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To TOE or not to TOE? That is the question in patients with portal hypertension and varices
  1. Christopher Leung1,
  2. Sern Wei Yeoh2,
  3. Lucy Y Lim2,
  4. Ray Boyapati2,
  5. Adam G Testro2,
  6. Rhys Vaughan2,
  7. Kaye Marion3,
  8. Louise M Burrell1,
  9. Peter W Angus2
  1. 1Department of Medicine, University of Melbourne and Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
  2. 2Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
  3. 3Statistics and Operations Research Group, School of Mathematical and Geospatial Sciences, RMIT University, Melbourne, Victoria, Australia
  1. Correspondence to Dr Christopher Leung, Liver Transplant Unit, Level 8, Harold Stokes Building, 145 Studley Road, Heidelberg, VIC, 3084, Australia; chris.leung{at}

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We read with interest your recently published review by Cardénas and Ginès on patients with cirrhosis, awaiting liver transplantation,1 with an emphasis on the high morbidity and mortality with variceal bleeding. Such patients may require a transoesophageal echocardiogram (TOE) to assess cardiorespiratory abnormalities potentially precluding a transplant, as well as for intraoperative haemodynamic monitoring and for investigation for endocarditis. However, the safety of performing a TOE in such patients is debated by clinicians due to the perceived risk of postprocedural bleeding.2 Three small studies have analysed post-TOE bleeding complications in patients with varices, having reported no bleeding in 26, 14 and 23 patients.3–5 We hypothesised that direct external trauma by the echocardiographic probe is unlikely to cause significant bleeding, as variceal bleeding is primarily caused by wall tension, a function of increasing variceal diameter and internal pressure.6 We therefore audited post-TOE bleeding rates at an Australian liver transplant referral centre in …

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  • Contributors PWA and LMB are equal authors. CL, LMB, LYL, RV, AGT and PWA were responsible for the conception and design of the study. SEY and RB collected the data which was analysed and interpreted by CL, SEY, LYL, RB and KM. CL and SEY drafted the article, and all other authors critically revised it for important intellectual content. All authors gave final approval of the manuscript version to be published. CL and SEY, as guarantors, are responsible for the overall content.

  • Funding None.

  • Competing interests All authors have completed the Unified Competing Interest form at (available on request from the corresponding author), and declare that no authors have financial or non-financial interests that may be relevant to the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.