiac arrest (CA), standardized protocols for interpretation and clinical application are lacking, resulting in heterogeneous practice. We aimed to characterize expert use of rTEE during CA and identify areas of consensus to inform protocol development.

We conducted a digital survey of 21-items among emergency physicians with formal rTEE training who actively use it during CA, assessing 6 domains: cardiac tamponade, pulmonary embolism (PE), return of spontaneous circulation (ROSC), rhythm and pulse assessment, cardiopulmonary resuscitation (CPR) quality, and termination of resuscitation. Responses were collected using 5-point Likert scales and ranking questions and analyzed descriptively. Agreement was categorized as strong consensus (≥70%), moderate (50–69%), or no consensus (<50%).

Seventeen physicians from 7 institutions across 5 states (47% male) completed the survey in 2025. In the cardiac tamponade domain, >85% agreed organized cardiac activity and sonographic evidence of tamponade were critical, but <60% reached consensus on effusion size thresholds or timing of intra-arrest pericardiocentesis. For PE, >90% prioritized clot in transit and septal bowing, while just over half considered McConnell’s sign to be important. All other factors failed to reach consensus for guiding arrest-specific interventions. In the ROSC domain, 82% supported using visualized cardiac activity and aortic valve opening, with moderate agreement on integrating rTEE with end-tidal CO₂ and arterial-line data. Rhythm and pulse assessment revealed variability, with only 35% relying primarily on rTEE versus rhythm strip or tactile pulse checks. For CPR quality, 82% agreed that aortic valve opening and end-tidal CO₂ were informative, though operationalization to guide compressors varied widely. Consensus was identified for rTEE findings used to justify termination of resuscitative efforts (>80%).

Among rTEE experts, strong consensus exists for some physiologic markers (e.g., cardiac activity, aortic valve opening), but practice heterogeneity persists in operationalizing findings for intervention. These results highlight critical gaps in standardization and support the need for a structured modified Delphi process to establish consensus and guide protocol development.