Role of routine esophagoduodenogastroscopy (EGD) to detect clinically silent TEE related esophago-gastric- (GE) lesions following transcatheter tricuspid edge-to-edge-valve repair (TEER)

The Transcatheter Edge-to-Edge Repair (TEER) is an established therapy for patients with symptomatic severe tricuspid regurgitation and a high surgical risk for a conventional surgical procedure. TEE is essential to guide this complex intervention and is proclaimed to be safe, but there exists so far to our knowledge no larger study investigating the safety of TEE in TEER. 

After one major clinically oligosymptomatic TEER complication with perforation of the oesophagus in our hospital we started to perform routine EGD as standard procedure after each TEER intervention to rule out major and minor GE-lesions and injuries. 

 

 

The aim of our study was to analyze the incidence of peri-interventional TEE related minor and major GE-complications during TEER procedure. 

 

 

At our hospital 47 patients with severe tricuspid valve regurgitation and high surgical risk underwent transcatheter edge-to-edge tricuspid valve repair with the TriClip system (Abbott, Chicago, IL, USA). 

All interventions were performed under general anesthesia and full heparinisation with an activated clotting time (ACT) of more than 250 sec. All patients received routine administration of pantozol 40 mg i.v. twice daily before and after the procedure. One day after the procedure all asymptomatic patients received routinely EGD.

The lesions of the esophagus were classified after the Forrest classification for upper gastrointestinal bleeding. 

 

 

47 patients (average age 81.4 +/- 4.4 years, 19 male, 11 pts. had type 2 diabetes, 20 pts. hypercholesterolemia, 38 pts. arterial hypertension, 44 pts. persistent atrial fibrillation, 42 NYHA III or IV, 6 pacemaker leads in RV, 2 pts were s/p bypass surgery, 6 pts. s/p mitral valve surgery) with a high surgical risk (mean logistic Euro-Score I 23.1% +/- 9.27%, mean logistic EuroScore II 6.45% +/- 2.91%) underwent successfully TEER. In total, there was a reduction of mean grade of tricuspid valve regurgitation from 4.1 +/- 0.76 to 1.4 +/-0.58; P < 0,001). The mean skin-to-skin intervention time was 119.46 +/- 51.83 min. By Post-TEER EGD 34 (72,34%) GE-lesions were detected: Forrest Ia 0 (0%), Forrest Ib 2 (5,8%), Forrest IIa 0 (0%), Forrest IIb 11 (32%), Forrest IIc 2 (5,8%) and Forrest III 4 (11%). The residual 9 lesions (26,5%) were irrelevant superficial lesions or hematoma. Six (17,6%, 2 Forrest IIb, 3 Forrest IIb, 1 Forrest IIc) of these clinically silent GE lesions were treated interventionally by clips. No patient needed blood transfusion. Interestingly there were only 3 lesions (1 Forrest Ib, 1 Forrest IIc and 1 Forrest III) found in the stomach although for TEER procedure a gastric view is mandatory and intensively used.

There was a tendency towards increase of asymptomatic lesions and also the severity of the lesions with longer intervention times and the number of implanted Clips. 

 

Our study shows that major GE injury and bleeding post-TEER is rare, but TEE-induced clinically silent lesions of the upper GE tract requiring interventional GE clip therapy do occur quite often during TEER especially if a longer intervention time is needed. Therefore performing EGD and invasive GE therapy after TEER procedures especially with long intervention times might be helpful in further lowering GE complications after successful TEER, even if the patient is asymptomatic. This should be further studied.