DK2985_C000 1..28 - AlSharqia Echo Club

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20Heart TransplantationPIERRE COUTURE, MICHEL CARRIERUniversity of Montreal, Montreal, CanadaI. Transesophageal Echocardiography andHeart Transplantation 471II. Surgical Considerations 471A. Standard Orthotopic HeartTransplantation 471B. The Bicaval Technique 472III. Transesophageal Echocardiography in thePerioperative Period 472IV. Transesophageal Echocardiography in theEarly Postoperative Period 475A. Right Ventricular Remodeling,Tricuspid Regurgitation, and AbnormalMovement of the Ventricular Septum 475B. Left Ventricular Mass and MitralValve Function 476C. Left Ventricular Diastolic Function 476D. Normal Echocardiographic Profileafter Heart Transplantation 477E. Abnormal Echocardiographic FindingsFollowing Heart Transplantation 478F. Detection of Acute AllograftRejection and Coronary ArteryDisease 479V. Conclusion 480References 480I. TRANSESOPHAGEALECHOCARDIOGRAPHY AND HEARTTRANSPLANTATIONTransesophageal echocardiography (TEE) plays animportant role during the process of cardiac transplantation.Therefore, a clear understanding of the surgical procedurehelps to provide key diagnostic information andappropriate monitoring parameters before, during andafter the procedure.II.SURGICAL CONSIDERATIONSThere are two techniques of orthotopic heart transplantation(OHT) currently used in clinical practice: thestandard technique originally described by Lower andShumway (1) and Shumway et al. (2) and the bicaval techniquedescribed by Dreyfus et al. (3) in 1991.A. Standard Orthotopic Heart TransplantationA standard anesthetic preparation for routine cardiacsurgery is performed including the use of a TEE probefor monitoring. The right internal jugular vein is left undisturbedfor later use for endomyocardial biopsies. A Swan–Ganz catheter is initially inserted to measure real timeright ventricular and pulmonary artery pressure but willbe pulled out during surgery. Both groins are preparedfor emergency cannulation and initiation of cardiopulmonarybypass if needed.471
472 Transesophageal EchocardiographyA standard median sternotomy is performed. Followinginjection of heparin, standard canulation of the ascendingaorta (Ao) and both vena cava is performed. Cardiopulmonarybypass (CPB) is initiated when the donor heartarrives in the operating room. Cross-clamping of the Aois followed by standard removal of the recipient’s failingheart leaving in place the posterior aspect of the leftand right atria, and keeping as much as possible of therecipient’s ascending Ao and pulmonary artery tissue.Mild systemic hypothermia is easily reached and maintainedthroughout surgery (348C).While the cardiectomy is performed, the donor heart isinspected and prepared in a cold bath saline solution. Theintegrity of the atrial septum is ensured and corrected if,for instance, a foramen ovale is detected. The tricuspidand mitral valve apparatus are also carefully inspected.Proper ligation of the superior vena cava is secured, theright atrial wall is opened from the inferior vena cava(IVC) to the right atrial appendage (RAA) and the leftatrial wall is trimmed and prepared. The ascending Aoand the pulmonary artery are completely dissected andseparated to facilitate proper exposure and suturingapproach (Fig. 20.1).The donor heart is brought into the thoracic cavity andthe left atrial anastomosis is first performed with 3.0 polypropylenecontinuous sutures. Retrograde cardioplegia isadministered through a catheter inserted in the coronarysinus by injection of a standard cold blood cardioplegicsolution at a rate of 100–200 mL/min and application ofice slush onto the right ventricle (RV) to keep the heartas cold as possible during surgical implantation (4). Theright atrial anastomosis (Fig. 20.2) is completed with 3.0polypropylene sutures, but a small gap is left to allowRASVCAoPAthe passage of the coronary sinus catheter up until boththe pulmonary and aortic anastomoses are completed.Donor and recipient pulmonary arteries are prepared,trimmed and anastomosed with a continuous 4.0 polypropylenesuture.Next, snares on both vena cava are released, the coronarysinus catheter is taken out, the operating table is put inthe Trendelenburg position and the clamp on the ascendingAo is released. With gentle massage of the heart, air isevacuated from the left ventricle (LV) and from theascending Ao through the suture line via the puncturedone to inject the antegrade cardioplegic solution at thedonor site. The hole created in the left atrial appendage(LAA) to decompress the LV during the harvest of thedonor heart is closed with a 3.0 polypropylene suture.The patient is weaned from the CPB after havingobtained a heart rate averaging 100 beats/min with isoproterenolinfusion and a good cardiac performance with systolicblood pressure (SBP) .90–100 mmHg. Atrial andaortic cannulae are removed while 500 mg of solumedrolis administered and protamine is injected. A Swan–Ganzcatheter is reinserted through the pulmonary artery tomonitor pulmonary artery pressure and cardiac output(CO). Two chest tubes are inserted in the mediastinum.Temporary pacing wires are sutured onto the RV. Thesternum is then closed according to a standard technique.B. The Bicaval TechniqueThis method, using a different technique of cardiectomyand anastomoses has been proposed to minimize the problemsarising from oversized posttransplant atria, such asstasis, spontaneous echo contrast and embolic complications.The right aspect of the left atrium (LA) isentered as for a routine mitral valve surgical approach.The incision is extended superiorly under the superiorvena cava (SVC) and inferiorly under the IVC (Fig. 20.3).During excision of the right atrium (RA), generous portionsof the SVC and IVC are left to facilitate donor andrecipient anastomoses. The donor LA is anastomosed tothe recipient LA as described in the standard method.The IVC and SVC are then anastomosed with 4-0 polypropylenesuture. The rest of the procedure continues asdescribed above for the standard approach to OHT.IVCRVIII.TRANSESOPHAGEALECHOCARDIOGRAPHY IN THEPERIOPERATIVE PERIODFigure 20.1 Classic biatrial technique of orthotopic hearttransplantation (Ao, aorta; IVC, inferior vena cava; PA, pulmonaryartery; RA, right atrium; RV, right ventricle; SVC, superiorvena cava).Transesophageal echocardiography in adult cardiac surgeryhas expanded its role during cardiac transplantation from auseful intraoperative tool to an equally valuable perioperativemonitoring tool. During the CPB weaning process,
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TransesophagealEchocardiographyMult
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Published in 2005 byTaylor & Franci
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ForewordThe use of transesophageal
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xPrefaceThere are several other ind
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ContentsForeword Jean-Francois Hard
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ContributorsRobert Amyot, MD, FRCPC
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ContributorsxviiFrançois Marcotte,
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xxAbbreviationsCNS central nervous
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xxiiAbbreviationsPMLPpaPPHPPHTNPraP
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How to Use the Transesophageal Echo
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1Principles of UltrasoundALAIN GAUV
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Principles of Ultrasound 3Table 1.1
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Principles of Ultrasound 5the ratio
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Principles of Ultrasound 7transduce
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Principles of Ultrasound 9(A)(B)Fig
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Principles of Ultrasound 11certain
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Principles of Ultrasound 13PULSERBE
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Principles of Ultrasound 152. Trans
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Principles of Ultrasound 17(A)(B)TV
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Principles of Ultrasound 19(A)(B)(E
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Principles of Ultrasound 21to the i
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24 Transesophageal Echocardiography
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3TransducersFRANÇOIS HADDADUnivers
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Transducers 43(A)(C)(B)Figure 3.3 (
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Transducers 45more frequencies than
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Transducers 47Figure 3.10 Beam focu
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Transducers 49sound that propagate
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Transducers 51(A)(B)(C)Figure 3.15
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5Quantitative EchocardiographyJEAN
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Quantitative Echocardiography 91dim
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Quantitative Echocardiography 93Fig
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Quantitative Echocardiography 101Fi
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Quantitative Echocardiography 105in
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Quantitative Echocardiography 115On
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Quantitative Echocardiography 117Ha
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Quantitative Echocardiography 119fl
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6Imaging Artifacts and PitfallsROBE
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Imaging Artifacts and Pitfalls 123F
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Imaging Artifacts and Pitfalls 125F
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Imaging Artifacts and Pitfalls 127(
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Imaging Artifacts and Pitfalls 1391
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142 Transesophageal Echocardiograph
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9Global Ventricular Function and He
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Global Ventricular Function and Hem
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10CardiomyopathyVICKY SOULIÈRE, PH
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Cardiomyopathy 217Figure 10.1 (A, B
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Cardiomyopathy 219Figure 10.4 Systo
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Cardiomyopathy 221RVOT must also be
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Cardiomyopathy 223either by reduced
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Cardiomyopathy 225Figure 10.10 Flow
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Cardiomyopathy 227On the other hand
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Cardiomyopathy 229volumes are both
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Cardiomyopathy 231(A)TMFAE(B)PVFDMe
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Cardiomyopathy 233(A)(B)LUPVLAAoLAA
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Cardiomyopathy 235(A)(B)LALV(C)Figu
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Cardiomyopathy 237than moderate MR
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Cardiomyopathy 23920. Yu EH, Omran
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12AortaIVAN IGLESIAS, DANIEL BAINBR
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Aorta 263GRADE 1:NORMALAoGRADE 2:IN
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Aorta 265(A)(B)LALMCARAAoRVRCAFigur
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Aorta 267Figure 12.9Short- (A, B) a
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Aorta 269(A)(B)AORTAMOBILEATHEROMA(
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Aorta 271diameter (22). Aneurysms o
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Aorta 273(A)(B)NCCRALARCCMPALCCANEU
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Aorta 275(A)(B)LAARTEFACT(C)AoARTEF
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Aorta 277(A)(B)AoLATVRAFL TLPVRV(C)
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Aorta 279(A)(B)AORTICHEMATOMAAo(C)A
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Aorta 281(A)(B)FLTLAo(C)(D)INTRALUM
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Aorta 28331. Bansal RC, Chandraseka
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14Perioperative Role of TEE in Mech
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TEE in Mechanical Circulatory Assis
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15Native Aortic ValveFRANÇOIS A. B
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Native Aortic Valve 331Figure 15.2
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Native Aortic Valve 333(A)(B)ARANTI
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Native Aortic Valve 335(A) (B) (C)
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Native Aortic Valve 337(A)(B)LAAoLV
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Native Aortic Valve 339(A)(B)MVAoVL
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Native Aortic Valve 341(A)(B)LAAoVL
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Native Aortic Valve 343(A)(B)SAMLAI
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Native Aortic Valve 345(A)(B)AoVLAT
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Native Aortic Valve 347Although the
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Native Aortic Valve 349substitution
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Native Aortic Valve 351(A)(B)AoVLVO
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Native Aortic Valve 353(A)(B)LARPAL
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Native Aortic Valve 355(A)(B)LAAoVR
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Native Aortic Valve 357In those pat
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Native Aortic Valve 359Table 15.4 E
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Native Aortic Valve 36111. Levine R
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17Mitral ValveANDRÉ SAINT-PIERRELa
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Mitral Valve 385(A)SCHEMATIC VIEW(B
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Mitral Valve 387Figure 17.5 Echocar
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Mitral Valve 389(A)(B)LVP3A2LAAA1Fi
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Mitral Valve 391(A)(B)(C)(D)A1LAP1L
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Mitral Valve 393(A)(B)LARALVRV(C)(D
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Mitral Valve 395(A)(B)AoVFLAIL P1LA
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Mitral Valve 397(A)(B)P3LALVLAAA1(C
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Mitral Valve 399(A)(B)LALAALV(C)(D)
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Mitral Valve 401Table 17.3Mitral Re
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Mitral Valve 403(A)(B)MITRAL VALVEV
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Mitral Valve 405(A)EKG(B)PVFPaSDRES
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Mitral Valve 407Table 17.4BVR Echoc
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Mitral Valve 409Left ventricular sy
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Mitral Valve 411(A)(B)LALVAoRV(C)TM
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Mitral Valve 413Table 17.8StenosisT
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Mitral Valve 415identification of a
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Page 526 and 527: 23Intracavitary ContentsMARIA DI LO
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Intracavitary Contents 521and angle
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Intracavitary Contents 52317. Lando
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25Indications for Perioperative Tra
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Indications for Perioperative TEE 5
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570 IndexAortic aneurysmclassificat
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572 IndexColor jet area, 402Commiss
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574 IndexHypotension, 491Hypothermi
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576 IndexMitral valve repair, 394,
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578 IndexRight atrial thrombus, 517
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580 IndexTricuspid leafletsanterior
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DK2985_C000 1..28 - AlSharqia Echo Club

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