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transoesophageal
echo study
It is beyond the scope of this textbook to provide a comprehensive overview
of transoesophageal echo (TOE), but for anyone performing transthoracic
echo (TTE) it is important to know how it fits into the cardiac imaging
armamentarium.
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The superior image quality of TOE means that it is generally indicated in
● patient refusal
● cervical spine instability
● any abnormality posing a risk of oesophageal or gastric
perforation, e.g. oesophageal obstruction (e.g. stricture,
tumour), oesophageal trauma, oesophageal fistula or
diverticulum.
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● Patient preparation
PART 2: CARDIAC IMAGING TECHNIQUES
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(and stomach), to rotate the probe to the left or right, and to flex the tip of the
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PART 2: CARDIAC IMAGING TECHNIQUES
CONSCIOUS SEDATION
i Where sedation is given, the aim is to achieve conscious sedation –
the patient should still be able to respond to verbal instructions
(such as ‘open your eyes’) from the sonographer. Oversedation to
the point of unconsciousness carries a significant risk of respiratory
depression for the patient (and litigation for the sonographer!).
probe into the patient’s mouth and, gently advancing it, ask the patient to
swallow. Once the probe has passed round the back of the throat, start to
straighten the tip of the probe and gently advance it to mid-oesophagus level,
usually 30–40 cm (distances are marked along the side of the probe). Never
advance the probe against resistance. When the patient has got used to the
probe (some retching is common initially), commence the study while keeping
a careful watch on their pulse, blood pressure and oxygen saturations.
Mid-oesophageal views
With the probe in mid-oesophagus a wide range of views can be obtained.
Starting with the transducer at an angle of 40° (all angles quoted are
approximate), the aortic valve is seen in short axis together with
surrounding structures (Fig. 7.2). Rotating a little further to 60° brings the
pulmonary and tricuspid valves into view, and then further rotation to 130°
provides a long-axis view of the left heart with clear views of both the aortic
and mitral valves (Fig. 7.3).
Centring the image on the mitral valve, rotation of the transducer back to
90° provides a 2-chamber view of the left heart (usually including a good
view of the LA appendage), and rotating further back to 60° reveals a
bicommissural view of the mitral valve. Returning to a transducer angle of
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Transoesophageal echo study
Aortic
regurgitation
NCC
LCC
RCC
Fig. 7.2 Transoesophageal echo short axis view of aortic valve showing
central jet of mild aortic regurgitation (LCC left coronary cusp; NCC
non-coronary cusp; RCC right coronary cusp)
Aortic valve
LA
AO
LV
Fig. 7.3 Transoesophageal echo long axis view of normal aortic valve
(Ao aorta; LA left atrium; LV left ventricle)
90° and rotating the probe towards the patient’s right produces the bicaval
view, showing the interatrial septum, LA and right atrium (RA), and
superior and inferior vena cavae (Fig. 7.4).
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PART 2: CARDIAC IMAGING TECHNIQUES
Inferior Superior
vena cava vena cava
LA
Interatrial
septum RA
View Bicaval
Modality TOE 2-D
Mitral valve
LA
Tricuspid valve
RA
RV LV
View 4-chamber
Modality TOE 2-D
Fig. 7.5 The 4-chamber view (LA left atrium; LV left ventricle; RA right
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by rotating the entire probe by 180° (so that the transducer points
Transgastric views
Advancing the probe into the stomach allows for a series of transgastric views.
With the transducer set at 0° you can obtain a short axis view of the left
ventricle (LV) at the level of the mitral valve and the papillary muscles (Fig. 7.6).
Rotating the transducer to 90° provides a 2-chamber view with a particularly
clear view of the papillary muscles and chordae tendineae. Further rotation of
the transducer to 120° brings the left ventricular outflow tract and aortic valve
into view. Remaining at an angle of 120° but rotating the probe towards the
patient’s right brings the right ventricle, tricuspid valve and RA into view.
Posteromedial Anterolateral
papillary papillary
muscle muscle
LV
Fig. 7.6 Transgastric short axis view (papillary muscle level) (LV left ventricle)
Advancing the probe further into the stomach, with the transducer angle at
0°, provides a deep transgastric view, with the transducer lying close to the
apex of the LV. This view provides a good alignment with the aortic valve for
Doppler studies.
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● After the transoesophageal echo
PART 2: CARDIAC IMAGING TECHNIQUES
study
Once you have withdrawn the TOE probe, check it for any signs of bleeding
(or for any damage) before sending it for sterilization. Be sure too to check
the patient’s mouth for any trauma. Once the patient has recovered from
the procedure (and any sedation) discuss the results and management plan
with them. Ensure they receive appropriate verbal and written instructions
before going home, including:
● to remain nil by mouth for an hour after the procedure (until the local
anaesthetic throat spray wears off)
● not to drive, operate machinery or sign any legal documents until the
next day
● to seek advice if they feel unwell or if a sore throat persists for more
than 48 h.
FURTHER READING
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