Echocardiographic assessment for ventricular assist device placement

Abstract

While many factors depend on successful implantation and outcome of left ventricular assist devices (LVAD), echocardiography remains an integral part and is vital to the success of this process. Transesophageal echocardiography (TEE) allows interrogation of all the cardiac structures and great vessels. The pre-implantation TEE exam establishes a baseline and may identify potential problems that need palliation. Among these, most significant are aortic insufficiency (AI), intracardiac thrombi, poor right ventricular (RV) function, and intracardiac shunts. The post-implantation exam allows for adequate de-airing of the heart and successful LVAD initiation. The position and flow profiles of the inflow and outflow cannulas of the LVAD may be assessed. Finally, it assists in the astute management and vigilant identification and correction of a number of complications in the immediate post-implantation period. TEE will continue to remain vital to the successful outcomes LVAD patients.

Keywords: Echocardiography; left ventricular assist devices (LVAD); transesophageal echocardiography (TEE); ventricular assist device.

Figure 1

2D TEE mid-esophageal 4-chamber view showing significant biventricular and biatrial enlargement from end-stage heart disease. TEE, transesophageal echocardiography; LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.

Figure 2

2D TEE mid-esophageal bicaval view with color flow Doppler demonstrating the absence of an interatrial shunt at a low Nyquist limit. TEE, transesophageal echocardiography; LA, left atrium; RA, right atrium; S, interatrial septum.

Figure 3

2D mid-esophageal long-axis view revealing moderate to severe aortic insufficiency (AI). LA, left atrium; LV, left ventricle; AV, aortic valve; RV, right ventricle.

Figure 4

2D mid-esophageal RV inflow-outflow view with color flow Doppler demonstrating moderate to severe tricuspid regurgitation (TR). LA, left atrium; RA, right atrium; RV, right ventricle.

Figure 5

3D TEE image after LVAD implantation demonstrating appropriate placement of the inflow cannula in the LV apex facing the mitral valve. TEE, transesophageal echocardiography; LVAD, left ventricular assist devices; CPB, cardiopulmonary bypass; LA, left atrium; RA, right atrium; RV, right ventricle; LV, left ventricle.

Figure 6

2D TEE mid-esophageal modified 4-chamber view showing the inflow cannula facing the mitral valve. TEE, transesophageal echocardiography; LA, left atrium; RV, right ventricle; LV, left ventricle.

Figure 7

3D TEE image showing the inflow cannula in the LV apex facing the interventricular septum. This TEE finding led to the repositioning of the inflow cannula. TEE, transesophageal echocardiography; LV, left ventricle.

Figure 8

3D TEE modified 4-chamber view demonstrating laminar blood flow with color flow Doppler in the inflow cannula. TEE, transesophageal echocardiography; CPB, cardiopulmonary bypass.

Figure 9

3D TEE en face view of the inflow cannula with color flow Doppler showing laminar blood flow. TEE, transesophageal echocardiography; LV, left ventricle.

Figure 10

3D TEE modified 4-chamber view demonstrating appropriate placement of the inflow cannula in the LV apex (facing the mitral valve), and laminar blood flow. TEE, transesophageal echocardiography; CPB, cardiopulmonary bypass; LA, left atrium; LV, left ventricle.

Figure 11

Pulsed-wave (PW) Doppler echocardiogram demonstrating the absence of cannula obstruction (peak velocities <1 m/s).

Figure 12

3D TEE en face view of the inflow cannula in the LV apex revealing the absence of tissue obstruction. TEE, transesophageal echocardiography; LV, left ventricle.

Figure 13

2D mid-esophageal long-axis view of the ascending aorta with color flow Doppler revealing laminar blood flow in the outflow graft.

Figure 14

Continuous wave Doppler echocardiogram demonstrating outflow graft patency.

Figure 15

2D TEE mid-esophageal long-axis view showing a suction event due to increased pump speed. The inflow cannula turned and faced the interventricular septum. TEE, transesophageal echocardiography; LA, left atrium; LV, left ventricle; S, interventricular septum; RV, right ventricle.