Transoesophageal echocardiography in the ICU

By Alex Yartsev - Nov 07, 2015

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.

Question 2 from the second paper of 2021 (Different uses of TOE)
Question 24 from the first paper of 2015 (in the evaluation of aortic dissection)
Question 13 from the second paper of 2010 (in the evaluation of aortic dissection)
Question 24 from the second paper of 2007 (in the evaluation of cardiac disease)
Question 20 from the first paper of 2005 (in the evaluation of aortic dissection)
Question 5 from the second paper of 2003 (compare to the PA catheter in the assessment of shock)

Sources for this information

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.

A Comparsion of TOE and TTE in the Assessment of Cardiac Disease
Category	TTE	TOE
Equipment	Small scale devices available Bedside apparatus ranges from cheap hand-held probes (sub-$10K ) to professional equipment (ranging $70K- $150K) Probes are easily replaceable when they break, as their cost is small	There is no cheap bedside option Bedside apparatus is portable but still large and expensive (ranging $70K- $150K) Expensive probes need to be carefully protected from such threats as patient's teeth
Time lag to diagnosis	Instant diagnosis	Slight delay
Need for sedation	Usually unnecessay	Frequently necessary
Invasiveness	Non-invasive	Minimally invasive
Absolute contraindications	None Severe left-sided rib fractures could be viewed as a relative contraindication	Oral or oesophageal surgery, anastomosis Oesophageal stricture or diverticulum Severe coagulopathy could be viewed as a relative contraindication
Factors affecting image quality	Body habitus Mechanical ventilation Patient position Exposure of chest wall (eg. severe burn, or open chest in cardiothoracic theatre)	Most of the time image quality is good; most important factor affecting it is the experience of the operator
Infection control	Probe needs to be disinfected with surface-acting disinfectant agents (similar to any other patient contact instrument); it is usually not exposed to patient body fluids. It cannot be subjected to autoclaving. Disposable sleeves are available.	The probe must be disinfected thoroughly in a manner similar to the disinfection of endoscopy probes, as it is exposed to patient body fluids. Protective sleeves are inappropriate. Most probe designs factor in the need to be subjected to automated cleaning, and tolerate high temperatures. The usual probe turnaround time is 20 minutes under ideal circumstances
Mortality and morbidity	Essentially, a benign and consequence-free procedure. The greatest risks are misinterpretation of data (leading to inappropriate management) and inaccurate findings (due to operator inexperience). No formal consent process is usually required (verbal / implied consent is sufficient)	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.
Focused assessment of the cardiac arrest patient	The subcostal view does not interfere with CPR, but is a sub-optimal view. Information derived from peri-arrest TTE is frequently useful and tends to change the management Some prognostic interest: patients with absent LV wall movement are highly unlikely to succeed at ROSC (only ~2.4% will go on to ROSC).	Also does not interfere with CPR, but offers much better quality of images. Likely to be the only option in perioperative cardiac arrest Same as TTE, changes management in arrest and can offer some prognostic information.
Assessment of ventricular function	TTE is a better modality for assessment of LV and RV function as it includes the true cardiac apex Multiple window directions enhance the ability to assess flow with Doppler	The cardiac apex is poorly seen with TOE. There are fewer windows, and Doppler assessment of flow is incomplete
Assessment of aortic dissection	Descending and thoracic aorta is either impossible or difficult to image.	TOE is the US modiality of choice for aortic dissection
Assessment of valve function	Valve function can be assessed to a high degree of accuracy provided image quality is satisfactory. Small vegetations cannot be excluded	Valve function can be assessed to a high degree of accuracy Valve images are of sufficiently high quality to appreciate small vegetations This is the modality of choice for infective endocarditis
Assessment of septal defects	Grossly, large defects and intracradiac shunts can be appreciated, but their quantitative assessment usually cannot be carried out	Intracardiac shunts and septal defects are well imaged. This is the modality of choice for such pathology.
Identification of intracardiac thrombi	Large LA and LV thrombi can be identified; small thrombi cannot be excluded.	All sorts of intracardiac thrombi can be identidfied; particularly the left atrial appendage is well visualised. This is the modality of choice for pre-cardioversion assessment of embolic risk.

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:

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.

Limitations

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

References

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.

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