Iatrogenic transmural oesophageal haematoma after a MitraClip procedure
Transoesophageal echocardiography (TEE) is a crucial imaging modality guiding numerous structural heart interventions. TEE is a safe procedure with low incidence of complications. Iatrogenic probe-related injuries mostly include harmless epithelial laceration and sore throat. However, life-threatening complications, such as oesophageal perforation, may also occur. In the current paper we describe a rare case of TEE-induced large oesophageal haematoma compressing the trachea and main bronchi. A
... nd main bronchi. A 61-year-old woman, not eligible for cardiac surgery, was admitted to our institution for a scheduled MitraClip procedure. She suffered from symptomatic heart failure (New York Heart Association class III) with reduced left ventricular ejection fraction (30%). The patient's comorbidities included stable coronary artery disease treated with percutaneous coronary intervention one year previously, history of myocardial infarction, obesity (body mass index of 38 kg/m 2 ), and metabolic syndrome. A year earlier she was implanted with a cardioverter defibrillator. TEE done during the referral for the MitraClip procedure showed severe central mitral regurgitation (MR) with a small cleft in the P2 segment. The MitraClip procedure was performed in a standard manner under general anaesthesia and with TEE guidance. The immediate outcome following implantation of two clips was satisfactory, as demonstrated by the reduction of MR severity from severe to mild. The good result was confirmed by postprocedural transthoracic echocardiography, visualising two MitraClip devices in a proper position, a reduction of MR from severe to less than moderate, and borderline mitral gradient of 13.5/5.5 mmHg. However, in the postoperative care unit the patient developed a refractory cough with audible stridor. Chest computed tomography examination showed an enlarged oesophagus (up to 38 × 32 mm), without any signs of bleeding or perforation but with a radiologic suggestion of haematoma within the oesophageal wall (Fig. 1A) . Moreover, the enlarged oesophagus was compressing the trachea and ostia of both main bronchi (Fig. 1B, C) . Bronchoscopy was performed and revealed compression of the tracheal wall by oesophageal haematoma at the level of the bronchial carina, a flattened trachea, a narrowed, fissure-shaped ostium of the left main bronchus, and the right main bronchus narrowed to 50%. A sample of mucopurulent secretion found in the left main bronchus was taken for further examination. Positive bacterial culture of enlarged spectrum b-lactamase-positive Klebsiella pneumoniae and clinical signs of infection were indications for meropenem treatment, which proved to be effective. The patient was closely monitored for two weeks in the intensive care unit. The oesophageal haematoma was treated conservatively.