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Perioperative three-dimensional transoesophageal echocardiography in patients receiving a Heartmate II LVAD. # MD , S. Bouchez, MD°, S. Jacobs, MD°, I Herck, 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 Aim of the abstract: 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. 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 : A Three dimensional transoesophageal echocardiography (Philips IE33 – intraoperative transducer X7-2t ; Philips, Andover, MA, USA ) was used in addition to standard twodimensional 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 threedimensional 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. Methods: LV apical inflow cannula in apex. No deviation to septum or lateral side. Perfect alignment towards mitral valve. 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 cannulas 2. Unloading of the left ventricle 3. Presence of spontaneous contrast, thrombi in left ventricle and aorta. 4. Septal deviation 5. Right ventricular function LV apical inflow cannula in apex Viewed from mitral valve towards apex. Position of cannula in apex. 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 Aortic outflow cannula in aorta. Aortic valve remains closed. The acquired images were assessed and interpreted both by experts in echocardiography and by physicians with limited experience in echocardiography. Results: Left atrial view: ellipsoïd appearance of mitral valve annulus, mitral valve remains open due to excessive LVAD suction. 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. Conclusions: Three-dimensional transoesophageal echocardiography is complementary to twodimensional echocardiography for the evaluation of the Heartmate II LVAD during the perioperative period.