DK2985_C000 1..28 - AlSharqia Echo Club

478 Transesophageal Echocardiography(A)HVFD(B)EKG40PrvS200mmHgFigure 20.9 Hepatic venous flow (HVF) in a 37-year-old man after cardiac transplantation. (A) Note the inverted systolic waveform orS. (B) The right ventricular pressure (Prv) waveform obtained from the paceport is also abnormal with rapid increase in diastolic pressureconsistent with abnormal right ventricular filling (EKG, electrocardiogram).dimension (Fig. 20.8), although maximal width orshort-axis dimension is also slightly larger than in controls(16). The increase in both donor and recipient atrial size isinversely correlated with survival (17).RVEDD (cm)RVEDA (cm2)RVWT (cm)5.04.03.02.030252015100.80.70.60.50.4TIME AFTER TRANSPLANTATIONNORMAL 1 WEEK 1 YEAR1 DAY 1 MONTHFigure 20.10 Serial right ventricular echocardiographicmeasurements after transplantation (+1 SD) are compared withcontrol values (n ¼ 10). Shown are right ventricular end-diastolicdimensions (RVEDD in cm), right ventricular end-diastolic area(RVEDA in cm 2 ) and right ventricular wall thickness (RVWT incm). [Adapted with permission from Bhatia et al. (11).]E. Abnormal Echocardiographic FindingsFollowing Heart TransplantationThe presence of the atrial suture line, with an increasedatrial size with subcontractile portion of the recipientatrium and asynchrony between the donor and recipientatria contraction promotes stasis, which may account forthe high prevalence of atrial spontaneous echo contrast(55%) as assessed with TEE. Left atrial thrombi wereobserved in 38% by TEE and are often missed by transthoracicechocardiography (TTE). Thrombi were locatedin the donor LAA (10/18), on the posterior wall of theLA (6/18), on the donor component of the atrial septum(1/18) and on the left atrial suture (1/18) (18). Thrombioccurred only in patients displaying spontaneous echocardiographiccontrast. Episodes of arterial embolismwere documented in 22 % of patients with both spontaneousechocardiographic contrast and left atrial thrombus (6% ofheart transplantation recipients) (18). The use of the modifiedbicaval heart transplantation technique seems todecrease the incidence of this problem considerably (19).Transesophageal echocardiography has also been found tobe superior to TTE in demonstrating thickening of the atrialseptum, bulging of the recipient and donor atrial septum,and shunt at the atrial level (18). It may identify uncommonpatent foramen ovale after heart transplantation (20). Coronaryfistula is another finding detected by TEE after hearttransplantation. The incidence of this iatrogenic complicationhas been estimated between 5% and 15%, a 20-fold increaseover the incidence of congenital coronary artery fistula. Theincreased incidence in this group is attributed to injury from