Preemptive Hemodynamic Transesophageal Echocardiography after Continuous Flow Ventricular Assist Device Implantation

Abstract

Purpose We prospectively evaluated the impact of preemptive hemodynamic transesophageal echocardiography [hTEE] on early postoperative management of an implanted continuous flow left ventricular assist device [CF-LVAD]. Methods Simple cardiac imaging utilizing an FDA-approved miniaturized monoplane TEE probe has been demonstrated to impact hemodynamic decision-making in a variety of situations in the intensive care unit [ICU]. Invariably the probe is placed in response to a hemodynamic perturbation. We performed an IRB-approved prospective evaluation of 68 hTEE exams in 30 consecutive patients after CF-LVAD implantation who had the probe placed preemptively immediately after ICU admission. Each exam included superior vena cava [SVC], midesophageal 4-chamber [ME4C] and transgastric short axis [TGSAX] views to assess volume status, left and right ventricular [LV, RV] filling, RV function, septal position and pericardial fluid. Documentation at each exam described whether [a] image quality allowed interpretation, [b] imaging confirmed adequate RV output and LV filling, or [c] imaging prompted a change in clinical management. Results Devices placed in the 30 patients included HeartMate II [21], HeartMate III [4], Jarvik 2000 [1], and CentriMag [1]. Imaging quality allowed adequate interpretation in 66 of the 68 hTEE exams [97%]. Of these, 36 exams [53%] confirmed the adequacy of RV output and LV filling, and 2 of these also ruled out pericardial tamponade. Twenty exams [29%] revealed abnormal findings: RV dysfunction [7], LV and RV over- or underfilling [7] or an incipient suction event [6]. Management changes in response included fluid loading or restriction, an increase or decrease in device speed, alterations in pulmonary vasodilator therapy and changes in vasopressor dosing. Another 10 exams confirmed the benefit of the changes made based on the abnormal hTEE findings. Conclusion In this series we observed that preemptive hTEE imaging on admission to the ICU assisted postoperative CF-LVAD management in 97% of exams. In 29% of these hTEE imaging prompted interventions that enhanced VAD function or prevented potentially dangerous events. Our findings warrant consideration of this modality as a standard component of initial hemodynamic monitoring in these patients.