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Massive gastrointestinal hemorrhage after transoesophageal echocardiography probe insertion
J St-Pierre1, L P Fortier, P Couture
1Department of Anaesthesia and Cardiac Surgery, Montreal Heart Institute, Quebec, Canada.
Insights
Massive gastric bleeding occurred after transesophageal echocardiography (TEE) during emergency coronary artery bypass surgery in a heparinized patient. TEE insertion before heparinization is recommended to prevent gastrointestinal hemorrhage.
Area of Science:
- Cardiology
- Gastroenterology
- Surgical Procedures
Background:
- Emergency coronary artery bypass graft surgery is a critical intervention for severe coronary artery disease.
- Transesophageal echocardiography (TEE) is a valuable tool for intraoperative cardiac monitoring.
- Heparinization is essential during cardiopulmonary bypass but carries bleeding risks.
Observation:
- A 50-year-old male presented with acute myocardial infarction and pulmonary edema.
- Following coronary artery bypass graft surgery and systemic heparinization, a TEE was performed.
- Massive gastric bleeding, evidenced by 1,200 ml of red blood drainage, was identified post-TEE.
Findings:
- Endoscopic examination revealed a gastroesophageal mucosal tear and esophageal erosions.
- The gastrointestinal hemorrhage was successfully managed with submucosal epinephrine injections.
- The patient was discharged eight days post-surgery with no further complications.
Implications:
- This case highlights a severe gastrointestinal hemorrhage complication associated with TEE in a heparinized patient.
- It suggests that TEE probe insertion should ideally precede heparin administration and cardiopulmonary bypass.
- This approach may mitigate the risk of TEE-associated gastrointestinal bleeding in high-risk surgical patients.
Purpose:
To describe a case of a massive gastric bleeding following emergency coronary artery bypass surgery associated with transoesophageal echocardiographic (TEE) examination.
Clinical Features:
A 50-yr-old man was referred for an acute myocardial infarction and pulmonary edema (Killip class 3). Twelve hours after his myocardial infarction, he was still having chest pain despite an i.v. heparin infusion. Coronary angiography revealed severe three-vessel disease with multifocal stenosis of the left anterior descending, circumflex and total occlusion of the right coronary artery. The patient was transferred to the operating room for emergency coronary artery bypass graft surgery. After total systemic heparinization (3 mg.kg-1) was obtained for cardiopulmonary bypass, a multiplane TEE probe was inserted without difficulty to monitor myocardial contractility during weaning from CPB. During sternal closure, the TEE probe was removed and an orogastric tube was inserted with immediate drainage of 1,200 ml red blood. Endoscopic examination demonstrated a mucosal tear near the gastro-oesophageal junction and multiple erosions were seen in the oesophagus. These lesions were successfully treated with submucosal epinephrine injections and the patient was discharged from the hospital eight days after surgery.
Conclusion:
This is a report of severe gastrointestinal hemorrhage following TEE examination in a fully heparinized patient. This incident suggest that, if the use of TEE is expected, the probe should preferably be inserted before the administration of heparin and the beginning of CPB.