Clinical utility of echocardiography in the management of implantable ventricular assist devices

Background: The high mortality rate of congestive cardiac failure, the cost and complications of cardiac transplantation, and the waiting list mortali ty rate resulting from donor organ scarcity have encouraged the development of surgical techniques as bridges to transplantation or as long-term palli ative therapy. Implantable left ventricular assist devices are now routinel y used as such a bridge, and within the REMATCH Trial, as permanent palliat ive devices in nontransplant candidates. These are mechanical managements w ith myriad mechanical complications and pitfalls. Echocardiography has been extensively used in our institution to detect and diagnose previously docu mented and hitherto unencountered complications of these procedures. Methods and Results: The role of echocardiography in these procedures, incl uding preoperative patient selection, intraoperative transesophageal echoca rdiography, and postoperative troubleshooting and late follow-up, is discus sed. We describe our clinical echocardiographic approach, which has develop ed over 91 assist-device procedures. The relative frequency and clinical im pact of specific anatomic, physiologic, hemodynamic, and mechanical feature s are described. New techniques such as the Doppler quantification of assis t device inflow obstruction are illustrated, as are the device cannula posi tion, the detection of device valve failure, and the parameters related to the remodeling procedure. Conclusions: Echocardiography in heart failure surgery has proved to be an invaluable tool in the diagnosis and management of mechanical complications . The experience gained in our institution may serve as an aid to new surgi cal programs treating these critically ill patients.