TOE Consent 🫀
Consent guide for transoesophageal echocardiogram (TOE). Procedure explanation, risks, benefits, alternatives, and patient information based on Queensland Health SW9033.
🔍 Procedure
- Transoesophageal echocardiogram (TOE): a diagnostic procedure to look at the chambers and valves of the heart using a flexible telescope with an ultrasound probe attached.
- The telescope is put into the mouth and passed down the oesophagus (feeding tube connecting mouth to stomach) while the patient is sedated, giving close-up views of the beating heart.
💡 Indications
- Assess a problem with one of the heart valves
- Look for infection
- Guide the heart specialist during procedures such as closing holes between heart chambers, or when inserting devices
- Before cardioversion (controlled electric shock for abnormal heart rhythm), to check for blood clots in the heart
📌 Preparation
- Follow instructions from Cardiac Investigations or Cardiology; the procedure may be delayed if preparation steps are not followed.
- Local anaesthetic plus sedation or general anaesthetic is required. If discharged the same day after sedation or general anaesthetic, the patient cannot drive and must have someone to escort them home.
- Do not drink alcohol, smoke, vape, or take recreational drugs for at least 24 hours before the procedure (may alter anaesthetic effects).
- Nil by mouth as instructed: do not eat (including lollies), drink, or chew gum after the advised time, otherwise the procedure may be delayed or cancelled.
- Most medicines should be continued at the usual time with a sip of water, unless the doctor gives specific exceptions (e.g. blood thinners, contraceptive pill, antidepressants, diabetes medicines including insulin). Bring all prescribed medicines, over-the-counter medicines, herbal remedies, and supplements.
- Tell the doctor if pregnant, breastfeeding, or possibly pregnant; drug or medication dependence; health problems (e.g. diabetes, high blood pressure, infectious diseases); previous or family problems with anaesthesia; false teeth, caps, loose teeth, or other dental problems; allergies/intolerances; swallowing problems or upper gastrointestinal conditions or surgery.
- If unwell on the day, telephone Cardiac Investigations or Cardiology for advice.
- Change into a hospital gown and remove some jewellery; belongings are kept safely during the procedure.
🧾 Procedure Walkthrough
- An I.V. cannula is inserted (usually hand or arm) for medication or fluids, including sedation.
- Routine observations before and during: cardiac rhythm, blood pressure, heart rate, respiratory rate, and oxygen levels.
- Dentures are removed if applicable, labelled, and stored safely until returned after the procedure.
- Positioned lying on the back or left side (occasionally right side). The back of the throat may be sprayed with local anaesthetic to make swallowing the ultrasound probe easier.
- The flexible telescope with ultrasound probe is passed via the mouth into the oesophagus.
- The probe remains in place for 15–30 minutes until the test is completed, then is removed.
- Transferred to recovery and monitored until fully awake. Inpatients return to the ward once awake and observations are stable. Outpatients are discharged into the care of a support person once recovered.
- Throat may feel numb afterwards. Do not eat or drink for two hours after the test, or until throat numbness goes away. If local anaesthetic spray/gel was used, wait 1 hour before testing gag reflex/swallow with sips of water, then usual diet.
- I.V. cannula is removed after recovery if no longer required.
⚠️ Risks & Complications
- Common: mild pain or discomfort around the I.V. insertion site; sore throat (may last up to two days).
- Uncommon: damage to teeth or jaw due to instruments in the mouth; tear in the oesophagus that usually settles without treatment; procedure may not be possible due to medical and/or technical reasons.
- Rare: abnormal heartbeat that usually settles without treatment; breathing problems (may need medication); oesophageal perforation (may need surgery to repair); death as a result of this procedure is extremely rare.
- If general anaesthetic or sedation is given, extra risks include: faintness or dizziness (especially when starting to move); fall in blood pressure; nausea and vomiting; weakness; heart and lung problems such as heart attack or pneumonia; stroke resulting in brain damage.
- Additional risks specific to the individual should be documented on the consent form before signing.
- There may be adverse consequences for health if the proposed procedure is not performed; discuss these with the patient.
💬 Common Patient Questions
- Will I be asleep? → Sedation makes you relaxed and drowsy; you may remember some or little of what happened, and may still be able to follow simple instructions (e.g. holding your breath). General anaesthetic may be used instead.
- How long does the probe stay in? → About 15–30 minutes.
- Can I eat or drink afterwards? → Not for two hours after the test, or until throat numbness goes away. After local anaesthetic spray/gel, wait 1 hour then test swallowing with sips of water before usual diet.
- Can I drive home? → No, if you had sedation or anaesthetic and are discharged the same day. You need someone to escort you home.
- When do I get results? → The cardiologist reviews the final images and sends a report to your treating team. Results are given at your next follow-up appointment.
- Can I change my mind? → Yes. If you have signed a consent form, you can change your mind at any time prior to the procedure.
✅ Benefits
- Close-up ultrasound views of the heart chambers and valves while the heart is beating
- Helps assess valve problems, look for infection, guide selected cardiac procedures, or check for clots before cardioversion
- In recommending the procedure, the doctor believes benefits exceed the risks involved
🔄 Alternatives
- An alternative may be available. The doctor will discuss the most appropriate examination for the patient’s circumstances, including risks and benefits of any alternative options, before signing the consent form.
- If the patient chooses not to have the procedure, they are not required to sign a consent form. Discuss potential adverse consequences of not having a TOE.
🧠 Special Considerations
- Sedation or general anaesthetic affects judgement for about 24 hours. For safety: do not drive any vehicle; do not operate machinery including cooking equipment; do not make important decisions or sign a legal document; do not drink alcohol, smoke, vape, or take recreational drugs (may react with anaesthetic medications).
- A doctor other than the consultant/specialist may assist with or conduct the procedure, including a doctor in training under supervision.
- Clinical student observation or assistance requires separate consent; declining does not affect access or treatment.
- Separate consent is required if video, audio, or images are recorded for training or research (not required for treatment).
- Interpreter support if required. Cultural or spiritual support available on request.
- If the patient becomes unwell after discharge, go to the nearest Emergency department or GP.
🗣️ Example Consent Script
- "We are recommending a TOE: an ultrasound probe passed down the oesophagus to get close-up pictures of your heart chambers and valves."
- "You’ll have local anaesthetic to the throat and sedation or a general anaesthetic. The probe stays in for about 15 to 30 minutes."
- "Common effects include a sore throat for up to a couple of days and some discomfort at the drip site. Less commonly there can be dental injury or a tear in the oesophagus. Rarely there can be breathing problems, heart rhythm changes, a perforation needing surgery, or extremely rarely death. Sedation or anaesthetic has its own risks, which we’ll discuss."
- "Afterwards you must not eat or drink until the throat numbness has worn off, and you cannot drive for 24 hours if you’ve had sedation. Do you have any questions?"