Esophageal Injury During Transesophageal Echocardiography-Guided Left Atrial Appendage Occlusion: A Narrative Review

Transesophageal echocardiography (TEE) remains an established imaging modality for guiding percutaneous left atrial appendage occlusion (LAAO), providing real-time visualization during transseptal puncture, device deployment, and procedural assessment. However, esophageal instrumentation and prolonged probe manipulation may result in gastrointestinal injury, particularly in patients with pre-existing esophageal abnormalities or increased bleeding risk. This narrative review summarizes the available evidence regarding the mechanisms, risk factors, clinical manifestations, diagnosis, management, and prevention of TEE-associated esophageal injury during LAAO while examining alternative imaging strategies. A literature search was conducted in PubMed, Scopus, Web of Science, and the Cochrane Library, supplemented by targeted searches of broader structural heart intervention literature. Although clinically recognized TEE-associated gastrointestinal complications are uncommon, studies employing systematic endoscopic surveillance have identified substantially higher rates of subclinical mucosal injury. Reported manifestations range from transient dysphagia and superficial mucosal lesions to gastrointestinal bleeding, intramural esophageal hematoma, perforation, and fistula formation. LAAO-specific registry and administrative datasets report gastrointestinal bleeding rates ranging from approximately 0.2% to 8.2%, but heterogeneous outcome definitions, ascertainment methods, and the absence of systematic endoscopic verification prevent these findings from being interpreted as rates of TEE-associated esophageal injury. Nevertheless, limited LAAO-specific evidence, heterogeneous outcome definitions, and differences in surveillance strategies preclude reliable estimation of procedure-specific esophageal injury incidence. Intracardiac echocardiography eliminates esophageal instrumentation but carries a distinct procedural risk profile, whereas cardiac computed tomography (CCT) provides complementary opportunities for preprocedural planning and postprocedural surveillance. Careful preprocedural assessment, judicious probe manipulation, early recognition of complications, and individualized imaging selection are important considerations. Prospective studies incorporating standardized esophageal injury endpoints are needed to establish the true clinical burden and guide preventive strategies.