title: Rescue transoesophageal echocardiography for refractory haemodynamic instability during transvenous lead extraction.
abstract: OBJECTIVE
  The rising number of cardiovascular implantable electronic devices has led to a steep increase in transvenous lead extractions (TLEs). Procedure-related, haemodynamically significant adverse events are uncommon during TLE yet remain an inevitable risk. While the use of transoesophageal echocardiography (TEE) as a guide to clinical decision-making during refractory circulatory instability has been well established, the specific utility of rescue TEE during TLE has not been comprehensively studied.
  
  
  RESULTS
  Twenty-six patients who required emergent TEE to determine the aetiology of intractable haemodynamic instability during TLE were evaluated. Pericardial effusion requiring urgent pericardiocentesis and/or cardiac surgical intervention was diagnosed by TEE in 10 patients, and progressed to cardiac arrest in 4 patients. Haemorrhagic shock developed in two patients suffering from femoral vein laceration and right haemothorax, respectively. One additional patient developed acute respiratory compromise and right ventricular dysfunction diagnosed by TEE, which necessitated prolonged post-operative intubation and inotropic therapy. In 14 patients, TEE excluded life-threatening cardiovascular injuries and enabled the pursuit of continued medical management. Two patients with reassuring TEE findings underwent intra-operative placement of chest tubes for pneumothorax. All the 26 patients were discharged from the hospital.
  
  
  CONCLUSIONS
  While TLE is a relatively safe procedure, life-threatening cardiovascular injuries remain a rare risk. In this study, the use of rescue TEE ruled out significant cardiovascular injuries in the majority of patients. Furthermore, rescue TEE had a substantial impact on the efficiency of determining the aetiology of refractory haemodynamic instability during TLE and thereby facilitated the timely initiation of definitive intervention.
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA jhilberath@partners.org.
authors.forename: Jan N
authors.initials: JN
authors.lastname: Hilberath
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Burrage
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: Stanton K
authors.initials: SK
authors.lastname: Shernan
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Varelmann
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: Kerry
authors.initials: K
authors.lastname: Wilusz
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: John A
authors.initials: JA
authors.lastname: Fox
authors.affiliation: Department of Anesthesiology, School of Medicine, University of Colorado, Aurora, CO 80045, USA.
authors.forename: Holger K
authors.initials: HK
authors.lastname: Eltzschig
authors.affiliation: Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: Laurence M
authors.initials: LM
authors.lastname: Epstein
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany.
authors.forename: Martina
authors.initials: M
authors.lastname: Nowak-Machen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000000981:diagnostic imaging* / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D020878:Device Removal / Q000009:adverse effects*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D004566:Electrodes; D004868:Equipment Failure; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D016896:Treatment Outcome
keywords: rescue echocardiography; resuscitation; transoesophageal echocardiography; transvenous lead extraction