Transesophageal echocardiography (TEE) is a low risk procedure frequently used for intraoperative monitoring in patients undergoing cardiac surgery. Daniel et al. [1] demonstrated an 0.18% overall complication rate in 10,419 awake and asleep TEE examinations. Gastrointestinal complications of TEE are rare and have been previously confined to the oropharynx and esophagus [2]. There are four cases of esophageal lacerations resulting in gastrointestinal bleeding in the literature [3,4]. We report a case of gastric laceration resulting in gastrointestinal bleeding in a patient after intraoperative TEE examination. Case Report A 65-yr-old man underwent elective aortic valve replacement for severe aortic regurgitation and mild aortic stenosis causing progressive angina and congestive heart failure. His medical history was also remarkable for coronary artery disease (status postcoronary artery bypass grafting in 1984), a previous cerebrovascular accident, and a remote smoking history. He denied a history of peptic ulcer disease, gastritis, or increased bleeding tendencies. His medications included daily enteric-coated aspirin, captopril, and atenolol. Preoperatively, the hemoglobin was 14.9 g/dL, the hematocrit was 42.9%, the prothrombin time was 12.8 s, and the partial thromboplastin time was 30 s. Cardiac catheterization demonstrated patency of three of four saphenous vein grafts. The ejection fraction was estimated to be 45%-55%. After induction of anesthesia and tracheal intubation, a Hewlett Packard Omniplane TEE probe was inserted into the esophagus without difficulty. The heart and aorta were examined from the esophagus and from the stomach. The probe was only slightly anteflexed in the stomach to obtain the short axis view of the left ventricle. The initial examination was performed without apparent incident and the probe was left in the unlocked position in the stomach throughout the pre-bypass period for monitoring of left ventricular function. After the examination, 24,000 U of heparin were administered intravenously. Aminocaproic acid 10 g was administered intravenously over 30 min, followed by an infusion of 5.0 g over 6 h. After heparinization, cardiopulmonary bypass was initiated, the native aortic valve was excised, and a Starr-Edwards valve was inserted. TEE imaging was done while on bypass to assist with the removal of intracardiac air. After uneventful separation from bypass, the probe was advanced to 50 cm and the tip was anteflexed to 120 degrees to obtain an apical long axis view for better visualization of the prosthetic valve. Two units of packed red blood cells was given for a hematocrit of 22% and 1 U of platelets was given for generalized nonsurgical bleeding. Protamine 350 mg was given to reverse the initial heparin dose of 24,000 U. An orogastric tube was placed as per routine after the TEE probe was removed and 150 mL of blood was suctioned from the stomach. On arrival in the intensive care unit, an additional 500 mL of blood was suctioned from the stomach and an emergent endoscopy was performed. The examination demonstrated a fibrin clot in the cardia of the stomach at the proximal aspect of a 5-cm strip of denuded mucosa Figure 1. The edges were sharp and well circumscribed and there was no active bleeding. An additional 3 U of packed red blood cells was given for a hematocrit of 26%. The patient made a full recovery without any evidence of further bleeding.Figure 1: The laceration is seen between the two arrows. The arrows point to the laceration's well circumscribed edges.Discussion The overall incidence of gastrointestinal bleeding with TEE in awake and asleep patients is 0.02%. Despite the low risk of bleeding, multiple factors contribute to the potential for gastrointestinal bleeding in patients requiring cardiopulmonary bypass [2,3,5,6]. Insertion and manipulation of the probe is blind, and there is no patient feedback for painful stimulus. Anticoagulation and postcardiopulmonary bypass coagulopathies may exacerbate any bleeding. Finally, the probe remains in the esophagus or stomach for the duration of surgery, and the examination is conducted prior to, during, and after cardiopulmonary bypass. Examination may require an apical four-chamber view, which requires into the stomach. In this patient, the apical fourchamber view was attempted to provide better visualization of the aortic valve. With this maneuver, the probe is anteflexed in the cardia of the stomach with the tip in contact with the gastric mucosa. The gastric cardia was the location of the laceration seen on endoscopy. The laceration appeared to be traumatic in origin due to the sharp, well circumscribed edges. We believe that in this patient, the laceration most likely occurred while obtaining this view. In conclusion, the potential for gastrointestinal bleeding exists in patients undergoing TEE examination during cardiac procedures. As the apical four-chamber view requires extreme anteflexion and may be more likely to injure the gastric mucosa, extra caution may be warranted when obtaining this view.
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Nov 25, 2002
Mario Petretta + 6
Open Access