Extensive Intramural Esophageal Hematoma After Transesophageal Echocardiography During Atrial Fibrillation Ablation

A 72-year-old man with persistent atrial fibrillation, a history of myocardial infarction and transient ischemic attack, and a CHADS2-VASc score of 3 on warfarin underwent an elective atrial fibrillation ablation. His international normalized ratio was 2.1 on the day of the procedure; he had taken his last warfarin dose 2 days before the procedure. The ablation was performed under general anesthesia, and an uncomplicated preprocedural transesophageal echocardiogram (TEE) was performed that excluded left atrial thrombus. The TEE probe was placed within the esophagus for the duration of the procedure, in part to guide the transseptal puncture. Wide-area circumferential ablation was performed to isolate the pulmonary veins, with further ablation of complex fractional atrial electrograms. Intravenous heparin was given during the procedure to maintain his activated clotting >300 seconds, and protamine was administered to reverse anticoagulation before removal of the sheaths at the end of the procedure.Seventeen hours after the procedure, the patient had 100 mL fresh hematemesis, developed melena, and complained of dysphagia. His hemoglobin had dropped by 2 U compared with the beginning of the procedure (166 to 144 g/L). The rest of the blood results were as follows: sodium, 148 …