DK2985_C000 1..28 - AlSharqia Echo Club

Heart Transplantation 477(A)BEFORE TRANSPLANTATION(B)LALV(C)AFTER TRANSPLANTATION(D)ATRIALANASTOMOSISLAALALVFigure 20.8 Mid-esophageal two-chamber view in a patient before (A, B) and after cardiac transplantation (C, D). The patient hadend-stage hypertrophic cardiomyopathy. Note the left atrial suture anastomosis after the procedure and the increase in the anteroposteriorsize of the left atrium (LA) (LAA, left atrial appendage; LV, left ventricle).examination of the mitral inflow shows a profile comparableto previously defined restrictive parameters (seeChapter 9); this evolves into a nonrestrictive pattern overa six weeks period leading to progressive improvementin postoperative diastolic function parameters anddecrease in left heart filling pressures (14). The presenceof recurrent or persistent severe diastolic dysfunctionwith restrictive filling within six months after transplantationis associated with a reduced late-term actuarialsurvival, independent of graft rejection (15).Evidence suggests that retaining normal LA size andshape by using the bicaval technique promotes ventricularfilling dynamics which more closely approximates normalphysiology (8). Ventricular filling is influenced by themechanical activity of residual recipient atrial tissueover that of the donor heart. In addition, “parasystolic”contraction of residual recipient atrial tissue also modifiesthe pulmonary venous flow: recipient atrial contractionoccurring in late systole results in an increase in thediastolic component (D-wave); if it happens in earlysystole the systolic component (S-wave) is decreased.End-diastolic atrial contraction will increase the velocityobserved during atrial reversal (AR wave) (10).D. Normal Echocardiographic Profileafter Heart TransplantationOne year after OHT, echocardiograms of recipients doingclinically well are characterized by increased left ventricularwall thickness and mass. Left ventricular dimensions,volumes and ejection fraction are within normal limits.Right ventricular wall thickness and cavity size areincreased with preserved right ventricular systolic function.The transplanted heart also shows an anteromedialtranslational motion during systole. The atria of the transplantedheart have unique echocardiographic features. Theanastomotic suture line is easily identified on 2D imagingas the waist of these hourglass-shaped atria (Fig. 20.8).This waist creates a natural point of subdivision withinthe native and donor atria. The markedly enlarged atrialvolume results primarily from an increased long-axis