The ABCs of left ventricular assist device echocardiography: a systematic approach

Abstract

Echocardiography is an important imaging modality used to determine the indication of left ventricular assist device (LVAD) implantation for patients with advanced heart failure (HF) and for serial follow-up to make management decisions in patient care post-implant. Continuous axial-flow LVAD therapy provides effective haemodynamic support for the failing left ventricle, improving both the clinical functional status and quality of life. Echocardiographers must develop a systematic approach to echocardiographic assessment of LVAD implantation and post-LVAD implant cardiac morphology and physiology. This approach must include the evaluation of left and right heart chamber morphology and physiology and the anatomy and physiology of the inflow and outflow cannulas and the rotor pump, and the determination of the degree of tricuspid regurgitation and the presence of interatrial shunts and aortic regurgitation. Collaboration among the echocardiography and HF/transplant teams is essential to obtain this comprehensive evaluation. We outline a systematic approach to evaluating patients with HF who have failed conventional therapy and require LVAD therapy as a bridge to cardiac transplantation or destination therapy.

The Incidence, Predictors and Outcomes of Gastrointestinal Bleeding in Patients with Left Ventricular Assist Device (LVAD)

“…Chart review was performed to extract information about each patient's demographics (age and gender), etiology of heart failure (ischemic vs. non-ischemic), right heart catheterization (RHC) pressures including mean right atrial pressure (MRAP) before LVAD implantation, transthoracic echocardiograph (TTE) parameters before and after LVAD implantation [3], LVAD pump speed, power and pulsatility index (PI), anticoagulation and anti-platelet therapy, laboratory values (INR, thromboelastography with MA score, hemoglobin, platelets, blood urea nitrogen, creatinine, albumin, and pre-albumin), and date of death. All the serological measurements were taken after LVAD placement and before GIB discharge.…”

Echocardiography in the Management of Patients with Left Ventricular Assist Devices: Recommendations from the American Society of Echocardiography

“…4 In evaluating patients with advanced HF for atrial septal defects (ASDs) and PFOs, the use of IV agitated saline combined with an appropriately performed Valsalva maneuver is necessary, because elevated left and/or RA pressures may reduce interatrial pressure gradients and preclude detection of the defect by color Doppler imaging or agitated saline injection alone. 39 Like ASDs, congenital and postmyocardial infarction ventricular septal defects (VSDs) can also result in immediate postimplantation right-to-left shunting with hypoxemia and a risk of paradoxical embolization during LVAD support. The presence of VSDs should be systematically excluded by color Doppler interrogation of the entire ventricular septum; if identified, VSDs should be closed at LVAD implantation.…”

“…4 The left atrium, left ventricle (including the LV apex and inflow cannula (Figures 4 and 5), aortic root, ascending aorta, outflow graft-to-ascending aorta anastomosis ( Figure 6), and transverse and descending aorta should all be directly visualized and carefully inspected for signs of air. 39 The ostium of the right coronary artery (RCA) is situated anteriorly in the aortic root and is a common destination for air ejected from the left ventricle. 4 Acute RV dysfunction or dilatation and/or an increase in the severity of TR should suggest the possibility of air embolization to the RCA, and this complication may resolve with watchful waiting.…”

“…39 Additional simultaneous orthogonal planes and real-time 3D imaging may be used to better identify the terminal portion of the cannula within the LV cavity ( Figures 4A,B and 5A). Although a certain degree of inflow-cannula deviation towards the interventricular septum may be unavoidable, an excessive degree of angulation may necessitate surgical revision, given an expected decrease in LV cavity size either acutely or later in the clinical course after initiation of MCS.…”

The use of echocardiography in acute cardiovascular care: Recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

“…Although echocardiography for extracorporeal support is highly specialized, certain key principles apply. 105,106 First, extracorporeal support is not a treatment per se, but rather a supportive therapy whilst awaiting resolution of the underlying pathological process. Thus echocardiography has a vital role in excluding any potentially treatable underlying cause for cardiorespiratory failure.…”