Thread by @dr_benoy_n_shah

On the left is a conventional adult transoesophageal echo probe

On the right is a neonatal TOE (TEE) probe

Occasionally, just occasionally, the latter is your friend (for an adult cardiologist/physiologist)...

A brief 🧵 on safe performance of TOE

#ECHOFIRST #cardiotwitter

TOE/TEE is actually one of the safer procedures we do, complications are less likely than with:

- Coronary angiography
- Pacemaker insertion
- Ablations
- PCI
- Valve interventions

And that's natural as it's an investigation, not a treatment/therapeutic procedure

Pharyngeal or oesophageal perforation/rupture is the most feared complication of TOE/TEE

It's incredibly rare - but does happen

TOE technique varies & how it is performed is crucial to minimizing the risk of major complication

This classic study from Werner Daniel & colleagues is now > 30yrs old!

>10000 patients
No reports of oesophageal rupture

But...

Note the incidence of not being able to insert the probe was 201/10419 - 1.9%

Higher than what we'd see today, but the point is it is NOT zero

And this message is crucial - do NOT approach TOE thinking "I'm going to get this probe down no matter what..."

No! That's trouble!

In this series of intra-op TOE (different to elective TOE under sedation), the risk of oesophageal perforation was 0.01% - 1 in 10000 cases

Calm voice
Reassurance
Clear explanation
Quiet room
Adequate throat spray
Gentle sedation (too much is as problematic as too little)

Now, if you can get over the tongue & to the back of the throat, you know you're in the right place

Ask pt to swallow & advance as they do...

If you feel resistance at this point... STOP!

Try again

Resistance twice?

Try something different
Maybe sit them up more
Talk to pt, explain what you need them to do
Try different neck position

Try again
*Gentle* pressure is ok if you're in the right place

Still won't go?

STOP!

Ask for help

If help can't help

This is when I've found a smaller probe (paediatric or even neonatal) very helpful...if you have one

It can't do 3D

But, more often than not, it's sufficient to answer your Q

- Is there a vegetation?
- Is there LAA thrombus?

The image quality is different of course as the frequency is different, but images still diagnostic in most cases

Here's an example
Adult probe just wouldn't go
Neonatal probe went down ok

Clinical Q - why is there AR? (poor TTE views)

Look what we found!

Severe LVSD also!

BAV with cusp prolapse and eccentric AR

Mechanism? ✅
Severity? ✅
3D of AV? ❌

But that's ok!

I've had to use the paediatric/neonatal probe about 5 times in the past 10 years

Like I said, just occasionally, it's very helpful!

End/