Abstract
We had a case in which a transesophageal echocardiography (TEE) probe migrated into the anterior mediastinum. The patient was a 62-year-old woman who had undergone mitral valve replacement (UMVR) for infectious endcarditis. The procedure was successfully finished. The TEE was inserted without any complications before the surgery and removed at the end of the surgery. However, postoperative bleeding from the ascending aorta was found after the MVR, and an emergency operation for hemostasis was performed. After the hemostatic procedure was completed, we inserted a TEE probe to examine whether aortic dissection had occurred. Insertion of the TEE probe was so difficult that the probe was inserted after a few tries. However, we found that the probe migrated into the anterior mediastinum while TEE was progressing. The oropharynx was perforated, and an operation to close it had to be performed. We considered several possible causes of the perforation. First, the operation was performed in an emergency situation and drapes were covering the patient's face at the time of TEE insertion. Second, the patient had been taking prednisolone over a long period of time which made her tissues fragile.
