Role of echocardiography in the perioperative management of mechanical circulatory assistance

Temporary mechanical circulatory support: insights and evolving strategies

PURPOSE

The goal of this study is to evaluate the utilization and outcomes of temporary mechanical circulatory support (MCS) among patients listed for cardiac transplantation (CT). There is a constant threat of sudden clinical deterioration in these patients that could necessitate emergent MCS. All advanced heart failure and transplant centers in India are plagued by issues of late referrals, low organ donation rates, and financial constraints. Here, we share our experience and explain our evolving strategies tailored to improve outcomes.

METHODS

Single-center retrospective analysis of temporary MCS implanted in patients listed for CT from January 1, 2015, to December 31, 2019.

RESULTS

A total of 35 patients had 41 MCS implantations. Twenty-four cases were pre-transplant and 11 cases were post-transplant. Veno-arterial extracorporeal membrane oxygenator was the most commonly (20 cases, 44.4%) used MCS modality. Primary outcome of in-hospital mortality was noted in 17 patients (48.5%) in this high-risk profile. All but 2 of the 12 patients that underwent pre-transplant MCS, and were bridged to cardiac transplant, survived the index hospitalization accounting for 90% survival in this subset of patients. The secondary outcome of MCS-related vascular injury was observed in 9 patients (25.7%).

CONCLUSION

This single-center observational study demonstrates that early planning and timely institution of MCS improves outcomes in high-risk MCS patients bridged to cardiac transplant. The incidence of MCS-related vascular complications can be improved with development of standard operating protocols.

Management of three cardiogenic pulmonary edemas occurring in a patient scheduled for left ventricular assist device implantation: indicators for determining left ventricular assist device pump speed

A male patient with Marfan syndrome underwent aortic root replacement and developed left ventricular (LV) failure. Four years later, he underwent aortic arch and aortic valve replacement. Thereafter, his LV failure progressed, and cardiogenic pulmonary edema (CPE) appeared, which we treated with extracorporeal LV assist device (LVAD) placement. Three months later, the patient developed aspiration pneumonia, which caused hyperdynamic right ventricle (RV) and CPE. We treated by changing his pneumatic LVAD to a high-flow centrifugal pump. A month later, he underwent thoracoabdominal aortic replacement. After four weeks, he developed septic thrombosis and LVAD failure, which caused CPE. We treated with LVAD circuit replacement and an additional membrane oxygenator. Four months later, he underwent DuraHeart(®) implantation. During this course, pulmonary artery wedge pressure (PAWP) varied markedly. Additionally, systolic pulmonary artery pressure (sPAP), left atrial diameter (LAD), RV end-diastolic diameter (RVEDD) and estimated RV systolic pressure (esRVP) changed with PAWP changes. In this patient, LV failure and hyperdynamic RV caused the CPEs, which we treated by adjusting the LVAD output to the RV output. Determining LVAD output, RV function and LV end-diastolic diameter are typically referred, and PAWP, LAD, RVEDD, and sPAP could be also referred.

Mechanical circulatory support

The role for temporary and durable mechanical circulatory support is rapidly expanding. As the use of these technologies continues to grow, the emergency physician has an increasing opportunity to participate in the advancement of these potentially life-saving technologies. This review discusses the current role of the intra-aortic balloon pump in cardiogenic shock, describes the complications and management strategies for the critically ill patient with a left ventricular assist device, and explores the emerging role of ECMO in the emergency department for patients presenting in refractory cardiogenic shock and cardiac arrest.

Role of Transesophageal Echocardiography in Perioperative Patient Management of Lung Transplantation Surgery

Lung transplantation is the only option for patients with end-stage lung disease. Chronic obstructive lung disease, idiopathic pulmonary fibrosis, cystic fibrosis and primary pulmonary hypertension are few common indications for lung transplantation. Patients with end-stage lung disease may have pre-existing cardiovascular compromise related to pulmonary hypertension and other cardiovascular lesions, such as coronary artery disease or valvular heart disease. Preoperative evaluation and optimization of hemodynamics is expected to improve outcomes from lung transplantation. Intraoperative hemodynamic instability is common during lung transplantation and requires highest level of cardiovascular monitoring. After transplantation, vascular anastomosis should be evaluated for flow patterns to rule out obstruction from stenosis or thrombosis. Postoperative complications are common and include bleeding, cardiac failure and hypoxemia from right to left shunt. Primary graft dysfunction may necessitate mechanical cardiorespiratory support. Transesophageal echocardiography plays a central role in preoperative evaluation, intraoperative hemodynamic management, evaluation of pulmonary vascular anastomosis, diagnosis of postoperative complications and also in the critical care management of mechanical cardiorespiratory support.

How to cite this article

Subramaniam K, Esper SA. Role of Transesophageal Echocardiography in Perioperative Patient Management of Lung Transplantation Surgery. J Perioper Echocardiogr 2013;1(2):48-56.