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Society of Cardiovascular Anesthesiologists

Cardiovascular Anesthesiology Section Editor: Charles W. Hogue, Jr. Perioperative Echocardiography and Cardiovascular Education Section Editor: Martin J. London Hemostasis and Transfusion Medicine Section Editor: Jerrold H. Levy


Transesophageal Echocardiography for Transmyocardial Laser Revascularization

Shvetank Agarwal, MD,* Vinayak Kamath, MD,† and Manuel Castresana, MD*

A 65-year-old man was scheduled for coronary artery

bypass grafting (CABG) and transmyocardial laser

revascularization (TMR). His coronary angiography

and left ventriculogram revealed severe diffuse atheroscle- rotic disease with an ejection fraction of 65%. Intraoperative transesophageal echocardiography (TEE) performed by using a Phillips iE33 ultrasound system and an X7-2T 3-dimensional (3D) echocardiographic matrix-array trans- ducer (Phillips Healthcare, Andover, MA) confirmed pre- served ejection fraction of 60% to 65%, no regional wall motion abnormality, and normal valves. A systematic exam- ination of the left ventricle (LV) and left atrial appendage did not reveal thrombus formation. CABG was completed uneventfully on cardiopulmonary bypass (CPB). After removing the cross clamp, de-airing the ascending aorta and saphenous grafts, and stabilizing the cardiac rhythm, 2D TEE was performed as outlined in Table 1. After an unremarkable TEE examination and while still on CPB, TMR was initiated with a holmium:yttrium-aluminum-garnet (Ho:YAG) laser (Cardiogenesis, Corporation, Kennesaw, GA). TEE was done throughout the TMR primarily to assess the adequacy of channelization and to detect any iatrogenic laser injury to the valvular structures. Laser pulses were seen as “fireworks” or a “blast of steam” in the 2D 4/5 chamber (C) view when the penetration was transmural; this was conveyed to the surgeon (Fig. 1 and Video 1, see Supplemental Digital Content 1, As the surgeon worked his way up from the LV apex and began making the channels in lateral and posterior surfaces of the LV, a Live 3D TEE 5C view was used not only to confirm transmural pen- etration but to also localize the exact origin of the blast of steam (Fig. 2 and Video 2, see Supplemental Digital Content 2, The surgeon was notified when a laser pulse was particularly close to the LV outflow tract to avoid damage to the mitral and aortic valves during subsequent laser firings (Video 2, see Supplemental Digital

From the Departments of *Anesthesiology and Perioperative Medicine and †Surgery, Georgia Regents University, Augusta, Georgia.

Accepted for publication November 26, 2013.

Funding: None.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Shvetank Agarwal, MD, Department of Anesthe- siology and Perioperative Medicine, Georgia Regents University, 1120 15th St., BIW-2144 Augusta, GA 30912. Address e-mail to

Copyright © 2014 International Anesthesia Research Society

DOI: 10.1213/ANE.0000000000000098

Content 2, The size of these artifacts may vary considerably depending on how dis- tended the LV is and the angle at which the laser enters the LV cavity. Also, within a fraction of a second, the blast of steam disintegrates into microbubbles that fill the entire LV cavity, which makes it difficult and irrelevant to measure the size of the blast. In all, the surgeon performed 25 TMR channels in the lower two-thirds of the LV, with a 1- to 2-minute pause for every 2 to 5 TMR channels to allow myocardial recovery and reduce the likelihood of ventricular arrhythmias. There was an immediate myocardial injury pattern, as evidenced by major ST elevations in both leads II and V, but no new regional wall motion abnormality on 2D TEE was observed.


TMR is an approved surgical procedure for diffuse, end-stage coronary artery disease either as a stand-alone procedure in patients with medically refractory angina who are not can- didates for further conventional revascularization proce- dures or in conjunction with CABG in patients who would be incompletely revascularized by CABG alone. 13 Once a reasonably popular procedure, TMR has received renewed interest in recent years. According to the Society of Thoracic Surgery database, 24,809 TMR procedures were performed nationwide in Society of Thoracic Surgery participating cen- ters from January 2002 to December 2012. a The procedure entails creation of 1-mm laser channels in the myocardium that presumably induce neovascular- ization, particularly at the junction of the channels and the myocardium over the ensuing 3 to 6 months. 4 Relief of angi- nal symptoms may also be due to ablation of sympathetic neurons supplying the myocardium. 5 When used along with CABG, TMR is usually done after CABG while still on CPB. Several different lasers have been used in the past, but only Ho:YAG and carbon dioxide (CO 2 ) lasers are Food and Drug Administration approved for this purpose (Table 1). TEE plays an important role in guiding this procedure. When TMR is done as a stand-alone procedure, a compre- hensive TEE examination (Table 2) should precede it to assess ventricular function and to document any preexist- ing RWMAs, valvular dysfunctions, and pericardial effu- sion. It is also important to diagnose intracardiac thrombus or air, because this could lead to systemic embolization during TMR. For this, the left atrial appendage should be interrogated in multiple zoomed midesophageal views at

a 2013 Harvest 1-Executive Summary Adult Cardiac Surgery Database. Avail- able at: executive-summaries. Accessed August 30, 2013.

TEE for Transmyocardial Laser Revascularization

Table 1. Comparison of Ho:YAG and CO 2 Lasers


Type of laser Manufactured by Food and drug administration approval for transmyocardial laser revascularization Laser guidance for proper epicardial positioning

Holmium:yttrium-aluminum-garnet (Ho:YAG) Cardiogenesis corporation, Irvine, CA Yes

Carbon dioxide (CO 2 ) PLC medical systems, Franklin, MA Yes

Not necessary

Helium-neon laser to position the hand piece

Transesophageal echocardiography for confirming transmural penetration

Not necessary for an experienced surgeon (auditory and tactile feedback enable the surgeon to confirm transmural penetration) Not necessary


Electrocardiographic synchronization

Synchronized to fire on R-wave (end-diastole) when heart is maximally distended and electrically quiescent Better tissue absorption and more efficient tissue penetration. Creates a more complete channel with less thermal injury to the surrounding tissue

Penetration and tissue injury

Less efficient tissue penetration. Requires 3 to 4 firings, with more thermoacoustic injury

Requires 3 to 4 firings, with more thermoacoustic injury Figure 1. Two-dimensional transesophageal echocardiography

Figure 1. Two-dimensional transesophageal echocardiography midesophageal 4-chamber view demonstrating a “blast of steam” appearance of the turbulence of blood in the left ventricular cavity due to transmural penetration of the Ho:YAG laser fiber bundle at the apex of the left ventricle.

Ho:YAG laser fiber bundle at the apex of the left ventricle. Video 1. This 2-dimensional transesophageal

Video 1. This 2-dimensional transesophageal echocardiography (TEE) video clip is in 3 parts. A, Midesophageal (ME) 4-chamber view dem- onstrating a “blast of steam” appearance of the turbulence of blood in the left ventricular (LV) cavity due to transmural penetration of the Ho:YAG laser fiber bundle at the apex of the LV. B, ME 4-chamber view with blast of steam originating at the lateral wall of the LV. C, ME 5-chamber view with blast of steam in the LV outflow tract.

5-chamber view with blast of steam in the LV outflow tract. Figure 2. Three-dimensional transesophageal

Figure 2. Three-dimensional transesophageal echocardiography midesophageal 5-chamber view exhibiting distortion of the left ven- tricle due to probe placement and a “blast of steam” in originating from the posterolateral wall of the left ventricular cavity due to trans- mural penetration of the Ho:YAG laser fiber bundle.

trans- mural penetration of the Ho:YAG laser fiber bundle. Video 2. This 3-dimensional midesophageal 5-chamber

Video 2. This 3-dimensional midesophageal 5-chamber transesoph- ageal echocardiography video clip shows a “blast of steam” appear- ance in the left ventricle (LV) due to transmural penetration of the Ho:YAG laser fiber bundle and is in 2 parts. A, Originating from the posterolateral wall of the LV. B, Originating at the LV outflow tract close to the aortic valve.


Table 2. Roadmap for Transesophageal Echocardiographic (TEE) Assessment During Transmyocardial Laser Revascularization


Assess for

TEE views ME 4C, TG mid-SAX ME 4C, TG mid-SAX ME 4C, mitral commissural, ME 2C, ME LAX ME AV SAX, ME AV LAX ME 4C, ME 2C, ME LAX ME 4C, ME 2C (zoomed in) ME 4C, ME 2C, ME LAX ME 4C, ME 5C

Prior to procedure

Overall cardiac contractility Preexisting regional wall motion abnormalities Preexisting mitral valvular dysfunction Preexisting aortic valvular dysfunction Thrombus in the left ventricle apex Thrombus in the left atrial appendage Intracardiac air (if done while on cardiopulmonary bypass) Notify surgeon of the “blast of steam appearance” signifying transmural penetration of the laser Notify surgeon if working close to vital structures (e.g., mitral and aortic valves) Overall cardiac contractility New regional wall motion abnormalities New mitral valvular dysfunction New aortic valvular dysfunction

During the procedure

ME 4C, ME 5 C

After the procedure

ME 4C, TG mid-SAX ME 4C, TG mid-SAX ME 4C, mitral commissural, ME 2C, ME LAX ME AV SAX, ME AV LAX

4C = 4-chamber; 5C = 5-chamber; AV = aortic valve; LAX = long axis; ME = midesophageal; SAX = short axis; TG = transgastric.

increments of 30° to 40º starting from the 4C at 0º with mod- erate anteflexion until the entire appendage is visualized.


apical thrombus must also be excluded, by scanning it in


midesophageal 4C, 2-chamber, mitral commissural, and


long-axis views, making sure to avoid any foreshorten-


of the LV apex.

When the channels are created, the laser energy is absorbed by the blood, and a blast of steam (sometimes referred as a “puff of smoke” or “fireworks”) appears in the LV on TEE, signifying transmural penetration of the

laser. However, absence of the “blast of steam” implies inadequate penetration, which can be communicated to the surgeon. In our experience, a 4C or 5C view allows visualization of the unique acoustic effect created by channels anywhere in the LV, including the inferior wall. Unlike CO 2 lasers, for which TEE is mandatory to confirm transmural penetration, Ho:YAG lasers provide the surgeon with adequate tactile and auditory indica- tions when the laser has completely channeled through the myocardium into the LV. 1 Placement of the probe distorts the LV. An approximate position of the probe

in relation to the important cardiac structures such as

the mitral and aortic valves as well as the conduction system near the atrioventricular groove can be esti- mated, and this can be communicated to the surgeon before the laser is even fired. Though not essential, the authors prefer 3D over 2D TEE as it allows better

localization of the origin of the blast of steam, enabling better collaboration with the surgeon. During the pro- cedure, however, 3D TEE is limited to Live 3D TEE rather than full volumes, especially in the presence of arrythmia. Consequently, volume rates may be subopti- mal whether the intention is to view a large pyramidal volume of data such as the entire LV. A thorough post- TMR, 2D, and 3D TEE along with color flow mapping should be done to check for injuries that may manifest

as a new or worsening of a preexisting mitral or aortic regurgitation Also, any new RWMAs should be assessed

in transgastric basal, mid-short-axis, and apical views.

Although bleeding from the epicardial surfaces often stops quickly, the TEE examination should include an


examination for pericardial effusions that can occasion- ally result from such bleeding. There is a propensity toward atrial and ventricular arrhythmias during and immediately after the procedure. Invariably, there is a transient injury pattern, with ST eleva- tions that usually resolve spontaneously. On occasion, how- ever, TMR can cause large areas of myocardial infarctions with subsequent ventricular dysfunction. 6 In summary, 2D and 3D TEE imaging modalities are use- ful in collaborating with the surgeon during the TMR as well as to monitor for potential complications inherent to the procedure. E


Name: Shvetank Agarwal, MD. Contribution: This author wrote the manuscript, designed the case-report, and acquired and interpreted TEE images and video loops. Attestation: Shvetank Agarwal approved the final manuscript. Name: Vinayak Kamath, MD. Contribution: This author helped write the manuscript. Attestation: Vinayak Kamath approved the final manuscript. Name: Manuel Castresana, MD. Contribution: This author helped write the manuscript. Attestation: Manuel Castresana approved the final manuscript. This manuscript was handled by: Martin J. London, MD.


We thank Nadine Odo for editing the manuscript.


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Clinicians Key Teaching Points

By Roman M. Sniecinski, MD, Donald Oxorn, MD, and Martin J. London MD

Based on the reptilian heart, where the ventricles are perfused via a diffuse network of sinusoids, transmyocardial revascularization (TMR) creates microchannels in the myocardium by using a laser. It may offer symptomatic relief from refractory angina in patients who have no other options for revascularization procedures. During TMR, a cloud of bubbles (termed a blast of steam in this report) is seen on transesophageal echocardiography (TEE) when the laser traverses the full thickness of myocardium; this through and through penetration is thought to be necessary for clini- cal benefit.

A comprehensive TEE examination should be performed at baseline focusing on any valvular disease or regional wall motion abnormalities that may be exacerbated during the procedure. The presence of thrombus in the left atrial appendage or left ventricular apex should also be excluded due to embolization risk.

In this case, the authors used both 2 dimensional (D) and live 3D TEE to confirm when transmural penetration had taken place by visualizing the cloud of bubbles. The 4- and 5-chamber views were used to ensure no damage occurred to the aortic or mitral valves from the laser. While bleeding from the resulting channels typically stops before chest closure, TEE is also useful to monitor for any resulting pericardial effusion.

Cardiac surgeons may choose to perform TMR when there are no suitable targets for conventional revascularization. The intraoperative echocardiographer should be aware that TEE can provide useful information before, during, and after the procedure.