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E ECHO ROUNDS
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DISCUSSION
Holmium:yttrium-aluminum-garnet (Ho:YAG)
Cardiogenesis corporation, Irvine, CA
Yes
Not necessary
Mandatory
Video 2. This 3-dimensional midesophageal 5-chamber transesophageal echocardiography video clip shows a blast of steam appearance 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.
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E Echo Rounds
Table 2.Roadmap for Transesophageal Echocardiographic (TEE) Assessment During Transmyocardial Laser
Revascularization
Prior to procedure
Assess for
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
ME
ME
ME
ME
ME
ME
ME
ME
TEE views
4C, TG mid-SAX
4C, TG mid-SAX
4C, mitral commissural, ME 2C, ME LAX
AV SAX, ME AV LAX
4C, ME 2C, ME LAX
4C, ME 2C (zoomed in)
4C, ME 2C, ME LAX
4C, ME 5C
ME 4C, ME 5 C
ME
ME
ME
ME
4C, TG mid-SAX
4C, TG mid-SAX
4C, mitral commissural, ME 2C, ME LAX
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 40 starting from the 4C at 0 with moderate anteflexion until the entire appendage is visualized.
LV apical thrombus must also be excluded, by scanning it in
the midesophageal 4C, 2-chamber, mitral commissural, and
LV long-axis views, making sure to avoid any foreshortening 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 indications 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 estimated, 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 procedure, however, 3D TEE is limited to Live 3D TEE
rather than full volumes, especially in the presence of
arrythmia. Consequently, volume rates may be suboptimal whether the intention is to view a large pyramidal
volume of data such as the entire LV. A thorough postTMR, 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
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examination for pericardial effusions that can occasionally 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 elevations that usually resolve spontaneously. On occasion, however, TMR can cause large areas of myocardial infarctions
with subsequent ventricular dysfunction.6
In summary, 2D and 3D TEE imaging modalities are useful in collaborating with the surgeon during the TMR as
well as to monitor for potential complications inherent to
the procedure. E
DISCLOSURES
Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost
JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary
Artery Bypass Graft Surgery: a report of the American College
of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines. Circulation 2011;124:e652735
4. Clements F. Pro: Transmyocardial laser revascularization is best
for treatment of severe coronary artery disease. JCardiothorac
Vasc Anesth 2003;17:4002
5. Allen KB, Dowling RD, Fudge TL, Schoettle GP, Selinger SL,
Gangahar DM, Angell WW, Petracek MR, Shaar CJ, ONeill
WW. Comparison of transmyocardial revascularization with
medical therapy in patients with refractory angina. N Engl J
Med 1999;341:102936
6. Goldberg RF, Fass AE, Frishman WH. Transmyocardial revascularization: defining its role. Cardiol Rev 2005;13:525
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 clinical 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.
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