EECHO ROUNDS

Transesophageal Echocardiography Findings

Associated with Transvenous Lead Extraction
Sasha K. Shillcutt, MD, FASE* and Thomas E. Schulte, MD*

67-year-old woman with a biventricular automatic

implantable cardioverter defibrillator (ICD) for
nonischemic cardiomyopathy (ejection fraction
10%15%) was admitted for fevers and a wrist infection.
Blood cultures revealed m
ethicillin-sensitive Staphylococcus
aureus that persisted for 2 weeks despite antibiotics.
Transesophageal echocardiography showed a vegetation
on the ICD lead with preserved valvular function. She was
scheduled for removal of her biventricular pacemaker/
ICD system. The use of an Excimer laser (Spectranetics
Corporation, Colorado Springs, CO) was planned for
extraction of 4 intracardiac leads (described below). Written
consent from the patient was obtained.
After induction of general anesthesia, a TEE probe was
placed without complication. TEE images were displayed
on a h
igh-definition screen in series with fluoroscopy to aid
the cardiologist with lead extraction.
Pre-extraction transesophageal echocardiography (TEE)
examination confirmed the presence of 4 leads: the right

Video 1.Midesophageal four chamber view showing two right

ventricle (RV) pacing leads traversing the tricuspid valve. A 0.6 1.3 cm
mobile mass on one of the RV leads is shown. LA = left atrium,
LV = left ventricle, RA = right atrium, RV = right ventricle.

From the *Department of Anesthesiology, University of Nebraska Medical

Center, Omaha, NE.
Accepted for publication May 7, 2012
Funding: None.
The authors declare no conflicts of interest.
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).
Reprints will not be available from the authors.
Address correspondence to Sasha K. Shillcutt, MD, Department of
Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska
Medical Center, Omaha, NE 68198-4455, Address e-mail to sshillcu@unmc.edu
Copyright 2012 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3182691aac

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Video 2.Midesophageal right ventricle inflow-ouflow view showing

microemboli produced by the Excimer laser during lead extraction,
significant RV dilation and depressed RV function. LA = left atrium,
RA = right atrium, RV = right ventricle.

Video 3.Midesophageal right ventricle

inflow-
ouflow view showing a large cellular cast originating from two right ventricle leads
after laser lead extraction. LA = left atrium, PA = pulmonary artery,
RA = right atrium, RV = right ventricle.

atrial (RA) pacing lead, the left ventricular implantable cardioverter lead coursing through the RA into the coronary
sinus, and the 2 right ventricular (RV) leads coursing through
the triscuspid valve (TV) fibrosed to the RV free wall (Fig. 1).
The 2 RV leads appeared to restrict motion of the posterior
leaflet of the TV. A vegetation (0.6 1.3 cm) was attached
to one of the RV leads as seen in the midesophageal (ME)
4-chamber view (Fig. 1) (Video 1, see Supplemental Digital
Content 1, http://links.lww.com/AA/A447). Moderate tricuspid regurgitation (TR) (defined by vena contracta = 0.5
cm) was present (Fig. 2, Panel A).1 Restriction of the posterior TV leaflet caused moderate TR, with eccentric and bidirectional jets orginating from a more apical coaptation point
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TEE in Lead Extraction

Figure 1.Midesophageal 4-chamber view demonstrating 2 right

ventricle leads traversing the right atrium through the tricuspid valve
into the right ventricle. A left ventricle implantable cardioverter defibrillator lead is also seen traversing the right atrium towards the
coronary sinus. A 0.6 1.3 cm mobile mass on one of the RV leads
is shown. RA = right atrium, RV = right ventricle, LA = left atrium,
LV = left ventricle.

due to the leads restricting closure of the TV seen in the

ME RV inflow-outflow view. Spectral Doppler of the TR jet
revealed a maximum velocity of 2.9 m/seconds (35 mm Hg)
(Fig. 3). The RV was severely dilated (5.1 cm) and function
was moderately depressed by visual estimation and tricuspid annular plane systolic excursion <1.5 cm. There was
no evidence of an intraatrial shunt by color Doppler with
Valsalva manuever.
TEE monitoring was used throughout the procedure. The ME 4-chamber, ME RV inflow-o utflow, and
ME bicaval views were all used for TV and right heart
imaging. The Excimer laser caused microbubbles visualized in the RA, RV (Video 2, see Supplemental Digital
Content 2, http://links.lww.com/AA/A448) and pulmonary artery (PA). During lead extraction, RV function
worsened; there was further RV dilation and depressed
RV systolic function (Video 2, http://links.lww.com/
AA/A448). After lead removal, the TR vena contracta
increased to 0.8 cm, consistent with severe TR (Fig. 2,
Panel B). 1 A large mobile cast (1x4 cm) seen in the ME
RV
i nflow-
o utflow view (Video 3, see Supplemental
http://links.lww.com/AA/A450) embolized into the
PA during one RV lead extraction. There was no evidence of a pericardial effusion. After emobolization,
arterial blood gas analysis was performed and showed
a PaO 2 of 158 with an Fio 2 of 0.5. The postoperative
chest radiograph was unchanged and the patients trachea was extubated without respiratory or cardiovascular complications.

DISCUSSION

The literature suggests that use of TEE during transvenous lead extraction improves efficacy and safety
of removal.2 TEE allows diagnosing of embolization

December 2012 Volume 115 Number 6

events, mechanical damage to the TV and monitoring for

pericardial bleeding. TEE can be used for hemodynamic
monitoring in these patients because most suffer from
heart failure, QRS abnormalities, or an ejection fraction
of <35%.3
The Excimer laser is a xenochloride laser that combines
photochemical destruction of cellular structures with explosive photothermal vaporization of cellular water, creating
microbubbles.4 Microbubbles can be seen in the ME RV
inflow-outflow view traversing the right heart or through
the PA in the upper esophageal aortic arch short-axis (SAX)
view. The presence of a patent foramen ovale, coupled with
increased RA pressure, may cause paradoxical embolization
and increase risk of ischemic stroke.5 Diagnosis of a patent
foramen ovale is important to communicate before use of
the laser. Color flow Doppler along the intraatrial septum
in the ME bicaval view, along with saline bubble contrast,
should be performed. Cellular casts from leads themselves,
infective endocarditis vegetations, microbubbles from the
laser, and lead thrombus may all embolize during extraction (Table 1).
Byrd et al. reviewed the incidence of complications
associated with 1684 patients undergoing lead removal.6
They reported cardiac tamponade as the most common
major complication in patients undergoing lead extraction,
reported in 1.4% of in-hospital extractions. Rapid pericardial effusion, from atrial or ventricular perforation, can
occur. Vigilent monitoring of the pericardium, in the ME
4-chamber view or in the transgastric left ventricle SAX
view should be performed during extraction.
Patients undergoing lead extraction may have significant RV dysfunction and TR. An increase in pulmonary
vascular resistance from microbubbles may worsen underlying pulmonary hypertension and right heart dysfunction.
Continuous wave Doppler through the TV to measure TR
jet maximum velocity in the RV i nflow-outflow view can be
used to measure changes in PA systolic pressure. Traction
on the RV during lead removal may cause transient dysfunction, arrhythmias, and subsequent RA distention, all
seen by TEE.
Thorough examination of the TV should be done before
extraction. Leads can restrict movement and cause significant TR. Extraction of fibrosed leads can damage TV leaflets
or rupture the RV free wall. The TV is best seen in the ME
4-chamber and ME RV inflow-outflow views. All 3 leaflets
can also be seen in the transgastric window, commonly
found between 20 to 50 (TV SAX view) and 60 to 90 (RV
inflow view) by anteflexion and rightward turning of the
probe.7 Two studies have shown an increase in TR after
8%12% of lead extractions.2,3
TEE allows the anesthesiologist and cardiologist to
collaborate during complex procedures. Complications
diagnosed by TEE during lead extraction include embolization, TV abnormalities, pericardial effusion and/or
cardiac tamponade, cardiac lacerations, vascular injury,
hemothorax, and arrhythmias (Table 2). TEE can serve
as both a useful monitor for guidance of lead extraction and also aid the anesthesiologist in hemodynamic
management. E

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E ECHO ROUNDS

Figure 2. Panel A shows a midesophageal right ventricle inflow view with a tricuspid regurgitation vena contracta of 0.5 cm before lead extraction
and 2 pacing leads traversing through the triscupid valve into the right ventricle. Panel B is a midesophageal right ventricle inflow view depicting
a tricuspid regurgitation jet vena contracta of 0.8 cm after both right ventricle leads were removed. RA = right atrium, RV = right ventricle.

Table 2. Complications From Transvenous Lead

Extraction
Complications
Embolization
Tricuspid valve abnormalities
Cardiac tamponade/pericardial effusion
Arrhythmia
Cardiac laceration
Vascular injury
Hemothorax

Figure 3. Continous wave Doppler through the tricuspid valve depicting a triscupid regurgitant jet maximum velocity of 2.9 meters/s (corresponding right atrium:right ventricle pressure gradient of 35 mm
Hg). TR = tricuspid regurgitation.

Table 1. Sources of Emboli During Lead Extraction

Sources of emboli
Microbubbles from laser
Cellular casts from the leads
Septic emboli from infected leads
Lead fragments
Lead thrombus

DISCLOSURES

Name: Sasha K. Shillcutt, MD, FASE.

Contribution: This author helped design the study, conduct
the study, analyze the data, and prepare the manuscript.
Name: Thomas E. Schulte, MD.
Contribution: This author helped design the study, analyze
the data, and prepare the manuscript.
This manuscript was handled by: Martin J. London, MD.

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REFERENCES
1. Zoghbi WA, E
xriquex-Sarano M, Foster E, Grayburn PA, Kraft
CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones
MA, Rakowski H, Stewart WJ, Waggoner A, Weissman NJ.
Recommendations for the evaluation of the severity of native
valvular regurgitation with two-
dimensional and Doppler
echocardiography. J Am Soc Echocardiogr 2003;16:777802
2. Endo Y, OMara JE, Weiner S, Han J, Goldberger MH, Gordon
GM, Nanna M, Ferrick KJ, Gross JN. Clinical utility of intraprocedural transesophageal echocardiography during transvenous lead extraction. J Am Soc Echocardiogr 2008;21:8617
3. Epstein AE, DiMarco JP, Ellenbogen KA, Estes III NA Mark,
Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill
SC, Hayes DL, Hlatky MA, Newby LK, page RL, Schoenfeld
MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS
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evice-based therapy of cardiac rhythm
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cardiology/Am heart association task force on practice guidelines (writing committee to revise the ACC/AHA/NASPE 2002
guideline update for implantation of cardiac pacemakers and
antiarrhythmia devices). J Am Coll Card 2008;51:2085105
4. Roeffel S, Bracke F, Meijer A, Van Gelder B, Van Dantzig JM,
Botman CJ, Peels K. Transesophageal echocardiographic evaluation of tricuspid valve regurgitation during pacemaker and
implantable cardioverter defibrillator lead extraction. PACE
2002;25:15836
5. Swanton BJ, Keane D, Vlahakes GJ, Streckenbach SC.
Intraoperative transesophageal echocardiography in the early
detection of acute tamponade after laser extraction of a defibrillator lead. Anesth Analg 2003;97:6546
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ANESTHESIA & ANALGESIA

TEE in Lead Extraction

Clinicians Key Teaching Points

 y Kent H. Rehfeldt, MD, Roman M. Sniecinski, MD,

B
Martin J. London, M.D

Laser use can facilitate removal of pacemaker and defibrillator leads by destroying adherent cellular materials encas-

ing the leads. However, laser-assisted lead extraction may be complicated by cardiac perforation, tamponade, paradoxical embolism, worsening of tricuspid regurgitation, and exacerbation of pulmonary hypertension. Transesophageal
echocardiography (TEE) performed during lead extraction can identify these complications and serve as a monitor of
right ventricular function, which can become significantly depressed.
Rapidly developing pericardial effusion and tamponade are the most common serious complications associated with
lead extraction and can be detected by TEE imaging in the midesophageal 4-chamber and transgastric short-axis
views. The presence of a patent foramen ovale should be determined before laser use since right-to-left embolization
of microbubbles, vegetations, or cellular casts may occur.
In this case, right ventricular function worsened, presumably due to either pulmonary embolization of microbubbles
or the cellular cast released during laser use. Although no pericardial effusion developed, the tricuspid regurgitation
increased from moderate to severe, as indicated by a vena contract width >0.7 cm.
TEE performed during laser-assisted lead extraction can be invaluable as sudden hemodynamic disturbances may
develop in these patients, many of whom already suffer from heart failure.

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