S. Bouchez, MD°, S. Jacobs, MD°, I Herck, MD#, F. De Somer, PhD*, Y. Van Belleghem, MD*.° Department of Anaesthesiology, University of Ghent, Belgium* Department of Cardiac Surgery, University of Ghent, Belgium

# Department of Intensive Care, University of Ghent, Belgium

Abstract:

Introduction : Perioperative transoesophageal echocardiography is an important tool in the management of patients receiving a Heartmate II (Thoratec Corporation, Pleasanton, CA, USA) left ventricular assist device (LVAD) and almost obligatory for surgical and anaesthetic decision making. We evaluated whether three-dimensional echocardiography offers incremental value in this setting.

Methods : A Three dimensional transoesophageal echocardiography (Philips IE33 – intraoperative transducer X7-2t ; Philips, Andover, MA, USA ) was used in addition to standard two-dimensional imaging for the assessment of proper placement and function of the LVAD in the surgical and early postoperative period. three successive patients presenting for implantation of a Heartmate II LVAD (Thoratec Corporation, Pleasanton, CA, USA) were evaluated.

Results : All assessors agreed that three-dimensional echocardiographic examination provided more accurate information for 1.correct cannula alignment, 2.unloading of the left ventricle , 3. presence of spontaneous contrast and the formation of thrombi in the left ventricle and aorta , and 4. the effect of the LVAD-device settings on global heart function. three dimensional information on ‘ventricular-assist’ functioning was a better guide to optimize pump performance. Images were easier to interprete by professionals with limited experience in echocardiography.Doppler flow measurements for the evaluation of cannula flow velocities as well as color flow imaging for the evaluation of valvular regurgitation still need to be assessed with two-dimensional echocardiography.

Conclusion : Three-dimensional transoesophageal echocardiography is complementary to two-dimensional echocardiography for the evaluation of the Heartmate II LVAD during the perioperative period.

Conclusions:

Three-dimensional transoesophageal echocardiography is complementary to two-

dimensional echocardiography for the evaluation of the Heartmate II LVAD during the

perioperative period.

Aim of the abstract:

The aim was to evaluate three dimensional transoesophageal echocardiography in addition to the standard

two-dimensional examination for the assessment of proper placement and function of the LVAD in the surgical and early

postoperative period.

Methods:

Three-dimensional and two-dimensional Echocardiography was performed in three patients receiving a Heartmate II LVAD ( Philips IE33 Intraoperative transducer X7-2t, Philips

Andover, MA, USA).

Assessment by 2D and 3D TEE :

1. Placement and alignment of cannulas2. Unloading of the left ventricle3. Presence of spontaneous contrast, thrombi in left ventricle and aorta.4. Septal deviation5. Right ventricular function

Assessment by 2D-doppler and Color flow doppler :

1. Cannula flow velocities ( only 2D TEE )

a/ LV apical inflow cannula

b/ Aortic outflow cannula

2. Valvular regurgitation ( 2D and 3D TEE )

a/ Tricuspid regurgitation

b/ Mitral regurgitation

c/ Aortic regurgitation

The acquired images were assessed and interpreted both by experts in echocardiography and by physicians with limited experience in echocardiography.

Results:

More accurate assesment when using 3D in evaluating :- Geometric position of inflow cannula in left ventricle - Septal deviation- Position of aortic outflow cannula- Presence of spontaneous contrast in aorta- The effect of the LVAD-device on global heart function

2D-color flow was the preferred method for the evaluation of valvular regurgitation. Images were easier to interprete by professionals with limited experience in echocardiography.

Perioperative three-dimensional transoesophageal echocardiography in patients receiving a Heartmate II LVAD.

LV apical inflow cannula in apex.No deviation to septum or lateral side.Perfect alignment towards mitral valve.

LV apical inflow cannula in apexViewed from mitral valve towards apex. Position of cannula in apex.

Aortic outflow cannula in aorta.Aortic valve remains closed.

Left atrial view: ellipsoïd appearance of mitral valve annulus, mitral valveremains open due to excessive LVAD suction.