Question 2

Discuss the use of trans-oesophageal echocardiography (TOE) in the ICU. Use the following headings in your answer: rationale for use, data obtained, and how it assists clinical management, associated risks, and limitations.

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College answer

Not available.


The act of helping the trainees structure their answer by offering specific headings is laudable, as without it this question could have easily turned into a trap for people who misunderstood the depth of what is expected (for example, from reading the first sentence, one would not immediately develop the impression that one needs to discuss the risks. 

"Rationale for use" of TOE can probably be interpreted as "scenarios which call for the use of TOE instead of TTE", as that would make the greatest amount of sense. A "rationale for use" which includes all the various applications of cardiac sonography would not be a sensible way to answer. Thus:

  • Superior resolution for imaging posterior cardiac structures
  • Does not interfere with CPR
  • Does not require an intact chest wall (thus, suitable for assessing patients with severe anterior chest wall burns, extensive rib fractures, and patients following cardiac surgery).

Data obtained

  • Stuctural data:
    • Intracardiac shunts and septal defects
    • Valve structure and function
    • Vegetations
    • Aortic dissection
    • Intracardiac thrombus
    • Guidance for procedures, eg. ECMO cannula positioning
  • Functional data:
    • Some contractility and systolic function data (though TTE is better for this)
    • Preload sensitivity (respiratory phasic size variation of the SVC)
    • Shunt flow 
    • Doppler analysis of pulmonary venous inflow
    • Cardiac tamponade effects
    • Cardiac motility and efficacy of resuscitation efforts during cardiac arrest

How it assists clinical management

  • Directs haemodynamic management (eg. by identifying fluid responsive patients)
  • Directs duration of antibiotic therapy (by identifying vegetation)
  • Assesses the success of procedures (eg. TAVI, ECMO cannulation)
  • Helps estimate risk of stroke prior to cardioversion of a patient in AF
  • Assists decisionmaking in cardiac arrest (where LV wall movement are absent, the patient is  highly unlikely to achieve ROSC).

Associated risks

  • Each procedure has a small but non-zero risk of major complications, including oesophageal perforation, endotracheal tube dislodgement, and death.
  • The nasogastric tube is often in the way, and ends up being removed. It then needs to be reinserted, with attendent complications.
  • In the non-intubated patient, the use of sedation carries its own risks.


  • Invasive
  • Potential risk of cross-infection
  • Probes are expensive and experts who can use them are even more expensive
  • Many contraindications, eg. oral or oesophageal surgery, upper GI anastomosis, oesophageal stricture or diverticulum, severe coagulopathy, etc
  • TTE is a better modality for assessment of the apex as well as LV and RV function


Cheitlin, Melvin D., et al. "ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography." A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). American College of Cardiology Foundation and American Heart Association (2003).

Roscoe, Andrew, and Tim Strang. "Echocardiography in intensive care."Continuing Education in Anaesthesia, Critical Care & Pain 8.2 (2008): 46-49.

Douglas, Pamela S., et al. "ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography⁎: A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for ...." Journal of the American College of Cardiology 50.2 (2007): 187-204.

Mayo, Paul H., Mangala Narasimhan, and Seth Koenig. "Critical care transesophageal echocardiography." Chest 148.5 (2015): 1323-1332.