Obstructive sleep apnoea, even when treated appropriately, may worsen long-term cardiac function and outcomes in patients who have heart failure with preserved ejection fraction.

The effects of beta-blockers on long-term morbidity and mortality have been established in patients with chronic heart failure (CHF) with reduced left ventricular function [1][2][3][4]. Among various beta-blockers, only carvedilol and bisoprolol are approved by Japanese guidelines for the treatment of patients with CHF [5]. Bisoprolol is highly selective for the beta-1 receptor, whereas carvedilol is a non-selective beta-blocker with simultaneous alpha-receptor antagonism [6]. However, there is no established clinical evidence on how to properly use these two agents. Our previous clinical trial, the Bisoprolol Improvement Group for Chronic Heart Failure Treatment Study in Dokkyo Medical University (BRIGHT-D), reported that bisoprolol is superior to carvedilol for myocardial protection in patients with CHF, as demonstrated by a greater reduction in high-sensitivity cardiac troponin T (hsTnT) [7].

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Intraoperative transesophageal echocardiography (TEE) is an invaluable tool for cardiac surgical decision-making. TEE is considered reasonably noninvasive and safe, but insertion and manipulation of the TEE probe can lead to complications. Here, we report a patient with aortic stenosis who experienced TEE-associated hypopharyngeal perforation at the pyriform sinus complicated by esophageal trauma, pneumomediastinum and pneumoretroperitoneum. Based on this case, we suggest that rare complications be kept in mind when using TEE intraoperatively.