EACTA - The European Association of Cardiothoracic Anaesthesiologists

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Scientific Debate

Toe education in UK

Sean Bennett

Sean Bennett is a consultant cardiothoracic anaesthetist at the Castle Hill Clinic in Hull, UK. He has been running practical training courses in TOE for years.

Email:

I will like to keep EACTA informed of the progress towards UK accreditation in TOE training. The syllabus is in line with the EACTA TOE training course, in that some TTE is included. Under the auspices of the BSE (British Society of Echocardiography) we have made the following the components of TOE training.

During an 24 month period the candidate must:

keep a log-book of 125 cases
No transthoracic cases to be included in the number of cases
A case mix is recommended, but the number of various cases has been relaxed to allow for institutional variation.
keep a video/disc log of 10 cases which may be called upon by the examiners.
take a written examination of 100 MCQ (including video/disc cases)

The candidate must have a BSE approved supervisor who oversees his/her work. The supervisor will be a BSE member (cardiologist or anaesthetist) who has a documented prior standard in TOE and who still actively performs TOE. The first (pilot) examination will be on October 30th 2003 in Birmingham at the start of the annual BSE conference. Written details from; BSE Administration, 9 Fitzroy Square London, W1T 5HW, e-mail:

Web:
» www.bcs.com/affiliates/bse.html
» www.acta.org.uk/Training_TOE.asp

Case report by Sean Bennett

A 45 year old man presented with; fatigue, shortness of breath and pyrexia. He admitted to having had a murmur since childhood but that it was ‘nothing to worry about’. His transthoracic echo (TTE) suggested a right atrial mass. He then had a TOE performed which was reviewed and gave a differential diagnosis of ; atrial myxoma/thrombus, tricuspid endocarditis (but no history of substance abuse) and ruptured sinus of Valsalva. Finally the patient went to the operating room after failure to improve medically. The TOE was repeated after induction and reveals the diagnosis. Answer now to gain marks. No mar for ‘endocarditis’ without more detail! Standard teaching is that TTE is the appropriate investigation for ventricular septal defects and that TOE only adds information about valvular function. However some authors would disagree (1).

Fig 1

Fig 2

In Figure 1 the TOE frame shows a mass in the region of the septal tricuspid leaflet. Even when the image is moving it is hard to be sure if this is originating from the valve itself or is indeed an atrial mass protruding into the right ventricle. This is not the right view for a ruptured sinus of Valsalva. Thus given the history a the mass seems likely to be a vegetation. But where from? Figure 2 reveals a sub-aortic jet, into the right ventricle. This is therefore a congenital membranous ventricular septal defect which has become the sight of infection. Surgery confirmed this, removed the vegetation and closed the hole. The patient made a full recover with an intact tricuspid valve.