Critical appraisal of transesophageal echocardiography: limitations and pitfalls.

As with any imaging technology, there are limitations and pitfalls to TEE. The limitations and pitfalls of TEE can be minimized best by experience. Initial training should not be circumvented, and maintenance of competency should be monitored strictly. Physicians with less than level II echocardiography training should work in close collaboration with an active echocardiography laboratory and have an appropriate review of current examinations. Both individual and laboratory standards for maintenance of competency should be established. Because of the new presentation of cardiac and extracardiac anatomy, unfamiliar but normal anatomy initially may be confused as abnormal. Additionally, certain structures are viewed in a manner that may mimic pathologic conditions. Because of the superior resolution offered by TEE, phenomena such as spontaneous contrast and ghosting are observed much more commonly than they are with transthoracic imaging. Highly detailed anatomic structures, such as atrial muscle bundles, sutures, and adipose tissue, are to be recognized and differentiated from thrombi, vegetation, and masses. Although TEE has been a dramatic step forward in diagnostic imaging, there is a potential for serious misinterpretation. This article discusses most of these potential problems; however, there always will be unique situations in which the findings must be addressed consistently and differentiated as normal, artifact, new observation, or misinterpretation.