【病例分享】为了治疗食管溃疡放置钛夹，结果导致心房穿孔

导读

Endoclips in the heart: unexpected outcome after treatment of esophageal ulcer

心脏上的钛夹：食管溃疡治疗的意外结局

By Miika Vuorinen, MD, PhD

&Markku Heikkinen, MD, PhD

A 73-year-old man presented to our hospital's emergency department because of hematemesis and recent chest pain. The patient had severe anemia (Hb 47 g/L), but he was hemodynamically stable. The next morning, gastroduodenoscopy showed Los Angeles stage D circumferential esophagitis and a large hiatal hernia. The gastric mucosa was normal, and there was no blood in the stomach. In the esophagus, a few centimeters above the gastric glands, an ulceration approximately 4 cm wide was seen (A). At the time, the ulcer did not bleed.

患者，男，73岁，因呕血和近期胸痛来到急诊室。患有严重贫血（Hb 47 g/L），但血液动力学稳定。第二天早晨，胃十二指肠镜检查显示洛杉矶D级食管炎和一个大型食管裂孔疝。胃黏膜正常，胃中无血液。在胃腺上方几厘米处的食管中，可见约4 cm宽的溃疡（A）。当时，溃疡没有出血。

A second epinephrine injection next to nonbleeding stigma caused a cracking sound when the penetrating mucosa and plastic needle catheter slipped about 5 mm inside the esophagus wall. There followed massive bleeding from the ulcered area. Several endoclips were placed on the bleeding area (B), but bleeding continued until the patient was pulseless. Cardiopulmonary resuscitation was ineffective. Autopsy showed a perforation 4 cm wide in the distal esophagus (C). Multiple endoclips were attached to the left cardiac atrium (D). To our best knowledge, this is the first time endoclips set to treat an esophageal ulcer have been reported to perforate the cardiac atrium.

在无出血征象的部位注射肾上腺素，当注射针穿刺黏膜并插入食管壁5mm时，血管破裂，随后溃疡区域大量出血。在出血区域（B）放置了多个钛夹，但患者仍持续出血，之后脉搏微弱，心肺复苏无效。尸检显示，在远端食管（C）有一个4 cm宽的穿孔。多个钛夹被连接到左心房（D）。据我们所知，这是首次为了治疗食管溃疡而放置钛夹结果导致心房穿孔的报告。

Douglas G. Adler等人的评论

Practitioners of endoscopic ultrasound, or transesophageal echocardiography, know that the left atrium abuts the left lateral distal esophagus. Cardiac procedures can sometimes have esophageal consequences, such as the ablation of aberrant pathways in patients with atrial fibrillation resulting in an atrial-esophageal fistula from injury of the adjacent esophageal wall.

进行超声内镜或经食管超声心动图检查的医生都知道左心房邻接食管远端左外侧。心脏手术有时会对食管产生不良影响，例如房颤患者异常传导路径的消融会导致相邻食管壁损伤，进而导致心房食管瘘。

In this case, a large esophageal ulcer appears to have eroded into the cardiac space and clips that were thought to have been placed on the ulcer were, in fact, being placed on the heart itself. Although the authors state that this is the first report of this, I suspect this has happened before and gone unreported given the longstanding use of clips in GI endoscopy. Esophageal stents can occasionally erode through this exact location and manifest as pericardial injury or even tamponade, demonstrating how closely these two structures are anatomically.

在本病例中，较大的食管溃疡似乎已经延伸到心脏，而原本认为放置在溃疡上的钛夹实际上放置在了心脏上。尽管作者声明这是此方面的首次报告，但我怀疑以前可能发生过这种情况，由于在胃肠道内镜操作中经常需要使用钛夹而未得到报告。食管支架偶尔会侵蚀至心脏，表现为心包损伤甚至填塞，这都表明食管和心脏这两个结构在解剖学上有多紧密。

Douglas G. Adler, MD, FASGE

GIE Senior Associate Editor

University of Utah School of Medicine

Salt Lake City, Utah

Mohamed O. Othman, MD

Associate Editor for Focal Points

Reference:

Vuorinen M, Heikkinen M. Endoclips in the heart: unexpected outcome after treatment of esophageal ulcer. Gastrointest Endosc. 2021 Feb;93(2):518-519. doi: 10.1016/j.gie.2020.07.048. Epub 2020 Jul 28. PMID: 32730820.