Bleeding Risk of Transesophageal Echocardiography in Patients With Esophageal Varices

Nigatu, Abiy; Yap, John Erikson L.; Chuy, Katherine Lee; Go, Benjamin; Doukky, Rami

doi:10.1016/j.echo.2018.11.017

Cited by 15 publications

(12 citation statements)

References 11 publications

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“…These findings indicate the safety of performing TEE in patients with pre-existing EV and are consistent with recent meta-analysis, which demonstrated an overall low risk of complications, including TEE-related bleeding, and perforation 17 18. On the other hand, the TEE group was associated with 8 days longer LOS.…”

Section: Discussionsupporting

confidence: 90%

Safety of performing transoesophageal echocardiography in patients with oesophageal varices

et al. 2019

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IntroductionOesophageal varices (EV) are one of the complications of liver cirrhosis that carries a risk of rupture and bleeding. The safety of performing transesophageal echocardiography (TEE) in patients with pre-existing EV is not well described in literature. Therefore, this retrospective study has been conducted to evaluate the safety of preforming TEE in this group of patients.MethodsThe study population was extracted from the 2016 Nationwide Readmissions Data using International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System for EV, TEE and in-hospital outcomes. Study endpoints included in-hospital all-cause mortality, hospital length of stay, postprocedural gastrointestinal bleeding and oesophageal perforation.ResultsA total of 81 328 discharges with a diagnosis of EV were identified, among which 242 had a TEE performed during the index hospitalisation. Mean age was 58.3 years, 36.6% female. In comparison to the no-TEE group, the TEE group was associated with comparable in-hospital all-cause mortality (7.0% vs 6.7%, p=0.86) and bleeding (0.9% vs 1.1%, p=0.75); however, TEE group was associated with longer hospital stay (14.9 days vs 6.9 days, p<0.01). There were no reported oesophageal perforations.ConclusionsTEE is not a common procedure performed in patients with pre-existing EV. TEE seems to be a safe diagnostic tool for evaluation of heart diseases in this group of patients.

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Section: Discussionsupporting

confidence: 90%

Safety of performing transoesophageal echocardiography in patients with oesophageal varices

et al. 2019

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“…Most reports that have attempted to quantify the risk of bleeding in patients with cirrhosis and esophageal varices consist of retrospective case series of TEE performed intra-operatively during orthotopic liver transplantation, (2)(3)(4)(5)(6) with meta-analysis indicating a pooled incidence of postprocedural bleeding of 1.4%. (7) Data regarding the outcomes of patients with cirrhosis and esophageal varices who undergo nonoperative TEE are limited to three small cases series encompassing a total of 58 patients, in whom no bleeding events were noted. (7)(8)(9) As patients with cirrhosis are at generally higher risk of adverse procedural outcomes, including hemorrhage, (10,11) it is notable that only two studies of variceal bleeding post TEE included a comparator group.…”

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confidence: 99%

“…(7) Data regarding the outcomes of patients with cirrhosis and esophageal varices who undergo nonoperative TEE are limited to three small cases series encompassing a total of 58 patients, in whom no bleeding events were noted. (7)(8)(9) As patients with cirrhosis are at generally higher risk of adverse procedural outcomes, including hemorrhage, (10,11) it is notable that only two studies of variceal bleeding post TEE included a comparator group. (12) A retrospective analysis of intra-operative TEE at the time of liver transplantation found no difference in blood transfusion requirements between those with or without esophageal varices, and noted a single case of overt bleeding in a patient who had undergone a prior transjugular intrahepatic portosystemic shunt (TIPS) procedure and had no varices on autopsy.…”

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confidence: 99%

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Bleeding Outcomes Following Transesophageal Echocardiography in Patients With Cirrhosis and Esophageal Varices

Sack

Zucker

2021

Hepatology Communications

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Despite scant evidence, current guidelines indicate that esophageal varices are a relative contraindication to transesophageal echocardiography (TEE). The aim of this study is to compare the risk of gastrointestinal bleeding following TEE among cirrhotic patients with and without endoscopically-documented esophageal varices. This is a retrospective analysis of patients with cirrhosis who underwent upper endoscopy within 4 years of TEE at five institutions between January 2000 and March 2020. Primary outcome was overt gastrointestinal bleeding. Secondary outcomes were hemoglobin decline by at least 2 g/dL or blood transfusion within 48 hours following TEE. Of the 191 patients, 79 (41.4%) had esophageal varices (30.4% large). No patient experienced a primary outcome. Secondary outcomes occurred in 52 (27.2%): 28 (35.4%) with esophageal varices and 24 (21.4%) without varices. After propensity-score covariate adjustment, the odds ratio for a secondary outcome in patients with esophageal varices was 1.49 (95% confidence interval 0.74-2.99). Restricting analysis to those who underwent endoscopy within 1 year of TEE did not significantly alter results. The risk of a secondary outcome was identical between patients who had upper endoscopy prior (27.5%) versus subsequent (26.7%; P = 1.00) to TEE. Conclusions: Among patients with cirrhosis, there was no overt gastrointestinal bleeding after TEE. The likelihood of a 2 g/dL decline in hemoglobin or blood transfusion within 48 hours following TEE was not significantly higher in patients with esophageal varices after controlling for confounders. Patients who underwent upper endoscopy before TEE did not manifest a lower risk of secondary outcomes versus those who had endoscopy after TEE, suggesting that routine preprocedural endoscopy is of marginal utility. (Hepatology Communications 2020;0:1-10).

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“…While a TEE is a relatively safe procedure, it nonetheless remains an invasive procedure with potential associated complications. Upper GI complications associated with probe insertion include dental trauma, tonsillar bleeding, jaw subluxation, esophageal perforation, rupture of esophageal varices [2], and splenic laceration due to deep gastric insertion of the probe [3]. Aspiration may occur in obese patients, and probe insertion has also been known to promote sympathetic and parasympathetic reflexes leading to hypertension, hypotension, tachyarrhythmias, bradyarrhythmias, and myocardial infarction [4].…”

Section: Introductionmentioning

confidence: 99%

Appropriate Use of Transesophageal Echocardiogram for Infective Endocarditis: A Single Center Experience

Singh

Naidu

Bader

et al. 2019

Cardiology Research and Practice

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Background Transesophageal echocardiogram (TEE) is a valuable tool in healthcare today with its ease of use, ability to visualize important structures not seen on transthoracic echocardiogram (TTE), and the relatively lower cost of TEE, high yield, and no significant radiation exposure. The American Society of Echocardiography (ASE) has developed an appropriate use criteria for use of TTE and TEE, which outline various scenarios where a TEE is indicated as an initial diagnostic testing modality and when it is useful as an adjunctive test in hopes of decreasing inappropriate use. Using these criteria as a guide, we devised a quality assessment study to investigate how well TEEs performed at our institution fit the appropriate use criteria specifically for the diagnostic workup of infective endocarditis. Methods A retrospective chart review was performed for all TEEs performed in 2017 with the indication of endocarditis. Baseline patient characteristics, presence of bacteremia, and the quality of the TTE preceding the TEE were noted, as well as whether a vegetation, abscess, or perforation was visualized. We also determined if there was a cardiology consultation placed prior to TEE and if the patient had met the definition for endocarditis as defined by the Duke criteria. Finally, we made note of the TEE findings and assessed whether the TEE met appropriate use criteria developed by the American Society of Echocardiography. Results A total of 50 patients who underwent TEE with the indication of “endocarditis” were identified. 36% of the TTEs prior to the TEE were rated as good quality, 40% as adequate, 4% as fair, 4% as suboptimal, 12% as technically difficult, and 4% were not rated. Vegetations were visualized on 12% of TTEs, 6% of patients had a prosthetic valve, and 6% had a cardiac device. In 20% of the cases, there was no cardiology consultation prior to the TEE and in 20% of the cases, there was no documented bacteremia. 26% of patients met the Duke criteria for endocarditis prior to TEE. Only 36% of TEEs revealed evidence of infection and of the patients with no evidence of infection, only 38% met appropriate use criteria. Overall, only 56% of patients met appropriate use criteria for TEE. Conclusion Transesophageal echocardiography is a valuable tool in a modern physician's arsenal for managing a variety of diseases and conditions. However, the procedure is not without associated risks and its ease of use and widespread adoption has led to frequent questionable appropriateness of use of the test. Only 56% of the TEEs performed in our analysis met appropriate use. More awareness and education is needed for the appropriate use criteria for transesophageal echocardiography as outlined by the ASE to help reduce patient exposure to procedure related complications and to decrease medical costs on unnecessary procedures.

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Bleeding Risk of Transesophageal Echocardiography in Patients With Esophageal Varices

Cited by 15 publications

References 11 publications

Safety of performing transoesophageal echocardiography in patients with oesophageal varices

Safety of performing transoesophageal echocardiography in patients with oesophageal varices

Bleeding Outcomes Following Transesophageal Echocardiography in Patients With Cirrhosis and Esophageal Varices

Appropriate Use of Transesophageal Echocardiogram for Infective Endocarditis: A Single Center Experience

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