September 2019

Complications related to peri‐operative transoesophageal echocardiography – a one‐year prospective national audit by the Association of Cardiothoracic Anaesthesia and Critical Care



Published: Anaesthesia. 2019 Jun 24. doi: 10.1111/anae.14734. [Epub ahead of print].

Authors: Ramalingam G, Choi SW, Agarwal S, Kunst G, Gill R, Fletcher SN, Klein AA; Association of Cardiothoracic Anaesthesia and Critical Care.

Article Description:

The authors studied the incidence of TOE-associated complication in the UK and Ireland.


  • The use of transoesophageal echocardiography (TOE) has increased in the last two decades and TOE is now a standard peri‐operative monitoring tool used for patients undergoing cardiac surgery. Being not a risk-free procedure, TOE may produce complications.
  • The authors recorded the total number of TOE examinations conducted in anaesthetised patients and the number of a TOE‐related complication from 28 centres across the UK and Ireland during 2017. All major complications at each centre were prospectively reported and recorded.
  • The incidence of peri‐operative TOE‐related complications in the included population was 0.08% and the incidence of death due to a TOE‐related complication was 0.03%.
  • The study was not designed to investigate strategies for the prevention of TOE‐related complications. However, it was reported that the probe insertion is likely the most hazardous part of the examination. The use of laryngoscope or videolaryngoscope may reduce the incidence of oropharyngeal mucosal injury, odynophagia and the number of insertion attempts. (1-2)
  • The article is accompanying with an interested editorial wrote by Ashworth and Greenhalgh (3) who showed off the question of whether to restrict perioperative TOE or to search for the strategies for prevention of those complications.
  • They suggested that (1) better estimation of risk-benefit ratio, (2) re-formulating the informed consent, (3) re-evaluation of the TOE training course and (4) encourage more research in this area.
  • Although complications are higher than reported beforehand, TOE is still vital and clinical-decision-changing in many occasions. Using a case-by-case decisions would help reduce TOE related complications.


  • The authors reported higher incidence of TOE-associated complications than previously reported and suggest a high probability of death following the development of a complication (~40%).
  • Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro-oesophageal injury.
  • This article suggested that the clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.


  1. Na S, Kim CS, Kim JY, Cho JS, Kim KJ. Rigid laryngoscope‐assisted insertion of transesophageal echocardiography probe reduces oropharyngeal mucosal injury in anesthetized patients. Anesthesiology 2009; 110: 38– 40. URL:
  2. Ishida T, Kiuchi C, Sekiguchi T, Tsujimoto T, Kawamata M. McGRATH MAC video laryngoscope for insertion of a transoesophageal echocardiography probe: a randomised controlled trial. European Journal of Anaesthesiology 2016; 33: 263– 8. URL:
  3. Ashworth AD, Greenhalgh DL. Strategies for the prevention of peri-operative transoesophageal echocardiography-relatedcomplications. Anaesthesia. 2019 Jul 4. doi: 10.1111/anae.14772. [Epub ahead of print]. URL:



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