Iatrogenic Dissection of Esophagus During a Transesophageal Echocardiogram

Abstract

Purpose: Transesophageal echocardiography (TEE) is a widely used imaging modality for the evaluation of multiple cardiovascular conditions and its clinical applications are numerous. It is a moderately invasive study that uses a diamond-shaped probe typically inserted blindly without fluoroscopic guidance. This carries rare but potentially serious complications. Rare reports have addressed the risk of TEE-induced trauma to the gastrointestinal tract (hypopharynx, esophagus, and stomach), the commonly used therapies, and the natural history of this type of injury. We review a case of iatrogenic dissection of the cervical portion of the esophagus during a TEE that was performed to evaluate for infective endocarditis in a 39 year old male with gram-positive cocci bacteremia. After multiple attempts to advance the probe, the operator was able to advance it partially with moderate resistance but was unable to obtain any images so the procedure was terminated. Upon removal of the instrument, there was evidence of bright red blood on the probe, and the patient complained of dysphagia to solids and liquids. Gastroenterology Service was consulted and an esophagogastroduodenoscopy (EGD) was performed. On EGD, the patient appeared to have a mucosal tear in the proximal esophagus; however, the endoscope could not be advanced distal to this tear due to luminal stenosis. An esophagogram was performed immediately following the EGD to rule out a transmural esophageal perforation. This revealed a contained tear in the upper esophagus with extravasation of contrast material into the anterior wall of the esophagus (false lumen). The patient was treated conservatively with nothing by mouth and parenteral nutrition. A follow-up endoscopy two weeks later confirmed adequate healing of the lesion. These as well as other potential gastrointestinal complications of TEEs are briefly discussed.Figure