Risk of transesophageal echocardiography in awake patients with cardiac diseases

Risk of Transesophageal Cardiac Diseases

Echocardiography

in Awake

Patients

with

Annette Geibel, MD, Wolfgang Kasper, MD, Abdullah Behroz, MD, Ulrike Przewolka, MD, Thomas Meinertz, MD, and Hanjoerg Just, MD

ecent studies described the diagnostic value of transR esophageal echocardiography in patients with different diseases of the heart and the thoracic aorta.le8 However, the risk and potential complications of the transesophageal approach are still under discussion. Schlueter et al6 reported no major side effects during the transesophageal approach in 300 consecutive patients. In accordance with these results, Engberding et al7 also observed no complications using the transesophageal technique in patients with aortic dissection or aortic aneurysm. More recently and in a similar patient population, Erbel et al8 described a 1% incidence of side effects (namely, 1 patient with an attack of asthma and another who experienced a transient atrioventricular heart block). In a prospective study in 54 consecutive patients with different heart diseases undergoing transesophageal echocardiography, we evaluated the presence and severity of “side effects” such as cardiac arrhythmias, marked changes in blood pressure or heart rate and evidence of myocardial ischemia during the diagnostic procedure. We studied prospectively 54 patients (29 men and 25 women,ages19 to 79 years, mean 54 f 15) with different heart diseases.Twenty-one patients had an aortic valve diseaseand 10 had a mitral valve disease.Infective endocarditis was suspectedin 12. Two patients had an aneurysm of the thoracic aorta and 2 had an aortic coarctation. In 3 patients a cardiac thrombus was suspected. One patient had an atria1 myxoma and in 1 patient a cardiac tumor was suspected.One patient had a combined aortic and mitral valve diseaseand another had an atria1 septal defect. Before the transesophagealexamination all patients had given informed consentand were in a fasting state for at least 4 hours. Transesophagealechocardiography was performed using the Varian 3400 R echocardiograph (Diasonics) with a commercially available 3.5-MHz transducer. The transducer contains 32 single elements (phased-array principle), arranged so that only horizontal sections (sector angle of 84”) can be obtained. Local anesthesia was performed with Xylocaine@ spray before inserting the gastroscope.No other premeditation was used. The technique of the transesophagealprocedure has been describedpreviously.2-4 The time of the transesophageal procedure was taken from the insertion of the scopeuntil its removal from the mouth. In all patients 24-hour Holter monitoring was performed usinga Cardiodata MK 4 system which hasbeen From the Innere Medizin III, University of Freiburg, 78 Freiburg, West Germany. Manuscript received January 28, 1988; revised manuscript received and accepted April 4, 1988.

shownto be appropriate for arrhythmia and ST-segment analyses.9 The transesophageal approach was performed during the 24 hours of Holter recording. The incidenceof cardiac arrhythmias during the controlperiod (24-hour Holter recording minus the time of the transesophagealprocedure) wascomparedwith the incidenceof cardiac arrhythmias during the transesophageal investigation. Using an automatic blood pressure measuringdevice (Oxford Accu Tracker), blood pressure and heart rate were obtained and registered every 2 minutes during the transesophagealapproach and every 15 minutes over the following 6 hours (control period). The results of the study are summarized in Table I. The mean duration of the transesophagealprocedure was 8.3 f 2.8 minutes (range 3 to 14). During the transesophagealprocedure we observed neither increasesin complexity or severity of supraventricular or ventricular arrhythmias nor induction of ventricular tachycardia or atrialjibrillation in any patient. Single premature ventricular complexes were observed in 19 of 54 patients (35%) during the transesophageal procedure and in 36 of 54 patients (67%) during the control period. In 17 of 19 patients (90%) with premature ventricular complexesduring the investigation, ventricular arrhythmias were observed during the control period (Table I). During the transesophagealprocedure the incidence of ventricular arrhythmias wassmall. The absolute value of premature ventricular complexesrangedfrom 1 to 89 during the transesophagealapproach, with a mean value of 17 f 23. During the control period (24-hour Holter recording minus the time of the transesophageal echocardiography), premature ventricular complexes rangedfrom 1 to 3,064 (mean 536 f 920). Two of the 54 patients had ventricular pairs both during the transesophagealapproach and during the controlperiod (Table I). Supraventricular premature beats occurred in 13 of 54 patients (24%) during the transesophagealinvestigation. These arrhythmias were also present during the control period. Eight patients had atrialfibrillation during the control period and the transesophagealprocedure without worsening of the arrhythmia (Table I). During the control period the ST segmentdecreased >0.15 mV in 13 of 54 patients (24%). During the transesophagealapproach no patient had evidence of STsegment changes. Onepatient developedan intermittent, second-degree atrioventricular block (type II) during the transesopha-

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BRIEF REPORTS

TABLE

I Clinical

Variables

and

Results

24Hour

Pt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

Age Ws), Sex 64, 75, 54, 36, 58. 38, 27, 27, 57, 31, 50, 33, 41, 63, 61, 66, 71. 57, 55, 63, 74, 73, 47, 41. 45, 44,F 70, 65, 57. 56, 63, 51, 53, 57. 30. 19. 66, 65, 22, 70, 43, 45,

F F F M F M F F F F M F M F M M M M F F M F M M

M F F M

M M M F

F F M

F F M M M M

46,F

66, 61, 51, 66, 53, 45, 55, 77, 71, 79, 65,

D (min)

9

8 7 11 4 6 6 7 14 14 7 6 7 4

9 AF 7 33 l-35 37 AF 173 14 5 31 3 122 46 7 83 33 177 1 3----844 39 31 15 831 7 93

F F

VP (beats)

136 1,339 94 l8

-

432

-

2191 37 68 36 5 121 47 4

-

2 -

-

AF AF 200 AF

63 8 477 9 48 5 66

9 8

12

378 27 142 8,427 14 AF

AF

PVB (beats)

VP (beats)

7 -

-

-

-

1 AF

8 2

3 -

-

8

AF

-

1 3

-

2

-

-

1 139

6 1

1 -

-

2,345 -

3 -

2

2 169 2.766

-

14 27 3,064 5 253 8 -

-

2 4

20 71

2,758 473 18 1,090 1,243 2,355 139

-

-

3

AF

14 AF

-

-

45

20

55

89

AF

-

2 5

AF

-

3

-

-

-

3 -

1

12 10

-

4 2 94 4

Mean Blood Pressure (Systok) CP TEE (mm Hg) (mm Hg) 132 166 115 147 116 117 122 122 144 125 120 126 121 112 105 111 128 128 111 137 108 111 125 122 80 121 125 108 142 146

162 167 137 131 124 136 163 125 130 136 119 139 123 127 145 130 114 152 162 144 120 108 134 139 72 123 125 128 151 142

111 133

117 130

106

126

106 148 151 150 148 135 105 139 114 123 104 115 124 153 142 104 107 140

101 152 152 165 158 159 147 150 116 116 103 108 140 155 155 117 123 165

1

54 -

5 22

TEE SVPB (beats)

3-

AF

6 6 5

3 7 10 6 12 6

Study

Monitoring

PVB (beats)

AF

14 M M M M M M M M F

Holter

CP SVPB (beats)

11 8 13 12 10 12 12 5 8 6 8 6 8 10 6 10 6 9 10 9 10 8 10 3 5 7 12 12

of the

1

-

-

5 36

-

1 3

-

15 22 3

AF

-

Mean Heart CP (beats/min) 65 88 68 105 73 82 112 73 56 75 83 78 65 70 71 84 65 75 60 81 67 77 68 69 92 71 118 78 94 56 110 68 70 73 91 75 85 84 72 88 64 79 97 77 85 95 65 63 73 73 83 56 98 77

Rate TEE (beats/min) 67 90 99 113 76 83 119 76 71 93 94 89 72 72 69 75 68 82 66 86 69 74 68 77 87 67 113 85 94 65 101 70 81 90 114 75 77 107 78 116 74 92 117 88 84 84 56 68 85 80 86 65 76 87

The lncldence of arrhythmias are expressed as absolute value during the control period and the transesophageal procedure The control systolic blood pressures refers to the mean of several values taken every 15 mwwtes over 6 hours after the procedure AF = atnal Pbnllabon, CP = control period (24hour Halter re@stratlon wthout the bme of the transesophageal procedure), D = time of the transesophageal approach from beginnIng the ~nserbon of the scope until Its removal from the mouth; PVB = premature ventrwlar beats, SVPB = supraventncular premature beats, TEE = transesophageal echocardlography; VP = ventrtcular par

geal procedure, which disappeared immediately after the investigation. Sinus rhythm and atrialfibrillation wereseenduring the control period and the transesophagealprocedure in 46 and 8 patients, respectively. Thirty-two of the 46 338

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patients with sinus rhythm showed an increase and 11 patients a decreaseof the heart rate during the transesophagealinvestigation in comparison with the control period (Table I). In the 32 patients the mean increaseof heart rate was 7.9 f 5.4 beatslmin and the mean de-

crease in the 11 patients was 7.3 f 5.6 beatslmin. In 7 of 8 patients with atria1 fibrillation the heart rate was slightly increased (mean increase 16.6 f 8.0 beatslmin). One patient showed a decrease from 85 to 77 beatslmin. During the transesophageal procedure 39 of 51 patients (77%) showed an increase of the systolic blood pressure and 11 patients a decrease (22%). In patients with an increase of systolic blood pressure the mean value changed from 125 f I6 mm Hg during the control period to I41 f 16 mm Hg during the transesophageal investigation. A decrease in blood pressure was observed from a mean value of 122 f 18 to 115 f 17 mm Hg (Table I). Other hemodynamic changes were not observed in this patient population.

This prospective study showsthat during transesophageal echocardiography the incidence of hemodynamic changes and occurrence of ventricular arrhythmias are low, even in patients with severe heart disease. Although it was difficult to compare the incidence of arrhythmias during the short time of the transesophageal examination with a much longer control period, the incidence of supraventricular or ventricular arrhythmias was not increased during the transesophageal approach and there was no evidence for the occurrence of malignant arrhythmias. The changes in heart rate and blood pressure were small and well tolerated by the patients. There was no evidence of myocardial ischemia during transesophageal echocardiography. However, the number of patients with severe coronary artery disease and at high risk for myocardial ischemia was small in this study population. These data agree with our previous uncontrolled experiences in more than 1,400 patients routinely studied by transesophageal echocardiography over a period of 41 months. In these patients we observed a very low overall

The AJC in August William

incidence of complications (Cl%), although 2 patients had an asymptomatic nonsustained ventricular tachycardia, 2 with congenital heart disease had right-to-left shunts due to severe arterial hypoxemia that required interrupting the transesophageal echocardiographic approach, 1 patient with atria1 fibrillation had pathologic bradycardia (treated by atropine) and 1 developed myocardial ischemia requiring cessation of the procedure. After comparing the incidence and seriousness of the complications with the diagnostic benefit, the transesophageal echocardiography seems to be a well-tolerated and safe diagnostic approach. 1. Daniel WG, Muegge A, Gahl K, Lichtlen PR. Echokarditische Diagnostik der infektioesen Endokarditis. Irr Ghal K, ed. Infektioese Endokarditis. Darmstadt: Steinkopff, 1983:108-l 32. 2. Hanrath P, Schlueter M, Langenstein BA, Polster J, Engel S, Kremer P, Krebber HJ. Detection of ostium secutuium atria1 septal defects by tramoesophageal cross-sectional echocardiography. Br Heart J 1983;49:350-358. 3. Hofmann T, Kasper W, Meinertz T, Spillner G, Schlosser V, Just HJ. Delermination of aortic value orifice area in aortic value stenosis by two-dimensional transesophageal echocardiography. Am J Cardiol 1987;59:330-335. 4. Kasper W, Hofmann T, Meinertz T, Billmann P, Byrtus M, Lang K, Spillner G, Schlosser V, Just HJ. Transesophageal echocardiography to detect dissection and aneurysm of the thoracic aorta. Z Kardiol 1986;75:609-615. 5. Koenig K, Kasper W, Hofmann T, Meinertz T, Just HJ. Tramesophageal echocardiography for diagnosis of rupture of the ventricular septum or left ventricular papillary muscle during acute myocardial infarction. Am J Cardiol 1987;S9:362. 6. Schlueter M, Hinrichs A, Thier W, Kremer P, Schroeder S, Cahalan K, Hanrath P, Siglow V. Transesophageal two dimensional echocardiography: comparison of ultrasonic and anatomic sections. Am J Cardiol1984:53:1173-1178. 7. Engberding R, Bender F, Grosse-Heitmeyer W, Most E, Mueller UF, Bramann HU, Schneider D. Iden@cation of dissection or aneurysm of the descending thoracic aorta by conventional and tramesophageal two-dimensional echocardiography. Am J Cardiol 1987:59:717-719. 8. Erbel R, Boerner N, Steller D, Brunier J, Thelen M, Pfeiffer C, Mohr-Kahaly S, Iversen S, Oelert H, Meyer J. Detection of aortic dissection by tramesophageal echocardiography. Br Heart J 1987;58:45-51. 9. Shook TL, Balke W, Kotilainen PW, Selwyn AP, Stone PH. Accuracy of detection of myocardial &hernia by amplitude-modulated andfrequency-modulated Halter technique. JACC 1986:7:104A.

1963

C. Roberts, MD

heAJCin August 1963contained 17articles (theAJC T in August 1988 contains 39 articles) occupying 130 pages. The lead article by Frick and associates* from Helsinki, Finland, described results of a study of 14 sedentary men aged 19 to 26 years just before and after a 2-month hard basic training period. The physical working capacity of the subjects was markedly improved, an improvement paralleled by an increase in heart volume. The cardiac output at rest was slightly higher after training due to an increase in stroke volume. Heart rate was reduced at rest in 11 of the 14 subjects. During exercise after training, stroke volume increased and heart rate decreased. Seftel and associates2 from Johannesburg, South Africa, described findings in 30 Bantu patients who had acute myocardial infarction, fatal in 15. Of the 30 pa-

tients, 27 were men aged 31 to 75 years (mean 51) and 3 were women aged 58, 61 and 62 years. The serum total cholesterol levels, known in 14 patients, were >200 mg/dl in 6 patients, <150 mg/dl in 1 and ranged from 79 to 370 mg/dl (mean 205). (The average serum total cholesterol of adults at the Baragwanath Hospital at the time was 150 f 33 mg/dl.) This report indicated that acute myocardial infarction, although quite rare, did occur in the South African Bantu in the 1950s. Schwartz and colleagues3 from Petah Tikva, Israel, investigated serum total cholesterol levels in 222 Israelis of Yemenite, Bedouin and European origin. Bedouins, a nomadic people living in the arid Negev region of southern Israel, ate a lactovegetarian diet of 1,500 to 2,000 calories daily; Yemenites consumed about 2,500 calories daily and Europeans ingested about 3,000 calories daily, THE AMERICAN

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