Frequency and outcome of TEE-Associated Esophago-Gastric (GE) Lesions Following Transcatheter Tricuspid Edge-to-Edge Valve Repair (T-TEER)

Background TEER is a well-established therapy for patients (pts) with severe tricuspid regurgitation and high surgical risk for a conventional surgical procedure. Transoesophageal echocardiography (TEE) is essential to guide this complex intervention and is generally considered to be safe. However, no larger study investigating the safety of TEE in TEER has been conducted. Purpose The aim of our study is to analyse the incidence of periinterventional TEE-related minor and major GE complications during T-TEER procedures, even among asymptomatic pts. This is particularly relevant since 89.5% of the pts required immediate oral anticoagulation on top of clopidogrel after the procedure. Methods In our hospital, 67 pts with severe tricuspid regurgitation underwent T-TEER. All interventions were carried out under general anesthesia and full heparinization with an activated clotting time (ACT) of > 250 sec. All pts received routine administration of pantoprazol 40 mg i.v. twice daily periinterventional. One day after the procedure, the pts underwent routine EGD. Esophageal lesions were classified according to the Forrest classification for upper gastrointestinal bleeding. Results 67 pts (mean age 80.9 ± 0.6 years, 30 males; Euro-Score I 23.6% ±1.6%; EuroScore II 7.0± 0.6%; DM (31.3%); Afib 55 (95.5%); NYHA III or IV (95.5%); PPM leads in RV 8 (11.9%) successfully underwent T-TEER. There was a significant reduction in the mean tricuspid regurgitation grade, from 4.1±0.1 to 1.9±0.1 (P<0.0001). The mean skin-to-skin intervention time was 113.5±6.3 min. Post-TEER EGD was performed on 53 pts (79.1%), revealing 38 (71.7%) GE lesions: Forrest Ia 0 (0%), Forrest Ib 2 (3.8%), Forrest IIa 1 (1.9%), Forrest IIb 14 (26.4%), Forrest IIc 3 (5.7%) and Forrest III 7 (13.2%). The remaining 11 patients (20.8%) had minimal superficial lesions or hematoma. 9 (17%) of these clinically silent GE lesions required interventional treatment with GE clips. No patients needed blood transfusion despite full oral anticoagulation. Interestingly, only 6 (15.8%) lesions were found in the stomach, despite the mandatory and intensive use of gastric view during the procedures. Intervention time was significantly longer in pts needing GE Clip therapy versus pts without GE Clip therapy: 140.3±17.6 min vs 105.5±7.8 min, p=0.036. A multivariate regression analysis including age, sex, BMI, Euroscore I, Euroscore II and DM identified that only the intervention time is an independent predictor for lesions requiring clip therapy during EGD. (p=0.047) Conclusion Our study demonstrates that major GE injuries and bleeding post TEER are rare. However, TEE-induced clinically silent lesions of the upper GE tract requiring interventional GE clip therapy do occur especially with longer interventional times. The impact of routine EGD following TEER on clinical outcomes, especially GE bleeding under oral anticoagulation should be further investigated in prospective randomized trials.