Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room

Publication Date: June 1, 2020
Last Updated: March 14, 2022

Key Points

Key points for the pre- and postprocedure assessment for intracorporeal LVAD placement

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 A complete pre-implantation examination should be performed in order to rule out hemodynamically significant valvular lesions, intracardiac shunts and thrombus, and evaluate baseline RV function.
 Evaluation of TR should include assessment of the tricuspid annulus, tricuspid leaflet tethering, RA and RV size, and position and motion of IAS and IVS during the cardiac cycle.
 Aortic regurgitation is likely to progress after LVAD implantation and to impair adequate systemic forward flow. It can be easily underestimated in patients with advanced heart failure. Re-evaluation of AR should be performed after institution of CPB, which may mimic the hemodynamic conditions during LVAD support.
 RV function should be evaluated by integrating several echocardiographic parameters.
 The same elements of the pre-implantation examination should be re-evaluated in the post-implantation period: intracardiac shunts, degree of TR, degree of AR, and RV function.
 The position of the IAS and IVS and the relative size of the LV and RV provide information regarding causes of decreased LVAD flow.
 Leftward shift of the IAS and IVS, decreased LV size, RV dilation and dysfunction indicate decreased preload to the LVAD due to RV failure.
 Decreased LV and RV size indicate decreased LVAD preload in the setting of hypovolemia or extrinsic compression.
 Position and flow by CFD and spectral Doppler should be evaluated and documented for both the inflow cannula and the outflow graft as outlined in the text.
Abbreviations: AR, Aortic regurgitation; CFD, color flow Doppler; CPB, cardiopulmonary bypass; IAS, interatrial septum; IVS, interventricular septum; LVAD, left ventricular assist device; RA, right atrium; RV, right ventricle; TR, tricuspid regurgitation.



Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room

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