Multiplane/3D transesophageal echocardiography monitoring to improve the safety and outcome of complex transvenous lead extractions

Abstract

Both transesophageal echocardiography (TEE) and intracardiac echocardiography have been used to assist transvenous lead extractions. The clinical utility of continuous echocardiographic monitoring during the procedure is still debated, with different reports supporting opposite findings. In cases where the procedure is expected to be difficult, we propose adding a continuous TEE monitoring using a static 3D/multiplane probe in mid-esophageal position, with digital remote manipulation of the field of view. This approach may improve the chances of a successful extraction, increase safety, or even guide the entire intervention. We present here a short case series where continuous monitoring by TEE played an important role.

Keywords: continuous echocardiography monitoring; intraprocedural echocardiography; multiplane echocardiography; transesophageal echocardiography; transvenous lead extraction.

Figure 1

A, Left arm phlebography. The subclavian vein stops abruptly (dark arrow), with collateral filling visible above; the right ventricular lead is indicated with an yellow arrow. B, In 2D transesophageal 4‐chamber view, the lead was difficult to image being situated very posteriorly; C, in short axis of the tricuspid valve, the lead becomes visible; D, bicaval view, demonstrating the relation between the lead and the superior vena cava

Figure 2

A, On tridimensional echocardiography, the lead was easily identifiable in the posterior commissure of the tricuspid valve from the right atrial aspect of the valve; B, the lead is free from adherences to the valve, coursing further to the apex of the right ventricle (RV). C, Transversal view of the superior vena cava demonstrated a lead (arrow) moving freely from the venous walls; D, RV segment of the lead, visible up to the apex

Figure 3

A, crushed leads (arrow) in the subclavian passage, visible on focused X‐ray. Note the presence of three leads (two active leads and one old inactive right ventricular lead); B, left arm phlebography confirming the crush

Figure 4

3D echocardiography focused on the right ventricle (RV) and right atrium during the ventricular lead extraction. A, Start of the procedure, with the two RV leads in situ (asterisk). B, The first lead was easily extracted; C, near inversion of the RV cavity (arrow, dashed contour) during pulling of the last lead; D, RV cavity re‐expanded after the lead detached (arrow, dashed contour)

Figure 5

Postimplantation of the new leads. A, Position of the new leads. The static echocardiography probe is also visible in mid‐esophageal position (arrow); B, biplane image of the left cavities; C, biplane image of the tricuspid valve (left long axis, right short axis), displaying a stable pre‐existent tricuspid valve regurgitation. Note that both the left and the right cavities could be imaged in multiplane, by remotely manipulating the field of view, without altering the probe position

Figure 6

A, ECG sinus rhythm with frequent multifocal premature ventricular complexes; B, normal thorax X‐ray, no lead fragment could be seen; C, CT scan frontal plane, focused on the caval veins: A linear structure (arrow) could be noticed in the proximal superior vena cava. D, CT focused oblique view of the right atrium and right ventricular, demonstrating the linear structure (arrow) coursing to the apex of the right ventricle

Figure 7

3D and multiplane sections of the right cavities demonstrating the presence of the radiotransparent insulation sheath. A, B, D, triplane sections of right atrium (RA) and right ventricular (RV). The silicone insulation sheath is coursing through the right atrium, the tricuspid valve, and ending in the right ventricular apex (F, arrow); C, 3D view of RA and RV in mid‐esophageal position, the insulation sheath is also visible as an relatively weak but clear linear echo (arrow); E, with high‐resolution angiography, the sheath could not be seen

Figure 8

Multiplane/3D echocardiography guiding the extraction. A, biplane image of the superior vena cava (SVC), with the silicone sheath visible (arrow); B, 3D biplane images of the free upper end of the sheath in the last 4 cm of the superior vena cava; C, modified biplane bicaval view: the extraction tool (red arrow) and the free upper end of the sheath (yellow arrow) seen in the superior vena cava; D, following the procedure, the SVC is free of any echos