Endoscopic Treatment of Transesophageal Echocardiography-Induced Esophageal Perforation

Rationale and clinical applications of 4D flow cardiovascular magnetic resonance in assessment of valvular heart disease: a comprehensive review

BACKGROUND

Accurate evaluation of valvular pathology is crucial in the timing of surgical intervention. Whilst transthoracic echocardiography is widely available and routinely used in the assessment of valvular heart disease, it is bound by several limitations. Although cardiovascular magnetic resonance (CMR) imaging can overcome many of the challenges encountered by echocardiography, it also has a number of limitations.

MAIN TEXT

4D Flow CMR is a novel technique, which allows time-resolved, 3-dimensional imaging. It enables visualisation and direct quantification of flow and peak velocities of all valves simultaneously in one simple acquisition, without any geometric assumptions. It also has the unique ability to measure advanced haemodynamic parameters such as turbulent kinetic energy, viscous energy loss rate and wall shear stress, which may add further diagnostic and prognostic information. Although 4D Flow CMR acquisition can take 5-10 min, emerging acceleration techniques can significantly reduce scan times, making 4D Flow CMR applicable in contemporary clinical practice.

CONCLUSION

4D Flow CMR is an emerging CMR technique, which has the potential to become the new reference-standard method for the evaluation of valvular lesions. In this review, we describe the clinical applications, advantages and disadvantages of 4D Flow CMR in the assessment of valvular heart disease.

Findings and outcomes of emergent endoscopies after cardiovascular surgery

Aims

Methods and Results

Conclusion

Esophageal perforation after transesophageal echocardiography: A case report

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Esophageal perforation after ambulatory Transesophageal Echocardiography is rare.

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High suspicion in crucial to establish a diagnosis.

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If discovered early, treatment of esophageal perforation could have good outcome.

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Endoscopy plays an important role in the diagnosis and treatment.

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The endoscopic approach is a safe and feasible option to avoid major surgery.

Introduction

Esophageal perforation is a rare and severe complication following transesophageal echocardiography (TEE) that carries high morbidity and mortality rates. Management of these perforations usually requires complex open surgeries. We present the case of an esophageal perforation following TEE treated with a combined approach of upper endoscopy and left cervicotomy.

Presentation of case

An 80 y/o male patient underwent a diagnostic TEE for mitral regurgitation. After discharge patient consulted back on the same day to the Emergency Department and a perforation of the cervical esophagus was diagnosed associated to an air-fluid collection in the mediastinum. The patient was treated with endoscopic closure of the perforation and left cervicotomy for mediastinal drainage. Patient was discharged home on POD 31 after full recovery. A written consent was previously obtained, and Institutional Review Board approval was not needed.

Discussion

Although not frequently seen, complications following TEE can be devastating if not diagnosed and treated early. Endoscopic closure of an esophageal perforation is a safe and feasible option with the already known advantages of a minimally invasive approach. Surgeons should have high suspicion if a patient present with characteristic symptoms after an uneventful procedure.

Conclusion

Esophageal perforation is a very rare complication of TEE. High suspicion is mandatory to reach prompt diagnosis and install effective treatment. Primary closure of the perforation is the treatment of choice, and the endoscopic approach is a safe and feasible option in high volume centers.

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.