With this document, we update the recommendations for transoesophageal echocardiography (TOE) of the European Association of Cardiovascular Imaging. The document focusses on the areas of interventional TOE, in particular transcatheter aortic, mitral, and left atrial appendage interventions, as well as on the role of TOE in infective endocarditis, adult congenital heart disease, and aortic disease.

After myocardial infarction, optimal clinical management depends critically on cardiac imaging. Remodelling and heart failure, presence of inducible ischaemia, presence of dysfunctional viable myocardium, future risk of adverse events including risk of ventricular arrhythmias, need for anticoagulation, and other questions should be addressed by cardiac imaging. Strengths and weaknesses, recent developments, choice, and timing of the different non-invasive techniques are reviewed for this frequent clinical scenario.

Aims: Left ventricular (LV) myocardial work index (LVMWI) derived from pressure–strain analysis resembles a novel non-invasive method for LV function evaluation. LV global longitudinal strain (LVGLS) has proven beneficial for risk stratification in cardiac amyloidosis (CA) patients. This study aimed to evaluate the potential additive value of LVMWI for outcome prediction in CA patients. Methods and results: We enrolled 100 CA patients in the period 2014–19 from Aarhus University Hospital, Denmark and Uppsala University Hospital, Sweden. All patients underwent comprehensive echocardiographic evaluation and were prospectively followed until censuring date on 31 March 2019 or death. During follow-up, we registered major adverse cardiac events (MACE) comprising heart failure requiring hospitalization and all-cause mortality. The median follow-up was 490 (228–895) days. During follow-up, a total of 42% of patients experienced MACE and 29% died. Patients with LVMWI 1043 mmHg% [hazard ratio (HR) 2.3, 95% confidence interval (CI) 1.2–4.3; P = 0.01]. Furthermore, patients with LVMWI 1039 mmHg% (HR 2.6, 95% CI 1.2–5.5; P < 0.05). Moreover, the apical-to-basal segmental work ratio was a significant MACE and all-cause mortality predictor. By combining LVMWI and apical-to-basal segmental work ratio, we obtained an independent model for all-cause mortality prediction (high vs. low risk: HR 6.4, 95% CI 2.4–17.1; P < 0.0001). In contrast, LVGLS did not predict all-cause mortality. Conclusion: LV myocardial work may be of prognostic value in CA patients by predicting both MACE and all-cause mortality.

Left atrial imaging and detailed knowledge of its pathophysiology, especially in the context of heart failure, have become an increasingly important clinical and research focus. This development has been accelerated by the growth of non-invasive imaging modalities, advanced image processing techniques, such as strain imaging, and the parallel emergence of catheter-based left atrial interventions like pulmonary vein ablation, left atrial appendage occlusion, and others. In this review, we focus on novel imaging methods for the left atrium, their pathophysiological background, and their clinical relevance for various cardiac conditions and diseases.