S4187 When Transesophageal Echocardiography Turns Traumatic: Delayed Esophageal Tear Following Watchman™ Placement

Introduction: Transesophageal echocardiography (TEE) is a minimally invasive cardiac imaging technique with a low but known risk of injury to the oropharynx, esophagus, or stomach. Large case series show that the incidence of esophageal perforation after TEE is approximately 0.01-0.03%. The risk of esophageal damage may be higher during prolonged probe insertion and in structural interventions such as the placement of a Watchman™ device. While case reports have documented esophageal perforations and hematomas, data on esophageal tears is limited. We present a rare case of a delayed partial-thickness esophageal tear following Watchman™ device placement, managed successfully through endoscopy. Case Description/Methods: An 82-year-old woman with atrial fibrillation underwent TEE-guided Watchman™ placement and developed hematemesis 1 week later. She presented after 4 episodes of large-volume hematemesis, found to be in hemorrhagic shock with a hemoglobin of 5.8 g/dL. Physical exam findings included pale skin, lethargic appearance, and abdominal tenderness to palpation. Massive transfusion protocol was initiated, and she was subsequently intubated for airway protection due to persistent hematemesis. Emergent esophagogastroduodenoscopy revealed a mid-esophageal lesion, approximately 30 cm from the incisor, with stigmata of recent bleeding, though visualization was limited by extensive blood and blood clots in the lower esophagus and fundus that were unable to be fully cleared. CTA chest showed no evidence of an aortoenteric fistula. Repeat esophagogastroduodenoscopy several hours later identified a partial-thickness esophageal tear, extending from the mid to distal esophagus, with a visible vessel protruding through the abnormal mucosa. Hemostasis was achieved after placement of 2 clips and injection of 8 mL of epinephrine. The patient remained stable with a hemoglobin of 12.2 g/dL and no further evidence of bleeding. Discussion: This case highlights a rare but clinically significant complication of TEE. Risk factors for esophageal injury include advanced age, frailty, and prolonged probe manipulation. While most esophageal perforations occur intraoperatively, delayed presentations are possible, such as with a delayed esophageal tear. Prompt recognition and multidisciplinary care are crucial for optimal patient outcomes. Endoscopic management is preferred to stabilize bleeding and close the defects.