Usefulness of oesophageal irrigation during transoesophageal echocardiographic guidance for structural heart interventions

Introduction

Transoesophageal echocardiography (TEE) is the standard imaging modality for structural heart interventions (SHI).¹ It is widely used and has a favourable safety profile. However, concerns have emerged regarding TEE-associated upper gastrointestinal (GI) tract complications.² Increasing procedural complexity and duration, along with frequent probe manipulation, may contribute to suboptimal image quality, reduced manoeuvrability, and elevated probe temperatures.

We developed a novel oesophageal assistance approach for TEE-guided SHI (EASI-TEE), incorporating a homemade oesophageal irrigation system (IS) to address procedural factors related to TEE probe use at the oesophageal level and enhance intraprocedural image guidance (Figure 1, Panel A). This study aimed to assess (i) the effectiveness of the IS in improving image quality, probe manoeuvrability, and temperature control, and (ii) the occurrence of oesophageal lesions compared with a historical cohort.

Figure 1.

Oesophageal irrigation system during structural heart intervention. (Panel A) Irrigation system with pediatric orogastric tube attached to the TEE probe. (Panel B) Effect of the irrigation system on image quality and probe manipulation during structural heart intervention. (Panel C) Effect of the irrigation system on probe temperature. (Panel D) Effect of the irrigation system on the occurrence of complex oesophageal and gastric lesion. (Panel E) Complex lesion rate of the EASI-TEE study compared to previous studies.

Methods

Fifty patients underwent oesophageal assistance during SHI guided by transoesophageal echocardiography. Institutional and Ethics Committee approved this study, and patients signed informed consent for procedures.

Echocardiographic study and irrigation system

Six interventional echocardiographers performed all intraprocedural TEE using a Philips EPIQ 7 (X8-2t) multiplane adult probe. The IS is described in Panel A. Image quality and probe manoeuvrability were assessed during the 5 min before and after each irrigation using a three-item scale (1 = good, 2 = suboptimal, 3 = poor).

Subgroup and endpoints

A subgroup of 22 patients underwent esophagogastroduodenoscopy (EGD) before TEE probe insertion and after SHI. Gastric lesions were classified as non-complex or complex, as previously defined.³ The primary endpoint was improvement by ≥1 grade or maintenance of good image quality and probe manoeuvrability after irrigation, assessed at each irrigation and across three procedural periods (0–45, 45–90, and >90 min). Temperature changes were also evaluated. The secondary endpoint was the incidence of complex GI lesions, compared with a historical cohort (n = 50). The safety endpoint was the absence of aspiration pneumonia during hospitalization and at 1 month.

Statistical analysis

Changes in image quality and manoeuvrability were assessed using the Stuart–Maxwell test, and temperature using paired Wilcoxon signed-rank tests. A P-value <0.05 was considered significant. Incidence of GI lesions was compared using multivariable logistic regression, adjusted for procedural variables that differed between groups. Results are reported as adjusted odds ratios with 95% confidence intervals. Analyses were performed using R.

Results

The mean patient age was 77.5 ± 6.1 years. The primary endpoint was achieved in 97.2% of cases. Image quality improved by ≥1 grade in 28.8%, remained stable in 69.9%, and remained poor in 1.3%. Probe manoeuvrability improved in 29.6%, remained stable in 68.4%, and remained poor in 2%. Significant improvements in image quality and manoeuvrability were observed after irrigation across all time intervals (P < 0.001) (Figure 1, Panel B). Probe temperature also decreased significantly post-irrigation (mean reduction 1°C, P < 0.001) (Figure 1, Panel C).

Among EASI-TEE patients who underwent EGD, 95.4% developed new post-procedural lesions compared with 86% in the historical cohort (P = 0.240). Minor lesions were more frequent (86.4% vs. 66%, P = 0.136), whereas complex lesions were less frequent (27.3% vs. 40%, P = 0.442). After logistic regression, the historical cohort had a higher risk of complex oesophageal lesions, with no significant difference in minor lesions (Figure 1, Panel D). No deaths or pneumonia occurred during hospitalization or at 1 month.

Discussion

This study showed that a novel oesophageal IS used during TEE-guided transcatheter SHI improved image quality and probe manoeuvrability while reducing probe temperature. Although no significant difference in overall GI lesion incidence was observed, the higher risk of complex lesions in the historical cohort suggests a potential protective effect.

Given the emergence of structural heart imaging as a subspecialty in which TEE is the primary tool, these improvements are particularly relevant. Reduced image quality due to anatomical factors or intracardiac device shadowing, intrinsic limitations of TEE (e.g. acoustic attenuation and beam widening),^1,2,4 and the cost or limited availability of alternative imaging modalities (e.g. intracardiac echocardiography) underscore the need for effective adjunctive tools. The IS is a simple tool that could have a positive impact on the SHI itself by improving guidance.

Our incidence of new lesions was similar to that reported by Freitas-Ferraz et al., who observed new lesions in 86% of patients, but 40% were classified as complex in the historical cohort,³ a percentage that has been reduced to 27% thanks to the IS. Similarly, Kuecken et al. reported a 30% incidence of major or endoscopy-requiring lesions in 40 patients undergoing tricuspid TEER.⁵

Study limitations

As a pilot study, findings on IS safety and efficacy are preliminary. The small EGD subgroup limited the analyses, and results should be considered hypothesis-generating. Manoeuvrability and image quality were subjectively assessed by a single operator; however, the involvement of multiple echocardiographers and predefined criteria was intended to mitigate this limitation.

Conclusions

The novel oesophageal IS maintains image quality, improves TEE probe manoeuvrability, and enhances temperature control during TEE-guided transcatheter SHI. The higher risk of complex lesions in the historical cohort suggests that the IS may reduce TEE-related complications without additional safety concerns. Further studies are needed to clarify its impact on complex lesions and TEE-related outcomes.

Author contributions

Julio Farjat-Pasos (Conceptualization, Investigation, Methodology [equal], Writing—original draft [lead]), Juan Hernando Del Portillo (Conceptualization, Data curation, Formal analysis, Writing—review & editing [equal]), Laurent Biertho (Methodology, Validation, Writing—review & editing [supporting]), Simon Marceau (Methodology, Supervision, Writing—review & editing [supporting]), Benoît M Labbé (Methodology, Writing—review & editing [supporting]), David Belzile (Supervision [supporting]), Kim O'connor (Methodology, Supervision, Validation [supporting]), Jonathan Beaudoin (Supervision, Validation [supporting]), Mathieu Bernier (Supervision, Validation [supporting]), Jean-Michel Paradis (Supervision, Validation, Writing—review & editing [supporting]), Stephan Langevin (Conceptualization [equal], Investigation, Methodology, Supervision, Validation, Writing—original draft [supporting]), Erwan Salaun (Conceptualization, Investigation, Methodology, Writing—original draft, Writing—review & editing [equal], Supervision, Validation [lead]), and Josep Rodés-Cabau (Conceptualization, Investigation, Methodology, Visualization, Writing—review & editing [equal])

Funding

None declared.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.