Abstract Introduction Hemothorax and mediastinal hematoma are rare complications that may occur following transesophageal echocardiography (TEE), particularly in patients who are taking anticoagulants. The incidence of these complications is relatively uncommon but can lead to significant clinical consequences, especially after procedures involving instrumentation of the thoracic cavity. Case Description An old female in her 80s with a history of severe asthma, deep vein thrombosis, and tachy-brady syndrome with pacemaker placement presented with progressive dyspnea. She had undergone TEE with synchronized cardioversion for atrial fibrillation three days prior to admission. Following the procedure, she experienced respiratory distress and dysphagia. Contrast-enhanced CT of the chest and abdomen revealed a large heterogeneous mediastinal mass/conglomerate adenopathy encasing the trachea and esophagus, associated mediastinal stranding, and a right-sided pleural effusion. No oral or IV contrast extravasation was seen. Comparison to a prior CT from a year ago demonstrated interval progression from previously mild mediastinal lymphadenopathy. Differential diagnoses included mediastinitis from esophageal microperforation, mediastinal hematoma/hemorrhage related to TEE, invasive esophageal carcinoma with adenopathy, and lymphoma. The patient was started on broad-spectrum antibiotics and admitted to the critical care unit. Endoscopy did not reveal any obvious perforation. Due to concerns about a lymphoproliferative process, the patient was taken to the operating room for thoracentesis and endobronchial ultrasound (EBUS). 900 cc of blood was aspirated from the right pleural cavity. EBUS confirmed findings consistent with mediastinal hematoma. There was significant improvement in mediastinal hematoma post thoracentesis. Repeat imaging after thoracentesis attached. Breathing significantly improved, and dysphagia resolved. Discussion TEE is a safe and minimally invasive procedure and has become a cornerstone in guiding both surgical and medical decision-making. TEE can cause severe complications, most commonly upper gastrointestinal (UGI) injuries. The true incidence and risk factors are difficult to define due to underreporting. More than 3% of patients undergoing TEE during transcatheter structural interventions experience major complications, especially elderly or anticoagulated patients. The suggested mechanisms are composed of vascular injury, intrathoracic pressure shifts, and procedural positioning, which can cause mediastinal hematomas or hemorrhage. Although the mediastinum usually limits vascular leaks, disruption of collateral vessels or major thoracic structures can result in hemothorax, particularly in anticoagulated patients. Case reports and procedural studies support that TEE, while generally safe, carries a risk of severe vascular injury and bleeding. Hemothorax and mediastinal hematoma are rare but serious complications of TEE, especially in patients on anticoagulation, highlighting the need for careful management. This abstract is funded by: None
Mushtaq et al. (Fri,) studied this question.