Using Aortic Arch Short Axis Views during Transesophageal Echocardiographic Examination Facilitates Right Ventricular Assist Device Imaging

Abstract

<h3>Introduction</h3> Recent increased utilization of percutaneous mechanical circulatory support for the management of cardiogenic shock and end-stage heart failure has resulted in the development and more widespread use of percutaneous right ventricular assist device (RVAD) technologies in right ventricular failure. RVADs require appropriate imaging to confirm correct positioning and ensure function. The proper imaging for this new technology has not been well described. We present two cases in which the upper esophageal (UE) aortic arch (AA) short-axis (SAX) view with transesophageal echocardiography (TEE) played an important role in RVAD management. <h3>Case Report</h3> <b>Case 1.</b> Device malposition: Four days after initial placement of a ProtekDuo cannula (CardiacAssist, Pittsburg, PA, USA) with extracorporeal RVAD under fluoroscopy, cannula malposition was noted intraoperatively. Under TEE UE AA SAX visualization, the cannula was advanced such that the tip remained in the main pulmonary artery throughout the cardiac cycle, ensuring proper flow (Figure 1A-C). <b>Case 2.</b> Device malfunction: One month after extracorporeal RVAD implantation, acute RVAD flow reduction and significant hemolysis were observed. The UE AA SAX view demonstrated thrombus formation on the tip of the RVAD outflow cannula (Figure 1D). The RVAD outflow cannula was exchanged surgically, and upon examination of the old cannula, the thrombus was noted to cause significant cannula exit obstruction. <h3>Summary</h3> These cases support the importance of the UE AA SAX TEE view in RVAD outflow imaging. When obtainable, this view should be included in routine RVAD assessment.