Transoesophageal echocardiography (TOE): contra-indications, complications and safety of perioperative TOE

Neil David Hauser,Justiaan Swanevelder

doi:10.1530/erp-18-0047

Abstract

Transoesophageal echocardiography (TOE) has, in certain clinical situations, become an almost universal monitor and diagnostic tool. In the perioperative environment, TOE is frequently used to guide anaesthetic management and assist with surgical decision making for, but not limited to, cardiothoracic, major vascular and transplant operations. The use of TOE is not limited to the theatre environment being frequently used in outpatient clinics, emergency departments and intensive care settings. Two case reports, one of oesophageal perforation and another of TOE utilization in a patient having previously undergone an oesophagectomy, introduce the need for care while using TOE and highlight the need for vigilance. The safe use of TOE, the potential complications and the suggested contraindications are then considered together with suggestions for improving the safety of TOE in adult and paediatric patients.

Highlights

Transoesophageal echocardiography (TOE) has become an integral tool in both diagnostic and therapeutic procedures, providing real-time images of the heart via the oesophagus [1, 2, 3, 4]
Upper gastrointestinal endoscopy may be considered for patients with known risk factors to identify features that may preclude a subsequent TOE examination, for example the presence of a residual stricture/narrowing as these may alter management [28]
The British Society of Echocardiography (BSE)-endorsed TOE safety checklist is divided into five sections and the resemblance to the World Health Organisation (WHO) checklist can be clearly seen: 1. Sign-in and patient checks: The completion of this subsection occurs with an awake patient and its content includes but is not limited to the patient’s details, their consent, presence of risk factors, presence of potential contra-indications and functioning monitoring

Summary

Introduction

Transoesophageal echocardiography (TOE) has become an integral tool in both diagnostic and therapeutic procedures, providing real-time images of the heart via the oesophagus [1, 2, 3, 4]. The first case is that of oesophageal perforation from the TOE probe in a patient with an undiagnosed hiatus hernia and the second involves the use of TOE in a patient with an oesophagectomy presenting for mitral valve surgery. Upper gastrointestinal endoscopy may be considered for patients with known risk factors (like previous oesophageal surgery) to identify features that may preclude a subsequent TOE examination, for example the presence of a residual stricture/narrowing as these may alter management [28]. The presence of oesophageal varices increases the risk of major haemorrhage and for this reason it is suggested that varices are a relative contra-indication to TOE examination This is despite there being no reports of procedure-related complications in patients with known varices [5] and provided that adequate surveillance and prior gastroscopy is undertaken before the TOE examination [38]. The BSE-endorsed TOE safety checklist is divided into five sections and the resemblance to the WHO checklist can be clearly seen: 1. Sign-in and patient checks: The completion of this subsection occurs with an awake patient and its content includes but is not limited to the patient’s details, their consent, presence of risk factors, presence of potential contra-indications and functioning monitoring

Team member signatures

Findings

Conclusion