An exceptional complication of transesophageal ultrasound in
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EP after TEE represents a medico-surgical emergency. Given the high rate of asymptomatic patients with COVID 19, the risk of contamination and the frailty of esophageal tissues, we should check coronavirus infection in every patient before TEE.

The patient was a 67-year-old woman with a medical history of hypertension and atrial fibrillation. She was admitted in our department because of one-week fever (38.3°C). She had no respiratory symptoms or history of gastro-esophageal disease. Physical examination revealed good general condition, with a blood pressure of 120/80 mm Hg, and a pulse rate of 80 beats per minute. Her oxygen saturation was 92% in ambient air. Pulmonary auscultation was normal. Cardiac auscultation showed normal heart sounds and a 3/6 systolic murmur to the mitral focus. The electrocardiogram was in sinus rhythm.

A transthoracic echography was performed, finding a slightly dilated left ventricle with preserved systolic function, severe mitral regurgitation by prolapse of the large mitral valve (A2 prolapse), and rupture of the chordae. There is moderate tricuspid regurgitation. Laboratory studies showed hemoglobin of 15.7 g/L and normal leukocyte count. There were elevated blood levels of C-reactive protein (150 mg/L; normal range, 0-10 mg/L).

Given the high probability of infectious endocarditis (IE) suspected by the presence of fever, a biological inflammatory syndrome, and severe mitral regurgitation by chordae rupture, we performed TEE which did not show any signs of IE. The introduction of the probe was uneventful, and the patient tolerated well the examination.

Immediately after the TEE, the patient reported severe neck pain and cervical swelling. Examination of the cervical region revealed swelling of five centimeters in diameter consistent with hematoma and subcutaneous emphysema. The oropharyngeal examination was without abnormalities.

A cervicothoracic computed tomography (CT) scan after oral contrast administration was performed showing perforation of the cervical esophagus, hematoma of the visceral space of the neck, and emphysema of the retropharyngeal space.

Intravenous antibiotics and parenteral nutrition were initiated. As a part of preoperative assessment, we performed a real-time PCR of nasopharyngeal swabs which was positive for SARS-CoV-2. The patient underwent emergent surgery, allowing the closure of the perforation, drainage of the collection, and feeding jejunostomy. Intraoperatively, the esophageal wall was inflammatory with evidence of reduced visceral perfusion throughout the esophagus. Unfortunately, the patient died, ten days later from severe refractory hypoxemia due to acute respiratory distress syndrome.