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Ann Thorac Surg 2001;72:1725-1726
© 2001 The Society of Thoracic Surgeons

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Case report

Transesophageal echocardiography: not an innocuous procedure

^a Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
^b Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
^c Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA

Accepted for publication November 14, 2000.

* Address reprint requests to Dr Mansour, Division of Cardiothoracic Surgery, The Emory Clinic, 1365 Clifton Rd NE, Atlanta, GA 30322, USA
e-mail: kmansour{at}emory.org

	Abstract

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We report 3 patients who sustained intrathoracic esophageal perforations due to transesophageal echocardiography encountered during the past 2 years. Lack of suspicion of this complication led to delay in diagnosis. Surgical management led to survival of all 3 patients.

	Introduction

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Transesophageal echocardiography (TEE) has been used in the operating room with increasing frequency since the early 1980s. Multiple studies in the past have previously documented its relative safety [1]. Two patients with esophageal perforation due to TEE have been reported in the nonsurgical literature and both ultimately died [2, 3]. We would like to bring to the attention of thoracic surgeons these potentially lethal complications of TEE by reporting 3 women who survived with intrathoracic esophageal perforation caused by TEE encountered at Emory University Hospital in the past 2 years. During this 2-year period, 3,074 TEE examinations were performed at Emory University Hospital and the Emory Clinic.

	Case reports

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Patient 1
An 80-year-old woman was referred for treatment of aortic stenosis. Due to polymyalgia rheumatica, she required daily low-dose steroid use for the previous 3 years. On July 8, 1998, an aortic valve replacement and coronary artery bypass were performed. After induction, the TEE probe was passed into the esophagus without difficulty. The patient did well postoperatively, and was extubated on the same day. On the 2nd postoperative day, her chest tubes were removed. Subcutaneous emphysema was then noted over the chest wall. A chest roentgenogram revealed a left-sided pleural effusion and a small left pneumothorax. A left chest tube was then placed with drainage of 40 cc of serosanguinous fluid. That evening, the patient developed respiratory distress and required reintubation. She subsequently developed left-sided infiltrates on her daily chest films. Blood and sputum cultures grew pseudomonas. Broad-spectrum antibiotic coverage including piperacillin/tazobactam and ciprofloxacin were begun on July 10, 1998. By July 28, 1998, she had made marked improvement and was transferred to a rehabilitation facility. During rehabilitation, her fevers returned and her chest roentgenograms worsened. She was transferred back to Emory University Hospital. New drainage was seen from her previous left chest tube site. A computed tomographic scan of the chest revealed a probable abscess cavity in her left lower lobe. A fistulogram performed through the draining left chest tube site revealed a connection with the lower esophagus. She was then taken to the operating room where a left thoracotomy was performed. A tear was visualized in the lower third of the esophagus. T-tube drainage of the esophagus was performed [4]. Three weeks postoperatively, her T tube was removed. She was discharged on September 14, 1998 in satisfactory condition. As of July 2000, the patient continues to do well, tolerating a regular diet.

Patient 2
A 70-year-old woman was referred for treatment of atrial fibrillation with a periodic rapid ventricular response. Her past medical history was significant for breast cancer, and she had previously undergone a bilateral lumpectomy followed by a course of radiation therapy. On June 10, 1999, a TEE was performed without difficulty. There was no evidence of thrombus in the left atrium or ventricle, 200 Joules were then used for cardioversion. Later, that evening, the patient developed severe burning substernal pain. A gastrographin esophagram showed a mid-esophageal perforation. The patient was taken to the operating room where a right thoracotomy was performed. The injury was noted at the right posterolateral aspect of the esophagus at the level of the azygous vein. The esophagus was rigidly adherent to the right mainstem bronchus. A primary esophageal repair with a double-layer technique and pleural flap was then performed. Her postoperative course included prolonged ventilator dependence and a tracheostomy. A gastrographin esophagram on July 21, 1999 again showed a minimal, well-contained mid-esophageal perforation. She was begun on a soft diet and was discharged home on August 14, 1999 in satisfactory condition, tolerating a diet by mouth. The patient is doing well 6 months after discharge.

Patient 3
On April 12, 2000, an 85-year-old woman underwent an off-pump coronary artery bypass operation. The TEE probe was placed after induction and was left in place until the chest was closed. There was no difficulty passing the TEE probe. On the 1st postoperative day, the patient’s chest tubes were removed. On the 2nd postoperative day, a right hydropneumothorax was seen on a routine anteroposterior chest roentgenogram. A right-sided chest tube was placed with the drainage of turbid fluid. Later that day, gastrointestinal contents were seen in her chest tube. The patient was then taken to the operating room where a right thoracotomy and primary repair of a mid-esophageal perforation was performed. On the 7th postoperative day, a gastrographin swallow revealed continued leakage. She was taken back to the operating room where a T-tube repair and drainage were performed. She subsequently did well and was discharged home on May 22, 2000. A follow-up appointment, 2 months post-discharge, showed the patient to be doing well, tolerating a regular diet by mouth.

	Comment

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Injury to the esophagus after transesophageal echocardiography is rare. But, the potential for esophageal rupture does exist. The main factors in iatrogenic injury related to TEE examinations are pressure generated by the probe and the inherent integrity of the esophageal wall. Daniel and associates [1] noted a complication rate of 0.18% and a mortality rate of 0.0098% with the use of TEE. These rates are similar to previously documented complication rates of patients undergoing gastroduodenoscopy examinations [5].

Urbanowicz and coworkers [6] in 1990 were unable to demonstrate high pressures caused by TEE probes against the esophageal wall in 5 patients and 126 dogs without intrathoracic abnormalities. They did however generate high pressure in 1 patient with a descending thoracic aneurysm. They speculated that "potential fixation of the esophagus to surrounding tissue may be related to the high pressures measured." The second patient in our series had received thoracic radiation therapy which could have caused periesophageal fibrosis and adherence to the right mainstem bronchus. This could have allowed the generation of high pressure by the TEE probe. The potential for tissue heating via ultrasonic energy was also investigated by Urbanowicz and colleagues [6]. Probes were left in contact with the esophagus at maximum power for up to 12 hours. They found no evidence of injury (either gross or microscopic) upon pathologic examination of the dogs’ esophageal walls.

Kharasch and Sivarajan [2] reported a perforation at the gastroesophageal junction after the use of intraoperative TEE in a patient with severe peripheral vascular disease. On the 1st postoperative day, an esophageal perforation was discovered at the gastroesophageal junction. An esophagogastrectomy was performed. However, the patient subsequently died on the 7th postoperative day. The authors of that article felt that the perforation "occurred during the retention of the probe and not during the insertion." In their opinion, chronic ischemia related to his vasculopathy predisposed this patient to pressure and heat-related necrosis.

Massey and colleagues [3] recently reported a case of esophageal rupture in a patient with an enlarged left atrium. The patient’s injury was not detected until the 4th postoperative day. Despite aggressive surgical management, including esophageal diversion, the patient died on the 9th postoperative day. The postmortem examination revealed a thin, friable esophagus, which was tethered to the left atrium in the region of the tear.

In our series, the first patient had been on steroids for 3 years prior to her TEE exam. The chronic use of steroids and their ability to cause tissue weakness may have contributed to her esophageal perforation. The diagnosis of the perforation was delayed for over 1 month. The occurrence of pneumothorax, effusion, sepsis, and respiratory distress in the early postoperative period should have led to early diagnosis and management. Our third patient had no preoperative clues to indicate that she was at risk for a TEE injury. Her operation was uneventful, however, the development of a pneumothorax and effusion after removal of her chest tubes should have alerted the surgeon to the possibility of an esophageal perforation. We speculate that her advanced age of 85 years might be a risk factor for esophageal perforation by TEE and now proceed with extreme caution in such patients.

In conclusion, because of the previously stated safety of TEE, the diagnosis of esophageal injury is rarely considered in the postoperative setting. Prior to the use of TEE, the risk of esophageal disease must be carefully assessed. Factors such as esophageal varices, ulceration, diverticula, tumors, and strictures should be carefully sought. These factors must be considered relative contraindications to TEE. If esophageal disease is suspected, by either symptom or history, esophagoscopy and or a contrast radiographic examination should be performed [1]. Once an injury has occurred, the time from injury to diagnosis is a critical factor in determining clinical outcome. The occurrence of pneumothorax or effusion in the immediate postoperative period following TEE should lead to the suspicion of an esophageal rupture. Contrast studies should then be performed [7]. Early diagnosis and management of these injuries should lead to improvement in morbidity and mortality.

	References

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1. Daniel W.G., Erbel R., Kasper W., et al. Safety of transesophageal echocardiography. Circulation 1991;83:817-821.[Abstract/Free Full Text]
2. Kharasch E.D., Sivarajan M. Gastroesophageal perforation after perioperative transesophageal echocardiography. Anesthesiology 1996;85:426-428.[Medline]
3. Massey S.R., Pitis A., Mehta D., Callaway M. Oesophageal perforation following perioperative transesophageal echocardiography. Br J Anaesth 2000;84:643-646.[Abstract/Free Full Text]
4. Mansour K.A., Wenger R.K. T-tube management of late esophageal perforations. Surg Gynecol Obstet 1992;175:571-572.[Medline]
5. Silvis S.E., Nebel O., Rogers G., Sugawa C., Mandelstam P. Endoscopic complications. JAMA 1976;9:928-930.
6. Urbanowicz J.H., Kernoff R.S., Oppenhein G., Parnagian E., Billingham M.E., Popp R.L. Transesophageal echocardiography and its potential for esophageal damage. Anesthesiology 1990;72:40-43.[Medline]
7. Bufkin B.L., Miller J.L., Mansour K.A. Esophageal perforation: emphasis on management. Ann Thorac Surg 1996;61:1447-1452.[Abstract/Free Full Text]

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