Supplementary Material for: Pan-Esophageal Submucosal Dissection following Transesophageal Echocardiography

A 73-year-old female underwent open mitral valve replacement with transesophageal echocardiography (TEE) guidance. She developed upper gastrointestinal bleeding postoperatively and was found on upper endoscopy to have a bleeding site at the gastric cardia with the appearance of focal trauma and a possible puncture site. A submucosal bluish protrusion was seen throughout the esophagus with a mucosal flap at the proximal esophagus. As a unifying diagnosis, it was suspected that the intraoperative TEE probe caused a submucosal dissection with point of entry at the proximal esophagus, running the entire length of the esophagus and exiting at the gastric cardia, giving rise to a clinical upper gastrointestinal bleed. Closure of the esophageal defect was achieved using an endoclip. A CT scan showed focal pneumomediastinum along the proximal esophagus, confirming the hypothesis. We report the first case to our knowledge of iatrogenic pan-esophageal submucosal dissection, which, in this case, presented as a clinical bleed from the exit point trauma to the gastric cardia mucosa caused by a TEE probe. Endoscopic management of the gastric injury as well as the esophageal defect led to resolution of the bleeding and avoidance of mediastinitis, respectively, allowing for an excellent recovery.