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

E ECHO ROUNDS

Transesophageal Echocardiography for

Transmyocardial Laser Revascularization
Shvetank Agarwal, MD,* Vinayak Kamath, MD, and Manuel Castresana, MD*

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 atherosclerotic 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 transducer (Phillips Healthcare, Andover, MA) confirmed preserved ejection fraction of 60% to 65%, no regional wall
motion abnormality, and normal valves. A systematic examination 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 Table1. 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, http://links.lww.com/AA/A700). 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 penetration but to also localize the exact origin of the blast of
steam (Fig.2 and Video2, see Supplemental Digital Content 2,
http://links.lww.com/AA/A701). 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 journals Web site (www.anesthesia-analgesia.org).
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Shvetank Agarwal, MD, Department of Anesthesiology and Perioperative Medicine, Georgia Regents University, 1120 15th
St., BIW-2144 Augusta, GA 30912. Address e-mail to sagarwal@gru.edu.
Copyright 2014 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000098

512 www.anesthesia-analgesia.org

Content 2, http://links.lww.com/AA/A701). The size of

these artifacts may vary considerably depending on how distended 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.

DISCUSSION

TMR is an approved surgical procedure for diffuse, e nd-stage

coronary artery disease either as a stand-alone procedure in
patients with medically refractory angina who are not candidates for further conventional revascularization procedures 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 centers from January 2002 to December 2012.a
The procedure entails creation of 1-mm laser channels
in the myocardium that presumably induce neovascularization, particularly at the junction of the channels and the
myocardium over the ensuing 3 to 6 months.4 Relief of anginal 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 (CO2) 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 comprehensive TEE examination (Table 2) should precede it to
assess ventricular function and to document any preexisting RWMAs, valvular dysfunctions, and pericardial effusion. 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
2013 Harvest 1-Executive Summary Adult Cardiac Surgery Database. Available at:
http://www.sts.org/sts-national-database/database-managers/
executive-summaries. Accessed August 30, 2013.

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TEE for Transmyocardial Laser Revascularization

Table 1.Comparison of Ho:YAG and CO2 Lasers

Type of laser
Manufactured by
Food and drug administration approval for
transmyocardial laser revascularization
Laser guidance for proper epicardial
positioning
Transesophageal echocardiography for
confirming transmural penetration
Electrocardiographic synchronization

Penetration and tissue injury

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

Carbon dioxide (CO2)

PLC medical systems, Franklin, MA
Yes

Not necessary

Helium-neon laser to position the hand piece

Not necessary for an experienced surgeon

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

Mandatory

Less efficient tissue penetration. Requires

3 to 4 firings, with more thermoacoustic
injury

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

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.

Figure 2. Three-dimensional transesophageal echocardiography

midesophageal 5-chamber view exhibiting distortion of the left ventricle due to probe placement and a blast of steam in originating
from the posterolateral wall of the left ventricular cavity due to transmural penetration of the Ho:YAG laser fiber bundle.

Video 1. This 2-dimensional transesophageal echocardiography (TEE)

video clip is in 3 parts. A, Midesophageal (ME) 4-chamber view demonstrating 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.

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

During the procedure

After the 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

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.
ACKNOWLEDGMENTS

We thank Nadine Odo for editing the manuscript.

REFERENCES
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2. Diegeler A, Cheng D, Allen K, Weisel R, Lutter G, Sartori M,
Asai T, Aaberge L, Horvath K, Martin J. Transmyocardial Laser
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ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ,

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Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost
JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary
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for treatment of severe coronary artery disease. JCardiothorac
Vasc Anesth 2003;17:4002

Clinicians Key Teaching Points

5. Allen KB, Dowling RD, Fudge TL, Schoettle GP, Selinger SL,
Gangahar DM, Angell WW, Petracek MR, Shaar CJ, ONeill
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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 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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