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Benoy Shah MD

May 18, 2023 • 14 tweets • 5 min read • Read on X

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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/

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More from @dr_benoy_n_shah

Benoy Shah MD

@dr_benoy_n_shah

Apr 29

Superb medical student on placement
Keen, energetic, friendly, smart
She wants to go into neurosurgery

I thought I'd better give her some advice
After what my wife went through in her training
I thought the advice was for the future
Little did I realise it had already started

What I had planned on saying:

You're going to receive a lot of unsolicited advice about your intended career

Most of it will be from men

Most will mean well, but will suggest a 'more family-friendly' career choice

Yet, even whilst a student, the 'advice' has started:

'Neurosurgery, are you sure?'
'It's very long & arduous training'
'It's not the most family friendly career'
'You might feel like that now, but in 10yrs you'll probably regret it'
'It's harder to find a partner when you're working all the time'
'GP is a better choice for balance'

Read 9 tweets

Benoy Shah MD

@dr_benoy_n_shah

Mar 17

**CASE OF THE MONTH**

Female, mid 20s
Fit & healthy
No CVS risk factors
Only 💊 is COC pill

Experiences central chest pain during sport (exertion), not happened before

Recently has been well, no coryzal or other symptoms

Here is admission ECG

First troponin I is 358ng/L (normal <18)
Second troponin I is 409ng/L

Here is chest x-ray, initially thought of as (and subsequently reported as) normal

Transthoracic echocardiogram is entirely normal

Normal LV & RV size & systolic function
No effusions
No masses
No valve disease

What would you do next?

Vote in next message...

Read 11 tweets

Benoy Shah MD

@dr_benoy_n_shah

Dec 15, 2024

Another nice example recently of the importance of a systematic approach to assessment of mitral regurgitation during TOE

Indication was known MR, assess suitability for TEER

Mid oesophageal 4Ch & 5Ch views...wondering if we have the right patient! No real MR to see...

The segmentation approach in the bicommisural view is a very reliable and easy-to-do method

Start at the lateral side of the valve with X-plane (Philips) / MultiD (GE) and you have A1-P1 coaptation on the right side...do this with 2D only & then with colour Doppler too

Then move to the middle of the valve with your cursor, cutting through A2 in bicomm view so you see A2-P2 coaptation on the right side

Still no MR!

Read 8 tweets

Benoy Shah MD

@dr_benoy_n_shah

Oct 30, 2024

Deep dive on #EARLYTAVR from ##TCT2024

Lots already said & discussed

It takes time to read the paper, read the supplementary appendix, analyse the results, think about them etc!

Some thoughts...🧵

On Sunday I wrote a thread about asymptomatic severe AS and what we knew already from RECOVERY & AVATAR RCTs and what the guidelines currently advocate

Here's the 🧵 in case you missed it

https://x.com/dr_benoy_n_shah/status/1850645694698135554?t=TAVDsW79WuDguZBGOutVBg&s=19

EARLY TAVR
Asymptomatic severe AS patients recruited between March '17 - Dec '21

75 sites across 🇺🇲 and 🇨🇦

Asymptomatic status confirmed by negative treadmill test in 90.6%
(Remaining 9.4% unable to do test, relied on detailed physician history)

That's a good % that did ETT 👏

Read 29 tweets

Benoy Shah MD

@dr_benoy_n_shah

Oct 27, 2024

Tomorrow - Oct 28th - we learn the results of 3 landmark randomised studies in patients with aortic stenosis (AS)

Results of EARLY-TAVR, EVOLVED & TAVR UNLOAD will be unveiled at #TCT2024 in a Joint LBCT Session with #NEJM

These could well be practice-changing studies...

A 🧵

#TCT2024
The first 2 RCTS - EARLY TAVR & EVOLVED - concern the management of asymptomatic severe aortic stenosis (ASAS for this 🧵)

Currently, ASAS (with normal LV function) is not a Class I indication for valve intervention in either 🇪🇺 or 🇺🇲 VHD guidelines

##TCT2024
There have been 2 RCTs of early intervention (surgery) vs routine care, aka 'watchful waiting'

It's worth reminding ourselves briefly of these studies, as the background is important in understanding EARLY TAVR in the right context

Read 21 tweets

Benoy Shah MD

@dr_benoy_n_shah

Mar 17, 2024

*Mitral valve assessment by TTE*

Transthoracic echocardiography (TTE), when performed with care and diligence, can reveal a lot about the valve. TOE isn't necessary in all cases to determine leaflet pathology.

A worked example below:

In the PLAX view, you can assess the scallops of the leaflets

In a true PLAX view with aortic valve clearly visible, you mostly see the A2-P2 interface. Here, you can see a clear & large prolapse of the posterior leaflet

If you tilt upwards towards the PLAX RV outflow (pulmonary valve) view you see mostly the A1-P1 interface

Here, you can see the valve looks slightly different & no prolapse is seen