Reply to S.W. MacGowan

We appreciate the interest expressed by Dr MacGowan in our paper [1], which emphasizes the risk of esophageal perforation during transesophageal echocardiography (TEE). Dr MacGowan presents a new case revealed at the post-mortem examination in a ventilated patient. We have found nine cases of esophageal perforation after TEE reported in the literature until now. MacGowan’s report is an interesting paper, which emphasizes difficulties to diagnose esophageal tear in sedated patients. Diagnosis of esophageal perforation is often late even in non-sedated patients. In our series of thoracic esophageal perforation free interval before diagnosis was more than 24 h in 23 (45%) of our 51 cases [2]. We agree with Dr MacGowan that in sedated patients dorsal pain, fever or subcutaneous emphysema are absent and uncontrolled sepsis may be the only diagnostic clue. Maybe the diagnosis would be made sooner by a bronchoscopy in the case reported by MacGowan? We have written flexed position of the tip of the probe for a long time and moving of the probe in a locked position are favoring factors that must be avoided [1]. Furthermore, underlying ischemia of the esophageal tissues might be increased by a high pressure ventilation. After all, MacGowan emphasizes the interest of postmortem examination, which is becoming more and more difficult to perform nowadays in our country.