Chest Pain Post-Transcatheter Aortic Valve Implantation: Don't Forget the Uncommon Complication.

Transesophageal echocardiography guides a range of structural heart disease interventions, especially in older adult and frail patients who are deemed not suitable to undergo surgical repair. Although rare, transesophageal echocardiography can be associated with esophageal trauma, including perforation. Treating physicians should be cognizant of such a complication. (Level of Difficulty: Intermediate.).

An 82-year-old woman with history of polymyalgia rheumatica, treated with steroids, and symptomatic severe aortic stenosis underwent transcatheter aortic valve implantation (TAVI) through a direct-aortic approach because her pelvic vasculature was of a small caliber and heavily calcified. A cardiac imaging specialist with more than 10 years of experience performed transesophageal echocardiography (TEE) to guide the procedure. Post-TAVI, the patient needed permanent pacemaker implantation as a result of a new onset conduction block. On day 1 post-TAVI, the patient reported chest pain, and excess drainage from the retrosternal drain was observed. She underwent exploration and evacuation of a retrosternal nonhemorrhagic fluid collection; there was no pericardial collection. The patient reported worsening chest pain on day 2 post-TAVI; she was also noted to have abdominal distention. A chest radiograph demonstrated widened mediastinum and pneumoperitoneum (Figure 1A). Computed tomography (CT) demonstrated a large amount of free air in the peritoneum extending to the gastroesophageal junction and midesophagus, suggestive of perforation (Figures 1B and 1C). A Gastrografin (diatrizoate meglumine and diatrizoate sodium solution) CT study confirmed distal esophageal perforation and a resultant lower mediastinal collection (Figures 1B and 1C). A water-soluble contrast dye swallow examination demonstrated stagnation of contrast material in the lower part of the esophagus and extravasation in the mediastinum (Figure 1D, Video 1). The patient was deemed not to be a suitable candidate for surgical repair. Endoscopic stent deployment failed to seal the esophageal perforation, however. The patient was therefore managed conservatively with parenteral nutrition and nasogastric drainage, but, unfortunately, she died 3 months later.

Figure 1

Transesophageal Probe-Induced Esophageal Perforation

(A) Chest radiograph demonstrating widened mediastinum and pneumomediastinum. (B) Computed tomography of the chest, axial section, demonstrating free air in the peritoneum. (C) Computed tomography of the chest, coronal section, demonstrating esophageal perforation with contrast extravasation. (D) Water-soluble contrast dye swallow study showing stagnation of contrast material in the lower part of the esophagus and extravasation in the mediastinum. The asterisks denote pneumoperitoneum, and the arrows point to esophageal perforation and contrast extravasation. @ = esophagus.

TEE is a routinely performed diagnostic procedure that also guides a range of structural heart disease interventions. Although not commonly perceived, recently published data raise some concern with the routine use of TEE in patients undergoing structural cardiac interventions. Esophageal perforation following TEE is a rare but serious complication with an estimated rate of 0.03% to 0.09%., It occurs more commonly in older women, in an intraprocedural setting, with the thoracic esophagus being the most common site of perforation. Risk factors include long-term steroid therapy, underlying esophageal disease, difficulty with probe insertion or advancement, poor image quality, and prolonged procedural time requiring probe maneuvering.,

This case demonstrates a rare but potentially fatal TEE complication and supports the growing body of evidence advocating the use of procedural TEE guidance on an individual, case by case basis, when necessary, rather than routinely. Moreover, one should recognize high-risk clinical settings where intraprocedural TEE and patient fragility are present, to use smaller TEE probes (pediatric or even neonatal TEE probes) even if probe insertion and manipulation are to be performed by a trained and skilled operator.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.