Anesth Analg 2003;97:654-656
© 2003 International Anesthesia Research Society
CARDIOVASCULAR ANESTHESIA
Intraoperative Transesophageal Echocardiography in the Early Detection of Acute Tamponade After Laser Extraction of a Defibrillator Lead
Brian J. Swanton, MB FFARCSI*,
David Keane, MD
,
Gus J. Vlahakes, MD
, and
Scott C. Streckenbach, MD*
*Department of Anesthesia and Intensive Care,
Cardiology Division, and
Department of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston
Address correspondence and reprint requests to Scott C. Streckenbach, Department of Anesthesia and Intensive Care, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114. Address e-mail to sstreckenbach{at}partners.org
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Abstract
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Laser-assisted intracardiac lead extraction is associated with a 1%–2% incidence of pericardial tamponade. Because of this risk, many of these procedures are being performed in an operating room with a cardiac surgeon immediately available. Transesophageal echocardiography is a useful intraoperative monitor during these procedures.
IMPLICATIONS: Laser-assisted intracardiac lead extraction is associated with a 1%–2% incidence of pericardial tamponade. Because of this risk, many of these procedures are being performed in an operating room with a cardiac surgeon immediately available. Transesophageal echocardiography is a useful intraoperative monitor during these procedures.
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Introduction
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In the United States, extraction of implanted cardioverter-defibrillator (ICD) and pacemaker leads has frequently been performed in the electrophysiology laboratory. Anesthesiologists have thus had limited exposure to this procedure. As the use of ICDs and pacemakers expands, the requirement for extraction of leads associated with these devices has also increased. The success rate for extracting entrapped pacemaker and defibrillator electrodes has been increased with the introduction of the excimer laser extraction sheath. However, this procedure may be complicated by pericardial tamponade in 1%–2% of cases (1). We report a case of acute pericardial tamponade associated with the laser extraction of a ventricular defibrillator lead, which was rapidly diagnosed by transesophageal echocardiography (TEE) and treated by immediate surgical drainage in the operating room.
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Case Report
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A 54-yr-old woman presented to the operating room for extraction of an abdominal ICD generator and dysfunctional right ventricular (RV) and superior vena caval leads by excimer laser sheath and re-implantation of a new ICD system. Replacement was indicated by increased impedance and excessive lead noise of the RV coil and to accommodate a new left-sided defibrillator lead with a pectoral generator. The ICD had been implanted 9 yr earlier after an episode of ventricular fibrillation in the setting of long QT syndrome, myotonic dystrophy, and pulmonary sarcoidosis. There was no history of intrapericardial surgery. Preoperative laboratory data were within normal limits, and chest radiograph revealed no acute pulmonary disease.
After insertion of a left-sided 14-guage IV catheter and a 20-gauge right radial arterial catheter, anesthesia was induced with propofol and fentanyl (400 µg), followed by cisatracurium to facilitate endotracheal intubation. Anesthesia was maintained with a propofol infusion and intermittent cisatracurium. A 7F triple-lumen right central venous catheter was inserted into the right internal jugular vein. A TEE probe was inserted and revealed mild mitral and tricuspid regurgitation, good biventricular function, and no pericardial fluid. Four units of packed red blood cells were in the operating room.
The patient was prepared and draped to include the abdominal ICD generator site and the entire anterior chest. A gowned and gloved cardiac surgeon was present during the procedure. The abdominal ICD generator and extrathoracic subcutaneous patch electrode were removed surgically. The superior vena cava electrode was laser-extracted uneventfully using an Excimer laser source with a wavelength of 308 nm (model Gem 4; Spectranetics Corporation, Colorado Springs, CO). The removal of the remaining RV defibrillator lead was associated with a significant amount of resistance from fibrous ingrowth encountered in the distal two-thirds of the RV coil. Extensive use of the laser sheath was required. Within minutes of extracting this final lead, TEE in a four-chamber view revealed rapidly evolving pericardial effusion with signs of tamponade (Fig. 1). The TEE findings included significant accumulation of pericardial fluid, biatrial collapse, RV diastolic collapse, and spontaneous intracardiac echo contrast. This was associated with a precipitous decrease in systemic blood pressure (Fig. 2), an increase in central venous pressure, and bradycardia. Given the TEE findings, the cardiac surgeon expeditiously performed a sternotomy and pericardiotomy. During this time, the blood pressure continued to decrease, reaching a systolic nadir of 35 mm Hg. Supportive treatment included norepinephrine 5–100 µg/min rapidly titrated, approximately 1 L of crystalloid, and 1 U of packed red blood cells. After pericardiotomy, the blood pressure rapidly increased. The total duration of hypotension was less than 4 min. Additional fentanyl (500 µg) was given, and a fentanyl-midazolam infusion was started. A perforation of the RV free wall near the apex was repaired. The remainder of the procedure was uneventful, and the patient was transferred to the intensive care unit intubated but hemodynamically stable.
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Figure 1. Transesophageal echocardiography (TEE) four-chamber view showing evidence of pericardial tamponade as indicated by pericardial fluid (arrow) and severe compression of the right and left atrial free walls (arrowheads). See also video clip #1.
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Figure 2. Strip chart recording of radial arterial blood pressure. Severe hypotension lasted for approximately 3.5 min.
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Postoperatively, she was somnolent for several days and had symptoms of dysphagia. A neurologic evaluation, which included a magnetic resonance image, did not define a specific origin. Her creatinine increased transiently to 2.1 mg/dL from her baseline of 1.3 mg/dL. She had multiple episodes of atrial fibrillation with rapid ventricular response requiring cardioversion. She made a full recovery and was discharged 3 wk later after the insertion of a new ICD system.
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Discussion
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This case report demonstrates the value of performing laser lead extraction in the operating room with a cardiac surgeon immediately available rather than in the electrophysiology laboratory. It also demonstrates the value of intraoperative TEE during these procedures.
Laser lead extraction begins with isolation of the proximal end of a defibrillator or pacemaker lead, usually within the pectoral pocket where the generator box is located. This is followed by introduction of a lead-locking stylet down the inner lumen of the lead to allow transmission of traction forces to the lead tip within the heart. A circumferential lasing sheath is then advanced over the lead (and lead locking stylet) under fluoroscopic and echocardiographic guidance. When resistance because of fibrous overgrowth is met, either within the implant vein or within the heart, pulses of energy measured in fluence (laser energy delivered per square millimeter of fiber) are transmitted through 120 optical fibers that are positioned around the perimeter of the laser sheath. Laser energy is delivered at the distal aspect of the sheath and focally vaporizes the fibrotic tissue, allowing for further advancement of the laser sheath along the implanted lead. When the laser sheath reaches the end of the lead, extraction is achieved by a combination of traction (inner lead-locking stylet) and counter traction (outer laser sheath).
As the number of patients with implantable pacing and defibrillating systems increases worldwide, it is likely that the number of lead extractions will continue to increase. Indeed, the North American Society of Pacing and Electrophysiology has published recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads (2). Excimer laser sheath devices have increased the success rate of lead extraction but have not decreased the incidence of major complications (3). Byrd et al. (1) recently published the results of 1684 laser lead extractions performed in the United States. The incidence of major complications (which included tamponade, hemothorax, pulmonary embolism, and migrating lead fragments) was 1.9% (Table 1). The incidence of in-hospital death was 0.8%.
Because of these risks, many institutions now perform laser lead extraction in the operating room with a cardiac surgeon immediately available rather than in the cardiac electrophysiology laboratory. Our practice also incorporates TEE, a central venous catheter, an arterial catheter, and a large-bore IV catheter in all such cases. We have 4 U of packed red blood cells in the operating room, which is our standard practice for all cardiac surgical cases.
Palliative pericardiocentesis was not used in this case because the surgeon was in the operating room ready to perform emergent sternotomy. When fully prepared, the surgeon can perform a sternotomy nearly as fast as pericardiocentesis. Opening the pericardium produced instant correction of the pathophysiology and facilitated definitive therapy.
This patient had several known risk factors for a major complication after lead extraction. These were female sex, multiple leads, lead implant duration more than eight years, and ICD rather than pacemaker leads (4). Unlike pacemaker leads, which are smooth and isodiametric, the larger ICD leads include a grooved defibrillating coil. Because of their larger surface area and grooves, ICD leads become more embedded with tissue ingrowth and are therefore harder to extract than pacemaker leads.
TEE proved advantageous in this particular case by providing very early and specific confirmation of progressive pericardial tamponade, a diagnosis that was certainly likely given the hemodynamic changes. However, the role of TEE is not limited to that of a hemodynamic monitor. TEE can be used to assess the tricuspid valve before and after lead extraction. Intracardiac RV leads typically lodge between the septal and posterior leaflets generating a varying degree of leaflet-lead attachment. Removal of RV leads can injure the tricuspid valve and significantly increase the degree of tricuspid insufficiency (5). TEE can also be used to detect thrombi or endocarditic masses that may be adherent to the intracardiac leads. These masses may dislodge during lead extraction and enter the pulmonary or systemic circulation. Laser lead extraction, which often requires traction on the right heart, can cause transient RV dysfunction and subsequent right atrial distention (Fig. 3). When this occurs in the presence of a patent foramen ovale, systemic embolization may occur.
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Figure 3. Transesophageal cardiography (TEE) four-chamber view during laser extraction before hemodynamic collapse. Transient right ventricular (RV) dysfunction because of the laser application and lead traction has led to a significant right atrial distention and leftward deviation of the interatrial septum.
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In summary, we present a case of cardiac perforation and pericardial tamponade after laser lead extraction of an ICD lead adherent to the RV free wall, which was immediately diagnosed with the assistance of intraoperative TEE and successfully treated in less than four minutes. This case illustrates both the value of intraoperative TEE in laser lead extraction and of performing such cases in the operating room with a cardiac surgeon immediately available.
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Footnotes
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Supplemental material available at www.anesthesia-analgesia.org.
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References
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- Byrd CL, Wilkoff BL, Love DL, et al. Clinical study of the laser sheath for lead extraction: the total experience in the United States. Pacing Clin Electrophysiol 2002; 25: 804–8.[Medline]
- Love CJ, Wilkoff BL, Byrd CL, et al. Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, and training. Pacing Clin Electrophysiol 2000; 23: 544–51.[Medline]
- Epstein LM, Byrd CL, Wilkoff BL, et al. Initial experience with larger laser sheaths for the removal of transvenous pacemaker and implantable defibrillator leads. Circulation 1999; 100: 516–25.[Medline]
- Love CJ. Current concepts in extraction of transvenous pacing and ICD leads. Cardiol Clin 2000; 18: 193–217.[Medline]
- Assayag P, Thuaire C, Benamer H, et al. Partial rupture of permanent pacemaker leads: detection by transesophageal echocardiography. Pacing Clin Electrophysiol 1999; 22: 971–4.[Medline]
Accepted for publication April 15, 2003.
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Abstract
Introduction
