The idea of TOE is well-represented in the CICM Part II exam. TOE images and interpretation of TOE data has never appeared, but the college has certainly thrown indications and risks of TOE at the candidates over the years.
The college answer to Question 24 from the second paper of 2007 offered a table, which is a reasonable brief list of advantages and disadvantages. It is offered below in an essentially unchanged form: minor refinements and adjustments were made, which were largely cosmetic in nature. The information regarding the application of one modality versus another in any given clinical setting is derived from the massive 2007 Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography.
Category | TTE | TOE |
Equipment |
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Time lag to diagnosis |
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Need for sedation |
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Invasiveness |
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Absolute contraindications |
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Factors affecting image quality |
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Infection control |
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Mortality and morbidity |
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Focused assessment of the cardiac arrest patient |
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Assessment of ventricular function |
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Assessment of aortic dissection |
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Assessment of valve function |
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Assessment of septal defects |
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Identification of intracardiac thrombi |
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A different arrangement of essentially the same information can be constructed to answer Question 2 from the second paper of 2021, where the examiners actually provided the candidates with specific headings to structure their answer. What follows is an attempt to discuss them. Mayo et al (2015) was a good resource for this, as their article discuss the main indications for TOE.
"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:
Data obtained
How it assists clinical management
Associated risks
Limitations
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.