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Cardiovascular Anesthesiology: Echo Rounds

Transesophageal Echocardiography Examination for Percutaneous Right Ventricular Assist Device Placement

Schulte, Thomas E. MD*; Um, John Y. MD; Shillcutt, Sasha K. MD, FASE*

Author Information
doi: 10.1213/01.ane.0000437083.28758.13

A 70-year-old man presented with ST elevation in leads II, III, and aVF with reciprocal depression in the anterior leads suggestive of inferior myocardial ischemia with right ventricular (RV) involvement. Emergent angiography revealed thrombus in the right coronary artery, and 2 bare metal stents were inserted. Despite treatment with infusions of heparin, abciximab, norepinephrine, and dopamine, he remained severely hypotensive and was brought to the operating room for percutaneous insertion of a right ventricular assist device (percRVAD). Written consent for publication of this report has been obtained.

A right radial arterial line, left femoral central venous line, and transesophageal echocardiography (TEE) were used for intraoperative anesthetic management. The right internal jugular (IJ) vein was reserved for a percRVAD outflow cannula because this allows for easier placement of an initial pulmonary artery (PA) catheter. TEE examination revealed severe RV dilation, and the RV free wall was severely hypokinetic. To place the percRVAD outflow cannula, a sheath was placed through the right IJ vein, and an Arrow Swan-Ganz catheter (Arrow International, Reading, PA) was directed into the main PA. Catheter placement was confirmed using the midesophageal (ME) RV inflow–outflow and upper esophageal aortic short-axis (UE Ao SAX) views. A 0.035” Cook wire (Cook Critical Care, Bloomington, IN) was then placed through the PA catheter, the catheter was removed, and a Medtronic Bio-Medicus 17F short tip multiorifice cannula (Medtronic Inc., Minneapolis, MN) was directed into the main PA. The ME RV inflow–outflow and UE Ao SAX views were used to confirm the percRVAD outflow cannula placement distal to the pulmonic valve (PV) (Fig. 1). When the cannula was placed at the PV, color Doppler revealed mild pulmonary insufficiency (PI) (Video 1, see supplemental digital content 1, This resolved with advancement of the cannula approximately 3 cm distal to the PV (Video 2, see supplemental digital content 2,

Figure 1
Figure 1:
Off-axis upper esophageal aortic short-axis view showing the percutaneous right ventricular assist device outflow cannula in the main pulmonary artery. AO = aorta; RV = right ventricle; PA = pulmonary artery.

The percRVAD inflow cannula was placed through the right femoral vein. A Medtronic 21F multistage venous cannula was placed over a Cook wire and the tip confirmed in the right atrium using the ME bicaval view. Both cannulas (Fig. 2) were connected to a Thoratec CentriMag pump (Thoratec Corporation, Pleasanton, CA), and 4 L/min of flow established. All inotropes were weaned over 48 hours, and the percRVAD was explanted on postoperative day 3. The patient was discharged to a skilled nursing facility on postoperative day 10.

Figure 2
Figure 2:
Chest radiograph showing the percutaneous right ventricular assist device (RVAD) inflow cannula from the femoral vein in the right atrium, and the percutaneous RVAD outflow cannula entering from the right internal jugular vein traversing the right atrium, right ventricle, and the main pulmonary artery.


RV failure has a poor prognosis and occurs secondary to complications of acute myocardial infarction, pulmonary embolism, cardiac transplant rejection, or postcardiotomy.1 The mortality of RV failure approaches 60% that is equal to myocardial infarction-associated left ventricular failure.2 The percRVAD works by unloading the RV and reducing RV wall tension during acute RV failure. Intraoperative TEE plays a critical role in proper device placement, immediate postprocedure evaluation, and assessment of RV function during weaning trials.3 Initial TEE examination should include a thorough evaluation of the right-sided structures, such as tricuspid valve anatomy and function before outflow cannula placement. The RV outflow tract along with the PV should be interrogated before outflow cannula placement to identify any obstruction, thrombus, or significant insufficiency of the PV. Significant tricuspid regurgitation and abnormal or paradoxical intraventricular septum motion before initiation of the percRVAD should be evaluated.

PercRVAD inflow and outflow cannulas can be placed in either femoral or IJ veins. The right IJ vein allows for easier placement of a PA catheter and is often the first choice for percRVAD outflow cannula placement. The ME RV inflow–outflow, ME bicaval, ME 4-chamber (4C), and transgastric RV inflow–outflow views can be used to visualize wires and cannulas transversing right-sided chambers. The UE Ao SAX view is optimal for visualization of wires and cannulas in the main or right PA. Proper percRVAD outflow cannula placement is confirmed with visualization of the cannula tip distal to the PV but proximal to bifurcation of right and left PAs. After initiation of the percRVAD, color Doppler is also used to confirm proper placement through visualization of continuous color flow at the tip of the multiorifice cannula. Improper placement of the percRVAD outflow cannula may result in PI (cannula should be advanced) or one-sided pulmonary flow (cannula should be withdrawn), resulting in pulmonary edema of the respective lung. The severity of PI should be documented before percRVAD placement for comparison after the outflow cannula transverses the PV. Proper percRVAD inflow cannula placement is confirmed in the right atrium using the ME bicaval view. Improper placement of the cannula too proximal (cannula in inferior vena cava) (Fig. 3) or distal (cannula in superior vena cava) would lead to inadequate return into the CentriMag.

Figure 3
Figure 3:
Midesophageal bicaval view with transesophageal echocardiography advanced distally and rightward turn showing percutaneous right ventricular assist device inflow cannula in the inferior vena cava just before the right atrium. IVC = inferior vena cava; RA = right atrium.

Immediate postpercRVAD assessment includes evaluating RV systolic and diastolic volume after device initiation, evaluation of left ventricular filling and function, assessment of right-sided valve function, and detection of air and thrombus. Tricuspid regurgitation should decrease with an increased flow of blood through the percRVAD. The ME 4C and ME RV inflow–outflow views can be used to confirm decompression of the RV.4 The ME RV inflow–outflow and UE Ao SAX views are used to confirm proper outflow cannula placement, where the tip of the outflow cannula is confirmed to traverse the PV and lie in the main PA. Air and thrombus in right-sided chambers may be detected using the ME 4C, ME RV inflow–outflow, ME bicaval, and transgastric RV inflow–outflow views immediately after initiation of the percRVAD.

During percRVAD placement, TEE is used for proper cannula placement, monitoring of ventricular function, and intraoperative hemodynamic assessment.

Clinician’s Key Teaching Points

By Roman M. Sniecinski, MD, Martin M. Stechert, MD, and Martin J. London, MD

  • The percutaneous right ventricular assist device (percRVAD) performs similarly to a surgically implanted right ventricular assist device via a less invasive, percutaneous route. The system consists of a centrifugal pump, an inflow cannula inserted through a large vein that lodges in the right atrium, and an outflow cannula placed in the pulmonary artery via a guidewire introduced through a standard pulmonary artery catheter. The efficiency of the system in unloading the right ventricle is determined by the amount of venous return that can be captured in the right atrium and successfully delivered into the pulmonary artery via the extracorporeal pump system.
  • In addition to obtaining a baseline examination of right ventricular function, which can be useful for comparison during weaning trials, transesophageal echocardiography (TEE) plays an important role during placement of a percRVAD. Contraindications to placement, such as severe pulmonary regurgitation or masses that could obstruct cannulas, should be excluded. Proper cannula position is confirmed by visualizing the tip of the inflow cannula in the right atrium and the outflow cannula within the main pulmonary artery.
  • In this case, TEE inspection revealed that the percRVAD outflow cannula initially was not advanced far enough into the pulmonary artery, resulting in pulmonic valve regurgitation. Further advancement of the cannula improved pulmonic valve regurgitation and efficiency of the right ventricular assist system.
  • Analogous to percutaneous placement, intraoartic balloon pumps, and left-sided left ventricular assist devices, TEE assumes an important role in the correct positioning of the percRVAD. TEE offers some advantages over fluoroscopy in this situation by readily assessing cardiac and valvular function in addition to assisting with correct placement of the device.


Name: Thomas E. Schulte, MD.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Attestation: Thomas E. Schulte approved the final manuscript.

Name: John Y. Um, MD.

Contribution: This author helped design and perform the study, analyze the data, and prepare the manuscript.

Attestation: John Um has approved the final manuscript.

Name: Sasha K. Shillcutt, MD, FASE.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Attestation: Sasha K. Shillcutt approved the final manuscript.

This manuscript was handled by: Martin J. London, MD.


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