Benoy Shah MD Profile picture
May 18 14 tweets 5 min read Twitter logo Read on Twitter
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 Image
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... ImageImage
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! Image
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 ImageImage
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

Dec 5, 2022
So...after time to read things through, a 🧵 on #IRONMAN

Better late then never! 😆

This was a useful exercise personally as iron deficiency (ID) in HF wasn't an area of great knowledge for me, but I've done my homework now!

Here's what I learnt

#cardiotwitter
Iron deficiency (ID) is common in HF. It isn't always associated with anaemia. Its aetiology is considered multifactorial:

⬇️ dietary iron intake
⬇️ dietary iron absorption
⬆️ GI tract iron loss
Impaired iron handling / redistribution
Previous studies of oral iron replacement were very small & did not find significant benefit

It is cheap & widely available but a very slow method of correcting ID, taking many months to produce noticeable changes
Read 23 tweets
Aug 28, 2022
#ESCCongress

Let's get straight to the point about #INVICTUS

The only people not surprised by the results are imagers that do TOEs (TEEs) on these patients! No way VKA was going to lose to NOACs here!😂

A 🧵...

#medtwitter #cardiotwitter #echofirst #epeeps
#ESCCongress
Patients with rheumatic MV disease typically have very different atrial appearances on TOE. No matter how well anticoagulated, there is very often spontaneous echo contrast in the LA

These atria are just different...why?

Who is this?
The answer is Ludwig Aschoff (1866 - 1942), German physician & pathologist

He described what are now known as Aschoff bodies - inflammatory infiltrates in the atrial walls that eventually turn to fibrotic tissue, which contributes to the atrial myopathy we see in these patients
Read 18 tweets
Aug 27, 2022
#ESCCongress
A bit of a deep dive on #REVIVED - not ocean floor deep, but just a little more than below the surface!

A lot has already been discussed today, so I'll try not to be too repetitive
#ESCCongress
This was NOT a trial of revasc in highly symptomatic patients or ACS patients. It was designed to answer the Q of whether PCI is beneficial in ischaemic myocardial dysfunction / ischaemic cardiomyopathy
#ESCCongress
These multi-centre RCTs are very hard work for steering committees and PIs, huge congrats to everyone that worked on delivering this trial - well done!
Read 24 tweets
Mar 12, 2022
*POSTERIORLY DIRECTED MITRAL REGURGITATION*

How many causes of posterior MR do you know?

Let's take a look in this mini 🧵

But...no cheating...vote first!

#echofirst #cardiotwitter #MedTwitter @ASE360 @BSEcho @TheBJCA @BJCA_Women_LTFT @global_wic @WessexSpRs
1. Anterior MV prolapse

Probably the first thing that occurs to most people

AMVL prolapse is less common than PMVL prolapse
Here you can see the highly eccentric, posteriorly directed jet of MR
Read 16 tweets
Jan 6, 2022
Electronic patient records (EPR) - I've seen some negative tweets recently about how cumbersome they can be...but EPR is here to stay so it's important to get them right

I'm fortunate to work somewhere with the most amazing EPR set-up...check it out!

A brief 🧵...
Our hospital's IT team have built 1 program from which we get all these options:

E-documents (clinic letters, memos etc)
Blood results
X-rays / scans
Drug chart
Request tests (bloods, imaging, micro, everything)
Link to primary care records
Observations (for in-patients)
There's so much more there too..."Outpatients" allows us to see what we have booked for upcoming clinics including procedural clinic lists like stress echo.

EDMS has the scanned records after hospital admissions

There's even a direct link to UpToDate!
Read 8 tweets
Dec 11, 2021
**VALVE CASE OF THE MONTH**
@BrHeartValveSoc

Last case of 2021!

If EVER you needed an example of why not to judge a 3-dimensional structure with 2-dimensional imaging...this it it!

I think you'll like this one...😁

#echofirst #cardiotwitter #MedTwitter
Male, late 60s, underwent biological MVR (29mm) 11 yrs previously for
Severe MR. Has permanent AF & VVIR pacemaker

Admitted to local hospital with breathlessness

This is admission chest x-ray
Treated with diuretics, offloaded successfully

Rpt CXR after a week - nearly normal
Read 19 tweets

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