Loss of Left Ventricular Vortex Ring in Left Ventricular Assist Device-Induced Right Ventricular Failure : Annals of Cardiac Anaesthesia

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Loss of Left Ventricular Vortex Ring in Left Ventricular Assist Device-Induced Right Ventricular Failure

Akiyama, Koichi1,2,3,; Wu, Isaac2; Itatani, Keiichi4; Tachibana, Yosuke3; Obata, Yurie3; Takayama, Hiroo2

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Annals of Cardiac Anaesthesia 26(2):p 235, Apr–Jun 2023. | DOI: 10.4103/aca.aca_288_20
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Normal blood flow in the left ventricle, which demonstrates vortex ring formation during diastole, plays a very important role. The vortex ring facilitates inflow into the left ventricle, minimizes the dissipation of energy, preserves momentum, and redirects flow towards the left ventricular outflow tract in an energy-efficient manner.[1] Right ventricular (RV) failure after left ventricular assist device (LVAD) implantation is a major cause of morbidity and mortality. LVAD flow can induce interventricular septal (IVS) flattening which in turn can cause RV failure, due to ventricular interdependence.[2] Figure 1 shows two intraoperative transesophageal echocardiographic images of the midesophageal long axis view following LVAD (HeartMate3, St Jude Medical) implantation. The image was analyzed using newly developed vector flow mapping software (Cardio Flow Design, Tokyo),[3] which determines blood flow patterns from both color Doppler and wall tracking data. At an optimal pump speed of 5000 RPM (left panel) the left heart appears appropriately filled with a normal vortex blood flow pattern (yellow arrows) during diastole.

Figure 1:
Vector flow mapping images of left ventricle with LVAD

Concurrent pulmonary artery and central venous pressure (PAP, CVP) waveforms reflect preserved RV function. However, at an elevated pump speed of 6500 RPM (right panel), the left heart appears underfilled with IVS flattening, and vortex ring formation is lost [Figure 1]. This resulted in a flat PAP waveform and increased CVP, consistent with RV dysfunction [Figure 1]. This suggests that the loss of left ventricular vortex ring formation may identify RV failure due to IVS flattening in patients with an LVAD.

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1. Akiyama K, Maeda S, Matsuyama T, Kainuma A, Ishii M, Naito Y, et al. Vector flow mapping analysis of left ventricular energetic performance in healthy adult volunteers. BMC Cardiovasc Disord 2017;17:21.
2. Moon MR, Castro LJ, DeAnda A, Tomizawa Y, Daughters GT 2nd, Ingels NB Jr, et al. Right ventricular dynamics during left ventricular assistance in closed-chest dogs. Ann Thorac Surg 1993;56:54–66;discussion 66-7.
3. Itatani K, Okada T, Uejima T, Tanaka T, Ono M, Miyaji K, et al. Intraventricular flow velocity vector visualization based on the continuity equation and measurements of vorticity and wall shear stress. Jpn J Appl Phys 2013;52:07HF16.
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