transesophageal echocardiogram ( tee ) has been introduced to the operating room over 30 years ago . we report a case of esophageal perforation caused by tee during an aortic valve replacement operation , treated successfully with a new endoscopic clip . to the best of our knowledge , this is the first case of post - tee esophageal perforation treated endoscopically with this new clip device . a 72-year - old female was admitted to the operating theater for aortic valve replacement . during the operation and in the first hours in the intensive care unit ( icu ) the patient had to undergo tee in order to assess postoperative left ventricle performance status . a deep 2  1.5 cm ulcer covered with blood thrombus was found approximately 2 cm above the gastroesophageal junction . the rest of the endoscopy was unremarkable . within the next 48 h , thoracic and only a few blood clots were found in the area between the stomach and the left liver hilum , but no signs of mediastinitis or free intra - abdominal air . four days later , as the patient became febrile , a second gastroscopy was performed . a 2  1.5 cm perforation was seen at the same site of ulcer with no bleeding ( fig . due to the patient 's clinical condition and the size of the gap , an endoscopic intervention was decided . a new 12-mm clip ( otsc ; ovesco endoscopy , tbingen , germany ) was engaged . the clip is made of nitinol and approximates large perforation margins like a surgical clamp . the edges of the perforation were approximated by using a specific endoscopic double grasping forceps and applying suction through the cap . thus , the tissue was pulled into the cap and the clip was released by rotating the wheel attached to the shaft of the endoscope . a nasogastric levin tube was uneventfully left in the stomach under direct vision for long - term enteral feeding . further , the patient was offered two intra - abdominal drainage catheters in the operating theater so that intra - abdominal air and blood clots be drained and high fever get under control . all intra - abdominal and peripheral blood cultures were sterile . the patient was kept on intravenous antibiotics , proton pump inhibitors and parenteral nutrition over the next 10 days followed by enteral feeding through the levin tube . two weeks later she was transferred to the clinical ward , experiencing no dysphagia , and was discharged fully recovered 3 months after the operation . tee has safely been applied in patients undergoing cardiac surgery and in icu departments for diagnostic purposes and monitoring over 30 years . factors that may determine the way of intervention following esophageal perforation are age , clinical condition , location and size of the perforation , cost of intervention and elapsed time since the injury . the time since perforation has occurred is crucial . a diagnosis delayed for more than 36 h is associated with high mortality ( 50% ) , despite surgical intervention . up to date , there have been no randomized controlled trials comparing surgical to endoscopic intervention regarding patient outcome . in our case , the tee performed in the operating theater and the icu led to esophageal perforation due to the patient 's esophagus anatomy . the delayed diagnosis of perforation is attributed to the blood thrombus on top of the ulcer seen in the first endoscopy that behaved as a sealant . our patient 's serious clinical condition precluded major surgical intervention , and it was decided to provide her with endoscopic therapy . additionally , due to the size of perforation and cost , a single clip that could seal the gap was very appealing . last , by leaving this clip in place for a long time , longer than common clips , could possibly guarantee safe sealing of this perforation . according to clip manufacturers , the clip may remain in place for over 6 months and is magnetic resonance imaging - safe . esophageal perforations closed endoscopically range from 3 to 25 mm in size . due to the new device technology ( twin grasper and the cap at the tip of endoscope ) , a single clip is enough and able to create a full - thickness closure of perforations up to 3 cm in diameter . this new clip provides a secure and successful esophageal perforation closure rate , up to 100% in perforations diagnosed within the first 24 h . according to this study , the clip remains in place for over 6 months and the mean repairing time of an esophageal perforation after successful multiple clipping is 18 days ( interquartile range 626 ) . most importantly , chronicity of perforation ( > 10 days ) was the only independent predictive factor for successful perforation closure in univariate and multivariate analysis . however , esophageal perforation as a complication of this clip during patient intubation has been reported in up to 3% of patients , but probably this can be attributed to the learning curve . indeed , in another study with 94 patients regarding the use of the otsc clip to narrow the pouch in patients who underwent gastric bypass surgery , no esophageal perforation occurred . in conclusion , although tee is a safe procedure , it may be complicated by esophageal perforation . we clearly showed and strongly suggest that esophageal perforation of 5 days can safely and successfully be treated endoscopically by applying this new otsc clip device .
esophageal perforation due to transesophageal echocardiogram ( tee ) during cardiac surgery is rare . 
 a 72-year - old female underwent tee during an operation for aortic valve replacement . 
 further , the patient presented hematemesis . 
 gastroscopy revealed an esophageal bleeding ulcer . 
 endoscopic therapy was successful . 
 although a ct scan excluded perforation , the patient became febrile , and a second gastroscopy revealed a big perforation at the site of ulcer . 
 the patient 's clinical condition required endoscopic intervention with a new otsc clip ( ovesco endoscopy , tbingen , germany ) . the perforation was successfully sealed . 
 the patient remained on intravenous antibiotics , proton pump inhibitors and parenteral nutrition for few days , followed by enteral feeding . 
 she was discharged fully recovered 3 months later . 
 we clearly demonstrate an effective , less invasive treatment of an esophageal perforation with a new endoscopic clip .