A case of massive hemoptysis following transesophageal echocardiogram

INTRODUCTION: Tracheal intubation leading to injury of the airway is a rare complication of transesophageal echocardiography (TEE). Tracheal trauma is not a described complication of TEE, and safety literature for this procedure remains silent on the matter. We describe the case of a patient on systemic anticoagulation and antiplatelet therapy who underwent TEE and suffered massive hemoptysis requiring bronchial artery embolization (BAE). CASE PRESENTATION: An elderly patient was admitted to the hospital with recently diagnosed atrial fibrillation and shortness of breath. The patient underwent a TEE with successful synchronized cardioversion on hospital day #2. Later that day the patient experienced respiratory distress and hemoptysis and was intubated. Oropharyngeal and gastrointestinal sources of bleeding were excluded. A bronchoscopy revealed active bleeding from an ulceration in the bronchus intermedius (BI) of the right lung. A 7 French Arndt endobronchial blocker (Cook Medical, Bloomington, Indiana) was placed and anticoagulation reversed. Bleeding stopped for two days, but then returned on hospital day #5, requiring BAE to the right bronchial artery. The procedure was successful, the patient was successfully extubated, and was discharged over the next 10 days. DISCUSSION: Massive hemoptysis and respiratory compromise as a result of tracheal trauma is not described in the TEE literature. This patient proved to be a difficult esophageal intubation secondary to a newly discovered Zenker's diverticulum. The risk for bleeding in this patient was higher secondary to anticoagulation with warfarin and antiplatelet therapy with ticagrelor. As in all cases of massive hemoptysis, key aspects of care in this case involved localization of bleeding, reversal of anticoagulation, and definitive management such as BAE. CONCLUSIONS: Tracheal trauma is not a described complication of TEE, but clinicians should be mindful of this possible complication in patients receiving anticoagulation. Typical management for massive hemoptysis was successful in this patient.