TOE, Transoesophageal Echocardiogram

Ultrasound imaging of the heart and the blood flow through it

This is a detailed ultrasound assessment of the heart using a special endoscope (a flexible tube) with an ultrasound transducer which produces ultrasound waves. The probe is passed through your mouth into the oesophagus (food pipe) just behind the heart. The word 'trans-oesophageal' means 'through the oesophagus'. The transducer sends ultrasound into the heart and then receives the echo, i.e. the signals that bounce back. The signals are transformed into pictures that show on a screen.

Transesophageal echocardiography (TOE) is used if the transthoracic echocardiogram (TTE) doesn’t produce clear results. Compared with transthoracic echo, TOE provides clearer and sharper images because the distance from the probe to the heart is much shorter and the ultrasound waves don’t have to pass through the chest wall and lungs. TOE is superior to TTE in evaluation of heart valves, both atria (top heart chambers), atrial septum, left atrial appendage (a muscular pouch connected to the left atrium where blood clots can sometimes be found in atrial fibrillation), aorta and pulmonary artery. TOE also has some disadvantages; it may be uncomfortable for the patient and usually requires a mild sedation (medicine to help you relax, e.g. Midazolam) and as semi-invasive test, it has small but finite risk of complications.

TOE is usually a one-off procedure; if echo follow-up is necessary, standard transthoracic (surface) echo is normally sufficient.

Indications

  • Poor image quality with transthoracic echocardiography
  • Detailed assessment of heart valves, especially prosthetic (artificial) valves
  • Suspicion on infective endocarditis (infection affecting heart valves)
  • Detection of thrombus (blood clot) within the heart prior to cardioversion (jump-starting the heart with electric shock, e.g. in atrial fibrillation)
  • Investigation of possible cardiac source of emboli (dislodged blood clot)
  • Evaluation of atrial septum, atrial septal defect (‘hole’ in the heart) and atrial septum aneurysm (floppy septum)
  • Investigation of cardiac masses
  • Evaluation of aorta, presence and severity of aortic atheroma / atherosclerosis (thickening of wall of the vessel) and aortic dissection (medical emergency with partial rupture of the aortic wall)
  • Intraoperative monitoring in cardiac surgery to assess adequacy of valve repair

Risks and complications

Transoesophageal echocardiography is a very safe procedure; the risk of problems occurring is small. I will explain possible risks in detail and you will be asked to sign informed consent. The complications involve soreness in the mouth and throat due to manipulation with the probe, damage to teeth (with plastic mouth guard in place, the risk is minimal), perforation of the oesophagus (risk is about 1:10,000) and somnolence from sedation.

Before the procedure

Do not eat or drink anything from midnight the night before your appointment. Please do not stop any medication, particularly anticoagulants. You can drink water, clear tea and black coffee (without milk) up to 2 hours before the procedure. Milk, food, sweets, tea or coffee with milk can be taken up to 6 hours before the procedure. Chewing gum and smoking not permitted on day of surgery. Please bring the actual list of medication including dosage with you. If you are diabetic please do not take your diabetic medication/insulin, but bring it along with some food with you so you can have it after the investigation is completed. Remove any full or partial dentures and tell the doctor if any of your teeth are loose. I will explain the test to you and any questions you may have can be answered at this time prior to you signing the consent form for the procedure. A small needle will be put in your arm. Three electrodes (plastic stickers) will be placed on your right side, left and right shoulder and attached with leads to the echo machine.

During the procedure

Anaesthetic spray (e.g. Xylocain spray) will be used to numb the throat and usually a small dose of sedation (medicine to help you relax, e.g. Midazolam) will be given. A saturation probe and blood pressure cuff will be attached to monitor the level of oxygen in the blood and blood pressure. The probe with lubricant will then be put on your tongue and you will be asked to swallow the probe which will be gently introduced to the gullet (= oesophagus). If necessary, the dose sedation can be titrated up during the procedure. Oxygen mask may be given to help with breathing. The difficult part of the test is the swallowing of the probe but once it is down in the oesophagus, the procedure becomes much more comfortable. Because of the position of the probe, you will not be able to talk during the test. The procedure takes approximately 20-30 minutes.

After the procedure

It can take up to 30 minutes for full feeling in your throat to return. Therefore you will only be allowed a drink of cold water 15 minutes after your test. You will be able to eat and drink normally after 30 minutes. You should remain on the department for at least this period of time and have some refreshment. Before you are discharged, I will shortly talk to you about the result of the test and any follow-up arrangements. Because of the sedation, it is best to discuss the results in detail in a separate session and have someone to pick you up from the clinic and stay with you for the rest of the day.

If sedation is administered, it can remain in your system for 24 hours, you should until then:
- Have someone to take you home and stay with you
- Not drive (you will not be covered on your insurance)
- Not return to work
- Not operate any kind of machinery, including domestic appliances
- Not drink alcohol
- Not sign any important or legal documents


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