ECHO ROUNDS

Intraoperative Transesophageal Echocardiography

Diagnosis of Rare Source of Right Ventricular Failure
After Heart Transplant
Nicholas W. Markin, MD, Candice R. Montzingo, MD, FASE, Sasha K. Shillcutt, MD, FASE,
and Tara R. Brakke, MD, FASE

44-year-old male born with d-transposition of the

great arteries underwent a Mustard atrial switch
procedure after birth (Fig. 1) and eventually developed failure of the morphologic right ventricle (RV). He
was admitted for New York Heart Association Class IV
heart failure symptoms requiring continuous inotropic
therapy and an intraaortic balloon pump to reduce the
work of his systemic ventricle, the RV. Heart transplantation
was performed, restoring the patient to normal anatomy.
Failure of the allograft RV was diagnosed on postoperative
day 1 using transthoracic echocardiography (Video 1A and B,
see Supplemental Digital Content 1, http://links.lww.com/
AA/A406). No improvement was subsequently seen and he
was scheduled for RV assist device (RVAD) placement on
postoperative day 10.
General anesthesia was induced and transesophageal
echocardiography (TEE) was performed showing a dilated
RV with depressed systolic function (Video 2A, see Supplemental Digital Content 2, http://links.lww.com/AA/A407).
A narrowing of the pulmonary artery (PA) anastomosis,
diameter of 1.14 cm, was seen approximately 2.5 cm above
the pulmonic valve (Fig. 2A) (Video 2B, http://links.lww.
com/AA/A407). Evaluation with 2-dimensional (2D) and
color-flow Doppler (CFD) of the anastomosis was performed and showed flow acceleration at the anastomosis
and turbulence distal to the narrowed region (Video 2C,
http://links.lww.com/AA/A407). Continuous-wave Doppler
showed a maximum velocity of 343 cm/second across this
narrowing, representing a peak gradient of 47 mm Hg (Fig.
3A). This anastomosis was revised during cardiopulmonary bypass (CPB) secondary to these findings and as
planned, a Thoratec PVAD (Thoratec Corporation, Pleasanton, CA) pulsatile ventricular assist device (VAD) for the
RV was implanted. Post-CPB imaging showed improved
PA internal diameter and decreased peak gradient to 12
mm Hg with the RVAD flow paused (Fig. 3B). The pulsatile
RVAD was used until RV function improved and removal
of the device occurred 17 days later.

From the Department of Anesthesiology, University of Nebraska Medical

Center, Omaha, NE.
Accepted for publication March 27, 2012.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.anesthesia-analgesia.org).
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Patient Consent Statement: Written consent to report this case was received
from the patient and his family.
Address correspondence to Candice Montzingo, MD, FASE, Department of
Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska
Medical Center, Omaha, NE 68198-4455. Address e-mail to cmontzin@
unmc.edu.
Copyright 2012 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e31825ab356

August 2012 Volume 115 Number 2

DISCUSSION
This patient underwent the Mustard procedure for correction of d-transposition of the great arteries, which
directs systemic venous blood through the left atrium,
left ventricle, and into the PA and directs pulmonary
venous blood through the right atrium, the morphologic
RV and into the aorta (Fig. 1B). Over time, the Mustard
procedure can lead to dysfunction of the morphologic
RV because it lacks sufficient contractile reserve and
atrioventricular valve function to generate systemic pressures long-term.
For many individuals with either congenital or acquired
forms of heart disease that result in decreased cardiac
function, cardiac transplantation is the final treatment
option for those who cannot recover with other therapies.1
RV failure continues to have significant morbidity for
patients undergoing cardiac transplantation, especially
those with high pulmonary vascular resistance preoperatively.2 RV failure after transplantation has been caused by
preexisting pulmonary hypertension, poor RV myocardial
protection, air embolism, or rare anatomic/anastomotic
complications. Such causes of postoperative RV dysfunction secondary to outflow tract obstruction have been
reported after anastomotic stricture after lung transplantation and kinking of the PA after heart transplantation.3,4 Pretransplant heart catheterization on our patient
demonstrated PA pressures of 40/25 mm Hg (mean 35
mm Hg) and pulmonary vascular resistance of 2.56
Woods units, which was appropriate to attempt cardiac
transplantation.
Postoperative treatment with a VAD has been used after
heart transplantation and for individuals with heart failure
after acute myocardial infarction.5 VAD therapy allows
recovery of ventricular function over time and eventual
removal of the device, as it occurred in this patient.
Examination after the RVAD was paused demonstrated
improved RV function and normal tricuspid annulus plane
systolic excursion before RVAD extraction on posttransplant day 27.
Regarding the intraoperative findings, a normal diameter of the PA at the level of the stricture is 1.5 to 2.1 cm and
normal flow through the PA and pulmonic valve should be
100 cm/second.6,7 Because the diameter of stricture on 2D
imaging was 1.14 cm, it was a smaller than expected
diameter for the PA. A focused evaluation using 2D echo in
2 orthogonal planes, midesophageal ascending aorta shortaxis view and midesophageal ascending aorta long-axis
view, was important for confirmation that a stenotic area
was present and not artifact. Manipulation of the TEE
probe depth in these 2 views allowed visualization of the
PA in long-axis and short-axis, respectively, though visualization of the PA with these views is not always available.
The use of CFD to demonstrate flow acceleration at the
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ECHO ROUNDS

Figure 1. D-Transposition of the great

vessels. A, Demonstrates uncorrected
D-transposition with mixing of oxygenated
and deoxygenated blood via an atrial
septal defect. The morphologic right ventricle (RV) is connected to the aorta (Ao)
and the morphologic left ventricle (LV) to
the pulmonary artery (PA). B, Demonstrates the anatomy and bloodflow after
correction with the Mustard atrial switch
procedure. A baffle directs deoxygenated
blood to the morphologic LV and out into
the PA and directs oxygenated blood into
the morphologic RV and systemically
through the aorta. RA right atrium;
LA left atrium. Figure Illustration by
Nicholas Markin.

stricture or turbulent flow distal and spectral Doppler to

measure flow velocities through the stricture assist in
showing its presence.
After the procedure, attempts to confirm the size of the
stricture was performed using the cross-sectional area
(CSA) calculation and using the proximal isovelocity surface area (PISA) radius. Estimation of the CSA of the
stenosis, assuming it to be circular, can be done using:

r2 area
0.572 1.02 cm2
A diameter of 1.14 cm gives a CSA of 1.02 cm2. Interrogation of stenotic lesions can use the PISA radius (r), the
aliasing velocity (Valias), the maximum velocity across
the region (Vmax) and the interface angle () to solve the
estimated orifice area:

2r2 Valias
Vmax

180

21.39 cm 2 50 cm/s
343 cm/s

113
180

1.11 cm2

The estimated area using both the CSA and PISA calculations supports the presence of the anastomotic stricture
seen on 2D imaging. Given a normal PA diameter of 2 cm,
CSA would be 3.14 cm2. A CSA of 1.0 to 1.1 cm2 would be
a moderate to severe stenosis.
Without identification of this anastomotic stricture it is
possible the patient would not have recovered appropriate
RV function to allow RVAD removal. PA anastomosis
visualization was not reported during transplantation with

area

Video 1. A, Transthoracic apical four-chamber transthoracic image

on postoperative day 2 showing a severely depressed right ventricle
(RV). B, Transthoracic parasternal left ventricular short-axis view of
the left ventricle (LV) and RV showing flattening of the interventricular
septum with a small LV cavity. RV right ventricle; LV left
ventricle; RA right atrium; LA left atrium.

258

The CFD image shows a PISA radius of 1.39 cm and an

interface angle of 113 (Fig. 2B) and Vmax of 343 cm/s as
determined by continuous-wave Doppler (Fig. 3A) giving
the estimated orifice area:

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Video 2. A, Midesophageal four-chamber view showing depressed

right ventricular (RV) function and flattening of the interventricular
septum. B, Midesophageal right ventricle outflow view, modified to
include the pulmonary artery anastomosis. The pulmonic valve can
be seen below the level of stenosis. C, Midesophageal RV outflow
view with color-flow Doppler demonstrating proximal flow convergence as blood flows through the anastomotic stricture. Still image
with measurement of the proximal isovelocity surface area radius is
seen in Figure 2B. RV right ventricle; LV left ventricle; RA right
atrium; LA left atrium; PA pulmonary artery.

ANESTHESIA & ANALGESIA

Rare Source of RV Failure After Heart Transplant

Figure 2. Echocardiography images. A, Midesophageal (ME) right

ventricle (RV) outflow view at 97 degrees showing the diameter of the
proximal pulmonary artery (PA) of 2.49 cm at the level of the
pulmonic valve (PV) and diameter of the narrowed anastomosis of
1.14 cm. B, Anastomotic narrowing shown from the ME RV outflow
view at 108 degrees. The radius of the isovelocity hemisphere of
1.39 cm is demonstrated at the aliasing velocity of 50 cm/s and the
interface angle of 113 degrees. LA left atrium; RV right
ventricle; AV aortic valve.

TEE and the direct appearance was normal according to the

operative report. None of the 4 transthoracic echocardiography examinations performed after transplant visualized
the anastomosis. Additionally, the external appearance of
the anastomosis was normal in the surgical field upon
reexamination during RVAD placement. Inspection of vascular anastomoses post-CPB with TEE to document normal
flow variables may help to reduce the risk of this type of
posttransplant right heart failure.
DISCLOSURES

Name: Nicholas W. Markin, MD.

Contribution: This author helped prepare the manuscript.
Name: Candice R. Montzingo, MD, FASE.
Contribution: This author helped prepare the manuscript.
Name: Sasha K. Shillcutt, MD, FASE.
Contribution: This author helped prepare the manuscript.
Name: Tara R. Brakke, MD, FASE.
Contribution: This author helped prepare the manuscript.
This manuscript was handled by: Martin J. London, MD.

August 2012 Volume 115 Number 2

Figure 3. Echocardiography images. A, Pulmonary artery (PA) viewed

from midesophageal (ME) ascending aortic short-axis view with
continuous-wave Doppler (CWD) at 0 degrees demonstrating a maximum velocity of 343 cm/s with corresponding peak pressure gradient
(PG) of 47 mm Hg as blood crosses the narrowed anastomosis. B, PA
viewed after revision of the anastomosis from the ME ascending aortic
short-axis view with CWD at 0 degrees demonstrating the velocity time
integral (VTI) with the RVAD paused. Maximum PG of 12 mm Hg and
mean PG of 5 mm Hg are shown. LA left atrium; RV right ventricle;
AV aortic valve; PV pulmonic valve.
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Esmailian F, Plunked MD, Kubak B. Seventeen-year experience
with 1,083 heart transplants at a single institution. Ann Thorac
Surg 2002;74:1558 66
2. Delgado JF, Gomez-Sanchez MA, Saenz de la Calzada C,
Sanchez V, Escribano P, Hernandez-Afonso J, Tello R, Gomez de
la Camara A, Rodrguez E, Rufilanchas JJ. Impact of mild
pulmonary hypertension on mortality and pulmonary artery
pressure profile after heart transplantation. J Heart Lung Transplant 2001;20:942 8
3. Soriano CM, Gaine SP, Conte JV, Fairman RP, White C, Rubin
LJ. Anastomotic pulmonary hypertension after lung transplantation for primary pulmonary hypertension. Chest 1999;116:
564 6
4. Wolfsohn AL, Walley VM, Masters RG, Davies RA, Boone SA,
Keon WJ. The surgical anastomoses after orthotopicheart transplantation: clinical complications and morphologic observations.
J Heart Lung Transplant 1994;13: 455 65
5. Anderson M, Smedira N, Samuels L, Madani M, Naka Y, Acker
M, Hout M, Benali K. Use of the AB5000 ventricular assist
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Ann Thorac Surg 2010;90:706 12

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6. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E,

Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS,
Solomon SD, Spencer KT, St John Sutton M, Stewart WJ.
Recommendations for Chamber Quantification: A Report from
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Clinicians Key Teaching Points

7. Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A,

Griffin BP, Iung B, Otto CM, Pellikka PA, Quinones M. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009;22:123

By Kent H. Rehfeldt, MD, Martin M. Stechert, MD, and

Martin J. London, MD

Right ventricular (RV) dysfunction after heart transplantation may result from pulmonary hypertension, inadequate
myocardial preservation, coronary air embolism, or anastomotic complications. Anastomotic complications include
kinking, torsion, or protruding suture lines. In cases of severe posttransplantation RV dysfunction, support with an RV
assist device may be necessary.
Multiple transesophageal echocardiography (TEE) views and imaging modalities should be routinely used to examine the RV
after heart transplantation. A qualitative assessment of RV size and systolic function may be obtained using the
midesophageal 4-chamber, RV inflow-outflow, and transgastric views. Color flow Doppler can be used to detect tricuspid
regurgitation (TR) and flow acceleration due to stenosis at the pulmonary artery (PA) anastomosis while continuous wave
Doppler (CWD) allows measurement of the TR velocity and pressure gradient across the PA anastomosis.
In this case, narrowing of the PA anastomosis was identified by 2-dimensional imaging and confirmed by color flow
acceleration; abnormally high flow velocities in the PA were noted during CWD examination. Later, off-line calculations
of the effective PA anastomotic area using the proximal isovelocity surface area (PISA) method correlated well with the
anastomotic area calculated using the measured diameter of the stricture. Revision of the PA anastomosis facilitated
recovery of RV function.
Although rare, anatomic irregularities of anastomoses after heart transplantation may contribute to cardiac dysfunction. A
comprehensive posttransplant TEE examination should include 2-dimensional and color Doppler imaging of anastomotic
areas along with spectral Doppler interrogation when needed.

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ANESTHESIA & ANALGESIA