Unilateral Pulmonary Edema During Transesophageal Echocardiography Shmuel Stienlauf, MD, Michaela Witzling, MD, Michael Herling, MD, and David Harpaz, MD, Holon and Tel-Aviv, Israel Transesophageal echocardiography is considered to be a relatively safe procedure, the complications of which are well known and include probe-related and procedure-related complications. Congestive heart failure rarely occurs. Unilateral pulmonary edema is relatively uncommon and to the best of our knowl- edge has never been reported in association with transesophageal echocardiography. Herein we de- scribe an unusual case of unilateral pulmonary edema that developed during the course of transesophageal echocardiography. (J Am Soc Echocardiogr 1998; 11:491-3.) Transesophageal echocardiography (TEE) is con- sidered to be a safe procedure, accompanied by a very low complication rate of less than 0.5%. 1-3 The com- plications of this procedure are well known. Conges- tive heart failure rarely occurs except in patients with preexisting significant myocardial compromise. Uni- lateral pulmonary edema (ULPE) is relatively un- common in heart failure. We describe an unusual case of ULPE that developed during the course of TEE. CASE REPORT A 59-year-old man was referred for an elective TEE for investigation of the potential source of emboli after a documented cerebrovascular accident and multiple infarcts found on a computed tomography of the brain. The patient’s past history included hypertension, non– insulin-dependent diabetes mellitus, and an old myocardial infarction with mild left ventricular systolic dysfunction with a left ventricular ejection fraction (LVEF) of 43%, as was estimated by a previous multiple gated acquisition scan. A Thallium-201 perfusion scan was negative for inducible ischemia. The patient’s New York Heart Association func- tional capacity was class II. The patient was treated with nitrates, ACE inhibitors, and a low dose of diuretics. Transthoracic echocardiography was performed in the left lateral decubitus position, lasting for 20 minutes, dur- ing which he was relaxed and without any apparent distress. The transthoracic study revealed a mildly enlarged left ventricle (a diastolic dimension of 57 mm) and a reduced left ventricular function caused by three vessels’ distribu- tion of wall motion abnormalities. The LVEF was esti- mated to be 32%. A Doppler study did not reveal any significant valvular regurgitation. After 20 minutes, in which the patient was sitting, the pharynx was anesthetized with 10% lidocaine spray. Ten milliliters of lidocaine gel was then given to the patient to swallow. No intravenous medications were injected. The patient was placed again in the left lateral decubitus posi- tion and the esophagus was immediately intubated. Vital signs before inserting the TEE probe were blood pressure 190/100 mm Hg, heart rate 120 beats/min, and arterial oxygen blood saturation (measured by pulse oximetry) 95%. Within 1 minute after swallowing the probe and the beginning of the TEE examination, the patient developed progressive dyspnea and the arterial oxygen blood satura- tion dropped to 84% to 85%. Blood pressure was 190/110 mm Hg and heart rate was 145 beats/min. The arterial oxygen saturation remained low despite oxygen supple- mentation by nasal cannula. The patient denied any chest discomfort. No electrocardiographic changes, new wall motion abnormalities, or mitral regurgitation were de- tected by the TEE. The TEE probe was withdrawn because of progressive dyspnea 1 minute later. The patient was admitted to the Internal Medicine ward. On admission he was mildly dyspneic, the respiratory rate was 18 per minute, blood pressure was 140/95 mm Hg, heart rate was 80 beats/min, and the arterial oxygen satu- ration was 90% (with oxygen supplementation). Fine respi- ratory crackles and reduced inspiratory sounds over the left lung were noted. The electrocardiograph remained un- changed without any changes compatible with acute isch- emia. Routine laboratory tests including cardiac enzyme levels were all within normal limits. Methhemoglobin and carboxyhemoglobin could not be detected in the blood. A chest radiograph, performed within 30 minutes of the acute event, revealed diffuse unilateral opacities over the left lung (Figure 1, A). The patient was treated only with oxygen supplementa- From the Department of Internal Medicine E, Department of Radiology and the Heart Institute, E. Wolfson Medical Center, Holon, and the Sackler Medical School, Tel-Aviv University. Reprint requests: David Harpaz, MD, The Heart Institute, E. Wolfson Medical Center, Holon, 58-100, Israel. Copyright © 1998 by the American Society of Echocardiography. 0894-7317/98 $5.00 + 0 27/4/89026 491