A case of massive hemoptysis following transesophageal echocardiogram

Abstract

IntroductionTracheal intubation leading to injury of the airway is a rare complication of transesophageal echocardiography (TEE). Tracheal trauma is not a described complication of TEE, and safety literature for this procedure remains silent on the matter. We describe the case of a patient on systemic anticoagulation and antiplatelet therapy who underwent TEE and suffered massive hemoptysis requiring bronchial artery embolization (BAE).Case presentationAn elderly patient was admitted to the hospital with recently diagnosed atrial fibrillation and shortness of breath. The patient underwent a TEE with successful synchronized cardioversion on hospital day #2. Later that day the patient experienced respiratory distress and hemoptysis and was intubated. Oropharyngeal and gastrointestinal sources of bleeding were excluded. A bronchoscopy revealed active bleeding from an ulceration in the bronchus intermedius (BI) of the right lung. A 7 French Arndt endobronchial blocker (Cook Medical, Bloomington, Indiana) was placed and anticoagulation reversed. Bleeding stopped for two days, but then returned on hospital day #5, requiring BAE to the right bronchial artery. The procedure was successful, the patient was successfully extubated, and was discharged over the next 10 days.DiscussionMassive hemoptysis and respiratory compromise as a result of tracheal trauma is not described in the TEE literature. This patient proved to be a difficult esophageal intubation secondary to a newly discovered Zenker's diverticulum. The risk for bleeding in this patient was higher secondary to anticoagulation with warfarin and antiplatelet therapy with ticagrelor. As in all cases of massive hemoptysis, key aspects of care in this case involved localization of bleeding, reversal of anticoagulation, and definitive management such as BAE.ConclusionsTracheal trauma is not a described complication of TEE, but clinicians should be mindful of this possible complication in patients receiving anticoagulation. Typical management for massive hemoptysis was successful in this patient.

Difficult TEE Probe Placement: The Evidence, Troubleshooting Techniques, and a Guide to Alternative Monitoring Options for Intraoperative Physicians

“…Complications during intraoperative TEE range from relatively minor such as transient dysphagia and pharyngitis to serious life-threatening injury including GI tract perforation and hemorrhage. 9 Complications specifically reported after difficult TEE placement include soft-tissue infection, 6 pulmonary hemorrhage, 8 and oropharyngeal hemorrhage requiring transfusion and surgical ligation. 7 These findings highlight the importance of a thorough preoperative assessment by the echocardiographer and a careful weighing of the risks and benefits of intraoperative TEE.…”

“…1 Several of these complications are related to insertion of the TEE probe, and case reports have described injury to patients after misplacement or excessive force during probe intubation. [4][5][6][7][8] Our institution encountered a recent case of difficult probe placement in a patient presenting for transcatheter mitral valve repair evaluation where the diagnostic utility of TEE was considered to be essential, both preoperatively and intraoperatively. Despite not having a history of esophageal disease or swallowing dysfunction, cardiologists were unable to pass the TEE probe because of "excessive resistance."…”

“…1 Several of these complications are related to insertion of the TEE probe, and case reports have described injury to patients after misplacement or excessive force during probe intubation. 4-8…”

Wire-guided and endoscopic-guided transesophageal echocardiographic probe insertion

“…Perforation and tracheal intubation by the TEE probe have been reported. 3,4 To assist probe advancement, the use of a balloon to occlude the diverticular orifice, allowing safe passage of the TEE probe, has been reported. 5 We report a 75-year-old man with a large symptomatic Zenker's diverticulum (4-5 cm in length) who also needed a TEE ( Figs.…”