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Transient Right Ventricular Failure and Transient Weakness: A TEE Diagnosis
DIAGNOSTIC DILEMMAS Steven Konstadt, MD Jack S. Shanewise, MD Section Editors
Transient Right Ventricular Failure and Transient Weakness: A TEE Diagnosis Galina Leyvi, MD, Ed Rhew, MD, Gregory Crooke, MD, and John D. Wasnick, MD, MPH
A
67-YEAR-OLD woman presented to the hospital in cardiogenic shock after acute anterior myocardial infarction. She was diagnosed as having ⫹4 mitral regurgitation and an ejection fraction of 15%. After diagnostic cardiac catheterization, she was taken to surgery for emergency revascularization and mitral valve replacement. After surgi-
From the Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York. Address reprint requests to Galina Leyvi, MD, Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, 4th floor, Silver Zone, 111 East 210th Street, Bronx, NY 10467. E-mail: [email protected] © 2005 Elsevier Inc. All rights reserved. 1053-0770/05/1903-0026$30.00/0 doi:10.1053/j.jvca.2005.03.020 Key words: ventricular assist device, Abiomed, transesophageal echocardiography, complications
cal repair, she was unable to be weaned from cardiopulmonary bypass despite aggressive inotropic support and intraaortic balloon counterpulsation. An Abiomed AB5000 (Abiomed, Inc, Danvers, MA) left ventricular assist device (LVAD) was placed using a left ventricular apical cannulation site. On postoperative day 1, the patient was noted to have delayed emergence from anesthesia and a new leftsided hemiparesis. The next day, the LVAD flow had fallen from 5 L/min to 3 L/min, unresponsive to volume, and with a rising central venous pressure (CVP) to 24 mmHg. Additionally, intermittent heart block and bradyarrhythmias were observed. This patient had developed transient reductions in LVAD flow, and the previously diagnosed left hemiparesis was noted to wax and wane. Emergent transesophageal echocardiography (TEE) was requested by the surgery service to rule out pericardial tamponade or right heart failure, either of which will result in reduction of LVAD flow. What is the correct diagnosis (Fig 1)?
Fig 1. Transesophageal echocardiographic findings in the left ventricular long-axis view.
406
Journal of Cardiothoracic and Vascular Anesthesia, Vol 19, No 3 (June), 2005: pp 406-408
TRANSIENT RIGHT VENTRICULAR FAILURE
DIAGNOSIS: PRESENCE OF LEFT VENTRICULAR AIR AT THE LOCATION OF THE LVAD INFLOW CANNULA
TEE demonstrated the inflow cannula in the left ventricular apex (arrow #1) and air bubbles in the ascending aorta (arrow #2) (Figs 1-3). Right ventricular function was impaired com-
407
pared with previous TEE images, and there was no compression consistent with pericardial tamponade. The left ventricle was adequately decompressed but not collapsed. The inflow cannula was visualized in the apex without obstruction. Significant air microbubbles were shown in the left ventricle, increas-
Fig 2. Transesophageal echocardiographic findings in the 4-chamber view. Arrow #3 points to the air bubbles in the left ventricle.
Fig 3. Transesophageal echocardiographic findings in the aortic arch. Arrow #4 points to the air bubbles in the aortic arch.
408
LEYVI ET AL
ing with each positive-pressure breath delivered from the ventilator. Although a bubble test had been performed before LVAD placement to rule out a patent foramen ovale, this was repeated to rule out any new intraventricular or intra-atrial defects that would lead to left-sided air entrainment. The bubble test was negative as was color-flow Doppler. Moreover, no air was seen in the left atrium. Air was shown in the left ventricle and appeared to be arising at the site of the apical left ventricular inflow cannula. A lesser amount of air was seen in the aorta near the aortic valve, and there was no significant aortic insufficiency. The conclusion is that air was entrained into the left ventricle from around or through the inflow cannula. Some air then moved into the aorta either through the native aortic valve or through the LVAD itself. The possibility of air entrainment by a left ventricular assist device is a recognized complication.1,2 Subatmospheric pressure is generated by the device, and air may be suctioned through needle holes along the interstices of the graft and suture lines. The most common locations to which air in the heart will migrate are the right coronary artery and the innominate artery. The transient symptoms of right ventricle failure, heart block,
and left hemiparesis may be ascribed to intermittent entrainment of air into the left ventricle. The AB5000 device is a vacuum-driven, external pulsatile ventricular assist device, unlike the BVS 5000 device, which relies on gravity for chamber filling. The AB5000 device generates ⫺60 cm H2O of suction as compared with the 0 to ⫺20 cm H2O that are likely generated by the BVS 5000 device. On the discovery of air entrainment at the apical cannula site, the surgeons decided to switch at the bedside from the vacuumdriven AB5000 device to the gravity driven BVS 5000. By this action, the air entrainment into the left ventricle was subjectively reduced by TEE visualization. With this, the variations in the patient’s right ventricular function, as indicated by LVAD flow and CVP, improved, as did her neurologic defect, which no longer waxed and waned. Later the patient was returned to the operating room in which the apical inflow cannula site was examined and bioglue (BioGlue; Cryolife International, Inc, Kennesaw, GA) applied to better prevent air entrainment. After application of additional sealant and reexamination of the inflow cannula, no air could be visualized. This case shows the importance of TEE in intraoperative and postoperative LVAD management.3
REFERENCES 1. Gerge SJ, Black JM, Boscoe MJ: Intraoperative transesophageal echocardiography for implantation of a pulsatile left ventricular assist device. Br J Anaesth 75:794-797, 1995 2. Mets B: Anasthesia for left ventricular assist device placement. J Cardiothor Vasc Anesth 14:316-326, 2000
3. Scalia GM, McCarthy PM, Savage RM, et al: Clinical utility of echocardiography in the management of implantable ventricular assist devices. J Am Soc Echocardiogr 13:754-763, 2000
Transient Right Ventricular Failure and Transient Weakness: A TEE Diagnosis Galina Leyvi, MD, Ed Rhew, MD, Gregory Crooke, MD, and John D. Wasnick, MD, MPH
A
67-YEAR-OLD woman presented to the hospital in cardiogenic shock after acute anterior myocardial infarction. She was diagnosed as having ⫹4 mitral regurgitation and an ejection fraction of 15%. After diagnostic cardiac catheterization, she was taken to surgery for emergency revascularization and mitral valve replacement. After surgi-
From the Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York. Address reprint requests to Galina Leyvi, MD, Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, 4th floor, Silver Zone, 111 East 210th Street, Bronx, NY 10467. E-mail: [email protected] © 2005 Elsevier Inc. All rights reserved. 1053-0770/05/1903-0026$30.00/0 doi:10.1053/j.jvca.2005.03.020 Key words: ventricular assist device, Abiomed, transesophageal echocardiography, complications
cal repair, she was unable to be weaned from cardiopulmonary bypass despite aggressive inotropic support and intraaortic balloon counterpulsation. An Abiomed AB5000 (Abiomed, Inc, Danvers, MA) left ventricular assist device (LVAD) was placed using a left ventricular apical cannulation site. On postoperative day 1, the patient was noted to have delayed emergence from anesthesia and a new leftsided hemiparesis. The next day, the LVAD flow had fallen from 5 L/min to 3 L/min, unresponsive to volume, and with a rising central venous pressure (CVP) to 24 mmHg. Additionally, intermittent heart block and bradyarrhythmias were observed. This patient had developed transient reductions in LVAD flow, and the previously diagnosed left hemiparesis was noted to wax and wane. Emergent transesophageal echocardiography (TEE) was requested by the surgery service to rule out pericardial tamponade or right heart failure, either of which will result in reduction of LVAD flow. What is the correct diagnosis (Fig 1)?
Fig 1. Transesophageal echocardiographic findings in the left ventricular long-axis view.
406
Journal of Cardiothoracic and Vascular Anesthesia, Vol 19, No 3 (June), 2005: pp 406-408
TRANSIENT RIGHT VENTRICULAR FAILURE
DIAGNOSIS: PRESENCE OF LEFT VENTRICULAR AIR AT THE LOCATION OF THE LVAD INFLOW CANNULA
TEE demonstrated the inflow cannula in the left ventricular apex (arrow #1) and air bubbles in the ascending aorta (arrow #2) (Figs 1-3). Right ventricular function was impaired com-
407
pared with previous TEE images, and there was no compression consistent with pericardial tamponade. The left ventricle was adequately decompressed but not collapsed. The inflow cannula was visualized in the apex without obstruction. Significant air microbubbles were shown in the left ventricle, increas-
Fig 2. Transesophageal echocardiographic findings in the 4-chamber view. Arrow #3 points to the air bubbles in the left ventricle.
Fig 3. Transesophageal echocardiographic findings in the aortic arch. Arrow #4 points to the air bubbles in the aortic arch.
408
LEYVI ET AL
ing with each positive-pressure breath delivered from the ventilator. Although a bubble test had been performed before LVAD placement to rule out a patent foramen ovale, this was repeated to rule out any new intraventricular or intra-atrial defects that would lead to left-sided air entrainment. The bubble test was negative as was color-flow Doppler. Moreover, no air was seen in the left atrium. Air was shown in the left ventricle and appeared to be arising at the site of the apical left ventricular inflow cannula. A lesser amount of air was seen in the aorta near the aortic valve, and there was no significant aortic insufficiency. The conclusion is that air was entrained into the left ventricle from around or through the inflow cannula. Some air then moved into the aorta either through the native aortic valve or through the LVAD itself. The possibility of air entrainment by a left ventricular assist device is a recognized complication.1,2 Subatmospheric pressure is generated by the device, and air may be suctioned through needle holes along the interstices of the graft and suture lines. The most common locations to which air in the heart will migrate are the right coronary artery and the innominate artery. The transient symptoms of right ventricle failure, heart block,
and left hemiparesis may be ascribed to intermittent entrainment of air into the left ventricle. The AB5000 device is a vacuum-driven, external pulsatile ventricular assist device, unlike the BVS 5000 device, which relies on gravity for chamber filling. The AB5000 device generates ⫺60 cm H2O of suction as compared with the 0 to ⫺20 cm H2O that are likely generated by the BVS 5000 device. On the discovery of air entrainment at the apical cannula site, the surgeons decided to switch at the bedside from the vacuumdriven AB5000 device to the gravity driven BVS 5000. By this action, the air entrainment into the left ventricle was subjectively reduced by TEE visualization. With this, the variations in the patient’s right ventricular function, as indicated by LVAD flow and CVP, improved, as did her neurologic defect, which no longer waxed and waned. Later the patient was returned to the operating room in which the apical inflow cannula site was examined and bioglue (BioGlue; Cryolife International, Inc, Kennesaw, GA) applied to better prevent air entrainment. After application of additional sealant and reexamination of the inflow cannula, no air could be visualized. This case shows the importance of TEE in intraoperative and postoperative LVAD management.3
REFERENCES 1. Gerge SJ, Black JM, Boscoe MJ: Intraoperative transesophageal echocardiography for implantation of a pulsatile left ventricular assist device. Br J Anaesth 75:794-797, 1995 2. Mets B: Anasthesia for left ventricular assist device placement. J Cardiothor Vasc Anesth 14:316-326, 2000
3. Scalia GM, McCarthy PM, Savage RM, et al: Clinical utility of echocardiography in the management of implantable ventricular assist devices. J Am Soc Echocardiogr 13:754-763, 2000