Upper Gastrointestinal Injuries Related to Perioperative Transesophageal Echocardiography: Index Case, Literature Review, Classification Proposal, and Call for a Registry

The Other Side of the Coin: Transesophageal Echocardiography Complications following Cardiac Surgery and Transcatheter Structural Heart Interventions

Transesophageal echocardiography (TEE) is widely used in cardiac surgery and interventional cardiology and is often an indispensable tool, giving supportive anatomical understanding and smooth guidance in both settings. Despite it being considered safe, fatal complications can commonly occur after a TEE examination in cardiac surgery operating rooms and catheterization laboratories. Currently, there is a lack of awareness of the scale of the problem, as there are only small amounts of data available, mainly derived from the surgical literature. This review summarizes the main predisposing factors for TEE-associated complications (classified as patient and procedure-related) and the main preventive strategies. We aim to apply preventive strategies more broadly, especially to patients at high risk of developing TEE-related serious adverse events.

Esophageal Submucosal Giant Hematoma Detected After Mitral Repair Using Transesophageal Echocardiography

Transesophageal echocardiography (TEE) is a necessary diagnostic tool for cardiac surgery, including for intraoperative evaluation of the morphology and function of each structure. On the other hand, many complications caused by insertion and manipulation of the TEE probe have been reported, such as gastrointestinal injuries and hematoma, as well as esophageal perforation. Here, we report a case in which a large submucosal esophageal hematoma was found on the fourth postoperative day after surgery using TEE for mitral regurgitation. The patient was an 81-year-old man who underwent mitral valve replacement for mitral regurgitation. On the fourth postoperative day, anorexia and blood-tinged sputum were observed. A computed tomography (CT) scan of the chest displayed a giant esophageal submucosal hematoma. When performing TEE, to avoid complications, it is important to handle the TEE probe with care and to avoid leaving the device at the same site for long periods of time.

Oesophageal perforation following transoesophageal echocardiography: A case report on successful conservative management

INTRODUCTION

Transoesophageal echocardiography (TOE) is a widely used intraoperative diagnostic tool in cardiac patients, and it is considered as a safe and non-invasive procedure. However, it has its known complications, which is estimated to be 0.18% with mortality reported as 0.0098%. Complications of TOE include odynophagia, upper gastrointestinal haemorrhage, endotracheal tube malpositioning and dental injury. One of the rarer complications includes oesophageal perforation, whose incidence is reported to be 0.01%.

CASE PRESENTATION

We present a case of a 61-year-old lady with mitral valve prolapse (MVP) who underwent TOE with subsequent presentation of odynophagia with left neck swelling. An upper endoscopy examination was inconclusive; however, a contrasted computed tomography of the neck showed evidence of cervical oesophageal perforation. She was managed conservatively and discharged well.

DISCUSSION

The trauma caused by TOE probe insertion and manipulation accounts for most of the upper gastrointestinal complications. Mortality of patients associated with oesophageal perforation can be up to 20% and doubled if the treatment is delayed for more than 24 h. Mechanism of injury from TOE probe is likely multifactorial. Predisposing factors that increase the risk of tissue disruption include the presence of unknown structural pathology. Imaging studies and an upper endoscopy examination may aid in the diagnosis of oesophageal perforation.

CONCLUSION

A high index of suspicion, coupled with a tailored, multidisciplinary approach, is essential to achieve the best possible outcome. Conservative management may be worthwhile in a stable patient despite delayed presentation. Although TOE is considered a safe procedure, physicians should be made aware of such a dreaded complication.

Conservative management for iatrogenic gastric perforation by transesophageal echocardiography

Background

Though several cases of upper gastrointestinal tract injury caused by transesophageal echocardiography (TEE) have been reported, gastric perforation is very rare. Herein, we report the case of TEE-associated gastric perforation that was successfully treated conservatively.

Case presentation

An 82-year-old man underwent mitral valve repair. Postoperative esophagogastroduodenoscopy and computed tomography revealed gastric perforation. Surgical treatment was initially considered, but conservative management was selected to avoid increasing operative stress, to minimize the need for total gastrectomy (including the lower esophagus), and to minimize the risk of a potential intraperitoneal infection spreading to the thoracic cavity.

Conclusion

Conservative management of gastric perforation can be successful even when the perforation is recognized later than 12 h following the event, provided that there are no abdominal symptoms and no signs of peritoneal effusion or sepsis. Our experience suggests that conservative management is a feasible option for treating TEE-associated gastric perforation in appropriately selected cases.

Aortic intramural hemorrhage: A distinct disease entity with mystery

Aortic intramural hemorrhage (IMH) is one of the disease processes that comprise the spectrum of acute aortic syndrome (AAS) with clinical manifestations and a mortality rate similar to those of classic aortic dissection (AD). However, IMH should be considered as a distinct disease entity rather than a precursor to classic dissection because of differences in their pathology, etiology, natural history, and imaging findings. Multidetector computed tomography (CT) is recommended as the first-line diagnostic imaging modality for IMH, but transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are also helpful. There is still debate over the appropriate treatment of IMH. Medical treatment of type B IMH appears effective and safe, while surgical treatment is recommended for type A IMH. Thoracic endovascular aortic repair (TEVAR) is a promising treatment for selected patients, and more clinical evidence needs to be assembled.

Transesophageal echocardiography to diagnose anomalous right coronary artery type R2A in dogs

OBJECTIVES

To assess the feasibility of transesophageal echocardiography (TEE) as an alternative to angiography for the diagnosis of R2A coronary artery (CA) abnormalities.

ANIMALS

Twenty-two dogs with a diagnosis of type R2A CA anomaly were reviewed/analyzed.

METHODS

A retrospective study of case records. Transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), angiography, and follow-up investigations of pulmonic stenosis (PS) with R2A CA were carried out to compare different diagnostic methods.

RESULTS

Based on the TTE morphology, PS with an aberrant CA was suspected in all dogs (n = 22) and later confirmed by angiography in 18 cases (18/22), and necropsy in two cases (2/22). In 12 cases (12/22), TEE and angiography were both performed and confirmed the diagnosis of an R2A anomaly. Two cases (2/22) were diagnosed only with TEE.

CONCLUSIONS

Transesophageal echocardiography may be considered an effective tool to diagnose CA abnormalities, in particular when TTE is inconclusive. Transesophageal echocardiography offers detailed and easily reproducible views of coronary ostia, and the spatial relationship between the right common CA and the great arteries. Although it is not possible to define the course of the more distal coronary branches, TEE has proven reliable in recognizing those elements that can constitute a risk for the execution of a balloon valvuloplasty (BV). Therefore, TEE can be used to confirm this type of CA anomaly and prevent a BV, which is contraindicated in these cases. In addition, TEE avoids any further vascular access, radiation exposure, and contrast medium injection.

Complications related to intraoperative transesophageal echocardiography in liver transplantation

Purpose

Intraoperative transesophageal echocardiography (TEE) has commonly been used for evaluating cardiac function and monitoring hemodynamic parameters during complex surgical cases. Anesthesiologists may be dissuaded from using TEE in orthotopic liver transplantation (OLT) out of concern about rupture of esophageal varices. Complications associated with TEE in OLT were evaluated.

Methods

We retrospectively reviewed charts and TEE videos of all OLT cases from January 2003 through December 2013 at Mayo Clinic (Jacksonville, Florida).

Results

Of the 1811 OLTs performed, we identified 232 patients who underwent intraoperative TEE. Esophageal variceal status was documented during presurgical esophagogastroduodenoscopy in 230 of the 232 patients. Of these, 69 (30.0 %), had no varices; 113 (49.1 %), 41 (17.8 %), and 7 (3.0 %) had grades I, II, and III varices, respectively. Two patients (0.9 %) had no EGD performed because of acute liver failure. During OLT, 1 variceal rupture (0.4 %) occurred after placement of an oral gastric tube and TEE probe; the patient required intraoperative variceal banding. Most patients had preexisting coagulopathy at the time of probe placement. The mean (SD) laboratory test results were as follows: prothrombin time, 21.7 (6.6) seconds; international normalized ratio, 1.9 (1.3); partial thromboplastin time, 43.8 (13.3) seconds; platelet, 93.7 (60.8) × 1000/μL; and fibrinogen, 237.8 (127.6) mg/dL.

Conclusion

TEE was a relatively safe procedure with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices and coagulopathy undergoing OLT. It appeared to effectively disclose cardiac information and allowed rapid reaction for proper patient management.

Progress in perioperative echocardiography: focus on safety, clinical outcomes, 3-dimensional imaging, and education

Gastric decompression with an orogastric tube after anesthetic induction does not appear to enhance image quality for routine cases. The insertion of a transesophageal echocardiographic (TEE) probe can cause significant upper-airway trauma, which can be minimized with rigid laryngoscopy. Limited TEE imaging without transgastric views appears to be safe and clinically adequate in patients with advanced liver disease and esophageal varices. Although esophagogastric perforation because of transesophageal echocardiography is rare, the risk is significantly higher with advanced age and female sex. The echocardiographic assessment of right ventricular function and left ventricular diastolic function can improve the prediction of atrial arrhythmias after elective lung resection. Furthermore, asymptomatic left ventricular systolic or diastolic dysfunction is an independent predictor of cardiovascular mortality and morbidity after open vascular surgery. Advances in 3D echocardiography have shown that hypertrophic cardiomyopathy frequently is associated with changes in the mitral valve complex that predispose to left ventricular outflow tract obstruction. Furthermore, 3D imaging of the mitral apparatus has highlighted the importance of the annular saddle shape and the anatomic variability in ischemic mitral regurgitation. Education in perioperative echocardiography is experiencing high demand that can be satisfied partially with simulators and Internet-based educational activities. These modalities will aid in the dissemination of echocardiography through perioperative practice.

Safety of transesophageal echocardiography

Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.

Advances in aortic valve repair: focus on functional approach, clinical outcomes, and central role of echocardiography

The surgical classification of aortic regurgitation (AR) is based on cusp mobility. Based on this classification, there are 3 classes of AR: type I is defined as normal cusp mobility, type II is defined as excessive cusp mobility, and type III is defined as restricted cusp mobility. Patients often have multiple coexisting mechanisms. Because aortic valve (AV) repair is safe, effective, and durable, it likely will become a mainstream surgical option for the management of significant AR, even in the setting of a bicuspid valve. Intraoperative transesophageal echocardiography has a central role at all stages in AV repair. Before cardiopulmonary bypass, it can accurately diagnose the mechanism of AR to guide operative strategy for successful repair. After separation from cardiopulmonary bypass, it can comprehensively evaluate the AV repair, including the likelihood that the repair will be durable in the long-term. Important echocardiographic predictors of a durable AV repair include the absence of AR, cusp coaptation above the annular plane, a coaptation length >4 mm, and an effective cusp height >8 mm. The clinical applicability of AV repair continues to expand and likely will evolve into a mainstream surgical therapy for AR, including minimally invasive techniques.

Distal oesophageal stricture after transoesophageal echocardiography in a cardiac surgical patient

Transoesophageal echocardiography (TEE) is an important tool for diagnosis and monitoring during anaesthesia in cardiac operation. TEE is generally considered a safe and minimally invasive technique. However, adverse events may occur during probe insertion or manipulation. We report a case of delayed distal oesophageal stricture with an associated scarring probably due to TEE during a cardiac operation. The patient, a 75-year-old female, underwent coronary artery bypass graft, mitral valve replacement, and tricuspid valve annuloplasty. Seven days after surgery, the patient complained of dysphagia without haemoptysis and drop of haematocrit. At 24 days after surgery, severe stricture of distal oesophagus with scarring was observed by oesophagography and stent insertion was done.

Fatal pneumoperitoneum caused by nasopharyngeal oxygen delivery after transoesophageal echocardiography for cardiac surgery

We report a case of fatal post-operative pneumoperitoneum in a patient who had undergone urgent mitral valve surgery. In the absence of a proven cause of the pneumoperitoneum (refusal by the family of an autopsy), we can only propose a hypothesis for its origin. The most probable one is that forceful or sustained retrograde flexion of the transoesophageal echocardiographic probe created a lower oesophagus or gastric rupture and that oxygen flow administered by the nasal cannula went straight to the abdominal cavity, leading to tension pneumoperitoneum.

Major complications related to the use of transesophageal echocardiography in cardiac surgery

OBJECTIVE

The purpose of this study was to determine the incidence of injury associated with transesophageal echocardiography (TEE injuries) in cardiac surgery.

DESIGN

Retrospective.

SETTING

University-affiliated hospitals.

PARTICIPANTS

Four thousand seven hundred eighty-four patients, 89% of all public hospital cardiac surgery patients in Victoria, from the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) database undergoing cardiac surgery with TEE between July 1, 2005, and June 30, 2007. Because ASCTS did not record TEE use before July 2005, it was assumed that 89% of an additional 11,719 cardiac surgery patients between July 2001 and June 2005 also had TEE.

INTERVENTIONS

The authors searched the ASCTS database for cardiac surgery patients who also had endoscopy and/or noncardiac surgery. The files of these patients were screened for possible esophageal or gastric tears or perforations. An expert panel determined likely TEE injuries.

MEASUREMENTS AND MAIN RESULTS

There were 6 TEE complications from July 1, 2005, to June 30, 2007 (13/10,000 patients). There were a further 8 TEE complications before June 30, 2005, an extrapolated overall rate of 9/10,000 TEE (95% confidence interval, 5-16/10,000). TEE complications were more frequent in patients more than 70 years old (relative risk [RR], 3.7; p = 0.03) and women (RR, 6.5; p < 0.001). Three patients with TEE injury died (2/10,000).

CONCLUSIONS

TEE is associated with an incidence of major injuries of about 1 per 1,000 patients, with older women having a much higher risk. TEE use in cardiac surgery should be evaluated in the light of practice guidelines and morbidity and mortality data and not considered routine.

Iatrogenic pulmonary artery rupture

PURPOSE OF REVIEW

Pulmonary artery rupture is probably the most devastating complication associated with the use of the pulmonary artery catheter. This rare but disastrous situation requires a clear intervention plan.

RECENT FINDINGS

The initial presentation of pulmonary artery ruptures may be as obvious as a massive pulmonary hemorrhage or as subtle as a cough associated with minimal hemoptysis, or it may even be totally asymptomatic. A patient presenting any clinical manifestation of pulmonary artery rupture may develop a pulmonary artery false aneurysm, which is the accumulation of blood in an aneurismal sac compressed by lung parenchyma. This condition requires intervention because delayed hemorrhage may occur and recurrence can be massive and fatal. Following an initial episode of suspected pulmonary artery rupture, the patient should undergo immediate radiological investigation. If a diagnosis of pulmonary artery false aneurysm is confirmed, selective angiographic embolization helps reduce morbidity and mortality.

SUMMARY

The incidence of pulmonary artery ruptures is probably underestimated because many hemoptysis episodes or radiological infiltrations associated with pulmonary artery catheter use are not investigated. Also, the natural evolution of the pulmonary artery false aneurysm is unknown. The incidence of spontaneous healing, bleeding recurrence or asymptomatic persistence is unknown following formation of a pulmonary artery false aneurysm.