Cardiovascular Disease |

An Atypical Cause of Hemoptysis After Transesophageal Echocardiogram Guided Pulmonary Vein Isolation FREE TO VIEW

Rachel Le, MD; Darlene Nelson, MD
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Mayo Clinic, Rochester, MN

Chest. 2013;144(4_MeetingAbstracts):123A. doi:10.1378/chest.1704672
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SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Complications of transesophageal echocardiogram (TEE) guided pulmonary vein isolation (PVI) are rare but potentially catastrophic. Serious direct complications from TEE are estimated to be 0.2-1.2%, most frequently including GI bleed or esophageal perforation.

CASE PRESENTATION: A 67 year-old man underwent TEE guided PVI for atrial fibrillation. He was intubated by direct laryngoscopy without complication. TEE was complicated by difficulty intubating the esophagus with the adult probe; with use of a pediatric probe the procedure was completed uneventfully. Post procedure he was noted to have hemoptysis. He was anti-coagulated with heparin initially and later transitioned to LMWH/ Coumadin for long term anticoagulation. Over the next twenty-four hours he complained of dysphagia and odynophagia with no recurrent bleeding. An esophagram was obtained to assess for perforation and negative. He was discharged home on hospital day #4 with a soft diet due to persistent dysphagia. That evening he experienced recurrent hemoptysis and was readmitted to the medical ICU. Serial hemoglobin assessment demonstrated a 1.6 mg/dL drop upon re-admission. During the next several hours 800 cc of bloody hemoptysis was noted. EGD was performed with difficult esophageal intubation due to blood, and a large hematoma in the posterior oropharynx. The distal esophagus, stomach and duodenum were unremarkable. Direct laryngoscopy demonstrated ecchymosis and edema versus hematoma of the right posterior hypopharyngeal region with no sign of active bleeding. CT angiogram of the neck confirmed a large hematoma in the right parapharyngeal region as shown in figure 1. Due to the hematoma size and recurrent bleeding surgical drainage was recommended and completed uneventfully. The patient was initiated on therapeutic anticoagulation the following day with no recurrent bleeding. He was extubated and maintained with NG tube feeds for seven days after which his diet was slowly advanced without difficulty.

DISCUSSION: Pharyngeal hematomas are an uncommon complication of TEE guided PVI. In assessing the etiology of hemoptysis after this procedure it is important to consider potential pharyngeal bleeding sources. A small esophageal tear from a traumatic TEE is at risk for extension due to aggressive anticoagulation. In addition, pharyngeal hematomas complicate the high-risk for embolic phenomenon present in patients immediately post-PVI by necessitating temporary withdrawal of anticoagulation.

CONCLUSIONS: Pharyngeal bleeding is a rare complication of TEE and should be included in the differential for a patient presenting with complaints of dysphagia or hemoptysis after TEE.

Reference #1: Hilberath JN, et al. Safety of Transesophageal Echocardiography. J Am Soc Echocardiography. 2010; 23:1115-27.

DISCLOSURE: The following authors have nothing to disclose: Rachel Le, Darlene Nelson

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