Complications Associated With Transesophageal Echocardiography in Transcatheter Structural Cardiac Interventions

Highlights

• The risk of a TEE-related complication was 3.6% over the past decade.

• Gastrointestinal hemorrhage is the most frequently reported complication.

• Intraoperative TEE during cardiac valve surgery had a lower risk of complications.

Background

Transesophageal echocardiograms (TEEs) performed during transcatheter structural cardiac interventions may result in greater complications than those performed in the nonoperative setting or even those performed during cardiac surgery. However, there are limited data on complications associated with TEE during these procedures. We evaluated the prevalence of major complications among these patients in the United States.

Methods

A retrospective cohort study was conducted using an electronic health record database (TriNetX Research Network) from large academic medical centers across the United States for patients undergoing TEE during transcatheter structural interventions from January 2012 to January 2022. Using the American Society of Echocardiography–endorsed International Statistical Classification of Diseases and Related Health Problems Clinical Modifications (10th edition) codes, patients undergoing TEE during a transcatheter structural cardiac intervention, including transaortic, mitral or tricuspid valve repair, left atrial appendage occlusion, atrial septal defect closure, patent foramen ovale closure, and paravalvular leak repair, were identified. The primary outcome was major complications within 72 hours of the procedure (composite of bleeding and esophageal and upper respiratory tract injury). The secondary aim was the frequency of major complications, death, or cardiac arrest within 72 hours in patients who completed intraoperative TEE during surgical valve replacement.

Results

Among 12,043 adult patients (mean age, 74 years old; 42% female) undergoing TEE for transcatheter structural cardiac interventions, 429 (3.6%) patients had a major complication. Complication frequency was higher in patients on anticoagulation or antiplatelet therapy compared with those not on therapy (3.9% vs 0.5%; risk ratio [RR] = 8.09, P < .001). Compared with those patients <65 years of age, patients ≥65 years of age had a higher frequency of major complications (3.9% vs 2.2%; RR = 1.75, P < .001). Complication frequency was similar among male and female patients (3.5% vs 3.7%; RR = 0.96, P = .67). Among 28,848 patients who completed surgical valve replacement with TEE guidance, 728 (2.5%) experienced a major complication.

Conclusions

This study found that more than 3% of patients undergoing TEE during transcatheter structural cardiac interventions have a major complication, which is more common among those on anticoagulant or antiplatelet therapy or who are elderly. With a shift of poor surgical candidates to less invasive percutaneous procedures, the future of TEE-guided procedures relies on comprehensive risk discussion and updating practices beyond conventional methods to minimize risk for TEE-related complications.

Introduction

Transesophageal echocardiograms (TEEs) allow for higher-resolution images of posterior cardiac structures compared with transthoracic echocardiograms, and their diagnostic capabilities have expanded to improved visualization of valvular pathology, workup of recurrent strokes, and evaluation for thromboembolic risk prior to cardioversion in atrial fibrillation.1, 2, 3 More recently, the role of TEE has evolved beyond simple image acquisition to real-time intraoperative visualization utilized to guide percutaneous structural interventions such as transcatheter aortic valve replacement (TAVR), transcatheter mitral valve repair (MVR), transcatheter tricuspid valve repair (TVR), left atrial appendage occlusion (LAAO), atrial septal defect (ASD) repair, ventricular septal defect (VSD) repair, patent foramen ovale (PFO) repair, and paravalvular leak repair (PVLR).3, 4, 5, 6 Transesophageal echocardiography has been considered a generally safe procedure, with the frequency of major complications ranging from 0.2% to 1.4% in both operative and nonoperative situations; however, it does carry an inherent risk as an invasive imaging technique.^7,8 Historically, complications during TEE have been rare injuries to the gastrointestinal tract because of direct mechanical trauma.^9,10 With the growing role in structural cases, complications have been more frequently reported secondary to the constant probe manipulation needed during procedures.^11,12

There is limited contemporary literature detailing the frequency of complications associated with TEE in transcatheter structural cardiac interventions. The potentially increased risk for TEE-related complications is concerning as we continue to see a dynamic shift to completing percutaneous procedures on these previously poor surgical candidates.¹³ Over 38,000 LAAOs were completed from January 2016 to December 2018, and over 11,000 transcatheter MVRs were completed in 2019 in the United States.^14,15 While smaller studies outside of the United States have reviewed this topic, the frequency of TEE-related complications for transcatheter structural cardiac interventions in the United States has not been previously described.^11,12 Additionally, no previous studies have contrasted the frequency of TEE-related complications from intraoperative TEE in cardiac surgery.

The current study aimed to evaluate the short-term complications for U.S. adult patients undergoing TEE for transcatheter interventions that include TAVR, MVR, TVR, LAAO, PVLR, ASD repair, VSD repair, and PFO closure. It also aimed to contrast the frequency of complications seen during cardiac surgery with intraoperative TEE guidance as well.