Left ventricular assist device (LVAD) implantation requires the use of intraoperative transesophageal echocardiography (TEE) to achieve optimal outcomes.1,2  The appropriate placement of the inflow cannula in the left ventricular (LV) apex is crucial to ensure optimal filling of the LVAD and prevent potentially fatal complications, such as device thrombosis, or suction events that can lead to low pump flows and ventricular tachycardia.1,2  Two-dimensional TEE remains the accepted standard for evaluating the inflow cannula placement; however, three-dimensional (3D) TEE may be valuable.1 

Three-dimensional TEE was used to determine the appropriate inflow cannula position after LVAD implantation. Figure A is a 3D image showing the inflow cannula appropriately placed in the LV apex facing the mitral valve and an adequately decompressed LV. Furthermore, the right ventricle (RV) maintains its normal contour, indicating the absence of excessive suction force from the LVAD on the interventricular septum.1  This is important because excessive suction can cause leftward interventricular septal deviation, RV dilatation, RV systolic dysfunction, and ventricular arrhythmias. Figure B is a 3D color-flow Doppler image demonstrating the laminar blood flow from the mitral valve into the inflow cannula. Figure C is a 3D en face view of the LV apex revealing the inflow cannula without any tissue obstruction. Notably, this en face view can only be obtained with 3D TEE. The latter two views can help rule out inflow cannula obstruction as the cause of low LVAD flows.1  The echocardiographic findings described above clearly demonstrate the potential utility of 3D TEE during LVAD implantation.

Competing Interests

The author declares no competing interests.

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