Evaluating the Safety Profile of Transesophageal Echocardiograms in a Community Hospital Setting

Mechanisms of Injury

One of the more common mechanisms includes direct mechanical injury. There are two major etiologies that contribute to direct mechanical injury: operator related and anatomically related. Many injuries result from transducer insertion and manipulation, which are influenced by factors such as multiple insertion attempts, excessive force, and fixed flexion of the transducer.^2–4 The subsequent injuries that can occur include mucosal abrasion, laceration, intramural hematoma, and mucosal perforation. Another crucial factor that contributes to direct mechanical injury includes the presence of anatomical variations such as the presence of strictures, diverticula, varices, and hiatal hernias. These increase the risk of direct mechanical injury due to difficulty with traversing the transducer throughout the anatomical tract.^2–4

Another important mechanism of injury is pressure-related injury, particularly influenced by prolonged time of procedure and extensive transducer manipulation. For example, prolonged and continuous transducer contact against esophageal mucosa can contribute to ischemia, which may lead to necrosis.^2,5 These predictors also contribute to thermal injury despite most transducers having built-in safety mechanisms to prevent the risk of overheating. Thermal injuries in particular carry a higher risk of prolonged procedure times (e.g., >60 minutes). ⁶ Rong et al ⁷ postulated that for every 10-minute increase in imaging time, there was an associated increase in odds of esophageal injuries, thus suggesting a dose-dependent relationship. The risk of thermal injury also increases when TEEs are used for guidance in other procedures, specifically procedures utilizing cryoablation and radiofrequency. This is particularly evident in ablations for atrial fibrillation occurring in the left atrium due to the proximity of the left atrium to the esophagus. In prolonged procedures that utilize TEE, cryoablation and radiofrequency can result in esophageal ulceration. ⁸

Operator Experience

Given TEEs are more invasive procedures than transthoracic echocardiograms, the risk of complications from performing these procedures is correlated to operator experience. Some studies suggest that the risk of major TEE-related complications is generally low when performed by experienced operators (0.1%–0.5%), and other studies suggest the rate of severe complications when performed by experienced operators is 1 in 10 000 cases.^7,9 Many institutions employ fellowships to help train cardiologists, which includes performing supervised TEEs as part of their curriculum. To ensure patient safety, TEEs done by fellows require supervision from an experienced echocardiographer (e.g., level III). To achieve level III training, 150 studies are required. Currently, there is a lack of literature that compares complication rates of TEEs from cardiology fellows to those from attending physicians.

Injury by Organ System

GI complications are the most frequently reported injuries following TEE and are typically mild and self-limited. ⁵ These include injuries such as petechiae, ecchymosis, and superficial abrasions (e.g., 2%–3% of cases). ⁷ More significant injuries, including intramural hematomas and mucosal lacerations, have been reported at higher rates in the setting of prolonged TEE use during structural cardiac interventions.^7,10–14 The most common symptomatic manifestations of injury are dysphagia and odynophagia, especially within the first 12 hours after the procedure. ¹⁵ These injuries are typically managed conservatively with analgesics and proton pump inhibitors (PPIs).

Major complications such as esophageal perforation are rare, occurring in approximately 0.01%–0.5% of all cases, but warrant prompt evaluation and surgical consultation. ⁷ Recognized risk factors include pre-existing GI pathology, anatomical distortion, and extrinsic esophageal compression from left atrium dilatation.^16,17 As such, the operator should be mindful of these variables and navigate accordingly and meticulously to decrease the risk of injury.

Another injury that operators should be mindful of includes bleeding of the GI tract with elevated risk present in patients with previous ulcerative processes, failure to adhere to medications such as PPI and histamine-2 receptor (H2) antagonists in the preoperative period, and the use of aspirin and anticoagulant medications.^4,18A careful review of medications prior to the procedure is paramount to mitigate bleeding related to these conditions.^4,18 A systematic review conducted by Gangwani et al ¹⁹ estimates the overall rate of GI complications from TEE to be 0.51%.

Dental complications can occur with initial intubation as with any other procedure, so if time and circumstances permit, patients would benefit from evaluation of dentition and oropharyngeal anatomy, prior to procedure, to minimize intubation-related dental complications. ²⁰

With regards to respiratory complications, the main complication is oxygen desaturation and aspiration. These complications increase with obesity and conditions such as obstructive sleep apnea, which tends to complicate procedures requiring sedation. Oxygen supplementation has been shown to be effective.^21,22

Infection

The American Heart Association (AHA) recommends prophylactic antibiotic therapy prior to procedures manipulating respiratory mucosa (e.g., bronchoscopy) for patients who have prosthetic valves, prior history of endocarditis, complex cyanotic heart disease, and surgically created pulmonary shunts. ²³ Although these recommendations can be applied in the context of TEE, there have been conflicting reports on the actual incidence of bacteremia explicitly associated with TEE performance; however, most reports suggest the rates appear to be relatively low. ²⁰

Regarding CV complications, most occur in intubated and sedated patients. When intubated, vagal and sympathetic reflexes can occur, which have CV effects, such as both hypertension and hypotension, arrhythmias, and bradycardia.^24–26 A contributing factor to this is the TEE transducer triggering vagal stimulation, within the esophagus, thus resulting in reflex bradycardia. As such, meticulous sedation with the aid of an anesthesiologist and close monitoring of vitals is paramount, to mitigate these occurrences. It is important to also be aware of certain comorbidities such as congestive heart failure (CHF) and pulmonary hypertension, which may affect the choice of anesthetics on these patients to avoid CV compromise. The indication for a TEE procedure can also impact the likelihood of experiencing injuries, especially if a TEE is used for surgical and interventional cardiac procedures. These carry an event risk of around 0.9% and 3.5%, respectively.^5,27,28

The purpose of this study was to determine the incidence of clinically apparent complications following TEE in the host hospital system’s patient population and whether exploring routine postprocedural endoscopic surveillance may be warranted in select clinical contexts.

Materials and Methods

This was a single-center, retrospective study of patients who underwent TEE in both an inpatient and outpatient setting, in a suburban community hospital in New York. This was considered an exempt study and was approved by Nassau University Medical Center’s Internal Review board. Data was collected on all adult patient visits from January 1, 2019, to May 30, 2024. The host institution maintains an accredited CV disease fellowship training program where they train under the supervision of board-certified CV disease attending physicians. All TEEs performed by fellows or attending physicians are done under the direct supervision of board-certified, level III-trained echocardiographers.

Results

Among the 441 patients included, 37.6% were white, 23.6% black, 32.7% Hispanic, 4.3% Asian, and 1.1% identified as “Other.” The cohort was 55.6% male with a mean age of 57.09 years (standard deviation 15.250). Of the 441 patients, one patient had recorded complications during the TEE. The patient was hypoxic following the procedure and was transferred to the cardiovascular care unit (CCU), and a computed tomography (CT) examination showed an esophageal perforation. The patient was subsequently transferred to an outside facility for definitive clinical management for the perforation.

Discussion

Only one patient out of this patient cohort had a TEE complication, which made the incidence of injury 0.23%. The remaining 440 patients had no documented complications, consistent with prior reports supporting the overall procedural safety of TEE in clinical practice. The single complication observed was an esophageal perforation. When compared with previously published data, the observed incidence of GI injury in this study was lower than the 0.51% reported by another retrospective analysis. ¹⁹ The single patient, in the current study, with the complication underwent TEE to evaluate the function of their bio-prosthetic aortic and mitral valves. This patient was on warfarin, which was held prior to the procedure. Postprocedural imaging found abnormal esophageal anatomy, specifically a paraesophageal hernia. Although causality cannot be established, this anatomical abnormality may have increased susceptibility to mechanical injury during transducer manipulation. Prior studies have evaluated whether a preprocedural esophagogastroduodenoscopy (EGD) may mitigate the risk of TEE-related injury but provided mixed results. One study demonstrated little benefit of routine preoperative EGD; however, that cohort primarily included patients with known esophageal strictures, varices, or fistulae. ²⁹ Benefits of similar screening in patients with other anatomical abnormalities such as paraesophageal hernias remain unclear and warrant further investigation.

The study patient’s time in the procedural suite was around one hour, which was within the standard period of noninterventional TEEs. Therefore, it is unlikely that this patient’s injury resulted from a prolonged procedural time. Another possible contributing factor to the complication seen in the study patient was the experience of the operator. Given the performing facility has a fellowship program with cardiology fellows in training (CFIT), the operator experience may have played a role in the injury. However, the CFIT was accompanied by a level III TEE operator who supervised the procedure and intervened if needed; therefore, this is less likely of a contributor than the abnormal anatomy.

Several studies have reported higher rates of esophageal injury when routine post-TEE EGD surveillance is performed. In one prospective study of patients undergoing structural cardiac interventions where TEE guided the procedure (e.g., valve repairs, closure procedures), a substantial 86% of patients exhibited new injuries after the procedure, as confirmed by postprocedural EGD. ⁵ Of these cases, 40% involved complex lesions such as intramural hematoma and mucosal laceration; however, none of these appeared to be hemodynamically significant. ⁵ Increased injury risk was associated with prolonged procedural time and poor image quality. ⁵ These findings may suggest that routine endoscopic surveillance may identify subclinical abnormalities that may not translate into clinically meaningful outcomes. Given that routine postprocedural EGD was not performed in the present study, these findings are limited to clinically apparent complications and cannot exclude the presence of subclinical esophageal injury. As such, comparisons with studies employing systematic endoscopic surveillance should be interpreted cautiously. Whether routine post-TEE EGD in asymptomatic patients provides a net clinical benefit remains uncertain, particularly given the inherent risks associated with additional invasive procedures.

Another retrospective study involving 859 cardiac surgical patients explored the incidence of major upper-GI complications following cardiac surgery with or without TEE involvement. ¹² The results revealed a 1.2% incidence of major upper-GI complications associated with TEE, although few resulted in hemodynamic instability.^12,19

Conclusion

This single-center study demonstrated that clinically apparent complications, following TEE, were rare during the review period and had an incidence of 0.23%. These findings suggested the overall safety of TEE in routine clinical practice, for this clinical practice, and could be replicated in other sites for continuous quality improvement. While prior studies utilizing routine postprocedural endoscopic surveillance have reported higher rates of subclinical injury, the clinical relevance of such findings remains uncertain. Further prospective studies are needed to clarify whether selective postprocedural endoscopic evaluation provides meaningful clinical benefits in asymptomatic patients.