European Journal of Echocardiography 2008 9(1):175-177; doi:10.1016/j.euje.2007.07.005
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org
Transesophageal guided left atrial positioning of a percutaneous ventricular assist device
Mohammad Kooshkabadi*,
Andreas Kalogeropoulos,
Vasilis C. Babaliaros and
Stamatios Lerakis
Emory University School of Medicine, Atlanta, GA 30322, USA
Received 5 April 2007; accepted after revision 22 July 2007; online publish-ahead-of-print 13 September 2007.
* Corresponding author. Tel: +1 404 843 0982; fax: +1 404 727 4724. E-mail address: mkooshk{at}emory.edu
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Abstract
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Cardiogenic shock in the setting of myocardial infarction continues
to represent a high proportion of immediate mortality in this
patient population, despite ongoing advances in thrombolytics,
PCI, and medical management of AMI. We present a case of peri-MI
cardiogenic shock necessitating deployment of a percutaneous
ventricular assist device (pVAD). TEE guidance played a crucial
role in optimal positioning of the venous cannula in the left
atrium.
Keywords: Transesophageal echocardiography; Percutaneous ventricular assist device
In the setting of myocardial infarction, cardiogenic shock remains
a leading cause of acute mortality.
1 Percutaneous insertion
of IABP and open chest insertion of left ventricular assist
devices (LVADs) in setting of cardiogenic shock and myocardial
infarction has been a temporizing measure prior to surgical
or percutaneous revascularization; and in other instances, provides
hemodynamic support to allow for the delayed recovery of revascularized
myocardium.
3,4 In 2001, Schuler
et al. published initial data
on the use of percutaneous left atrial to femoral bypass (pVAD,
Tandem Heart).
5 Tandem Heart (Cardiac Assist, Pittsburgh, PA)
is a low-speed centrifugal continuous flow pump that was shown
to provide 4.0 L/min of assisted cardiac output in setting of
peri-infarct cardiogenic shock. Implantation of the Tandem Heart
uses standard transseptal puncture techniques to access the
left atrium, and in the latter study, position of the venous
inflow cannula was confirmed by manual dye injection under fluoroscopy.
5
Transesophageal technique is routinely used at our institution, in assisting percutaneous deployment of atrial septal closure devices, percutaneous mitral valve clips and LAA occlusion devices.2,5,6,8 Here, we present a case of deployment of a pVAD into the left atrium with guidance by transesophageal echocardiogram.
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Case report
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A 47-year-old man with history of multiple myocardial infarctions
and ischemic cardiomyopathy presented with cardiogenic shock
in setting of inferior MI. IABP had been inserted at time of
PCI and stenting of the RCA. Patient remained in cardiogenic
shock several days after revascularization, and his course was
further complicated by incessant polymorphic ventricular tachycardia.
He was transferred to Emory University Hospital, for placement
of percutaneous VAD, and further evaluation for possible cardiac
transplant. TEE was utilized to guide various steps in placement
of the venous cannula in the left atrium. Standard biatrial
views were utilized during puncture across the fossa ovalis
with modified Ross needle. Most important, left atrial images
in coaxial views were used to aid in the localization of the
tip of the venous cannula.
Figure 1 shows how the tip was
initially in contact with the left atrial wall, which would
have compromised the suction mechanism of the pVAD. Optimal
position in the left atrium was achieved under TEE guidance
by pulling back and anteriorly rotating the venous cannula (
Figures 2 and
3); color Doppler then demonstrated the suction mechanism
through the holes of the venous cannula tip (
Figures 4 and
5). The patient's hemodynamics improved over the next week
allowing for initiation of ACE inhibitor and beta-blocker regimen
and successful weaning from the pVAD.
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Discussion
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Echocardiography plays an important role today in the catheterization
laboratory. It provides guidance for the safe and successful
percutaneous deployment of multiple new devices by our interventional
colleagues. Cardiogenic shock in the setting of myocardial infarction
continues to represent a high proportion of immediate mortality
in this patient population, despite ongoing advances in thrombolytics,
PCI, and medical management of AMI. pVAD represents a next step
in supporting patients in cardiogenic shock.
4 This case demonstrates
the utility of TEE in guiding the deployment and positioning
of the pVAD's venous cannula in left atrium. Recent study of
the Tandem Heart in setting of AMI and cardiogenic shock showed
improved outcome in comparison to IABP.
4 Additionally, the results
of the REMATCH trial show clear survival benefit for end-stage
heart failure patients who received an LVAD and we will likely
see the application of pVAD in this patient population in the
near future.
7 TEE then will have a pivotal role, and efforts
at standardizing and reporting of optimal TEE views should be
undertaken with this patient cohort.
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Supplementary material
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Supplementary data associated with this article can be found in the online version.
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References
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- Holmes DR, Bates EX, Kleimen NS, Sadowski Z, Horgan JH, Morris DC, et al. Contemporary reperfusion therapy for cardiogenic shock: the GUSTO-I trial experience. J Am Coll Cardiol (1995) 26:668–74.[Abstract]
- Jorgensen J, Palmer S, Kalogeropoulos A, Arita T, Block P, Martin R, et al. Implantation of left atrial appendage occlusion devices and complex appendage anatomy: the importance of transesophageal echocardiography. Echocardiography (2007) 24:159–61.[CrossRef][Web of Science][Medline]
- Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M, et al. Left ventricular assist device and drug therapy for the reversal of heart failure. N Engl J Med (2006) 355:1873–84.[Abstract/Free Full Text]
- Thiele H, Sick P, Boudriot E, Diederich KW, Hambrecht R, Niebauer J, et al. Randomized comparison of intra-aortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J (2005) 26:1276–83.[Abstract/Free Full Text]
- Thiele H, Lauer B, Hambrecht R, Boudriot E, Cohen HA, Schuler G. Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance. Circulation (2001) 104:2917–22.[Abstract/Free Full Text]
- Hanna IR, Kolm P, Martin R, Reisman M, Gray W, Block PC. Left atrial structure and function after percutaneous left atrial appendage transcatheter occlusion (PLAATO): six-month echocardiographic follow-up. J Am Coll Cardiol (2004) 43:1868–72.[Abstract/Free Full Text]
- Rose EA, Gelijins AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med (2001) 345:1435–43.[Abstract/Free Full Text]
- Block PC. Percutaneous transcatheter repair for mitral regurgitation. J Interv Cardiol (2006) 19:547–51.[CrossRef][Medline]
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