Complications related to peri‐operative transoesophageal echocardiography – a one‐year prospective national audit by the Association of Cardiothoracic Anaesthesia and Critical Care

Abstract

Summary Previous studies on the safety of peri‐operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. That said, there has been a paucity of prospective multicentre studies in this important area of clinical practice. We carried out a one‐year prospective study in 2017, co‐ordinated by the Association of Cardiothoracic Anaesthesia and Critical Care, to determine the rate and severity of complications associated with peri‐operative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients. With the help of clinicians from 28 centres across the UK and Ireland, we recorded the total number of examinations conducted in anaesthetised patients during the study period. All major complications at each centre were prospectively reported and recorded. Of the 22,314 examinations, there were 17 patients diagnosed with a major complication which caused either palatal injury or gastro‐oesophageal disruption. This corresponds to an incidence of 0.08% (95%CI 0.05–0.13%) or approximately 1:1300 examinations. There were seven deaths reported during the study period which were directly attributed to these complications, corresponding to an incidence of 0.03% (95%CI 0.01–0.07%) or approximately 1:3000. These figures are higher than previously reported and suggest a high probability of death following the development of a complication (~40%). Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro‐oesophageal injury. We suggest clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.

Esophageal Perforation with Transesophageal Echocardiography in an Elderly Patient with Prominent Vertebral Osteophytes: A Case Report and a Review of the Literature

“…[1][2][3][4] Although it is an uncommon complication, esophageal perforation is associated with prolonged hospitalization and a mortality rate of 40%. 1 Risk factors associated with esophageal perforation include, but are not limited to, preexisting esophageal pathologies such as esophageal stricture, Zenker's diverticulum, fibrosis from prior chest radiation, and ulceration caused by medication. Severe cardiomegaly 5 and large calcified lymph nodes 6 have been reported as rare causes of esophageal perforation.…”

“…Iatrogenic esophageal perforation caused by transesophageal echocardiography (TEE) is a rare event with an associated high mortality rate. 1 Compression of the esophagus by vertebral osteophytes is currently not a contraindication to TEE according to practice guidelines. 2 We present the case of an elderly patient who developed an esophageal perforation after TEE secondary to prominent thoracic vertebral osteophytes compressing the esophagus during a transcatheter aortic valve replacement (TAVR) procedure.…”

Safety and feasibility of transesophageal echocardiography in patients with prior esophageal surgery

“…Due to the close proximity of the esophagus to posterior cardiac structures, TEE provides visualization that may not be possible with transthoracic echocardiography 1,2 . Despite its many advantages, TEE is moderately invasive and has been associated with rare but serious complications including, but not limited to, esophageal perforation, gastrointestinal bleeding, and pharyngeal hematoma 3–8 …”

Letter in reply to Gianni et al on “Prevention, diagnosis, and management of atrioesophageal fistula”

“…The limitations of mechanical deviation of the esophagus is obvious: mechanical manipulation of the esophagus may be harmful as indicated by a recent study showing that transoesophageal echocardiography (TOE) probe-related mortality occurred one in 3000 general anesthetic cardiac surgery/procedural cases. 5 The authors share and discuss their current ablation practice, which is the case for most operators worldwide, when it comes to ablation of the posterior wall. There is caution in the amount of force applied, power used, and a start-stop technique may be deployed in situations where there is a rise in esophageal temperature.…”

“…It remains to be seen whether esophageal cooling can provide sufficient protection to eliminate AEF, but it is an attractive approach. The limitations of mechanical deviation of the esophagus is obvious: mechanical manipulation of the esophagus may be harmful as indicated by a recent study showing that transoesophageal echocardiography (TOE) probe‐related mortality occurred one in 3000 general anesthetic cardiac surgery/procedural cases 5 …”