Esophageal injury following transesophageal echocardiography is uncommon. Perforation has been reported in 0.03% in a large series. Few cases of submucosal dissection have been reported. A 73-year-old female underwent open mitral valve repair and left atrial appendage closure. Intraoperative transesophageal echocardiography was performed. Patient was noted to have an upper gastrointestinal bleeding intraoperatively. Then was transferred to intensive care unit postoperatively and upper endoscopy was performed. After extensive irrigation, the bleeding site was identified at the cardia with fresh blood and the appearance of a focal trauma with the possibility of a puncture site. There was no evidence of an ulcer or visible vessel. This was achieved using epinephrine injection and CLEP placement. On withdrawal, a tubular protrusion with bluish discoloration was seen running the length of the esophagus, most pronounced in the mid-esophagus. With normal overlying mucosa, the abnormality was presumed to be arising from the submucosal space. Indeed, at the proximal esophagus, there was a 5 mm mucosal disruption suggestive of trauma with extension into a false track. Suspected intraoperative transesophageal echocardiography probe caused a submucosal dissection with point of entry at the proximal esophagus, traversed the entire length of the esophagus and exited at the gastric cardia, giving rise to a clinical bleed. A single CLEP was placed at the proximal mucosal defect and patient was started on prophylactic antibiotics. A CT scan of the thorax showed focal pneumomediastinum along the right proximal esophagus without evidence of mediastinal collection or hematoma, confirming the hypothesis. Multidisciplinary decision including thoracic surgery, cardiac surgery and gastroenterology was made to manage expectantly. Repeat upper endoscopy post-op day 2 confirmed complete closure of the proximal esophageal defect with no evidence of bleeding in the stomach. Patient transferred to the surgical ward and eventually. Complete CT with oral contrast demonstrated no contrast extravasation and resolving pneumomediastinum. This was confirmed with subsequent dynamic swallowing study. Decision to manage the defect with endoscopic CLEP closure was based on the corollary of the per-oral endoscopic myotomy procedure. In that context, mucosal approximation at the site of entry is achieved with endoscopic CLEPS and less than 0.1% of post-procedural leak and mediastinitis is reported. Submucosal dissection is a rare complication of transesophageal echocardiography. As demonstrated in this case, mucosal flap closure can be safely achieved using endoscopic CLEP placement with successful outcome.

esophageal injuries

transesophageal echocardiography

perforation

upper gastrointestinal bleeding

submucosal dissection