Dear Editor,
Transesophageal echocardiography (TOE) is commonly considered a relatively safe and mini-invasive imaging technique[1] often performed on extremely fragile patients with multiple comorbidities and poly-pharmacotherapy.
The latest guidelines on performing TOE published by the American Society of Echocardiography, indicate generic coagulopathy as a relative contraindication to the examination;[2] however, it is important to consider that a large number of patients who have indications to perform a TOE may be considered as affected by a “iatrogenic” coagulopathy because of anticoagulant drugs (e.g., patients with mechanical prosthetic valves).
In a recent report on the European Heart Journal - Cardiovascular Imaging,[3] we have described a case of a spontaneous retrobulbar hemorrhage following an urgent TOE in a patient taking warfarin and INR of 5 because of the suspect of thrombosis on an aortic mechanical valve. The occurrence of spontaneous retrobulbar hemorrhage has also been described few years ago as a complication of upper gastrointestinal endoscopy,[4] raising the concern that this uncommon complication might not be so rare.
The introduction of the probe may indeed cause multiple gag reflexes with Valsalva-like maneuvers in patients that are not or partially sedated. The increase in the arteriovenous pressure gradients during these maneuvers has probably led to vascular lesions in the retrobulbar region resulting in blood extravasation. Considering that a substantial proportion of patients that are candidates to TOE are taking Vitamin K antagonists, it is important to notice that, to date, there are no clear guidelines regarding the safety and risk of TOE related to INR ranges and level.[1] Of note, studies in patients with atrial fibrillation have shown that the risk of intracranial hemorrhages (ICHs) increases significantly at INR levels ≥3.5, triplicating the odds ratio of ICH for INR levels ≥4.5[5] and a meta-analysis on anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy indicate an absolute risk of hemorrhage of 30.1%/year for INR >5.[6]
In light of our previous experience, considering the above-mentioned evidence, we deem it appropriate to recommend special attention to anticoagulated patients with a careful evaluation of the benefit-risk balance of the procedure, especially in patients with an INR >5, even in the urgency setting where relative contraindications are often overlooked. In particular, we suggest that an INR level above the upper therapeutic limit would represent an absolute contraindication in elective TOE and a relative contraindication in urgent setting. In the latest European Guidelines on valvular heart disease,[7] the fluoroscopy is suggested with TOE as imaging technique for the management of left-sided obstructive and nonobstructive mechanical prosthetic thrombosis. It might represent a possible alternative tool in anticoagulated patients with elevated INR value or unknown anticoagulation status and should be better taken into account by clinicians and suggested by the current guidelines for this special setting as first-line technique together with transthoracic echocardiography because of its safety of execution.
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REFERENCES
1. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr 2010;23:1115–27.
2. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921–64.
3. Natale F, Loffredo F, Molinari R, Golino P, Cimmino G. An unusual case of retrobulbar haemorrhage following a transoesophageal echocardiogram: A rare but a potential severe complication. Eur Heart J Cardiovasc Imaging 2022;23:e543.
4. Glover H, Khan MI, Manoj K. An unusual adverse event of EGD. Gastrointest Endosc 2020;91:707–8.
5. Singer DE, Chang Y, Fang MC, Borowsky LH, Pomernacki NK, Udaltsova N, et al. Should patient characteristics influence target anticoagulation intensity for stroke prevention in nonvalvular atrial fibrillation?: The ATRIA study. Circ Cardiovasc Qual Outcomes 2009;2:297–304.
6. Oake N, Jennings A, Forster AJ, Fergusson D, Doucette S, van Walraven C. Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: A systematic review and meta-analysis. CMAJ 2008;179:235–44.
7. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2022;43:561–632.
