Video Clips
Anesthesia & Analgesia: Volume 105, Issue 3, Page 583.
"Perioperative Echocardiographic Examination for Ventricular Assist Device Implantation" by Chumnanvej et al.
Data Files:
- Video Clip 1
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Clip 1. Left ventricular thrombus. Transgastric mid short-axis view displaying the left ventricle (LV) and right ventricle (RV) before implantation of a LV assist device. There are two intraventricular mobile echodensities of cystic or filamentous appearance. Opening of the ventricles revealed extensive amount of adherent thrombus, which were evacuated before implantation of the device inflow cannula.
- Video Clip 2
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Clip 2. Agitated saline contrast study for PFO before LVAD insertion. Agitated saline contrast study before a left ventricular device insertion showing no evidence of a patent foramen ovale (PFO). Notice the bowing of the interatrial septum towards the right atrium (RA) due to left ventricular failure with increased left atrial (LA) pressures. This hemodynamic condition prevents an optimal study secondary to loss of the transient RA/LA pressure differential.
- Video Clip 3
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Clip 3. Color Doppler study for PFO after LVAD insertion. Mid-esophageal color Doppler view showing the presence of a patent foramen ovale (PFO) in the same patient shown in Clip 2. The change in hemodynamic conditions with reduced left atrial (LA) pressures due to the left ventricular assist device insertion, with maintained or increased right atrial (RA) pressures, can unmask an unsealed PFO as shown in this image.
- Video Clip 4
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Clip 4. Air in Ascending Aorta after LVAD insertion. Mid-esophageal long-axis view of the ascending aorta immediately following discontinuation of cardiopulmonary bypass. Air bubbles are noticed in the ascending aorta (Asc Ao). Also evident is the continuous closed position of the aortic valve, compatible with full support of a pulsatile device.
- Video Clip 5
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Clip 5. Air in RV after VAD insertion. Mid-esophageal 4 chamber view at the end of a biventricular assist device implantation procedure, before discontinuation of cardiopulmonary bypass. Abundant right ventricular air is present. Underfilling of the left ventricle promoting conditions for chordal and valvular systolic anterior motion of the mitral valve can also be observed. These findings are less significant in the case of total ventricular support. LA=left atrium, LV=left ventricle, RV=right ventricle.
- Video Clip 6
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Clip 6. LVAD ventricular inflow cannula. Mid-esophageal 4 chamber view showing the inflow cannula of a left ventricular assist device at the apex of the left ventricle, aligned with the mitral valve opening. Shifting of the interventricular septum is also noted, consistent with transient reduction in LVEDP below the RVEDP.
- Video Clip 7
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Clip 7. Color Doppler of LVAD ventricular inflow cannula. Mid-esophageal 4 chamber color Doppler view showing laminar flow into the inflow cannula at the apex of the left ventricle, aligned with the mitral valve opening.
- Video Clip 8
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Clip 8. LVAD atrial inflow cannula. Upper esophageal two-dimensional view to display the left atrial cannulation. This position of the inflow cannula is less frequent than the left ventricular insertion.
- Video Clip 9
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Clip 9. Color Doppler of LVAD outflow cannula. Rotating upper-esophageal image of the ascending aorta. The outflow cannula of a left ventricular assist device can be followed along its extension up to its anastomosis to the ascending aorta (Ao). Low turbulence flow into the aorta can be noticed, as well as flow distribution antegradely towards the systemic circulation and retrogradely towards the aortic root. Increased flow in the pulmonary artery can also be noticed, compatible with the presence of a biventricular assist device in this patient.
- Video Clip 10
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Clip 10. Color Doppler of LVAD outflow cannula with anastomotic site. Mid-esophageal long axis view showing the anastomotic site of the left ventricular assist device outflow cannula into the ascending aorta (Asc Ao).
- Video Clip 11
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Clip 11. Sutured aortic valve after LVAD insertion – short axis. Mid-esophageal short axis view of the aortic valve showing echodensities attached to the aortic valve commissures and absence of systolic aortic valve opening consistent with surgical closure of the aortic valve. Such intervention is one of the alternatives when significant aortic regurgitation is observed before implantation of a LVAD.
- Video Clip 12
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Clip 12. Sutured aortic valve after LVAD insertion – long axis with color Doppler. Mid-esophageal two-dimensional long axis view of the aortic valve for the same case shown in Clip 11. The absence of aortic valve opening, absence of valvular regurgitation and the sutures can be observed. Asc Ao=ascending aorta, LVOT-left ventricular outflow tract.
- Video Clip 13
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Clip 13. Pericardial patch closure of aortic valve. Mid-esophageal two-dimensional long axis view showing a thin echodense mobile structure at the level of the aortic valve (AoV). Significant aortic insufficiency was present pre-operatively in this case leading to removal of the aortic valve and insertion of a pericardial patch to prevent blood regurgitation into the left ventricle (LV) following device insertion. LA=left atrium, Ao=aorta.
- Video Clip 14
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Clip 14. Intermittent opening of aortic valve for axial flow VAD. Mid-esophageal long axis view of the aortic valve demonstrates intermittent opening of the valve.. This is compatible with the presence of an axial flow device (Heartmate II) providing partial support with consequent ventricular ejection.
- Video Clip 15
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Clip 15. Incomplete coaptation of tricuspid valve associated with functioning LVAD. Mid-esophageal 4 chamber view following implantation of a left ventricular assist device (LVAD). The leftwards displacement of the interventricular septum induced by the functioning LVAD results in incomplete closure of the tricuspid valve, seen in this image as incomplete coaptation of the anterior and septal leaflets. There is dilatation of the right ventricle, which may be caused and/or worsened by the resulting tricuspid regurgitation.
- Video Clip 16
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Clip 16. Tricuspid regurgitation after LVAD. Mid-esophageal 4 chamber view following implantation of a left ventricular assist device (LVAD). Significant tricuspid regurgitation (TR) persisted after LVAD placement in a patient with right ventricular dilatation and dysfunction with resulting TR. More consistent reduction of TR following LVAD insertion is obtained with use of an annular ring. RA=right atrium, RV=right ventricle.
- Video Clip 17
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Clip 17. Color Doppler of RVAD atrial inflow cannula. Mid-esophageal bicaval color Doppler view of the right atrium (RA) showing continuous flow into the right ventricular assist device inflow cannula.
- Video Clip 18
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Clip 18. RVAD outflow cannula. Mid-esophageal view of the right ventricular outflow tract, pulmonary artery (PA) and its bifurcation into the right (RPA) and left (LPA) pulmonary arteries. The connection and alignment of the outflow cannula of the right ventricular assist device with the main PA can be assessed.
- Video Clip 19
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Clip 19. Color Doppler of RVAD outflow cannula. Mid-esophageal color Doppler view of the right ventricular outflow tract and pulmonary artery (PA). Flow from the outflow cannula of the right ventricular assist device into the main PA can be assessed.
- Video Clip 20
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Clip 20. Tamponade RA compression. Mid-esophageal 4 chamber view obtained in the beginning of a chest re-exploration following implantation of a left ventricular assist device. The patient presented low systemic and device flows. Extensive amount of pericardial blood and hematoma can be noticed as well as significant compression of the right atrium.
- Video Clip 21
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Clip 21. LVAD inflow cannula perforation. Mid-esophageal aortic valve long axis view showing air ejected into the ascending aorta (Ao) from an LVAD outflow cannula. In this case, the air was entrained from a tear found in the inflow cannula of a HeartMate I device.
- Video Clip 22
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Clip 22. LVAD inflow cannula thrombus. Mid-esophageal 4 chamber view. There is a mobile echodensity at the inlet of the left ventricular assist device inflow cannula consistent with a thrombus. Obstruction of the inflow cannula caused by mechanisms such as thrombus, kinks, and partial occlusion by the left ventricular wall can produce increase in the velocity at the inflow cannula (see Fig. 6 in the manuscript).
- video Clip 23
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Clip 23. RVAD inflow cannula thrombus. There is a mobile echodensity consistent with thrombus vs. vegetation next to the right atrial (RA) site of the inflow cannula of a right ventricular assist device. LA=left atrium.
- Video Clip 24
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Clip 24. Impella. Mid-esophageal long-axis view demonstrating an Impella® LVAD. The device is inserted retrogradely from the aorta, through aortic valve, into the left ventricle. Blood is axially pumped from the device’s inflow located in the left ventricle to the device’s outflow positioned the aortic valve in the ascending aorta. The correct position of the device’s tip is 3-4 cm from the aortic valve annulus, reaching the anterior mitral leaflet edge. There is no occlusion of the device’s inlet by the ventricular wall.
- Video Clip 25
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Clip 25. TandemHeart®. Mid-esophageal 4 chamber view of following implantation of the percutaneous TandemHeart® device. Notice the trans-septal position from the right atrium (RA) to the left atrium (LA), allowing for decompression of the left heart through the entry ports located in the distal tip of the inflow cannula (clip provided by O. H. Frazier and C. J. Gemmato, Texas Heart Institute).
- Video Clip 26
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Clip 26. Jarvik 2000 intraventricular portion. There is a highly echogenic echodensity in the apex of the heart, which corresponds to a Jarvik 2000 axial pump. Paradoxical motion of the interventricular septum is also noted (green arrow), (clip provided by O. H. Frazier and C. J. Gemmato, Texas Heart Institute).
- Video Clip 27
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Clip 27. Jarvik 2000 outflow cannula. Mid-esophageal posterior. The extension of the outflow cannula of a Jarvik2000 device can be examined until its anastomosis to the descending aorta. Color Doppler imaging evidences laminar flow in the cannula (clip provided by O. H. Frazier and C. J. Gemmato, Texas Heart Institute).
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