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The Standard Transoesophageal Examination 

The Standard Transoesophageal Examination
Chapter:
The Standard Transoesophageal Examination
Author(s):

Patrizio Lancellotti

and Bernard Cosyns

DOI:
10.1093/med/9780198713623.003.0003
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date: 15 July 2020

  1. 3.1 Transoesophageal echocardiography (TOE)

  2. 3.2 The standard transoesophageal 3D echo examination

  3. 3.3 The storage and report on on transoesophageal

3.1 Transoesophageal echocardiography (TOE)

Clinical indications, procedure, and contraindications

TOE examination is indicated when TTE is unable or unlikely to answer the clinical question

Search for a potential cardiovascular source of embolism

  • Left ventricular apex or aneurysm (transgastric and low TOE 2CV views)

  • Aortic and mitral valve (look for vegetations, degenerative changes, or tumours, i.e. fibroelastoma)

  • Ascending and descending aorta, aortic arch (aneurysm, thrombi, atherosclerotic lesions)

  • Left atrial appendage (including PW Doppler); note spontaneous contrast

  • Left atrial body including atrial septum; note spontaneous contrast

  • Fossa ovalis/foramen ovale/atrial septal defect/atrial septal aneurysm; contrast + Valsalva

Infective endocarditis

  • Mitral valve in multiple cross-sections

  • AV in long- and short-axis views; para-aortic tissue (in particular short-axis views of AV and aortic root) to rule out abscess

  • Tricuspid valve in transgastric views, low oesophageal view, and RV inflow–outflow view

  • Pacemaker, central intravenous lines, aortic grafts, Eustachian valve, pulmonic valve in high basal short-axis view of the right heart (inflow–outflow view of the RV)

Aortic dissection, aortic aneurysm

  • Ascending aorta in long-axis and short-axis views; note maximal diameter, flap, intramural haematoma, para-aortic fluid

  • Descending aorta in long- and short-axis views

  • Aortic arch

  • Aortic valve (note mechanism of aortic regurgitation)

  • Relation of dissection membrane to coronary ostia

  • Pericardial effusion, pleural effusion

  • Entry/re-entry sites of dissection (colour Doppler)

  • Spontaneous contrast or thrombus formation in false lumen (use colour Doppler to characterize flow/absence of flow in false lumen)

Mitral regurgitation

  • Mitral anatomy (transgastric basal short-axis view, multiple lower transoesophageal views). Mechanism and origin of regurgitation (mapping of prolapse/flail to leaflets and scallops, papillary muscle and chordal integrity, vegetations, paraprosthetic leaks)

  • Colour Doppler of regurgitant jet (including proximal jet width and proximal convergence zone)

  • Left upper and right upper pulmonary venous pulsed Doppler

Prosthetic valves

  • Obstruction (reduced opening/mobility of cusps/discs/leaflets and elevated velocities by CW Doppler)

  • Regurgitation, with mapping of the origin of regurgitation to specific sites (transprosthetic, paraprosthetic); dehiscence/rocking of prosthesis

  • Pathologic structural changes: calcification, immobilization, rupture, or perforation of bioprosthesis leaflets; absence of occluder in mechanical prostheses

  • Presence of paraprosthetic structures (vegetation/thrombus/pannus, suture material, strand, abscess, pseudoaneurysm, fistula)

Intra-operative or periprocedural (catheterization laboratory)

  • Intra-operative monitoring of valvular repair (mainly mitral and aortic)

  • Intra-operative monitoring of left ventricular function in high-risk patients

  • Monitoring and guidance of valve interventions, e.g. transcatheter aortic valve implantation, transcatheter mitral repair, paravalvular leak closure

  • Monitoring and guidance of atrial septal defect closure or left atrial appendage closure

Competency in TOE

  • Part of cardiology and cardiothoracic anaesthesiology training

  • Certification in TOE by the European Association of Cardiovascular Imaging and the European Association of Cardiothoracic Anaesthesiologists (requires training under a supervisor, submitting a log book, and passing a multiple-choice question exam testing theoretical knowledge and image interpretation)

Instrument and procedure

  • Miniaturized transducer mounted on an endoscopic shaft. The transducer-containing instrument tip can be mechanically flexed anteriorly, posteriorly, to the right, and to the left

  • Transducers are ‘multi-plane’ (rotatable within their casing, changing the imaging plane orientation around their central axis between 0̊ and 180̊). The knobs for these manoeuvres, together with the control for plane orientation, are located at the handle of the instrument

  • 2D or 2D and 3D images, with centre frequencies of 5–7 MHz

  • Pulsed-wave, continuous-wave, and colour Doppler

  • Probe must be mechanically cleansed and chemically disinfected after each use. Specific prescriptions exist for this, or the probe can be inserted in a dedicated cleaning apparatus. Cleaning procedures take at least 20–30 min

  • Instruments should be inspected for damage after use, and periodic leakage current tests are recommended by the manufacturers

Checklist before TOE

  • Appropriate indication

  • History of difficult earlier TOEs, difficulty in swallowing or serious pharyngeal, laryngeal, or oesophageal disease (i.e. diverticula, tumours, strictures)

  • Patient consent

  • Patient has fasted at least four hours

  • ECG monitoring

  • Intravenous access

  • Conscious sedation, most widely with midazolam 2–4 mg (patient will be unfit for driving thereafter); deep sedation is not advisable

  • Topical pharyngeal anaesthesia (value is unclear)

  • Bite guard

  • Left lateral decubitus position

  • If a lot of sedation is used or the patient is in severely impaired haemodynamic condition, monitor oxygen saturation and blood pressure

Introduction of TOE probe (Fig. 3.1.1)

  • Probe should be advanced along a posterior and medial line through the pharynx and into the oesophagus

  • The upper oesophageal sphincter typically offers mild resistance, which waxes and wanes; no more than mild pressure should be applied

  • Strong, elastic resistance suggests that the probe tip is caught in one of the recessus piriformes at the sides of the larynx

  • No force should ever be applied during intubation. Check that the patient’s head is not at a substantial angle with the neck

  • Patient should try to swallow

  • The tip may be guided with index and middle finger of one hand

  • In case of difficulty, try with the patient sitting up

  • In ventilated patients, use of a laryngoscope facilitates TOE probe placement

Safety and contraindications

  • Overall very safe

  • Complications include laryngospasm, arrhythmias (both fast and slow), oesophageal perforation, and haemorrhage from oesophageal tumours

  • Substantial resistance to advancement of probe: postpone TOE and ask for endoscopic exam

  • Methaemoglobinaemia due to the topical anaesthetic agents prilocaine and benzocaine

  • Electrical current leakage may occur after damage to the probe, such as from the patient’s teeth; therefore, the probe has to be inspected after each use for damage

  • If sedatives are used, resuscitation equipment and training are mandatory, and a benzodiazepine antagonist, e.g. flumazenil (0.3–0.6 mg), must be available

  • Oesophageal or pharyngeal tumours are contraindications

  • Anticoagulation, thrombocytopenia, or oesophageal varices increase the risk of bleeding, but are not absolute contraindications

  • In aortic dissection, tight and documented blood pressure control during TOE is necessary

Course of the exam

  • The sequence of the examination is not standardized

    • if the procedure is not well tolerated, the main structure of interest should be visualized immediately

    • if the procedure is well tolerated or the patient in anaesthesia, a full systematic examination is advisable

    • a systematic exam has three parts

      1. 1. transoesophageal windows

      2. 2. transgastric windows

      3. 3. aortic windows

Standard 2D views and Doppler recordings of the TOE examination

Lower–mid-oesophageal probe position (Fig. 3.1.2ABC)

The following structures are visualized:

  • left and right ventricle. LV often foreshortened, because good contact of the probe tip with the oesophagus often necessitates anteflexion

  • atrioventricular valves

  • atrial and ventricular septum

Fig. 3.1.2A Lower–mid-oesophageal probe position

Fig. 3.1.2A
Lower–mid-oesophageal probe position

After reducing the image depth, the mitral valve is examined by displaying it in the centre of the screen and systematically performing stepwise plane rotation

Fig. 3.1.2BC Focus on mitral valve
Schematic overview of mitral leaflets and scallops and the main TOE cross-sections used in mitral imaging. A1, A2, A3 are the segments of the anterior mitral leaflet opposite to P1, P2, P3. MC is a ‘bicommissural’ view of the mitral valve and the LV which bisects both mitral commissures and is found midway between two-chamber and four-chamber view at approximately 45̊. 2Ch, two-chamber view, 3Ch, three-chamber view, 4Ch, four-chamber view. Reproduced, with permission, from Hahn RT, et al., J Am Soc Echocardiogr 2013;26:921–64

Fig. 3.1.2BC
Focus on mitral valve

Schematic overview of mitral leaflets and scallops and the main TOE cross-sections used in mitral imaging. A1, A2, A3 are the segments of the anterior mitral leaflet opposite to P1, P2, P3. MC is a ‘bicommissural’ view of the mitral valve and the LV which bisects both mitral commissures and is found midway between two-chamber and four-chamber view at approximately 45̊. 2Ch, two-chamber view, 3Ch, three-chamber view, 4Ch, four-chamber view. Reproduced, with permission, from Hahn RT, et al., J Am Soc Echocardiogr 2013;26:921–64

Upper oesophageal probe position (Figs. 3.1.3–3.1.6)

Main pulmonary artery and cranial atrial view (0̊). These views also show the superior vena cava (SVC) in a short axis and the inflow of the upper right pulmonary vein (RUPV) (Fig. 3.1.5).

Fig. 3.1.5 Focus on pulmonary artery (LPA/RPA left/right pulmonary artery; MPA main pulmonary artery

Fig. 3.1.5
Focus on pulmonary artery (LPA/RPA left/right pulmonary artery; MPA main pulmonary artery

Fig. 3.1.3 Upper oesophageal probe position
Aortic valve long- (120̊–150̊) and short-axis views (30̊–60̊); the latter also shows the right ventricular inflow and outflow tract with the pulmonary valve. Aortic valve and aortic pathology should be systematically evaluated using long- and short-axis views. Orthogonal simultaneous views as generated by matrix (3D) transducers are helpful; e.g. to ensure that the true maximal anteroposterior diameter of the aortic annulus or the ascending aorta is displayed. In the short-axis view of the aortic valve, the right coronary artery takes off at approximately 6 o’clock and the left at approximately 1 o’clock. The right heart wraps around the aortic valve, with right atrium, tricuspid valve, inflow and outflow of the right ventricle, and pulmonary valve (at best faintly visible).

Fig. 3.1.3
Upper oesophageal probe position

Aortic valve long- (120̊–150̊) and short-axis views (30̊–60̊); the latter also shows the right ventricular inflow and outflow tract with the pulmonary valve. Aortic valve and aortic pathology should be systematically evaluated using long- and short-axis views. Orthogonal simultaneous views as generated by matrix (3D) transducers are helpful; e.g. to ensure that the true maximal anteroposterior diameter of the aortic annulus or the ascending aorta is displayed. In the short-axis view of the aortic valve, the right coronary artery takes off at approximately 6 o’clock and the left at approximately 1 o’clock. The right heart wraps around the aortic valve, with right atrium, tricuspid valve, inflow and outflow of the right ventricle, and pulmonary valve (at best faintly visible).

Fig. 3.1.4 Focus on LA appendage
Left atrial appendage and left upper pulmonary vein views (0̊–90̊; following Figure 3.1.4AB). The configuration of the left atrial appendage is quite variable. If not seen well at 0̊ slightly cranial from a four-chamber view, the plane should be rotated up to 90̊ to display the appendage in full length. Note spontaneous contrast, flow velocities (by pulsed Doppler inside the appendage, D) and possible thrombi, not to be confounded with pectinate muscles, which are small wall structures oriented perpendicular to the appendage long axis. Immediately posterior to the appendage, and separated by a tissue ridge, the inflow of the left upper pulmonary vein is located, which should be sampled by pulsed-wave Doppler especially for assessment of mitral regurgitation severity (C).

Fig. 3.1.4
Focus on LA appendage

Left atrial appendage and left upper pulmonary vein views (0̊–90̊; following Figure 3.1.4AB). The configuration of the left atrial appendage is quite variable. If not seen well at 0̊ slightly cranial from a four-chamber view, the plane should be rotated up to 90̊ to display the appendage in full length. Note spontaneous contrast, flow velocities (by pulsed Doppler inside the appendage, D) and possible thrombi, not to be confounded with pectinate muscles, which are small wall structures oriented perpendicular to the appendage long axis. Immediately posterior to the appendage, and separated by a tissue ridge, the inflow of the left upper pulmonary vein is located, which should be sampled by pulsed-wave Doppler especially for assessment of mitral regurgitation severity (C).

Sagittal view of the right and left atrium and superior/inferior caval veins (approximately 90̊). This view is important to visualize atrial septal defects of secundum and sinus venosus type, foramen ovale, pacemaker electrodes, and the right atrial appendage (Fig. 3.1.6).

Transgastric views (Fig. 3.1.7)

  • Short-axis view of the LV at the papillary muscle level and at the MV level (0̊). Inferior wall is on top and anterior wall at the bottom of the screen

  • 2CV view of the LV (90̊). Subvalvular mitral apparatus (chordae, papillary muscles) are very well seen

  • A long-axis equivalent at 90–120̊ shows the aortic valve and LVOT at an angle amenable to spectral-Doppler examination

  • Right heart views (long-axis view of the RV inflow and outflow tract)

  • Deep transgastric view with maximal anteflexion (transgastric 4CV, 5CV, or long-axis view at 0̊–90̊). Spectral-Doppler examination of the AV is often possible in these views

Views of descending aorta and aortic arch (Fig. 3.1.8)

  • Structures in the aorta should be evaluated changing systematically between short- and long-axis views.

Fig. 3.1.8 Focus on the aorta. Long- (left) and short- (right) axis view of descending aorta. Note atherosclerotic plaques (arrows)

Fig. 3.1.8
Focus on the aorta. Long- (left) and short- (right) axis view of descending aorta. Note atherosclerotic plaques (arrows)

Essential imaging for specific clinical indications

Infective endocarditis

  • MV in multiple cross-sections

  • AV in long- and short-axis view; aortic wall thickening (possible abscess)?

  • TV in transgastric views, low oesophageal view, and right ventricular inflow–outflow view (modified aortic valve short-axis view)

  • Pacemaker, central intravenous lines, Eustachian valve in sagittal right atrial view at 90̊

Source of embolism

  • LA appendage (including pulsed-wave Doppler of inflow/outflow velocities): spontaneous contrast, sludge, thrombus?

  • LA body: spontaneous contrast, thrombus, myxoma?

  • Aortic and mitral valve: vegetations, fibroelastoma?

  • Ascending and descending aorta and aortic arch: mobile thrombus, dissection flap?

  • Interatrial septum: foramen ovale, septal defect, septal aneurysm?

Aortic dissection and other aortic diseases

  • Ascending aorta in long-axis and short-axis views, maximal diameter; note flap or intramural haematoma, para-aortic fluid, pericardial fluid, pleural fluid, entry and re-entry sites, spontaneous contrast or thrombus formation in false lumen

  • Descending aorta in long- and short-axis views; note pathology as for ascending aorta

  • Aortic arch; note maximal diameter, flap, intramural haematoma, para-aortic fluid

  • AV (degree and mechanism of regurgitation, annular diameter, number of cusps). Relation of dissection membrane to coronary ostia

Mitral regurgitation

  • Mitral anatomy (transgastric basal short-axis view, multiple lower transoesophageal views)

  • Mechanism and origin of regurgitation (detection and mapping of prolapse/flail to leaflets and scallops, papillary muscle and chordal integrity, vegetations)

  • LA colour Doppler mapping with emphasis on jet width and proximal convergence (‘PISA’) zone (use zoom, modify colour-bar baseline to magnify proximal convergence zone)

  • Left and right upper pulmonary venous flow

Prosthetic valve evaluation

  • Morphologic and Doppler evidence of obstruction (reduced opening/mobility of cusps/discs/leaflets, and elevated velocities by continuous-wave Doppler

  • Morphologic and Doppler evidence of regurgitation, with mapping of the origin of regurgitation (transprosthetic, paraprosthetic); dehiscence?

  • Prosthetic structure: calcification, perforation of bioprostheses, absence of occluder?

  • Presence of additional paraprosthetic structures (vegetation, thrombus, or pannus; suture material, strand, abscess, pseudoaneurysm, fistula)

Suggested reading

1. Flachskampf FA, Badano L, Daniel WG, et al. Recommendations for transoesophageal echocardiography—update 2010. Eur J Echocardiogr 2010;11:461–76.Find this resource:

2. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921–64.Find this resource:

3. Habib G, Badano L, Tribouilloy C, et al; European Association of Echocardiography. Recommendations for the practice of echocardiography in infective endocarditis. Eur J Echocardiogr 2010;11:202–19.Find this resource:

Copyright note: schematic drawings and some tables are reproduced, with permission, from Flachskampf FA, et al., Recommendations for performing transoesophageal echocardiography, Eur J Echocardiography 2001;2:8–21.Find this resource:

3.2 The standard transoesophageal 3D echo examination

General principles (Boxes 3.2.1, 3.2.2)

3D TOE protocol

Aortic valve (AV)

  • 60̊ mid-oesophageal, short-axis view

  • With or without colour (zoomed or full-volume acquisition) (Fig. 3.2.2A)

  • 120̊ mid-oesophageal, long-axis view

  • With or without colour (zoomed or full-volume acquisition) (Fig. 3.2.2B)

Fig. 3.2.2A AV seen from the aorta (left) and from the left ventricle (right) (LCC = left coronary cusp; NCC = non-coronary cusp; RCC = right coronary cusp) Fig. 3.2.2B Longitudinal view of the AV

Fig. 3.2.2A
AV seen from the aorta (left) and from the left ventricle (right) (LCC = left coronary cusp; NCC = non-coronary cusp; RCC = right coronary cusp)

Fig. 3.2.2B
Longitudinal view of the AV

Mitral valve (MV)

  • 0̊ to 120̊ mid-oesophageal views

  • With or without colour (zoomed or full-volume acquisition) Fig. (3.2.3AB)

Fig. 3.2.3A MV from a ventricular perspective (LVOT = left ventricular outflow tract; RV = right ventricle)

Fig. 3.2.3A
MV from a ventricular perspective (LVOT = left ventricular outflow tract; RV = right ventricle)

Fig. 3.2.3B MV seen from the left atrium (LCC = left coronary cusp; NCC = non-coronary cusp; RCC = right coronary cusp; LAA = left atrial appendage; A = anterior and P = posterior scallops)

Fig. 3.2.3B
MV seen from the left atrium (LCC = left coronary cusp; NCC = non-coronary cusp; RCC = right coronary cusp; LAA = left atrial appendage; A = anterior and P = posterior scallops)

Pulmonary valve (PV)

  • 90̊ high-oesophageal view • With or without colour (zoomed acquisition) Fig. 3.2.4AB)

Tricuspid valve (TV)

  • 0̊ to 30̊ mid-oesophageal 4CV

  • With or without colour (zoomed acquisition)

  • 40̊ transgastric view with anteflexion Fig. (3.2.5AB)

Fig. 3.2.5A Right atrial view of the TV (RVOT = right ventricular outflow tract)

Fig. 3.2.5A
Right atrial view of the TV (RVOT = right ventricular outflow tract)

Fig. 3.2.5B Right ventricular view of the TV (A = anterior; S = septal; P = posterior; TL = tricuspid leaflet)

Fig. 3.2.5B
Right ventricular view of the TV (A = anterior; S = septal; P = posterior; TL = tricuspid leaflet)

Left ventricle (LV)

  • 0̊ to 120̊ mid-oesophageal views

  • Encompassing the entire ventricle (full-volume acquisition) (Fig. 3.2.6)

Fig. 3.2.6 3D view of the left ventricle

Fig. 3.2.6
3D view of the left ventricle

Right ventricle (RV)

  • 0̊ to 120̊ mid-oesophageal views

  • Encompassing the right ventricle tilted to be in the centre of the image (full-volume acquisition)

Interatrial septum

  • 0̊, the probe is rotated to the interatrial septum (zoomed or full-volume acquisition) (Fig. 3.2.7)

Fig. 3.2.7 Right atrial view of the interatrial septum with an ASD (ASD = atrial septal defect; SVC = superior vena cava; IVC = inferior vena cava)

Fig. 3.2.7
Right atrial view of the interatrial septum with an ASD (ASD = atrial septal defect; SVC = superior vena cava; IVC = inferior vena cava)

Specific windows and views

Before TAVI

  • Aortic annulus measure/stepwise approach (Fig. 3.2.8)

  • Coronary ostia distance (Fig. 3.2.9)

Fig. 3.2.8 Evaluation of the aortic annulus

Fig. 3.2.8
Evaluation of the aortic annulus

Fig. 3.2.9 Measure of the coronary ostia distance

Fig. 3.2.9
Measure of the coronary ostia distance

Suggested reading

1. Flachskampf FA, Badano L, Daniel WG, et al. Recommendations for transoesophageal echocardiography—update 2010. Eur J Echocardiogr 2010;11:461–76.Find this resource:

2. Lang RM, Badano LP, Tsang W, et al. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging 2012;13:1–46.Find this resource:

3. Faletra FF, Pedrazzini G, Pasotti E, et al. 3D TEE during catheter-based interventions. JACC Cardiovasc Imaging 2014;7:292–308.Find this resource:

4. Faletra FF, Ramamurthi A, Dequarti MC, et al. Artifacts in three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr 2014;27:453–62.Find this resource:

3.3 The storage and report on transoesophageal echocardiography (Tables 3.3.1, 3.3.2, 3.3.3A, 3.3.3B, 3.3.4)

Table 3.3.1 Minimal basic dataset to acquire and store

Projectionsa

Doppler

2Db

Colourc

Spectrald

PW

CW

1. Mid-oesophageal views

A Four-chamber view

e

B Left atrial appendage view

C Two-chamber view of LV

D Cross-commissural view of MV

E Long-axis view of LV, MV, AV, and aortic root

F Short-axis view at the level of the AV

G Views of PV, pulmonary artery, and bifurcation

H Bicaval view

e

J Views of pulmonary veins

2. Transgastric view

A Short-axis view of LV

B Two-chamber view of LV

C Long-axis view of LV (includes LV outflow tract)

D Long-axis view of right heart

E Short-axis view of right heart

3. Views of descending thoracic aorta

A Short axis

B Long axis

c

4. Views of aortic arch

c

5. Views of ascending aorta

c

a. Red boxes (*): mandatory acquisitions; Orange boxes (**): conditional acquisitions.

b. 2D imaging of these views can be obtained by proper positioning of the transducer along with advancement, pulling out, flexion, retroflexion, sideward flexion, and/or rotation of the probe.

c. Colour-flow Doppler examination may be performed at the end of the grey-scale (B-mode) imaging of all four valves and the atrial septum. Colour Doppler interrogation is essential when the TTE study data are considered suboptimal in quality in comparison with the TOE examination (e.g. dissection of the aorta).

d. PW and CW Doppler are optional when the required assessments (e.g. RV systolic pressure, diastolic LV function, valve gradients, pulmonary venous flow), have already been performed in the previous transthoracic study. A new interrogation is rational when the TTE study data are considered suboptimal in quality in comparison with the TOE examination. Left atrial appendage velocities can only be measured during the TOE study.

e. Occasionally, agitated saline contrast at rest and with release of Valsalva manoeuvre may be required to reveal intracardiac or intrapulmonary shunting.

Table 3.3.2 3D dataset acquisition and display

AV

LV

RV

PV

MV

IAS

TV

60̊ mid-oesophageal, short-axis view

The Standard Transoesophageal ExaminationThe Standard Transoesophageal Examination

FZ

120̊ mid-oesophageal, long-axis view

The Standard Transoesophageal ExaminationThe Standard Transoesophageal Examination

FZ

0̊ to 120̊ mid-oesophageal views

The Standard Transoesophageal ExaminationThe Standard Transoesophageal Examination

Z

LV - 0̊ to 120̊ mid-oesophageal views encompassing the entire ventricle

The Standard Transoesophageal Examination

F

RV - mid- 0̊ to 120̊ oesophageal views with the RV tilted to be in the centre of the image

The Standard Transoesophageal Examination

F

0̊ with the probe rotated to the IAS

The Standard Transoesophageal Examination

FZ

90̊ high-oesophageal view

The Standard Transoesophageal ExaminationThe Standard Transoesophageal Examination

Z

120̊ mid-oesophageal, 3-chamber view

The Standard Transoesophageal ExaminationThe Standard Transoesophageal Examination

Z

0̊ to 30̊ mid-oesophageal, 4-chamber view

The Standard Transoesophageal ExaminationThe Standard Transoesophageal Examination

Z

40̊ transgastric view with anteflexion

The Standard Transoesophageal ExaminationThe Standard Transoesophageal Examination

Z

F full-volume acquisition

Z zoomed acquisition

The Standard Transoesophageal Examination loops without colour

The Standard Transoesophageal Examination loops with colour

Table 3.3.3A Recommendations for reporting TOE

Facility i.e. Hospital name, Unit, Department.

Patient first name

xxxx

Patient last name

xxxx

Date of birth

dd-mm-yyyy

Gender

F

Patient ID

12345

Study quality

Good

Referring Physician/Dept.

A.S. (name with initials)

Study ordered

dd-mm-yyyy

Study performed

dd-mm-yyyy

Indication for the study

e.g. Shortness of breath

Echo instrument identifier

Brand name of echo machine (e.g. HP)

Location of patient (✓)

ICU ✓

Heart rhythm: e.g. atrial fibrillation

OR

Intubated (Y/N)

N

ER

Heart rate (bpm) : 90

Sedated (Y/N)

Y

PACU

Weight (kg)

70

Echo lab

Blood pressure (mmHg): 120/80

Height (cm)

167

Outpatient

BSA (m2)

1, 8

Probe insertion: easy, difficult, failed

B-mode and Doppler measurements

Aorta

Diameter (mm)

Dissection (Y/N)

Plaque thickness (mm)

Plaque mobile (Y/N)

Root (sinus level)

33

n

0-3,

>3

Sinotubular junction

32

n

0-3,

>3

Ascending aorta

33

n

0-3,

>3

Arch

30

n

0-3,

>3

Descending aorta

28

n

0-3,

>3

n

Table 3.3.3B Recommendations for reporting TOE

Atria

Size (normal, dilated)

Spontaneous contrast (Y/N)

Thrombus (Y/N)

Tumour (Y/N)

Device (Y/N)

Right atrium

n

n

n

n

n

Left atrium

d

n

n

n

n

Left atrial appendage

comments, e.g.: thrombus, spontaneous contrast, etc.

Interatrial septum

comments, e.g.: normal, aneurysmal, PFO, ASD (type), shunt (R>L, L>R, bidirectional)

Other comments

Ventricles

LV

RV

LV regional function (1=normal, 2=hypokinetic, 3=akinetic, 4=dyskinetic)

Size (normal, dilated)

Basal Segments

Mid Segments

Apical Segments

The Standard Transoesophageal Examination

1. Anterior

7. Anterior

13. Anterior

Hypertrophy (Y/N)

2. Anteroseptal

8. Anteroseptal

14. Septal

3. Inferoseptal

9. Inferoseptal

15. Inferior

Thrombus (Y/N)

4. Inferior

10. Inferior

16. Lateral

5. Posterior

11. Posterior

17. Apex

Overall function (normal, ↓, ↓ ↓, ↓ ↓ ↓)

6. Lateral

12. Lateral

Comments:

Valves

Annulus (normal, dilated, calcified)

Stenosis (no, mild, moderate, severe)

Area

Gradient

Regurg. (0−4+)

Leaflet Morphology e.g. normal, myxomatous, calcified, vegetation, perforated, bicuspid, thickened

Leaflet/Disc Motion e.g. normal, prolapse flail, restricted, SAM

Aortic valve (NCC/RCC/LCC)

n

no

Mitral valve (A1, A2, A3/P1, P2, P3)

d

no

P2-3

++

myxomatous

prolapse

Tricuspid

n

no

Prosthetic (1)

Prosthetic (2)

Table 3.3.4 Recommendations for reporting TOE

COMMENTS

As in the transthoracic examination, open-text field or descriptive statements should elucidate the main findings of the study. This part of the report is crucial and answers the clinical queries, highlights the important findings and compares the data of the index study with previous ones. Major limitations or particular conditions (clinical, haemodynamics, etc.) prone to influencing the results should be reported. Additional data that cannot be included in the above tables are also prescribed in this section (e.g. incidental finding of pleural effusion, pericardium description. [etc.]). It is also recommended (especially with computerized report generation) to specify whether certain cardiac structures have or have not been studied. It is mandatory to note all side effects and complications.

CONCLUSION

An echocardiographic study report should end with clear conclusions, emphasizing the main findings of the diagnosis and severity of the heart diseases.

SIGNATURES

Sonographer (or trainee physician) performing exam

Name of anyone senior who has reviewed the study

Suggested reading

1. Flachskampf F, Badano L, Daniel WG, et al. Recommendations for transoesophageal echocardiography: update 2010. Eur J of Echocardiography 2010;11:557–76.Find this resource:

2. Lang R, Badano LP, Tsang W, et al. EAE/ASE Recommendations for image acquisition and display using three-dimensional echocardiography. Eur Heart J Cardiovascular Imaging 2012;13:1–46.Find this resource:

3. Recommendations for a standardized report for adult perioperative echocardiography from the Society of Cardiovascular Anaesthesiologists/American Society of Echocardiography Task Force for standardized perioperative echocardiography report. (<http://www2.scahq.org/sca3/teereport.shtml>).

List of abbreviations

2D, two-dimensional echocardiography; AV, aortic valve; CW, continuous-wave Doppler; ER, emergency room; IAS, interatrial septum; ICU, Intensive Care Unit; LV, left ventricle; MV, mitral valve; OR, Operating room; PACU, postanaesthaesia care unit; PV, pulmonic valve; PW, pulsed-wave Doppler; RV, right ventricle; TV, tricuspid valve