Complication Of Transesophageal Echocardiography Research Articles

The Year in Perioperative Echocardiography: Selected Highlights From 2022

THIS SPECIAL article is part of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the Editorial Board for the opportunity to continue this series, which focuses on the past year's research highlights that pertain to perioperative echocardiography in relation to cardiothoracic and vascular anesthesia. The major selected themes for 2022 include (1) updates on mitral valve assessments and interventions, (2) training and simulation updates, (3) outcomes and complications of transesophageal echocardiography, and (4) point-of-care cardiac ultrasound. The themes selected for this special article are just a sample of the advances in perioperative echocardiography during 2022. An appreciation and understanding of these highlights will help to ensure and improve the perioperative outcomes for patients with cardiovascular disease undergoing cardiac surgery.

S2203 An Unexpected Case of Esophageal Perforation Following Transesophageal Echocardiography

Introduction: Esophageal perforation is a serious complication of transesophageal echocardiography (TEE). Although extremely rare, perforations of the esophagus can lead to life-threatening complications with high morbidity and mortality. We present a unique case of esophageal perforation in a patient with no history of esophageal pathology, documented prior well-tolerated TEEs, and no clinical signs or symptoms of perforation peri or post procedure. Case Description/Methods: A 79 year-old female with multiple comorbidities including hypertension, moderate aortic stenosis, chronic atrial fibrillation with a 27mm Watchman device presented to the ED for chest pain, shortness of breath, nausea, and vomiting. The patient was discharged earlier that morning after a post-Watchman TEE was performed. During the procedure, the probe was passed without difficulties and no peri-procedural complications were documented. Post-procedure, the patient had no complaints and was able to tolerate oral intake. After arriving home, the patient began to experience severe substernal pain and throat irritation and returned to the ED. Urgent chest radiography showed findings concerning for pneumomediastinum. Stat computed tomography (CT) revealed extensive supraclavicular soft tissue emphysema along with gas in the anterior and middle mediastinum; no definitive perforation was seen. An urgent esophagogastroduodenoscopy (EGD) was performed and confirmed a linear esophageal perforation 15 cm from incisors below the cricopharyngeus. Due to the unique location of the perforation, one Ovesco clip was deployed over the defect. The patient later developed respiratory failure and unfortunately expired within a week. Discussion: Although TEEs have been safely used as a cardiac diagnostic and monitoring modality, complications can occur. Esophageal perforations are attributed to increased mucosal pressure and thermal damage to the esophageal wall. Absolute contraindications include severe dysphagia and history of esophageal disorders. Risk factors for TEE-associated perforations include patient’s advanced age, multiple comorbidities, and an enlarged left atrium which can cause thinning of the esophageal wall. This case ultimately highlights the serious morbidity and mortality associated with post-TEE esophageal perforations. It is crucial that appropriate screening is done to identify high-risk individuals before such procedures are done.

A case of esophageal perforation after intraoperative transesophageal echocardiography in a patient with a giant left atrium: unexpectedly large distortion of the esophagus revealed on retrospectively constructed three-dimensional imaging

BackgroundEsophageal perforation is a rare but serious complication of transesophageal echocardiography (TEE). An enlarged left atrium (LA), which is commonly associated with mitral stenosis (MS), is an under-recognized risk factor for esophageal perforation after intraoperative TEE.Case presentationWe describe a case of TEE-induced esophageal perforation after cardiac surgery in a 79-year-old woman with a giant LA due to MS. Esophageal perforation was detected on postoperative day 6. After surgical repair, the patient gradually recovered with prolonged conservative treatment. Retrospectively constructed three-dimensional chest computed tomography images revealed an unusually distorted esophagus that was possibly vulnerable to injury.ConclusionA giant LA can markedly distort the esophagus. It should be recognized as a risk factor for TEE-induced esophageal perforation.

Utility of Screening EGD in High Risk Patients Undergoing Transesophageal Echocardiography

Introduction: Transesophageal echocardiography (TEE) probes are introduced and advanced into the distal esophagus blindly. Concern for esophageal injury often prompts gastroenterology consultations for screening esophagogastroduodenoscopies (EGDs), especially in patients who are at high risk for esophageal lesions. There is insufficient data in the current literature on the utility of screening EGDs prior to TEE. Methods: This is a retrospective study at a tertiary referral center. We reviewed charts of all patients who underwent a TEE between August 2015 and November 2016. We included all adult patients (≥18 years old), who underwent and EGD within a month of TEE. Results: 3,130 TEEs were performed during the study period and only 4 (0.13%) potential complications were identified. 213 patients underwent 226 EGDs within one month of the TEE. 89 (39.4%) EGDs were preformed prior to TEE and 137 (60.6%) after. Average time between procedures was 9 days. 106 patients were considered high risk. EGD indications are summarized in TABLE 1. No TEE complications were reported in patients without active symptoms, including those who were defined as high risk patients for esophageal lesion such as cirrhotics and those with prior history of upper GI bleed. We identified only 4 patients with potential TEE complications; one patient developed melena and acute drop in hemoglobin one day after TEE, EGD revealed a small false esophageal lumen with active oozing from the site, attributed to blunt trauma. Another patient developed melena one week after a TEE, which started in the setting of supratherapeutic INR. EGD demonstrated a visible esophageal vessel vs clot in upper third of the esophagus and an ischemic appearing necrotic mucosa in middle esophagus. The two other patients reported GI bleeding prior to TEE: hematemesis and hematochezia. EGDs in both cases were performed the within 24 hours after TEEs and showed Mallory Weiss tear in the distal esophagus in the former and diffuse severe esophagitis with small oozing ulcerations in upper and lower esophagus in the latter. In the latter two cases other associated interventions and lesions could explain the findings and symptoms. Conclusion: Our results demonstrate the low rate of esophageal complications related to TEE, including in high risk patients. In asymptomatic high risk patients screening EGD may not be beneficial or change management. On the other hand, high risk patients with active bleeding symptoms may benefit from EGDs prior to TEEs.361_A Figure 1 No Caption available.361_B Figure 2 No Caption available.

Safety of transesophageal echocardiography‑guided electrical cardioversion in patients with atrial fibrillation and inadequate anticoagulation.

INTRODUCTION Restoring sinus rhythm in patients with atrial fibrillation (AF)/atrial flutter (AFl) requires adequate oral anticoagulation prior to direct current cardioversion (DCC). Some patients eligible for DCC are not properly anticoagulated. OBJECTIVES The aim of the study was to assess risk factors for thrombus and spontaneous echo contrast (SEC) in the left atrium (LA) as well as the safety profile of transesophageal echocardiography (TEE)-guided DCC in patients with inadequate anticoagulation. PATIENTS AND METHODS From the cohort of 316 patients admitted for DCC, 139 patients (mean [SD] age, 63.4 [11.5] years) had inadequate anticoagulation; 91 patients were admitted urgently for acute coronary syndrome, heart failure (HF), or poor tolerance of arrhythmia. The mean (SD) CHA2DS2‑VASc score was 3.0 (1.7). RESULTS TEE revealed a left atrial appendage (LAA) thrombus in 16 patients (11.5%), and SEC in the LA in 63 patients (45.3%). In a univariate analysis, LAA thrombus was more common in patients after myocardial infarction (odds ratio [OR], 3.92; 95% CI, 1.34-11.48; P = 0.009), while SEC in the LA was more common in patients with HF (OR, 2.23; 95% CI, 1.1-4.53; P = 0.02) and left ventricular ejection fraction of less than 40% (OR, 3.65; 95% CI, 1.66-8.06; P = 0.001). In a multivariate model, the most powerful SEC‑predicting factor was the LA size exceeding 45 mm (OR, 3.08; 95% CI, 1.3-7.29). DCC was performed in 105 patients. No complications of TEE or DCC were observed. CONCLUSIONS AF/AFl inadequately treated with oral anticoagulation predisposes to thrombus formation and SEC in the LA. Once thrombus is excluded, DCC is a safe procedure. There were no predictors of LAA thrombus; therefore, TEE before DCC should be performed in all patients with AF/AFl in accordance with the guidelines.

Transesophageal Echocardiography Complications in Adult Cardiac Surgery: A Retrospective Cohort Study

Although there have been several large reviews documenting the complications following intraoperative transesophageal echocardiography (TEE), most of these prior reports are almost 2 decades old and may not reflect current practices. The purpose of this study was to determine the incidence and types of complications following TEE in a contemporary cardiac surgical population. We conducted a retrospective analysis of all cardiac surgical patients having undergone an intraoperative TEE between April 1, 2004, and April 30, 2012. Patients with TEE-related complications were identified from our institutional cardiac surgical database to have their medical records manually reviewed through International Classification of Diseases-10th Revision coding for: 1) a priori defined complications including dysphagia, vocal cord and laryngeal injury, dysphonia, accidental puncture and laceration during a procedure, and hemorrhage and hematoma complicating a procedure; 2) the requirement for an in-hospital esophageal or bronchial endoscopy procedure; or 3) the requirement for postoperative specialist consultation from gastrointestinal bleed or other surgery services. A multivariable model was then developed to identify risk factors for TEE complications. Of the 7,954 cardiac surgical cases performed during the study period, 1,074 had their records manually reviewed and 111 (1.4%) patients had possible complications. Multivariate analysis showed an increased risk of complications associated with age, body mass index, previous stroke, procedure other than isolated coronary artery bypass grafting, cardiopulmonary bypass time, and return to the operating room for any reason (model c-statistic= 0.81). The overall incidence of TEE complications after cardiac surgery was 1.4%. Advanced age, low body mass index, complexity of procedure, prior stroke, prolonged bypass time, and return to the operating roomappear to be significant risk factors for TEE complications.

Superior Thyroid Artery Pseudoaneurysm as a Complication of Transesophageal Echocardiography

The pseudo-aneurysm is a hematoma of post-traumatic origin, and capsulated button which is in communication with the lumen of the artery of relevance. Singular occurrence in the district ENT, if not recognized early the pseudo-aneurysm can result in dramatic events such cataclysmic bleeding or acute occlusion of the upper airway. In literature there are outstanding references to the pseudo-aneurysm of the superior thyroid (ATS). We present a rare case of pseudo-aneurysm occurred after the ATS trans-esophageal echocardiography (TEE) and external cardioversion.

Conservative management of a case of transesophageal echocardiogram-induced esophageal perforation

Esophageal injury or perforation is a rare but life threatening complication of transesophageal echocardiography (TEE). Most of the patients manifest symptoms within 24 hours of the procedure and upper esophagus is the most common site of injury. Incidence of esophageal perforation is relatively rare, in a large series of 10,000 cases of TEE, the incidence of esophageal perforation was reported in 3 cases (0.03%) and in another study it was found to be 1 in 5,000 TEEs, 0.02%. This is a case report that highlights a case of esophageal perforation and false passage discovered accidentally 24 hours postoperatively, in contrast to most of the previous esophageal perforation case reports, a conservative management was undertaken successfully since the discovery of the complication until the full recovery and the discharge of the patient from the cardiac ICU, a follow up upper gastrointestinal endoscopy and CT chest showed progressive resolution of the hematoma surrounding the esophagus, healing of the false passage and recovery of the mediastinal gas locules.

Esophageal Perforation Associated With Fontan Operation

A 10-year-old girl with unbalanced atrioventricular septal defect and aortic arch interruption with interrupted inferior vena cava and dextrocardia had undergone a modified Norwood procedure followed by a Kawashima operation in 2002 and 2005, respectively. In 2012, she underwent Fontan operation with diversion of hepatic veins to left pulmonary artery. Intraoperative transesophageal echocardiography (TEE) was used. She was noted to have an esophageal perforation, diagnosed on the 10th postoperative day. She was managed with thoracic drainage, cervical esophagostomy, and feeding jejunostomy. Esophageal perforation is a rare complication of TEE and requires very aggressive treatment.

Safety of Transesophageal Echocardiography in Patients with Gastroesophageal Varices

Purpose: Limited data is available on the safety and complications rate of transesophageal echocardiography (TEE) in patients with gastroesophageal varices. This study aims at evaluating the gastrointestinal complications in patients with gastroesophageal varices who had TEE performed and the clinical efficacy of performing upper endoscopy (EGD) prior to TEE in reducing complication rate or altering management plan in this patients' group. Methods: Retrospective database analysis for all patients with known liver cirrhosis with portal hypertension or esophageal varices who underwent TEE between January-2007 and December-2011 in a single center. Data included patient's age, gender, MELD score, Platelets count, INR, grade of varices on most recent EGD, stigmata for risk of bleeding, severity of portal hypertensive gastropathy. Data also included post TEE complications including GI bleeding (a drop in hemoglobin >2 g/dL or a need for blood-product transfusion within 48 hours of TEE), clinical or radiographic evidence of perforation, clinical worsening of hepatic encephalopathy. Data is presented as medians (Interquartile). Results: A total of 20 patients with esophageal varices who underwent TEE were analyzed (12M, 8F), median age 57 years (47-60), MELD score 16 (11-28), platelets count 102 (55-147), INR 1.7 (1.3-2.2). Four patients had history of variceal bleeding in the past with band ligations performed. Most recent EGD in these patients showed grade 2 varices without high risk stigmata. Rest of patients had grade 1 varices. Four patients had severe hypertensive portal gastropathy. Cardiologist requested EGD prior to TEE in 7 patients; three of them never had an EGD before while 2 patients had an EGD at 10 and 12 months, respectively, prior to TEE which showed small varices, their repeat EGD showed similar findings. The other 2 patients had variceal screening before but the duration from their last EGD was unknown. No post TEE complications were reported in the studied patients including no GI bleeding, perforation or worsening encephalopathy. Conclusion: The study suggests that TEE may be a safe procedure if patients had grade 1 or 2 varices on their most recent EGD even if they had variceal bleeding before. An EGD that was performed within the recommended duration interval for variceal screening is likely adequate without a need for a repeat EGD prior to the TEE study. Patients with severe hypertensive portal gastropathy may also have low risk of post TEE complications.

Esophageal Perforation, the Most Feared Complication of TEE: Early Recognition by Multimodality Imaging

Esophageal perforation is the most feared complication of transesophageal echocardiography (TEE), although the overall risk is extremely low. We report a case of esophageal perforation in a 77-year-old woman who had no apparent contraindications to TEE. Chronic steroid therapy for symptoms of asthma as well as osteophytic changes of the cervical vertebrae contributed to her increased risk of perforation. Unlike in prior reports, the perforation in this case was fortuitously recognized rapidly due to ingestion of a carbonated beverage for evaluation of a hiatal hernia suspected during a subsequent transthoracic echocardiogram performed because of inadequate TEE images after a difficult intubation. The incidence of esophageal perforation in our series (1 in 5,000 TEEs, 0.02%) is similar to that reported in the literature. Early recognition and prompt surgical repair of the esophageal perforation led to favorable outcome in our patient.

Is threshold for treatment of methemoglobinemia the same for all? A case report and literature review

Acquired methemoglobinemia (MetHb) is a rare complication of exposure to toxic chemicals or drugs, most commonly topical anesthetic agents. This condition occurs when the rate of methemoglobin production exceeds the rate of methemoglobin reduction. Topical anesthetics have been reported to cause MetHb, but this adverse event is extremely rare and is not usually listed as one of the possible complications of transesophageal echocardiography (TEE). However, the number of published case reports of TEE-associated MetHb has recently increased. Benzocaine (ethyl aminobenzoate) is a topical anesthetic widely used for oropharyngeal anesthesia before TEE. Health care providers who are not familiar with the association of TEE and benzocaine-induced MetHb may not recognize the idiosyncratic and often nonspecific characteristics of this condition. Recognition is critical, as clinically important symptoms may occur at relatively low MetHb levels. If left untreated, MetHb can lead to cardiopulmonary compromise, severe neurologic impairment, and even death. The current report documents a case of TEE-associated MetHb from a high-volume (3000 cases per year including 300-350 TEEs per year) echo laboratory. Our patient was symptomatic and severely distressed, despite a MetHb level of only 10.8%. This case report emphasizes the importance of early recognition and treatment of MetHb, as it represents a medical emergency and can be severely symptomatic, especially in young children and the elderly, even with low MetHb levels.

Iatrogenic Dissection of Esophagus During a Transesophageal Echocardiogram

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

Usefulness and Complications of Transesophageal Echocardiography in Pediatric Patients

小児の経食道心エコーは成人に比べ合併症の危険性が高く, 普及の障害となってきた. 小児においては事故抜管, 気道の圧迫, 左房・大動脈の圧迫が最も問題となる. しかし, 合併症という罪の反面, 小児においても経食道心エコーが非常に有用であった症例, 経食道心エコーにより救命できた症例もしばしば経験される. 近年では, 経食道心エコーなしでは事実上試行不可能といわれている小児心房中隔欠損症のカテーテル治療も普及しつつある. 小児麻酔において経食道心エコーを安全かつ効果的に使用するためには, その功と罪をよく理解し, 十分な適応の検討, 適切なプローブの選択, 慎重な操作, 経験の蓄積が必要となる.

Fatal ventricular arrhythmia as a complication of transesophageal echocardiography

To report a case of serious ventricular arrhythmia during transesophageal echocardiography. A 58-year-old woman with previous mitral and tricuspid valve replacement and permanent pacemaker implantation suffered from recurrent fever and Staphylococcus aureus bacteremia. Transesophageal echocardiography was performed as part of the assessment for infective endocarditis. During this procedure the patient developed sustained ventricular tachycardia and subsequently ventricular flutter. She was successfully resuscitated. Subsequently the procedure was undertaken under general anesthesia with no complications. The increasing use of TEE in a wider spectrum of patients, many of whom are seriously ill, may result in serious side-effects.

Acute Myocardial Infarction During Transesophageal Echocardiography.

We describe the occurrence of acute myocardial infarction during transesophageal echocardiography (TEE) in a patient with atrial fibrillation and underestimated angina. Such a case has not been previously reported in the literature. This case illustrates one of the possible complications of TEE, leading us to suggest systematic sedation in patients with angina in whom TEE is envisaged.

Complications of transesophageal echocardiography in the ED

The complication rate of transesophageal echocardiography (TEE) performed in clinical settings outside the emergency department (ED) has been reported to be 1% to 3%. The rate of complications of performing TEE in the ED has not been established. The purpose of this study was to determine the rate of complications associated TEE with carried out on ED patients, and to investigate parameters that might predict complications. A retrospective chart review was carried out on consecutive ED patients undergoing TEE at a major referral center. Complications were abstracted. Parameters to predict complications were assessed, including age, gender, vital signs, pulse oximetry values, serum bicarbonate level, and hematocrit level. A total of 142 patients underwent TEE in the ED during the study period; 88 of these were trauma patients. There were 18 (12.6%) complications: death (1), respiratory insufficiency/failure (7), hypotension (3), emesis (4), agitation (2), and cardiac dysrhythmia (1). None of the tested variables predicted a complication. TEE carried out in the ED has a higher complication rate than has been reported in other clinical settings.

Transesophageal echocardiography in diagnosing cardioembolic stroke.

Stroke is a disease with high morbidity and mortality that afflicts older people. The most common type of stroke is ischemic, and 15-20% of these strokes are cardioembolic. Because clinical features are not very specific for the type of stroke, diagnostic aides are needed to identify the mechanism of stroke so that appropriate therapy can be initiated. Numerous studies have shown that transesophageal echocardiography (TEE) is a more sensitive tool for diagnosing cardioembolic stroke than transthoracic echocardiography (TTE). However TTE and TEE are still considered complementary as they both provide unique information. The many abnormalities that can be identified by TEE and their therapy are discussed in this review, along with indications and complications of TEE. TEE has demonstrated that cardioembolic causes of stroke are much more common than previously thought. With a more precise diagnosis, appropriate therapy can be provided to help prevent cardiogenic stroke.

An Unusual Complication of Transesophageal Echocardiography

To the Editor: Transesophageal echocardiography (TEE) is frequently used by anesthesiologists in the perioperative period [1]. We report an unusual complication of TEE. The case involved a 75-yr-old woman undergoing mitral valve repair. Monitors included a TEE probe and an esophageal stethoscope (Mon-a-therm Registered Trademark; Mallinckrodt Medical Inc., St. Louis, MO) placed in the esophagus after induction of general anesthesia. The esophageal stethoscope was used primarily for monitoring esophageal temperature, and an earpiece was not attached. During surgery, the TEE probe was manipulated several times to evaluate the adequacy of valvular repair. At the conclusion of surgery the TEE probe was removed, and it was noted that the distal end of the esophageal stethoscope had retracted into the mouth and only the thermistor wire was visible. Gentle traction on the wire yielded resistance. On direct laryngoscopy, only the wire was visible entering the esophagus. Gentle traction on the wire under direct visualization was again met with resistance. Finally, rigid esophagoscopy was performed and the stethoscope was retracted with minimal trauma. The stethoscope seemed kinked back upon itself in the esophagus Figure 1. The patient's postoperative hospital stay was complicated by fever and dysphagia. A barium swallow was negative for esophageal perforation but did reveal the presence of a previously undiagnosed Zenker's diverticulum. No further complications developed, and the patient was discharged from the hospital 1 wk after surgery.Figure 1: Shows how traction on the thermistor wire in a previously kinked esophageal stethoscope will result in bending of the distal end at a 90 degrees angle, making it impossible to be pulled out and increasing the potential for esophageal perforation by the hard plastic at the end of the stethoscope.Although esophageal perforation is the most dangerous recognized complication of TEE [2], loss of an esophageal stethoscope due to TEE probe manipulation has not been reported as a cause of perforation so far. Our patient required rigid esophagoscopy, which itself may lead to esophageal perforation. Our patient's undiagnosed Zenker's diverticulum probably exacerbated our difficulties. Many patients undergoing TEE may have similar undiagnosed esophageal abnormalities. The temptation to forcefully pull the stethoscope should be resisted because, as shown in Figure 1, strong traction on the thermistor wire makes the distal, stiff end of the stethoscope bend at 90 degrees, actually wedging the stethoscope into the esophagus, making removal more difficult and trauma by the rigid plastic tip more likely. This case suggests that the anesthesiologist must be aware of this hazard. Easy strategies, such as taping the stethoscope to the endotracheal tube or connecting an earpiece to the distal end, would prevent this complication. This report identifies the often unappreciated potential of the TEE to displace an esophageal stethoscope with potential for esophageal perforation. Similar displacement during a nasogastric tube insertion leading to intestinal obstruction has been described before [3]. Anthony Yasick, MD Satwant K. Samra, MD Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, MI 48109-0048

An Unusual Complication of Transesophageal Echocardiography

To the Editor: Transesophageal echocardiography (TEE) is frequently used by anesthesiologists in the perioperative period [1]. We report an unusual complication of TEE. The case involved a 75-yr-old woman undergoing mitral valve repair. Monitors included a TEE probe and an esophageal stethoscope (Mon-a-therm Registered Trademark; Mallinckrodt Medical Inc., St. Louis, MO) placed in the esophagus after induction of general anesthesia. The esophageal stethoscope was used primarily for monitoring esophageal temperature, and an earpiece was not attached. During surgery, the TEE probe was manipulated several times to evaluate the adequacy of valvular repair. At the conclusion of surgery the TEE probe was removed, and it was noted that the distal end of the esophageal stethoscope had retracted into the mouth and only the thermistor wire was visible. Gentle traction on the wire yielded resistance. On direct laryngoscopy, only the wire was visible entering the esophagus. Gentle traction on the wire under direct visualization was again met with resistance. Finally, rigid esophagoscopy was performed and the stethoscope was retracted with minimal trauma. The stethoscope seemed kinked back upon itself in the esophagus Figure 1. The patient's postoperative hospital stay was complicated by fever and dysphagia. A barium swallow was negative for esophageal perforation but did reveal the presence of a previously undiagnosed Zenker's diverticulum. No further complications developed, and the patient was discharged from the hospital 1 wk after surgery.Figure 1: Shows how traction on the thermistor wire in a previously kinked esophageal stethoscope will result in bending of the distal end at a 90 degrees angle, making it impossible to be pulled out and increasing the potential for esophageal perforation by the hard plastic at the end of the stethoscope.Although esophageal perforation is the most dangerous recognized complication of TEE [2], loss of an esophageal stethoscope due to TEE probe manipulation has not been reported as a cause of perforation so far. Our patient required rigid esophagoscopy, which itself may lead to esophageal perforation. Our patient's undiagnosed Zenker's diverticulum probably exacerbated our difficulties. Many patients undergoing TEE may have similar undiagnosed esophageal abnormalities. The temptation to forcefully pull the stethoscope should be resisted because, as shown in Figure 1, strong traction on the thermistor wire makes the distal, stiff end of the stethoscope bend at 90 degrees, actually wedging the stethoscope into the esophagus, making removal more difficult and trauma by the rigid plastic tip more likely. This case suggests that the anesthesiologist must be aware of this hazard. Easy strategies, such as taping the stethoscope to the endotracheal tube or connecting an earpiece to the distal end, would prevent this complication. This report identifies the often unappreciated potential of the TEE to displace an esophageal stethoscope with potential for esophageal perforation. Similar displacement during a nasogastric tube insertion leading to intestinal obstruction has been described before [3]. Anthony Yasick, MD Satwant K. Samra, MD Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, MI 48109-0048