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Complications of Transesophageal Echocardiography: A Review of Injuries, Risk Factors, and Management

Published:February 12, 2022DOI:https://doi.org/10.1053/j.jvca.2022.02.015
      Transesophageal echocardiography (TEE) use has become widespread in cardiac surgical operating rooms over the last 2 decades. Surgical and medical decision-making often are guided by the findings of the TEE examination, rendering TEE an invaluable tool both inside and outside the operating room. TEE has become ubiquitous in some parts because it is considered safe and relatively noninvasive. However, it is imperative for clinicians to understand that TEE can cause severe and possibly life-threatening complications, and the risks of TEE must be balanced against its benefits as a diagnostic tool. Upper gastrointestinal (UGI) injuries are the most commonly described complications of TEE; however, the relative infrequency of injuries and lack of uniform reporting make it difficult to definitively identify potential risk factors. Some large retrospective trials suggested that patient factors (age, body mass index, anatomic abnormalities), comorbid conditions (previous stroke), and procedural variables (procedure time, cardiopulmonary bypass time, etc.) are associated with TEE-related injuries. In this narrative review of complications from TEE, the authors focus on the incidence of UGI injuries, the spectrum of injuries associated with TEE, risk factors that may contribute to UGI injuries, as well as diagnosis and management options. Lastly, the discussion focuses on the prevention of injuries as TEE use continues to become more prevalent.

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      References

        • Savage RM
        • Lytle BW
        • Aronson S
        • et al.
        Intraoperative echocardiography is indicated in high-risk coronary artery bypass grafting.
        Ann Thorac Surg. 1997; 64 (discussion 373-4): 368-373
        • Flachskampf FA
        • Wouters PF
        • Edvardsen T
        • et al.
        Recommendations for transoesophageal echocardiography: EACVI update 2014.
        Eur Heart J Cardiovasc Imaging. 2014; 15: 353-365
      1. American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography.
        Anesthesiology. 2010; 112: 1084-1096
        • Purza R
        • Ghosh S
        • Walker C
        • et al.
        Transesophageal echocardiography complications in adult cardiac surgery: A retrospective cohort study.
        Ann Thorac Surg. 2017; 103: 795-802
        • Eltzschig HK
        • Rosenberger P
        • Loffler M
        • et al.
        Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery.
        Ann Thorac Surg. 2008; 85: 845-852
        • Tan Z
        • Roscoe A
        • Rubino A.
        Transesophageal echocardiography in heart and lung transplantation.
        J Cardiothorac Vasc Anesth. 2019; 33: 1548-1558
        • Essandoh M
        • Bhatt A
        • Flores A
        • et al.
        Transesophageal echocardiography monitoring during lung transplantation.
        J Cardiothorac Vasc Anesth. 2017; 31: e98-e99
        • Kihara C
        • Murata K
        • Wada Y
        • et al.
        Impact of intraoperative transesophageal echocardiography in cardiac and thoracic aortic surgery: Experience in 1011 cases.
        J Cardiol. 2009; 54: 282-288
        • Parker BK
        • Salerno A
        • Euerle BD.
        The use of transesophageal echocardiography during cardiac arrest resuscitation: A literature review.
        J Ultrasound Med. 2019; 38: 1141-1151
        • Slama MA
        • Novara A
        • Van de Putte P
        • et al.
        Diagnostic and therapeutic implications of transesophageal echocardiography in medical ICU patients with unexplained shock, hypoxemia, or suspected endocarditis.
        Intensive Care Med. 1996; 22: 916-922
        • Mishra M
        • Chauhan R
        • Sharma KK
        • et al.
        Real-time intraoperative transesophageal echocardiography–how useful? Experience of 5,016 cases.
        J Cardiothorac Vasc Anesth. 1998; 12: 625-632
        • Wigg AJ
        • Tashkent Y
        • Chen JW.
        Is transesophageal echocardiography really safe during liver transplant surgery in patients with high-risk varices?.
        Liver Transpl. 2021; 27: 767-768
        • Hogue Jr., CW
        • Lappas GD
        • Creswell LL
        • et al.
        Swallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography.
        J Thorac Cardiovasc Surg. 1995; 110: 517-522
        • Kallmeyer IJ
        • Collard CD
        • Fox JA
        • et al.
        The safety of intraoperative transesophageal echocardiography: A case series of 7200 cardiac surgical patients.
        Anesth Analg. 2001; 92: 1126-1130
        • Rousou JA
        • Tighe DA
        • Garb JL
        • et al.
        Risk of dysphagia after transesophageal echocardiography during cardiac operations.
        Ann Thorac Surg. 2000; 69 (discussion 489-90): 486-489
        • Lennon MJ
        • Gibbs NM
        • Weightman WM
        • et al.
        Transesophageal echocardiography-related gastrointestinal complications in cardiac surgical patients.
        J Cardiothorac Vasc Anesth. 2005; 19: 141-145
        • Owall A
        • Stahl L
        • Settergren G.
        Incidence of sore throat and patient complaints after intraoperative transesophageal echocardiography during cardiac surgery.
        J Cardiothorac Vasc Anesth. 1992; 6: 15-16
        • Huang CH
        • Lu CW
        • Lin TY
        • et al.
        Complications of intraoperative transesophageal echocardiography in adult cardiac surgical patients - experience of two institutions in Taiwan.
        J Formos Med Assoc. 2007; 106: 92-95
        • Chin JH
        • Lee EH
        • Choi DK
        • et al.
        A modification of the trans-oesophageal echocardiography protocol can reduce post-operative dysphagia following cardiac surgery.
        J Int Med Res. 2011; 39: 96-104
        • Freitas-Ferraz AB
        • Rodes-Cabau J
        • Junquera Vega L
        • et al.
        Transesophageal echocardiography complications associated with interventional cardiology procedures.
        Am Heart J. 2020; 221: 19-28
        • Freitas-Ferraz AB
        • Bernier M
        • Vaillancourt R
        • et al.
        Safety of transesophageal echocardiography to guide structural cardiac interventions.
        J Am Coll Cardiol. 2020; 75: 3164-3173
        • Kumar S
        • Brown G
        • Sutherland F
        • et al.
        The transesophageal echo probe may contribute to esophageal injury after catheter ablation for paroxysmal atrial fibrillation under general anesthesia: A preliminary observation.
        J Cardiovasc Electrophysiol. 2015; 26: 119-126
        • Memtsoudis SG
        • Rosenberger P
        • Loffler M
        • et al.
        The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery.
        Anesth Analg. 2006; 102: 1653-1657
        • Ellis JE
        • Lichtor JL
        • Feinstein SB
        • et al.
        Right heart dysfunction, pulmonary embolism, and paradoxical embolization during liver transplantation. A transesophageal two-dimensional echocardiographic study.
        Anesth Analg. 1989; 68: 777-782
        • Aniskevich S
        • Shine TS
        • Feinglass NG
        • et al.
        Dynamic left ventricular outflow tract obstruction during liver transplantation: The role of transesophageal echocardiography.
        J Cardiothorac Vasc Anesth. 2007; 21: 577-580
        • Boone JD
        • Sherwani SS
        • Herborn JC
        • et al.
        The successful use of low-dose recombinant tissue plasminogen activator for treatment of intracardiac/pulmonary thrombosis during liver transplantation.
        Anesth Analg. 2011; 112: 319-321
        • De Marchi L
        • Wang CJ
        • Skubas NJ
        • et al.
        Safety and benefit of transesophageal echocardiography in liver transplant surgery: A position paper from the Society for the Advancement of Transplant Anesthesia (SATA).
        Liver Transpl. 2020; 26: 1019-1029
        • Myo Bui CC
        • Worapot A
        • Xia W
        • et al.
        Gastroesophageal and hemorrhagic complications associated with intraoperative transesophageal echocardiography in patients with model for end-stage liver disease score 25 or higher.
        J Cardiothorac Vasc Anesth. 2015; 29: 594-597
      2. Hui RW, Leung CM. Incidence of gastrointestinal bleeding after transesophageal echocardiography in patients with gastroesophageal varices: A systematic review and meta-analysis [e-pub ahead of print]. J Am Soc Echocardiogr. doi: 10.1016/j.echo.2021.11.014. Accessed 3/10/22.

        • Stevenson JG.
        Incidence of complications in pediatric transesophageal echocardiography: Experience in 1650 cases.
        J Am Soc Echocardiogr. 1999; 12: 527-532
        • Muhiudeen IA
        • Roberson DA
        • Silverman NH
        • et al.
        Intraoperative echocardiography in infants and children with congenital cardiac shunt lesions: Transesophageal versus epicardial echocardiography.
        J Am Coll Cardiol. 1990; 16: 1687-1695
        • Muhiudeen IA
        • Silverman NH
        • Anderson RH.
        Transesophageal transgastric echocardiography in infants and children: The subcostal view equivalent.
        J Am Soc Echocardiogr. 1995; 8: 231-244
      3. Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography.
        Anesthesiology. 1996; 84: 986-1006
        • Anantharam B
        • Chahal N
        • Stephens N
        • et al.
        Temporo-mandibular joint dislocation: An unusual complication of transoesophageal echocardiography.
        Eur J Echocardiogr. 2010; 11: 190-191
        • Na S
        • Kim CS
        • Kim JY
        • et al.
        Rigid laryngoscope-assisted insertion of transesophageal echocardiography probe reduces oropharyngeal mucosal injury in anesthetized patients.
        Anesthesiology. 2009; 110: 38-40
        • Sriram K
        • Khorasani A
        • Mbekeani KE
        • et al.
        Tongue necrosis and cleft after prolonged transesophageal echocardiography probe placement.
        Anesthesiology. 2006; 105: 635
        • Takasaki Y.
        Transient lingual ischaemia during anaesthesia.
        Anaesthesia. 2003; 58: 717
        • Daniel WG
        • Erbel R
        • Kasper W
        • et al.
        Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations.
        Circulation. 1991; 83: 817-821
        • Augoustides JG
        • Hosalkar HH
        • Milas BL
        • et al.
        Upper gastrointestinal injuries related to perioperative transesophageal echocardiography: Index case, literature review, classification proposal, and call for a registry.
        J Cardiothorac Vasc Anesth. 2006; 20: 379-384
        • Oshiro M
        • Kanda H
        • Oshiro A
        • et al.
        Conservative management for iatrogenic gastric perforation by transesophageal echocardiography.
        JA Clin Rep. 2018; 4: 52
        • Soong W
        • Afifi S
        • McGee EC.
        Delayed presentation of gastric perforation after transesophageal echocardiography for cardiac surgery.
        Anesthesiology. 2006; 105: 1273-1274
        • Greene MA
        • Alexander JA
        • Knauf DG
        • et al.
        Endoscopic evaluation of the esophagus in infants and children immediately following intraoperative use of transesophageal echocardiography.
        Chest. 1999; 116: 1247-1250
        • Khandheria BK
        • Seward JB
        • Tajik AJ.
        Transesophageal echocardiography.
        Mayo Clin Proc. 1994; 69: 856-863
        • Chandra A
        • Chen TC
        • Tang Z
        • et al.
        Bleeding risk in patients with cirrhosis undergoing transesophageal echocardiography: 6-year experience from parkland health and hospital system.
        J Am Soc Echocardiogr. 2019; 32: 678-680
        • Sack JS
        • Li M
        • Zucker SD.
        Bleeding outcomes following transesophageal echocardiography in patients with cirrhosis and esophageal varices.
        Hepatol Commun. 2021; 5: 283-292
        • Spier BJ
        • Larue SJ
        • Teelin TC
        • et al.
        Review of complications in a series of patients with known gastro-esophageal varices undergoing transesophageal echocardiography.
        J Am Soc Echocardiogr. 2009; 22: 396-400
        • Nowak-Machen M
        • Schmid E
        • Schlensak C
        • et al.
        Safety of transesophageal echocardiography during extracorporeal life support.
        Perfusion. 2016; 31: 634-639
        • Hilberath JN
        • Oakes DA
        • Shernan SK
        • et al.
        Safety of transesophageal echocardiography.
        J Am Soc Echocardiogr. 2010; 23 (quiz 1220-1): 1115-1127
        • Messina AG
        • Paranicas M
        • Fiamengo S
        • et al.
        Risk of dysphagia after transesophageal echocardiography.
        Am J Cardiol. 1991; 67: 313-314
        • Grimm JC
        • Magruder JT
        • Ohkuma R
        • et al.
        A Novel risk score to predict dysphagia after cardiac surgery procedures.
        Ann Thorac Surg. 2015; 100: 568-574
        • Khandheria BK.
        The transesophageal echocardiographic examination: Is it safe?.
        Echocardiography. 1994; 11: 55-63
        • Chan KL
        • Cohen GI
        • Sochowski RA
        • et al.
        Complications of transesophageal echocardiography in ambulatory adult patients: Analysis of 1500 consecutive examinations.
        J Am Soc Echocardiogr. 1991; 4: 577-582
        • Sutton DC.
        Accidental transtracheal imaging with a transesophageal echocardiography probe.
        Anesth Analg. 1997; 85: 760-762
        • Birchem SK.
        Benzocaine-induced methemoglobinemia during transesophageal echocardiography.
        J Am Osteopath Assoc. 2005; 105: 381-384
        • Kharasch ED
        • Sivarajan M.
        Gastroesophageal perforation after intraoperative transesophageal echocardiography.
        Anesthesiology. 1996; 85: 426-428
        • Urbanowicz JH
        • Kernoff RS
        • Oppenheim G
        • et al.
        Transesophageal echocardiography and its potential for esophageal damage.
        Anesthesiology. 1990; 72: 40-43
        • O'Shea JP
        • Southern JF
        • D'Ambra MN
        • et al.
        Effects of prolonged transesophageal echocardiographic imaging and probe manipulation on the esophagus–an echocardiographic-pathologic study.
        J Am Coll Cardiol. 1991; 17: 1426-1429
        • Savino JS
        • Weiss S.
        Safety of transesophageal echocardiography is still unclear.
        Anesthesiology. 1990; 73: 366-367
        • Venticinque SG
        • Kashyap VS
        • O'Connell RJ
        Chemical burn injury secondary to intraoperative transesophageal echocardiography.
        Anesth Analg. 2003; 97: 1260-1261
        • Levy PY
        • Teysseire N
        • Etienne J
        • et al.
        A nosocomial outbreak of Legionella pneumophila caused by contaminated transesophageal echocardiography probes.
        Infect Control Hosp Epidemiol. 2003; 24: 619-622
        • Mathur SK
        • Singh P.
        Transoesophageal echocardiography related complications.
        Indian J Anaesth. 2009; 53: 567-574
        • Massey SR
        • Pitsis A
        • Mehta D
        • et al.
        Oesophageal perforation following perioperative transoesophageal echocardiography.
        Br J Anaesth. 2000; 84: 643-646
        • Fernandez FF
        • Richter A
        • Freudenberg S
        • et al.
        Treatment of endoscopic esophageal perforation.
        Surg Endosc. 1999; 13: 962-966
        • Min JK
        • Spencer KT
        • Furlong KT
        • et al.
        Clinical features of complications from transesophageal echocardiography: A single-center case series of 10,000 consecutive examinations.
        J Am Soc Echocardiogr. 2005; 18: 925-929
        • Kelava M
        • Koprivanac M
        • Alfirevic A
        • et al.
        Safety of transesophageal echocardiography for cardiac surgery in patients with histories of bariatric surgery.
        J Am Soc Echocardiogr. 2020; 33: 130-132
        • Spahn DR
        • Schmid S
        • Carrel T
        • et al.
        Hypopharynx perforation by a transesophageal echocardiography probe.
        Anesthesiology. 1995; 82: 581-583
        • Langmore SE.
        Evaluation of oropharyngeal dysphagia: Which diagnostic tool is superior?.
        Curr Opin Otolaryngol Head Neck Surg. 2003; 11: 485-489
      4. Plowman EK, Anderson A, York JD, et al. Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes [e-pub ahead of print]. J Thorac Cardiovasc Surg. doi: 10.1016/j.jtcvs.2021.02.087, Accessed 3/10/22.

        • Bavalia N
        • Anis A
        • Benz M
        • et al.
        Esophageal perforation, the most feared complication of TEE: Early recognition by multimodality imaging.
        Echocardiography. 2011; 28: E56-E59
        • Flynn AE
        • Verrier ED
        • Way LW
        • et al.
        Esophageal perforation.
        Arch Surg. 1989; 124 (discussion 1214-5): 1211-1214
        • Cote G
        • Denault A.
        Transesophageal echocardiography-related complications.
        Can J Anaesth. 2008; 55: 622-647
        • Schweigert M
        • Sousa HS
        • Solymosi N
        • et al.
        Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system.
        J Thorac Cardiovasc Surg. 2016; 151: 1002-1009
        • Lindenmann J
        • Matzi V
        • Neuboeck N
        • et al.
        Management of esophageal perforation in 120 consecutive patients: Clinical impact of a structured treatment algorithm.
        J Gastrointest Surg. 2013; 17: 1036-1043
        • Kuppusamy MK
        • Hubka M
        • Felisky CD
        • et al.
        Evolving management strategies in esophageal perforation: Surgeons using nonoperative techniques to improve outcomes.
        J Am Coll Surg. 2011; 213 (discussion 171-2): 164-171
        • Ishida T
        • Kiuchi C
        • Sekiguchi T
        • et al.
        McGRATH MAC video laryngoscope for insertion of a transoesophageal echocardiography probe: A randomised controlled trial.
        Eur J Anaesthesiol. 2016; 33: 263-268
        • Hillenbrand KD
        • Racine CL
        • McNeil JS
        • et al.
        Difficult TEE probe placement: The evidence, troubleshooting techniques, and a guide to alternative monitoring options for intraoperative physicians.
        Semin Cardiothorac Vasc Anesth. 2019; 23: 369-378
        • Nijenhuis VJ
        • Alipour A
        • Wunderlich NC
        • et al.
        Feasibility of multiplane microtransoesophageal echocardiographic guidance in structural heart disease transcatheter interventions in adults.
        Neth Heart J. 2017; 25: 669-674