TRANSESOPHAGEAL echocardiography (TEE) is an integral tool for intraoperative monitoring and diagnosis in patients undergoing cardiac surgery.1TEE remains a moderately invasive procedure with a very low incidence of complications, ranging from 0.2% to 1.2%.2,3The spectrum of complications has included injury to the gastrointestinal tract, obstruction of airways, dysrhythmias, hemorrhage, or entrapment of other upper airway tubes.2–6 

A common concern is that placement of the TEE probe in the anesthetized patient eliminates signs of severe patient discomfort that might herald or result from damage to gastrointestinal tissues. Consequently, contraindications to insertion of a TEE probe have included extensive esophageal disease, such as strictures, masses, diverticula, or untreated varices, as well as recent gastric hemorrhage, ulcers, masses, or symptomatic hiatal hernias. A history of preexisting esophageal or gastric disorder usually alerts physicians to avert complications. We report a case involving delayed presentation of gastric perforation at a rare site by TEE probe after cardiac surgery.

An 83-yr-old man was transferred to our institution with substernal chest pain. The initial workup revealed myocardial infarction and a coronary angiogram that showed significant three-vessel disease. A transthoracic echocardiogram revealed left-ventricular hypertrophy, a left-ventricular ejection fraction of 45%, and posterolateral akinesis.

The patient’s medical history was significant for hypertension, atrial fibrillation, transient ischemic attacks, and prostatectomy. Medications before hospitalization included aspirin, atenolol, amlodipine, and benazepril, all of which were continued in the Cardiovascular Intensive Care Unit. A heparin infusion was started for his coronary occlusive disease, and esomeprazole was added for stress ulcer prophylaxis.

The patient was brought to the operating room for coronary revascularization. After induction of general anesthesia and tracheal intubation, an adult omniplane TEE probe (Omni III 21378A; Philips Medical Systems, Andover, MA) was inserted without difficulty. Imaging studies were easily obtained by both the resident and attending anesthesiologists. Three-vessel coronary artery bypass grafting, radiofrequency pulmonary vein isolation, and left atrial appendage stapling were performed, with an aortic cross-clamp time of 73 min and a cardiopulmonary bypass time of 103 min. The TEE probe remained in situ  a total of 5 h, for the duration of the operation. Upon completion of surgery, the probe was removed without difficulty, with the tip in neutral position. Postoperatively, the patient was brought intubated and sedated to the Cardiovascular Intensive Care Unit.

On the second postoperative day, a routine chest radiograph showed significant pneumoperitoneum, which had not been present on previous studies. However, because the patient was asymptomatic and tolerating clear liquids, this finding was attributed to inadvertent intraoperative diaphragmatic injury, which had become radiographically evident only after removal of mediastinal drainage tubes. On the third postoperative day, the patient grew progressively disoriented. He also developed hypotension unresponsive to fluid resuscitation, eventually requiring vasopressin infusion. Despite continued absence of fever, anemia, leukocytosis, or abdominal pain, computed tomography of the abdomen demonstrated gross extravasation of oral contrast from the proximal stomach.

Broad-spectrum antimicrobials (ampicillin/sulbactam, metronidazole, and fluconazole) were started, and the patient was urgently taken to the operating room for laparotomy. Exploration revealed a 2-cm perforation at the lesser curvature of the stomach, near the gastroesophageal junction. The surrounding margins were clean, with minimal bleeding and no signs of ulceration or chronic granulation. The perforation was repaired with an omental patch, and a jejunostomy tube was inserted. The patient’s postlaparotomy course was protracted, including mechanical ventilation for an additional 6 days and a total intensive care unit stay of 12 days. He subsequently developed intraabdominal sepsis, acute renal failure, and cognitive dysfunction, dying after 27 hospital days.

Complications related to TEE use in cardiac surgery are infrequent, with upper gastrointestinal injury occurring in 0.04% to 1.2% of cases.2,3Bleeding is the typical presentation, diagnosed either upon withdrawal of the TEE probe or after finding anemia refractory to transfusion. Gastric perforation from TEE is an exceedingly rare event. In two studies reviewing data on a sum of more than 20,000 procedures, including patients undergoing TEE with conscious sedation, there were no incidents of gastric perforation.4,5Kallmeyer et al.  2examined the complication rate in a series of 7,200 cardiac surgical patients and found gastrointestinal injury in 0.1%, the most severe of which resulted in esophageal perforation leading to hydropneumothorax. Esophageal abrasions and bleeding were the more common of the remaining complications.2More recently, Lennon et al.  3reported six cases of “major gastrointestinal injury” in a series of 859 cardiac surgical patients, including three incidents of perforation at the cardia.

Our case involved a late and unusual presentation of perforation near the gastroesophageal junction, in a patient without underlying gastrointestinal pathology. Because benign pneumoperitoneum after cardiac surgery is not uncommon,7it was only after the patient’s clinical condition had deteriorated that computed tomography and subsequent laparotomy were performed. Based on the gross appearance of surrounding gastric tissue during laparotomy, the surgeon concluded that the injury was likely to have resulted from the TEE probe. The location and lack of underlying pathology were inconsistent with perforation from peptic ulcer disease.8 

Transesophageal echocardiography can lead to upper gastrointestinal injury from a combination of two mechanisms.6Mechanical trauma may occur during probe insertion or manipulation, with upper esophageal injury being more common than lower esophageal or gastric.5Alternatively, sustained contact between probe and esophagus, as frequently occurs during cardiac surgery, can lead to pressure on the surrounding tissues, with the potential for ischemia and thermal injury.6,9Based on the operative findings, we suspect that the former mechanism was responsible for gastric perforation in our case.

Complications from TEE use are rare but potentially severe. The late and uncommon presentation of this case, in the context of previously reported incidents of trauma from TEE, underscores the need for a high index of suspicion after cardiac surgery. Postoperative complaints of dysphagia or odynophagia, as well as evidence of leukocytosis, fever, refractory anemia, or pneumoperitoneum, should be thoroughly investigated, even if significant time has elapsed between TEE and presentation.

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