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[Intraoperative transesophageal echocardiography as monitoring procedure in noncardiac surgery patients]. Anaesthesist 2021; 70:1059-1072. [PMID: 34762164 DOI: 10.1007/s00101-021-01035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 11/27/2022]
Abstract
Transesophageal echocardiography (TEE) is firmly established in cardiac surgery for diagnostics, hemodynamic monitoring and as a guiding tool. Dynamic and (patho)physiological processes of the heart can be immediately depicted. Ideally, therapeutic changes can be derived. For this reason, TEE is increasingly used in high-risk non-cardiac surgery interventions and in the interventional setting. In the first part of this advanced training series, general aspects regarding TEE examinations as well as indications and contraindications are presented. Clinical fields of application, where TEE can play a role in hemodynamic monitoring are outlined. The second part focusses on an emergency examination pathway and differential diagnoses, which can be made in the event of intraoperative hemodynamic instability or unexplained hypoxemia using TEE. The article concludes with an outlook on the use of computer-aided evaluation of TEE images.
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Hauser ND, Swanevelder J. Transoesophageal echocardiography (TOE): contra-indications, complications and safety of perioperative TOE. Echo Res Pract 2018; 5:R101-R113. [PMID: 30303686 PMCID: PMC6144934 DOI: 10.1530/erp-18-0047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Transoesophageal echocardiography (TOE) has, in certain clinical situations, become an almost universal monitor and diagnostic tool. In the perioperative environment, TOE is frequently used to guide anaesthetic management and assist with surgical decision making for, but not limited to, cardiothoracic, major vascular and transplant operations. The use of TOE is not limited to the theatre environment being frequently used in outpatient clinics, emergency departments and intensive care settings. Two case reports, one of oesophageal perforation and another of TOE utilization in a patient having previously undergone an oesophagectomy, introduce the need for care while using TOE and highlight the need for vigilance. The safe use of TOE, the potential complications and the suggested contra-indications are then considered together with suggestions for improving the safety of TOE in adult and paediatric patients.
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Affiliation(s)
- Neil David Hauser
- Department of Anaesthesia & Perioperative Medicine Groote Schuur & Red Cross Children’s Hospitals, University of Cape Town, Cape Town, South Africa
| | - Justiaan Swanevelder
- Department of Anaesthesia & Perioperative Medicine Groote Schuur & Red Cross Children’s Hospitals, University of Cape Town, Cape Town, South Africa
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Dalia AA, Flores A, Chitilian H, Fitzsimons MG. A Comprehensive Review of Transesophageal Echocardiography During Orthotopic Liver Transplantation. J Cardiothorac Vasc Anesth 2018; 32:1815-1824. [PMID: 29573952 DOI: 10.1053/j.jvca.2018.02.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Indexed: 12/14/2022]
Abstract
Orthotopic liver transplantation (OLT) is characterized by significant hemodynamic disturbances and anesthetic challenges. Intraoperative transesophageal echocardiography (TEE) can be used to guide management during these procedures. This review examines the role of echocardiography during OLT, presents common TEE findings during each phase of OLT, and discusses the benefits demonstrated with TEE use and the safety of TEE in this patient population. Finally, the authors propose an algorithm for the safe use of TEE during OLT.
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Affiliation(s)
- Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Antolin Flores
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Hovig Chitilian
- Department of Anesthesiology, Pain Medicine, and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael G Fitzsimons
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Herbold T, Chon SH, Grimminger P, Maus MKH, Schmidt H, Fuchs H, Brinkmann S, Bludau M, Gutschow C, Schröder W, Hölscher AH, Leers JM. Endoscopic Treatment of Transesophageal Echocardiography-Induced Esophageal Perforation. J Laparoendosc Adv Surg Tech A 2018; 28:422-428. [PMID: 29327976 DOI: 10.1089/lap.2017.0559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Perforation of the esophagus is the most severe complication of transesophageal echocardiography (TEE) and can lead to mediastinitis, pleural empyema, or peritonitis. Currently, the majority of patients receive operative treatment with only 6% treated endoscopically. We report our experience with endoscopic and conservative approaches. METHODS We retrospectively reviewed all patients treated for esophageal perforation and included all patients with perforation caused by TEE. All patients with perforation of the esophagus by TEE probe underwent conservative or endoscopic treatment, drainage of pleural and mediastinal retentions, and adjusted to antibiotic therapy. RESULTS From January 2004 to December 2014 a total of 109 patients were treated for esophageal perforation in our department. In 6 patients (5.5%) the perforation was caused by TEE. Location was cervical and midthoracic in 2 and 4 cases, respectively. All patients underwent successful endoscopic treatment and no further surgical procedure, such as esophageal suture or resection was necessary. The mean time between TEE and therapy of the perforation was 7.3 days. In all patients closure of the leakage could be achieved within 30 days. Mortality rate was 0%. CONCLUSIONS Esophageal perforations caused by TEE are typically small, in the cervical and mid esophagus, and minimally contaminated. These are good prognostic factors for successful endoscopic treatment with preservation of the esophagus. Operative treatment should only be considered in cases of failed endoscopic treatment.
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Affiliation(s)
- Till Herbold
- 1 Department of General-, Visceral- and Tumor-Surgery, University of Aachen , Aachen, Germany .,2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Seung-Hun Chon
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Peter Grimminger
- 3 Department of General, Visceral, and Transplant Surgery, University of Mainz , Mainz, Germany
| | - Martin K H Maus
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Henner Schmidt
- 4 Department of Visceral and Transplant Surgery, University Hospital of Zürich , Zürich, Switzerland
| | - Hans Fuchs
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Sebastian Brinkmann
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Marc Bludau
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Christian Gutschow
- 4 Department of Visceral and Transplant Surgery, University Hospital of Zürich , Zürich, Switzerland
| | - Wolfgang Schröder
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Arnulf H Hölscher
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Jessica M Leers
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
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Markin NW, Sharma A, Grant W, Shillcutt SK. The safety of transesophageal echocardiography in patients undergoing orthotopic liver transplantation. J Cardiothorac Vasc Anesth 2015; 29:588-93. [PMID: 25622974 DOI: 10.1053/j.jvca.2014.10.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the safety of transesophageal echocardiography for the evaluation and intraoperative monitoring of patients during orthotopic liver transplantation. DESIGN Retrospective observational study. SETTING Tertiary care, university teaching hospital. PARTICIPANTS Patients (n = 116) who underwent intraoperative transesophageal echocardiography during liver transplantation. INTERVENTIONS Intraoperative transesophageal echocardiography during liver transplantation. MEASUREMENTS AND MAIN RESULTS The authors evaluated the safety of intraoperative transesophageal echocardiography in patients undergoing liver transplantation through a retrospective chart review. Complications associated with transesophageal echocardiography use were divided into minor and major complications. Out of 116 patients who underwent intraoperative transesophageal echocardiography, there was one minor and one major complication. The major complication rate was 0.86% (1/116) and the overall complication rate was 1.7% (2/116). There was no statistically significant correlation between pre-transplant sclerotherapy for treatment of varices and intraoperative transesophageal echocardiography-related gastrointestinal bleeding. Although the reported complication rate is higher than what has been quoted in the cardiac literature, intraoperative transesophageal echocardiography during liver transplantation has a low complication rate. CONCLUSIONS Intraoperative transesophageal echocardiography is a relatively safe method of monitoring cardiac performance in liver transplant patients.
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Affiliation(s)
| | | | - Wendy Grant
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Sainathan S, Andaz S. A Systematic Review of Transesophageal Echocardiography-Induced Esophageal Perforation. Echocardiography 2013; 30:977-83. [DOI: 10.1111/echo.12290] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Sandeep Sainathan
- Department of Thoracic Surgery; Bronx-Lebanon Hospital Center; Bronx; New York
| | - Shahriyour Andaz
- Department of Thoracic Surgery; South Nassau Communities Hospital; Oceanside; New York
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Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr 2011; 23:1115-27; quiz 1220-1. [PMID: 20864313 DOI: 10.1016/j.echo.2010.08.013] [Citation(s) in RCA: 312] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Indexed: 01/09/2023]
Abstract
Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.
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Affiliation(s)
- Jan N Hilberath
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Smyth K, Hebballi R, Peterson MK. Use of transoesophageal echocardiography during the peri-operative period for trauma patients. J ROY ARMY MED CORPS 2011; 156:373-9. [PMID: 21302659 DOI: 10.1136/jramc-156-04s-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The medical facility at Camp Bastion continues to evolve as a consequence of the increased throughput of battlefield trauma patients. There is a requirement for rapid and accurate diagnosis of haemodynamic instability and continued haemodynamic monitoring throughout the peri-operative period. Transoesophageal echocardiography (TOE) has been used for this purpose in the arena of cardiac anaesthesia since the mid 1980s. It is being introduced to other peri-operative settings where severe haemodynamic instability is expected. The old proverb: 'There are none so blind as those who cannot see' (Jeremiah 5:21) is applicable to this topic, in that TOE is proven to be a rapid, portable, safe and effective tool in the assessment of the haemodynamically unstable patient. This paper explores the application of TOE for the assessment of the major causes of haemodynamic instability in the trauma population.
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Affiliation(s)
- K Smyth
- Royal Air Force, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester
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9
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Gastric bleeding detected by transesophageal echocardiography during cardiopulmonary bypass. J Anesth 2010; 24:110-3. [DOI: 10.1007/s00540-009-0825-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 07/22/2009] [Indexed: 11/24/2022]
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10
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Côté G, Denault A. Transesophageal echocardiography-related complications. Can J Anaesth 2008; 55:622-47. [DOI: 10.1007/bf03021437] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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11
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Ayres NA, Miller-Hance W, Fyfe DA, Stevenson JG, Sahn DJ, Young LT, Minich LL, Kimball TR, Geva T, Smith FC, Rychik J. Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease. J Am Soc Echocardiogr 2005; 18:91-8. [PMID: 15637497 DOI: 10.1016/j.echo.2004.11.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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12
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Aviv JE, Di Tullio MR, Homma S, Storper IS, Zschommler A, Ma G, Petkova E, Murphy M, Desloge R, Shaw G, Benjamin S, Corwin S. Hypopharyngeal Perforation Near-Miss During Transesophageal Echocardiography. Laryngoscope 2004; 114:821-6. [PMID: 15126737 DOI: 10.1097/00005537-200405000-00006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES/HYPOTHESIS The traditional blind passage of a transesophageal echocardiography probe transorally through the hypopharynx is considered safe. Yet, severe hypopharyngeal complications during transesophageal echocardiography at several institutions led the authors to investigate whether traditional probe passage results in a greater incidence of hypopharyngeal injuries when compared with probe passage under direct visualization. STUDY DESIGN Randomized, prospective clinical study. METHODS In 159 consciously sedated adults referred for transesophageal echocardiography, the authors performed transesophageal echocardiography with concomitant transnasal videoendoscopic monitoring of the hypopharynx. Subjects were randomly assigned to receive traditional (blind) or experimental (optical) transesophageal echocardiography. The primary outcome measure was frequency of hypopharyngeal injuries (hypopharyngeal lacerations or hematomas), and the secondary outcome measure was number of hypopharyngeal contacts. RESULTS No perforation occurred with either technique. However, hypopharyngeal lacerations or hematomas occurred in 19 of 80 (23.8%) patients with the traditional technique (11 superficial lacerations of pyriform sinus, 1 laceration of pharynx, 12 arytenoid hematomas, 2 vocal fold hematomas, and 1 pyriform hematoma) and in 1 of 79 patients (1.3%) with the optical technique (superficial pyriform laceration) (P =.001). All traumatized patients underwent flexible laryngoscopy, but none required additional intervention. Respectively, hypopharyngeal contacts were more frequent with the traditional than with the optical technique at the pyriform sinus (70.0% vs. 10.1% [P =.001]), arytenoid (55.0% vs. 3.8% [P =.001]), and vocal fold (15.0% vs. 3.86% [P =.016]). CONCLUSION Optically guided trans-esophageal echocardiography results in significantly fewer hypopharyngeal injuries and fewer contacts than traditional, blind transesophageal echocardiography. The optically guided technique may result in decreased frequency of potentially significant complications and therefore in improved patient safety.
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Affiliation(s)
- Jonathan E Aviv
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Medical Center, New York-Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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Eltzschig HK, Kallmeyer IJ, Mihaljevic T, Alapati S, Shernan SK. A practical approach to a comprehensive epicardial and epiaortic echocardiographic examination. J Cardiothorac Vasc Anesth 2003; 17:422-9. [PMID: 12968228 DOI: 10.1016/s1053-0770(03)00145-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE More than a decade before the introduction of intraoperative transesophageal echocardiography (TEE), epicardial echocardiography was already in use as a diagnostic imaging modality to assist cardiac surgeons and anesthesiologists with clinical decision making. Although TEE has since become increasingly more popular, epicardial echocardiography may be the most convenient intraoperative imaging technique when TEE probe placement cannot be performed or is contraindicated. The authors developed a comprehensive examination protocol for the intraoperative interrogation of cardiac structures using an epicardial/epiaortic echocardiographic approach. DESIGN Retrospective analysis of patient's medical records. SETTING Single-center academic tertiary care hospital. PARTICIPANTS Patients undergoing cardiac surgery. INTERVENTIONS A total of 10 echocardiographic views were obtained for imaging cardiac structures, the ascending aorta, and proximal aortic arch. The described imaging planes permit the evaluation of ventricular performance, valvular function, cardiac structural abnormalities, and aortic disease. MEASUREMENTS AND MAIN RESULTS A comprehensive epicardial/epiaortic echocardiographic examination was performed in 20 patients undergoing cardiac surgery requiring a full sternotomy. The described imaging planes were obtained in all patients in less than 8 minutes (range, 3.5-8 minutes; mean, 5.5 minutes). CONCLUSION The present manuscript delineates a protocol for performing a comprehensive, intraoperative epicardial/epiaortic echocardiographic examination. Echocardiographic imaging planes of cardiac and aortic anatomy are described. This protocol may be useful for cardiac surgeons and anesthesiologists seeking to use this technique as a cardiac imaging modality that is complementary to TEE.
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Affiliation(s)
- Holger K Eltzschig
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Abstract
OBJECTIVE To evaluate the safety and utility of transesophageal echocardiography performed by intensive care physicians in critically ill patients. DESIGN Retrospective chart review. SETTING A 24-bed multidisciplinary adult intensive care unit in a 692-bed tertiary referral teaching hospital. PATIENTS Two hundred fifty-five intensive care patients. INTERVENTIONS We studied 255 consecutive intensive care patients who underwent transesophageal echocardiography between January 1996 and January 2000. MEASUREMENTS AND MAIN RESULTS Three hundred eight transesophageal echocardiography studies were successfully performed; the probe could not be passed in one patient with a cervical fracture. The indications included unexplained hypotension (40%), known or suspected endocarditis (27%), assessment of ventricular function (15%), pulmonary edema (5%), source of embolus (4%), assessment of aorta (4%), and other (5%). In 67% of hypotensive patients, transesophageal echocardiography revealed the cause of hemodynamic instability, leading to a management change and improvement in blood pressure in 31%. This included surgery in 22% without the need for additional tests. Overall, transesophageal echocardiography findings led to a significant change in management in 32% of all studies performed. One patient receiving continuous positive airways pressure suffered pulmonary aspiration during tracheal intubation before transesophageal echocardiography, two patients had hypotension associated with sedative medication, and there was one case of oropharyngeal bleeding after probe insertion. CONCLUSION Transesophageal echocardiography when performed by intensive care physicians is a safe procedure and provides useful information for the evaluation and management of critically ill patients.
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Law-Koune JD, Fischler M. [A new case of perforation of the esophagus during intraoperative transesophageal echocardiography]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:310-4. [PMID: 12033101 DOI: 10.1016/s0750-7658(02)00594-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We describe a novel case of peroperative oesophageal perforation following insertion of a transoesophageal echocardiography probe. Histories of left pneumonectomy and oesophageal fragility probably explained this complication. The perforation was stitched and the coronary artery bypass graft surgery was delayed by a few days. Early postoperative period was not marked by infectious complication but the patient could not weaned from ventilatory support. She died 6 months later.
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Affiliation(s)
- J D Law-Koune
- Service d'anesthésie, hôpital Foch, 92151 Suresnes, France
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Lecharny JB, Philip I, Depoix JP. Oesophagotracheal perforation after intraoperative transoesphageal echocardiography in cardiac surgery. Br J Anaesth 2002; 88:592-4. [PMID: 12066741 DOI: 10.1093/bja/88.4.592] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although transoesophageal echocardiography (TOE) can be considered a safe procedure, severe complications may occur. We report an oesophagotracheal perforation diagnosed 7 days after a complex and very long four-valve replacement procedure in a patient with a poor preoperative condition. We believe that an ischaemic lesion of the oesophagotracheal wall caused by the TOE probe was the initial event leading to this perforation. This observation raises concerns about the safety of prolonged TOE monitoring and suggests that a combination of risk factors (i.e. a small stature, a very long procedure, congestive heart failure, and a low cardiac output before and after cardiopulmonary bypass) may warrant increased precautions while performing TOE during cardiac surgery.
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Affiliation(s)
- J B Lecharny
- Service d'Anesthésiologie et Réanimation Chirurgicale, Hôpital Bichat-Claude Bernard, Paris, France
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Greim CA, Trautner H, Krämer K, Zimmermann P, Apfel CC, Roewer N. The detection of interatrial flow patency in awake and anesthetized patients: a comparative study using transnasal transesophageal echocardiography. Anesth Analg 2001; 92:1111-6. [PMID: 11323330 DOI: 10.1097/00000539-200105000-00006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED The Valsalva maneuver in the awake patient and the ventilation maneuver in the tracheally intubated anesthetized patient are two provocation methods to detect a patent foramen ovale (PFO) by means of contrast transesophageal echocardiography. In 60 patients undergoing posterior fossa surgery, a contrast agent was administered via a peripheral vein during a Valsalva maneuver immediately before anesthesia induction, followed by central venous administration during a ventilation maneuver in the same patients when anesthetized and endotracheally intubated. We evaluated both maneuvers with a 32-element monoplane transnasal transesophageal echocardiography probe to trace the atrial flow of the contrast agent in a 90 degrees bicaval view. A maneuver was rated positive when more than four bubbles appeared in the left atrium during the first three cardiac cycles after intrathoracic pressure release. The right atrial cross-sectional area before pressure release, and the peak septal excursion during atrial contrast opacification, were measured. McNemar's test was used to assess a paired dichotomous response on the two maneuvers for a significant difference. In 56 patients, the ventilation maneuver was significantly (P < 0.037) more often positive for PFO (n = 14) than the Valsalva maneuver (n = 7). Although there was no difference in the methods regarding the peak septal excursion, the mean right atrial area before pressure release was significantly smaller during the ventilation maneuver than during the Valsalva maneuver (11.2 +/- 3.1 cm(2) vs 14.4 +/- 3.3 cm(2), n = 42, P < 0.05). In the patients with a positive ventilation, but a negative Valsalva maneuver, the discrepancy was even larger (10.9 +/- 4.4 cm(2) vs 16.3 +/- 4.2 cm(2), n = 7, P < 0.001). We conclude that the ventilation maneuver is superior to the Valsalva maneuver in detecting PFO. Our data suggest that a peak pressure of 30 cm H(2)O during the ventilation maneuver achieves a more pronounced reduction in right atrial load and allows right atrial pressure to exceed left atrial pressure when intrathoracic pressure is released. IMPLICATIONS A controlled ventilation maneuver in anesthetized patients immediately before posterior fossa surgery may be superior to the preoperative Valsalva maneuver in detecting a patent foramen ovale by contrast transesophageal echocardiography. This approach identifies patients at high risk for paradoxic embolism, but it is not practical for preoperative identification of patients who might benefit from patent foramen ovale closure before surgery.
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Affiliation(s)
- C A Greim
- Department of Anesthesiology, University Hospital Würzburg, Josef-Schneider-Str. 2, 97080 Würzburg, Germany.
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Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg 2001; 92:1126-30. [PMID: 11323333 DOI: 10.1097/00000539-200105000-00009] [Citation(s) in RCA: 300] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
UNLABELLED Transesophageal echocardiography (TEE) is an invaluable intraoperative diagnostic monitor that is considered to be relatively safe and noninvasive. Insertion and manipulation of the TEE probe, however, may cause oropharyngeal, esophageal, or gastric trauma. We report the incidence of intraoperative TEE-associated complications in a single-center series of 7200 adult cardiac surgical patients. Information related to intraoperative TEE-associated complications was obtained retrospectively from the intraoperative TEE data form, routine postoperative visits, and cardiac surgical morbidity and mortality data. The overall incidences of TEE-associated morbidity and mortality in the study population were 0.2% and 0%, respectively. The most common TEE-associated complication was severe odynophagia, which occurred in 0.1% of the study population. Other complications included dental injury (0.03%), endotracheal tube malpositioning (0.03%), upper gastrointestinal hemorrhage (0.03%), and esophageal perforation (0.01%). TEE probe insertion was unsuccessful or contraindicated in 0.18% and 0.5% of the study population, respectively. These data suggest that intraoperative TEE is a relatively safe diagnostic monitor for the management of cardiac surgical patients. IMPLICATIONS The overall morbidity (0.2%) and mortality (0%) rates of intraoperative transesophageal echocardiography (TEE) were determined in a retrospective case series of 7200 adult, anesthetized cardiac surgical patients. The most common source of TEE-associated morbidity was odynophagia (0.1%), which resolved with conservative management. These results suggest that TEE is a safe diagnostic tool for the management of cardiac surgical patients.
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Affiliation(s)
- I J Kallmeyer
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Kallmeyer I, Morse DS, Body SC, Collard CD. Case 2-2000. Transesophageal echocardiography-associated gastrointestinal trauma. J Cardiothorac Vasc Anesth 2000; 14:212-6. [PMID: 10794346 DOI: 10.1016/s1053-0770(00)90022-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- I Kallmeyer
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999. [DOI: 10.1213/00000539-199910000-00010] [Citation(s) in RCA: 436] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quiñones MA, Cahalan MK, Savino JS. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999; 89:870-84. [PMID: 10512257 DOI: 10.1097/00000539-199910000-00010] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J S Shanewise
- Division of Cardiac Anesthesia and Critical Care, Emory University School of Medicine, Atlanta, Georgia, USA
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Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quiñones MA, Cahalan MK, Savino JS. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999; 12:884-900. [PMID: 10511663 DOI: 10.1016/s0894-7317(99)70199-9] [Citation(s) in RCA: 233] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- J S Shanewise
- American Society of Echocardiography, Raleigh, NC 27607, USA
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23
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Greim CA, Brederlau J, Kraus I, Apfel C, Thiel H, Roewer N. Transnasal Transesophageal Echocardiography. Anesth Analg 1999. [DOI: 10.1213/00000539-199902000-00015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Greim CA, Brederlau J, Kraus I, Apfel C, Thiel H, Roewer N. Transnasal transesophageal echocardiography: a modified application mode for cardiac examination in ventilated patients. Anesth Analg 1999; 88:306-11. [PMID: 9972746 DOI: 10.1097/00000539-199902000-00015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED In 42 endotracheally intubated patients, we examined the utility of a miniaturized monoplane probe for transnasal transesophageal echocardiography (TEE). Transnasal TEE was prospectively evaluated in 26 deeply and 16 mildly sedated patients receiving topical anesthesia with lidocaine jelly 2%. The patients with deep sedation were additionally examined with transoral monoplane and multiplane TEE. Transnasal esophageal insertion of the TEE probe was successfully performed in 90% of patients. Endotracheal malpositioning was corrected in two patients. Nasal bleeding required treatment in another patient. Topical anesthesia was adequate in 82% of mildly sedated patients. Left ventricular short- and four-chamber long-axis views of good quality were obtained with transnasal (transoral) monoplane TEE in 76% (81%) and 92% (96%) of patients (differences not significant). Compared with conventional multiplane TEE, transnasal monoplane TEE missed diagnoses in 19% of patients. The relative error (mean +/- SEM) of quantification with transnasal TEE was <9% +/- 2% for ventricular diameters and <7% +/- 2% for cross-sectional area measurements, with a bias of 0.5 +/- 3.8 cm2 and 0.1 +/- 2.4 cm2 (mean +/- 2 SD) for left ventricular end-diastolic and end-systolic short-axis areas. The relative error in measuring intracardiac flow velocities was >40%, but systolic to diastolic peak velocity ratios at the valvular site were determined with an error <4% +/- 3%. Transnasal monoplane TEE can be performed even in mildly sedated patients with an endotracheal tube without further need for analgesia or sedation. The technique is as useful as conventional transoral TEE to image standard tomographic planes for quantification, but it is less suited for comprehensive echocardiographic diagnosing. IMPLICATIONS Transnasal insertion of a miniaturized monoplane transesophageal echocardiography (TEE) probe was studied in endotracheally intubated patients. Nasal passage was well tolerated even by patients with only mild sedation. Imaging quality was similar to conventional transoral monoplane TEE with larger transducers, but technical restraints cause a deficit in complete cardiac diagnosing obtained with multiplane TEE.
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MESH Headings
- Anatomy, Cross-Sectional
- Anesthesia, Intravenous
- Anesthesia, Local
- Anesthetics, Local/administration & dosage
- Bias
- Blood Flow Velocity/physiology
- Cardiac Output/physiology
- Echocardiography
- Echocardiography, Transesophageal/adverse effects
- Echocardiography, Transesophageal/instrumentation
- Echocardiography, Transesophageal/methods
- Epistaxis/etiology
- Equipment Design
- Female
- Heart Valves/diagnostic imaging
- Humans
- Hypnotics and Sedatives/administration & dosage
- Intubation, Intratracheal
- Lidocaine/administration & dosage
- Male
- Middle Aged
- Miniaturization
- Nose
- Prospective Studies
- Respiration, Artificial
- Sensitivity and Specificity
- Transducers
- Ventricular Function, Left
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Affiliation(s)
- C A Greim
- Department of Anesthesiology, Julius-Maximilians-Universität, Würzburg, Germany.
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St-Pierre J, Fortier LP, Couture P, Hébert Y. Massive gastrointestinal hemorrhage after transoesophageal echocardiography probe insertion. Can J Anaesth 1998; 45:1196-9. [PMID: 10051939 DOI: 10.1007/bf03012463] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To describe a case of a massive gastric bleeding following emergency coronary artery bypass surgery associated with transoesophageal echocardiographic (TEE) examination. CLINICAL FEATURES A 50-yr-old man was referred for an acute myocardial infarction and pulmonary edema (Killip class 3). Twelve hours after his myocardial infarction, he was still having chest pain despite an i.v. heparin infusion. Coronary angiography revealed severe three-vessel disease with multifocal stenosis of the left anterior descending, circumflex and total occlusion of the right coronary artery. The patient was transferred to the operating room for emergency coronary artery bypass graft surgery. After total systemic heparinization (3 mg.kg-1) was obtained for cardiopulmonary bypass, a multiplane TEE probe was inserted without difficulty to monitor myocardial contractility during weaning from CPB. During sternal closure, the TEE probe was removed and an orogastric tube was inserted with immediate drainage of 1,200 ml red blood. Endoscopic examination demonstrated a mucosal tear near the gastro-oesophageal junction and multiple erosions were seen in the oesophagus. These lesions were successfully treated with submucosal epinephrine injections and the patient was discharged from the hospital eight days after surgery. CONCLUSION This is a report of severe gastrointestinal hemorrhage following TEE examination in a fully heparinized patient. This incident suggest that, if the use of TEE is expected, the probe should preferably be inserted before the administration of heparin and the beginning of CPB.
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Affiliation(s)
- J St-Pierre
- Department of Anaesthesia and Cardiac Surgery, Montreal Heart Institute, Quebec, Canada
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Chow MS, Taylor MA, Hanson CW. Splenic laceration associated with transesophageal echocardiography. J Cardiothorac Vasc Anesth 1998; 12:314-6. [PMID: 9636915 DOI: 10.1016/s1053-0770(98)90013-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- M S Chow
- Department of Anesthesia, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104-4283, USA
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27
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Saphir JR, Cooper JA, Kerbavez RJ, Larson SF, Schiller NB. Upper airway obstruction after transesophageal echocardiography. J Am Soc Echocardiogr 1997; 10:977-8. [PMID: 9440076 DOI: 10.1016/s0894-7317(97)80015-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although transesophageal echocardiography is considered a generally safe procedure, occasional complications have been reported. Serious esophageal trauma and Mallory Weiss tear have been described, as well as post-transesophageal echocardiography dysphagia. However, to our knowledge, upper airway and esophageal obstruction have not been previously cited. A case of upper airway obstruction resulting from a transesophageal echocardiography procedure is herein detailed.
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Affiliation(s)
- J R Saphir
- Alta Bates Medical Center, Berkeley, CA 94705-2067, USA
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Suriani RJ, Cutrone A, Feierman D, Konstadt S. Intraoperative transesophageal echocardiography during liver transplantation. J Cardiothorac Vasc Anesth 1996; 10:699-707. [PMID: 8910147 DOI: 10.1016/s1053-0770(96)80193-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the safety, value, and impact of transesophageal echocardiography during liver transplantation. DESIGN Retrospective. SETTING University teaching hospital. PARTICIPANTS AND INTERVENTIONS The medical records of 346 patients and the videotapes of 100 intraoperative transesophageal echocardiography examinations were reviewed. MEASUREMENTS AND MAIN RESULTS Transesophageal echocardiography was indicated for intraoperative monitoring in 62 patients, 41 of whom had pertinent findings, and for diagnostic purposes in 38 patients, 14 of whom had the expected diagnosis verified. Thirty-one patients had no intraoperative findings. Information that would not have been detected intraoperatively by other means included intracardiac defects, the potential for transpulmonary air passage, valvular regurgitation, the presence or absence of ventricular dysfunction, and embolization occurring at allograft reperfusion. Unanticipated findings during the initial transesophageal echocardiography examination as well as evaluation of intraoperative events resulted in a major impact on patient management in 11% of patients. Preoperatively, 64 patients had a prothrombin time greater than 14 seconds; 56 had a platelet count less than 100,000/mm3; and 23 had esophageal varices, 7 of whom had not had variceal sclerotherapy. Two patients had a complication possibly caused by transesophageal echocardiography (sinus bradycardia and upper gastrointestinal bleeding). No patient experienced documented variceal hemorrhage, esophageal or gastric perforation, and/or oropharyngeal trauma. CONCLUSIONS It appears that transesophageal echocardiography can be performed safely in patients undergoing liver transplantation, is efficacious in rapidly disclosing new information and monitoring during periods of hemodynamic instability, and may have a significant impact on intraoperative patient management during liver transplantation.
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Affiliation(s)
- R J Suriani
- Department of Anesthesiology, Mount Sinai Medical Center, New York, NY, USA
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Hogue CW, Lappas GD, Creswell LL, Ferguson TB, Sample M, Pugh D, Balfe D, Cox JL, Lappas DG. Swallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg 1995; 110:517-22. [PMID: 7637370 DOI: 10.1016/s0022-5223(95)70249-0] [Citation(s) in RCA: 136] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The frequency, importance to patient outcomes, and independent predictors of postoperative swallowing dysfunction documented by barium cineradiography were examined in 869 patients undergoing cardiac operations over a 12-month period. Swallowing dysfunction was diagnosed in 34 patients (4% incidence) and was associated with documented pulmonary aspiration in 90% of these patients, increased frequency of pneumonia (p < 0.0001), need for tracheostomy (p = 0.0002), length of stay in the intensive care unit (p = 0.0001), and duration of hospitalization after the operation (p = 0.0001). Independent predictors of postoperative swallowing dysfunction determined by multivariate logistic regression included age (p < 0.001), length of tracheal intubation after the operation (p = 0.001), and intraoperative use of transesophageal echocardiography (p = 0.003). Dysfunctional swallowing after cardiac operations, a serious complication significantly related to postoperative respiratory morbidity and extended length of hospitalization, is more common in older patients. An association between intraoperative use of transesophageal echocardiography and swallowing dysfunction was also observed in our patients.
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Affiliation(s)
- C W Hogue
- Department of Radiology, Washington University School of Medicine, St. Louis, Mo., USA
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Badaoui R, Choufane S, Riboulot M, Bachelet Y, Ossart M. [Esophageal perforation after transesophageal echocardiography]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1994; 13:850-2. [PMID: 7668425 DOI: 10.1016/s0750-7658(05)80924-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Transoesophageal echocardiography (TOE) is increasingly used in cardiology, cardiac surgery and intensive care. Its complications are rare. We report a case of perforation of the oesophagus after TOE in a 71-year-old woman, scheduled for an elective aortic valve replacement. Her medical history included arterial hypertension but no pre-existing oesophageal disease. A Hewlett Packard ultrasound imaging system was used, with a 5 MHz single plane probe. After local anaesthesia, the transducer probe was inserted into the distal oesophagus, after three attempts, without any apparent incident. A few hours later, the patient complained of acute cervical and dorsal pain. Examination showed severe skin emphysema in of neck, but neither breathing difficulties, nor haemodynamic modifications. The EKG was normal and body temperature at 38.8 degrees C. The opacification of the oesophagus showed a passage of the contrast medium into the mediastinum. Emergency surgical exploration by left cervicotomy showed a perforation of 2 to 3 cm of the posterior wall of oesophagus, treated with terminal oesophagostomy and drainage. The pressure by the TOE probe on the oesophagus may explain this perforation. The outcome was uneventful. Although TOE is a semi-invasive technique with a low risks its benefit/risk ratio should be considered in each patients before using it.
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Affiliation(s)
- R Badaoui
- Service d'Anesthésiologie, CHU Nord, Amiens
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