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Upper GI injuries related to transesophageal echocardiography (TEE) were the norm during structural heart interventions -- even in the hands of experienced operators, according to a report.

A new gastric or esophageal injury was observed immediately after a TEE-guided procedure in 86% of patients. Complex lesions such as intramural hematomas and mucosal lacerations were observed in 40% of the 50 people in the prospective study by Josep Rodés-Cabau, MD, of Quebec Heart and Lung Institute and Laval University in Quebec City, and colleagues.

Predictors of complex lesions were longer procedural time under TEE manipulation (OR 1.27 for every 10 minutes of imaging, 95% CI 1.01-1.59) and poor or suboptimal image quality (OR 4.93, 95% CI 1.10-22.02), the investigators showed.

As they explained in the study online in the , one of the main mechanisms behind the TEE-injuries in transcatheter cardiac interventions is direct mechanical trauma caused by the probe in patients under intensive heparin anticoagulation.

"Imaging experts performing this technique should be aware of the nature of potential complications, to take the necessary precautions to prevent their occurrence and facilitate early diagnosis and treatment," Rodés-Cabau and co-authors urged.

"However, it is of note that even though patients had a high incidence of TEE-related injuries, all complications were managed conservatively, the majority of dysphagia or odynophagia episodes were self-limited, and there were no cases of perforation or death related to a TEE complication," the researchers wrote.

Thus, they cautioned, routine endoscopic investigation should not be recommended in all patients undergoing structural cardiac procedures.

Participants in the study with mild symptoms and minor or small complex lesions were treated with analgesics, proton pump inhibitors, and a soft diet. Only when a large hematoma arose and there were severe symptoms did patients undergo cessation of oral intake and temporary interruption of their usual anticoagulation, the researchers said. There were no deaths, readmissions, or complications related to the use of TEE over a median 45 days of follow-up.

Even so, operators may reduce the risk of TEE-related injury by measures such as considering other modes of imaging and the use of conscious sedation, Rodés-Cabau's group recommended.

"During the course of the intervention, operators should try to minimize unnecessary manipulation, avoid maintaining the probe flexed or locked during long periods of time, freeze the image when the probe is not being used to prevent it from overheating, and always consider the need to terminate a procedure with a low expected success rate based on a long TEE imaging time," the investigators wrote.

Structural interventions in the report included mitral and tricuspid valve repair, left atrial appendage closure, and paravalvular leak closure. All were performed under general anesthesia and at a single center.

Study participants were a median 76.8 years old, and roughly one-third were women. Median left ventricular ejection fraction was 50%. The cohort was notable for having a high prevalence of comorbidities (hypertension in 90%, chronic kidney disease in 58%), the researchers said.

Before and after each procedure, a thoracic surgeon performed an esophagogastroduodenoscopy (EGD). An abnormal baseline EGD, observed in 50% of the cohort, was associated with development of new complex lesions. However, this association did not persist on multivariable adjustment.

The study lacked an event adjudication committee, the researchers said, adding that the 50-person sample was also relatively small.

"Additionally, the current study lacked extended follow-up, which would help us understand the longer-term significance of these findings," Jayashri Aragam, MD, and Zaid Almarzooq, MBBCh, both of Harvard Medical School in Boston, wrote in an .

Nevertheless, this was the first prospective study of TEE safety in transcatheter structural heart procedures, Aragam and Almarzooq said. They noted that the older studies -- mostly in surgical cohorts -- were limited by their retrospective design and inconsistent methods for identifying complications.

"[G]iven the experience of the TEE operators in this study and assuming trainees were not involved, one would believe that the complication rates may be even higher at other institutions with lower procedure volumes and less experienced operators," the editorialists said.

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