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Year : 2009  |  Volume : 53  |  Issue : 5  |  Page : 567-574 Table of Contents     

Transoesophageal Echocardiography Related Complications

1 Head, Divison of Cardiothoracic Anaesthesia, Division of Cardiothoracic Anaesthesia,Department of Anaesthesiology,Institute of Medical Sciences,Banaras Hindu University,Varanasi 221005, India
2 PDCC Student, Division of Cardiothoracic Anaesthesia,Department of Anaesthesiology,Institute of Medical Sciences,Banaras Hindu University,Varanasi 221005, India

Date of Web Publication3-Mar-2010

Correspondence Address:
S K Mathur
Department of Anaesthesiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005
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Source of Support: None, Conflict of Interest: None

PMID: 20640107

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The application of transesophageal echocardiography (TEE ) has been continuously increasing over past several decades. It is usually considered a very safe diagnostic and monitoring device. Though the complications are rare, but these complications must be known to the operators performing TEE. The goal of this article is to encapsulate the potential complications associated with TEE. The complications are primarily related to gastro intestinal, cardiovascular and respiratory systems along with some miscellaneous problems related to probe insertion, drugs and inexperience of the operator. Strategies for the prevention of these complications are also analyzed in order to avoid the risk.

Keywords: Transesoph ageal echocardiography, Complications, Prevention

How to cite this article:
Mathur S K, Singh P. Transoesophageal Echocardiography Related Complications. Indian J Anaesth 2009;53:567-74

How to cite this URL:
Mathur S K, Singh P. Transoesophageal Echocardiography Related Complications. Indian J Anaesth [serial online] 2009 [cited 2021 Mar 6];53:567-74. Available from: https://www.ijaweb.org/text.asp?2009/53/5/567/60335

   Introduction Top

Transesophageal echocardiography (TEE) is a semi invasive monitoring and diagnostic modality of immense utility. The practical clinical use of TEE was first described in 1976 when a modified rigid endo­scopic probe with single M-mode crystal was used. Since thattime, TEE technology has evolved rapidly with developments in flexible endoscopic probe tech­nology, phased-array ultrasound systems, and crystal miniaturization. Presently, TEE is being used widely in operation theatres, intensive care units, cardiac cath­eterization laboratory and day care units. Although the technique is quite safe, if conducted by a skilled per­son, it is important to overview the procedure related complications, considering its widespread use. In the following article, we are trying to give a deep insight regarding the complications of TEE examinations.

   Gastrointestinal Complications Top

1. Injuries of Gastrointestinal Tract:

Dental traumas [1] , submucosal hematoma of pha­ryngeal area [2],[3] jawsubluxation [4],[5] and tonsillar bleeding are related to probe insertion in upper gastrointestinal(GI)tract. Esophageal perforations mostly occur in the ab­dominal followed by intrathoracic and cervical por­tions of the esophagus. They are caused by anatomic variations like GI abnormalities, extrinsic compression of esophagus from enlarged left atrium, [6],[7] calcified lymph node [8] and cervical spur. Other causes are poor patient cooperation and inadequate technical skill or mucosal damage due to movement, is chemia, heat and pressure generated by the probe (TEE probe can gen­erate a pressure of 60 mmHg ).

The hypopharynx and upper esophagus are most prone to perforation [3] caused by neck extension with or without prominent anterior vertebral osteophytes and by stretching ofmucosaandmuscular fibres. Shearing forces, prolonged flexion of probe tip and probe mobilization in a locked position can lead to tearing of oesophagus. [9]

Non pulsatile flow, prolonged cardio pulmonary bypass [10] , distended atrium [11] , mechanical compression [12]­and excessive heat are the factors which can cause ischaemic esophageal wall injury.

In conscious and sedated patient, perforations are evident from signs of subcutaneous emphysema, dysp­noea and pain. But under general anaesthesia, esoph­ageal intubation is easy and perforation usually goes unnoticed, ultimately resulting in mediastinitis, sepsis and multi organ failure. [13] Diagnosis can be confirmed ra­diologically by computedtomography and chest radio­graphs and may include findings like pneumothorax, au­ fluid level, mediastinal shift, subcutaneous emphysema, pleural effusion and empyema­.

2. Gastroesophageal Lesions and Anatomic Variations

Lesions such as neoplasm, diverticulum [4] , cervical spine [2],[14] orinflammatorymucosal changes are risk fac­tors for complications associated with TEE probe in­sertion. As there is no direct visualization of esophagus during TEE probe insertion and manipulations, it re­quires more attention compared to conventional opti­cal gastroscopy. Esophageal intubations most often fail at the level of cricopharynx due to prominence of cri­coid muscle. Schatzki's ring and prior cervical surgery [15] can lead to esophageal narrowing and can cause com­plications during TEE. Disorders like esophageal acha­lasia, barrett's esophagus, chemical esophagitis, late scleroderma, Chagas disease and benign and malig­nant esophageal tumors can reduce esophageal lumen. Peptic ulcer and gastroesophageal reflux disease(GERD) can lead to strictures which ultimately can cause erosion and bleeding of esophagus. Probe of TEE can easily slip into Zenkers diverticulum and can cause perforation. [16]

Normal anatomical variations like aortic impres­sion, large left atrium and left mainbronchus orpatho­logical variations such as mediastinal tumours' and esophageal duplication cyst compress esophagus and hamper esophageal intubations. [17]

Vascular abnormalities like esophageal varices due to portal hypertension can cause bleeding during TEE. [18] Cervical spine abnormalities due to trauma or subluxation at C 1 and C2 vertebrae may make esophageal intubation difficult and can also lead to neurological deficit. [19]

3. Unsuccessful Esophageal Intubation

Factors contributing to this problem are lack of cooperation from patients and inexperience of opera­toras well as anatomic abnormalities like double aortic arch [20] , cervical osteophytes [21] and mucosal abnormali­ties such as prior radiation exposure, decreased saliva production and prior tracheostomy. Mallory-Weiss syn­drome which is associated with forceful vomiting ef­forts has been reported during'' EE which leads to failed intubations. [21]

4. Bleeding of Esophageal Tract

Risk factors associated with upper GI bleeding due to 'FEE include previous ulcerative process, vaso­active drugs and failure to use H2 antagonist drugs in the perioperative period. [22] Long bypass period, reoperation [23] , emergency surgery, aspirin [24] and anti­coagulant [25] use are other factors which are associated with GI bleeding.

5. Changes in Esophgeal Integrity

TEE exposes the esophageal mucosa to ultra sound waves and pressure for long periods. Mucosal edema, erosion, hematomas and petechiae can be pro­duced specially in small children. [26]

6. Injure to Other Solid Organs & Oral Inju­ries

Splenic laceration can occur due to deep inser­tion of the probe into the stomach for transgastric im­aging . [27] Dysphasia can occur due to local compres­sion from probe insertion which affects pharyngoesoph­ageal tissue and laryngeal nerve especially in female and paediatric patients. [28],[29],[30] Dysphagiais also associatedwith pulmonary aspiration. TEE in sitting position can cause dysphasia which is due to local effect of probe, com­bined with extreme flexion of head. [31] Tongue swell­ing [32] and necrosis [33] may also occur due to prolonged placement of TEE probe.

7. Probe Tip Buckling

Probe tip buckling is caused due to tip flaccidity in an old TEE probe, improper insertion, general ana­esthesia and inexperience. It can cause injury when withdrawn hastily: [31],[34]

8. Other Foreign Bodies in Esophagus

Breakage and dislodgement of temperature probe and esophageal stethoscope during TEE are re­ported. [35],[36] Nasogastric tube and feeding tube share the same space and thus may lead to shearing, dislodgement of the spur and poor TEE imaging.

   Respiratory Complications Top

TEE examinations in sedated patient may be as­sociated with small reduction of 0 2 saturation. Inci­dence of oxygen desaturation and aspiration increases with obesity [37] and during emergency procedures. [38] To avoid this complication, oxygen supplementation is ad­vocated in sedated patient. In awake patients, prob­lems such as bronchospasm, laryngospasm, posterior pharyngeal wall hematoma, supraglottic hematoma and stenosis may occur along with pulmonary edema, atelectasis and airway obstruction. [39],[40],[41],[42],[43],[44] TEE probe placement, motion and removal may lead to displace­ment or accidental extubation of endotracheal tube particularly in children. [45] Compression of pulmonary tree or endotracheal tube may hamper ventilation. [44],[45],[46],[47],[48]

   Cardiovascular Complications Top

Esophageal intubation can induce vagal and sym­pathetic reflexes such as hypertension or hypotension, tachyarrhythmias orbradycardia and even myocardial infarction. [49],[50],[51] Anhythmias are manifested as non-sus­tained ventricular and supra ventricular tacky arrhythmias, atrial fibrillation and 3 rd degree heart block. [52] It can also induce angina and myocardial is­chemia. Risk factors like sedation along with fasting, patient on anti-hypertensioe drugs and also hypoxemia may precipitate heart failure and fatal arrhythrnias. [53],[54]

Valsalvamaneuver associated with retching and coughing leads to increase in intrathoracic, central venous and pulmonarypressures and release is associ­ated with abrupt decrease of systemic pressure. Large intrathoracic pressure and associated hemodynamic changes resulting from retching may cause fatal pulmo­nary embolisation from right atrium mass, [55],[56] mitral veg­etation and left intracardiac thrombus [57] resulting in stroke, aortic dissection and cardiac tamponade. [58]

   Infections Top

Risk of bacteremia is associated with TEE and may lead to morbid infections such as endocarditis. The most common organisms responsible for bacteremia after TEE intubation include á-hemolytic streptococ­cus, staphylococcus aureus Scientific Name Search  and staphylococcus epidermidis. [59]

Use of prophylactic antibiotic therapy during TEE, though controversial, is suggested forpatients who are immuno suppressed, have prosthetic valves, cyanotic congenital heart disease, surgically constructed shunts and previous history of endocarditis. [60] Contaminated TEE probe and the lubricating jelly are the sources of infection. [61],[62] Aproperly cleaned probe with glutaral­dehyde can reduce the incidence of post TEE infec­tions.

   Medication Related Complications Top


Sedation improves patients' tolerance to TEE probe insertion and reduces coughing, vomiting and pain. Benzodiazepines, propofol and short actingnar­cotics are most commonly used for sedation. Side ef­fects of these drugs like respiratory depression, hy­potension, agitation and allergy may occur and must be treated promptly.

Local Anaesthetic Medication:

Local anaesthetic used systemically to blunt the hemodynamic effects of TEE, for superior laryngeal nerve block and in j elly can cause anaphylactic or over­dose reactions. Congenital absence of methemoglobin reductase enzyme and topical local anaesthetics like prilocaine , lidocaine and benzocaine can lead to meth­ emoglobinemia. [63],[64],[65] It can be diagnosed by central cyanosis and low Hb saturation unresponsive to oxy­gen therapy. Dyspnoea, confusion, dizziness, coma and death may occur.

   Miscellaneous complication Top

Probe contamination:

Disruption ofprotective probe sheath can create a lumen between core and sheath which can get filled with fluids and contaminants such as glutaraldehyde and which can be ingested during TEE. [66]

Location related complication:

TEE in emergency unit, especially intrauma pa­tients, leads to more complications such as death, res­piratory insu$iciency, hypotension, emesis, agitation and cardiac dysrhythmias. These are the patients which present with compromised hemodynamic and respira­tory conditions and unstable cervical spine damage. These patients are with full stomach and altered senso­rium andthus are at increased risk of aspiration. There­fore, endotracheal intubation is highly recommended in these patients.

Effect of ultrasound waves on tissues:

Powerful ultrasound beam can cause vibration of gas filled structures leading to hemorrhage and hemoly­sis. [67] It can also produce excessive heat and damage of surroundingtissues. But in TEE, low intensityof SMHz is used which is devoid of any harmful effects. [68],[69]

Relative Contraindications of TEE




Mediastinal radiation

Recent upper gastrointestinal surgery

Recent esophagitis

Thoracic aortic aneurysm

Esophageal pathology




Varices Esophagitis

Prevention of TEE complications

Evaluation and surveillance of patients:

1. Informed consent must be obtained.

2. Careful medical history.

  • Allergyy
  • Bleeding disorder:
  • Dysphagiato solid and liquid.
  • Esophageal varices, diverticulum, esophageal web, upper GI bleeding, peptic ulcer, GERD& hiatal herniaa
  • Previous gastric, esophageal and neck surgeries.
  • Radiation therapy.
  • Cervical arthrosis.
  • Use of antacid, salicylates, anticoagulants and antiplatelet agents.

3. Physical Examination.

  • The oral and dental hygiene and loose teeth.
  • Assessment ofneck mobility, stability and arthritic changes.
  • Assessment of airway.

4. Endocarditis prophylaxis for high risk patients.

5. Fasting for 6 hr before an elective procedure.

6. Surveillance and monitoring of vital signs at baseline

and throughout the procedure.

7. 02 supplementation and venous access should be established.

Suction device and resuscitation equipments must be kept ready.

8. In emergency settings, rapid sequence induction with orotracheal intubation is performed while in elective procedures, TEE can be performed on awake or mildly sedated patient with 6 hr fasting.

9. Dentures should be removed and bite guard should be placed to protect instrument and fingers.

10. TEE probe should be lubricated and kept in un­locked control-wheel position. It should never be forced into the passage. TEE probe must be in­spected for mechanical dysfunction and damage of outer sheath causing electrical and thermal inju­ries leading to anhythmias anddeath. [70]

11. Awake patient is asked to swallow while under general anesthesia probe can be placed under di­rect latyngoscopy which reduces the trauma.

12. Insertion of probe only upto 40-50 cm from inci­sors is advocated. Anynasogastric orfeedingtube ortemperature probe should be removed to avoid potential, kinking, knotting or gastric migration and prevent intetference during imaging.

13. During cardiac surgery special care is taken as the probe is used for longer duration and anticoagula­tion during cardiopulmonary bypass and hypoth­ermia leave the mucosa more vulnerable to pres­sure necrosis and ischemia.

14. Patient should be monitored until fully awake and eating and drinking is allowed once the effect of local anesthetic is dissipated.

Transesophageal echocardiography provides bet­ter imaging of cardiac anatomy and function but since it is more invasive than ttansthoracic echocardiography, operators should be aware of the likely complications, minimize the risk factors and take measures to prevent the complications.

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