A case report of acute right ventricular failure in a patient undergoing transoesophageal echocardiogram for evaluation of tricuspid regurgitation

Background: Transoesophageal echocardiography (TEE) is generally considered a low-risk procedure. However, in patients with severe tricuspid regurgitation (TR) complicated by right ventricular (RV) dysfunction and pulmonary hypertension (PH), standard procedural sedation can precipitate life-threatening haemodynamic collapse. Case summary: An 83-year-old woman with end-stage renal disease, severe PH (95 mmHg), and severe TR underwent a TEE. Shortly after induction with propofol and probe insertion, the patient developed profound systemic hypotension (56/30 mmHg). Real-time TEE imaging revealed acute, severe RV dilatation and a precipitous decline in systolic function. The procedure was immediately aborted, and the patient was stabilized with intravenous phenylephrine and ephedrine. She returned to her haemodynamic baseline within 20 min of procedure termination and probe removal. Discussion: This case highlights the 'triple hit' effect that places patients with RV failure at high risk during sedation: propofol-induced systemic vasodilation, the vagal response to probe insertion, and hypercapnia-induced increases in pulmonary vascular resistance (PVR). For this high-risk phenotype, a 'slow and low' anaesthetic titration, meticulous PVR management, and early consideration of RV-protective vasopressors are essential to prevent catastrophic RV-pulmonary uncoupling.