• Percutaneous left ventricular assist position
The report should include the position of the catheter inlet area, position of the catheter outlet area, and the direction of the catheter– Dilated left ventricle with severely reduced left ventricular systolic function– In limited views, the right ventricle is normal in size with mildly reduced systolic function.– A small pericardial effusion is noticed– Percutaneous left ventricular assist device catheter position:1. At the start of the study, the inflow area was XX cm below the aortic valve. It wasreadjusted to XX cm below the aortic valve with echocardiographic guidance.2. The outlet area is above the aortic valve3. Catheter is angled towards the left ventricular apex4. After readjustment of catheter mitral regurgitation improved from mild to trace– A VA ECMO inflow cannula is noted in the IVC– Compared to the prior study from ***, the percutaneous left ventricular assist device catheter appeared deeper at the beginning of this study and was readjusted during this study.(Please refer to specific device guideline for positioning recommendations)
• Aortic Stenosis Evaluation with Dobutamine
This is divided into three sections: A. Summary of the test, B. Echo conclusions, and C. Stress conclusions
A. Summary of the test:
LVOT 20mmRest:LVOT VTI 13 cm, Stroke Volume 41 ml, AV VTI 69.8 cm, Vmax 3.42 m/s, Mean gradient 27 mmHg, AVA 0.6 cm2Dobutamine 5mcg:LVOT VTI 13 cm, Stroke volume 41 ml, AV VTI 73.9 cm, Vmax 3.58 m/s, Mean gradient 31 mmHg, AVA 0.6 cm2Dobutamine 10mcg:LVOT VTI 15 cm, Stroke volume 47 ml, AV VTI 74.4 cm, Vmax 3.57 m/s, Mean gradient 30 mmHg, AVA 0.6 cm2Dobutamine 20mcg:LVOT VTI 16.8 cm, Stroke volume 53ml, AV VTI 77.8 cm, Vmax 3.88 m/s, Mean gradient 34.8 mmHg, AVA 0.7 cm2– The resting stroke volume was 41 ml with a stroke volume index of 21 ml/m2 (low output state). The stroke volume index increased to 53 ml/m2 with dobutamine. Despite a > 20% increase in the stroke volume with dobutamine, there was no significant change in the aortic valve area. This indicates a severe low-flow, low-gradient aortic stenosis.
Table
Stage
LVOT VTI (cm)
Stroke Volume
AV VTI (cm)
V max (m/s)
Mean gradient (mmHg)
AVA (cm2)
Rest
Dobutamine 5 mcg/min
Dobutamine 10 mcg/min
Dobutamine 20 mcg/min
B. Echo Conclusions:
– The left ventricular size is normal and systolic function is moderately reduced. Regionalwall motion abnormalities are consistent with coronary artery disease and prior myocardial infarction– The right ventricle is mildly dilated with mildly reduced systolic function– Sclerodegenerative valve disease with moderate to severe low-flow, low-gradient aortic stenosis– Sclerodegenerative mitral valve disease and leaflet tethering causing moderate mitralregurgitation– Moderate tricuspid regurgitation in setting of at least moderate pulmonaryhypertension– Biatrial enlargementC. Stress Conclusions:
– A limited heart rate response was achieved– There is no ECG or Echocardiographic evidence of inducible ischemia with low-dose dobutamine.– This study is non-diagnostic for ischemia– Despite a > 20% increase in the stroke volume with dobutamine, there was no significant change in the aortic valve area. This indicates a severe low-flow, low-gradient aortic stenosis.
A. Summary of the test:
LVOT 20mmRest:LVOT VTI 13 cm, Stroke Volume 41 ml, AV VTI 69.8 cm, Vmax 3.42 m/s, Mean gradient 27 mmHg, AVA 0.6 cm2Dobutamine 5mcg:LVOT VTI 13 cm, Stroke volume 41 ml, AV VTI 73.9 cm, Vmax 3.58 m/s, Mean gradient 31 mmHg, AVA 0.6 cm2Dobutamine 10mcg:LVOT VTI 15 cm, Stroke volume 47 ml, AV VTI 74.4 cm, Vmax 3.57 m/s, Mean gradient 30 mmHg, AVA 0.6 cm2Dobutamine 20mcg:LVOT VTI 16.8 cm, Stroke volume 53ml, AV VTI 77.8 cm, Vmax 3.88 m/s, Mean gradient 34.8 mmHg, AVA 0.7 cm2– The resting stroke volume was 41 ml with a stroke volume index of 21 ml/m2 (low output state). The stroke volume index increased to 53 ml/m2 with dobutamine. Despite a > 20% increase in the stroke volume with dobutamine, there was no significant change in the aortic valve area. This indicates a severe low-flow, low-gradient aortic stenosis.
Table
Stage
LVOT VTI (cm)
Stroke Volume
AV VTI (cm)
V max (m/s)
Mean gradient (mmHg)
AVA (cm2)
Rest
Dobutamine 5 mcg/min
Dobutamine 10 mcg/min
Dobutamine 20 mcg/min
B. Echo Conclusions:
– The left ventricular size is normal and systolic function is moderately reduced. Regionalwall motion abnormalities are consistent with coronary artery disease and prior myocardial infarction– The right ventricle is mildly dilated with mildly reduced systolic function– Sclerodegenerative valve disease with moderate to severe low-flow, low-gradient aortic stenosis– Sclerodegenerative mitral valve disease and leaflet tethering causing moderate mitralregurgitation– Moderate tricuspid regurgitation in setting of at least moderate pulmonaryhypertension– Biatrial enlargementC. Stress Conclusions:
– A limited heart rate response was achieved– There is no ECG or Echocardiographic evidence of inducible ischemia with low-dose dobutamine.– This study is non-diagnostic for ischemia– Despite a > 20% increase in the stroke volume with dobutamine, there was no significant change in the aortic valve area. This indicates a severe low-flow, low-gradient aortic stenosis.
Table
| Stage | LVOT VTI (cm) | Stroke Volume | AV VTI (cm) | V max (m/s) | Mean gradient (mmHg) | AVA (cm2) |
|---|---|---|---|---|---|---|
| Rest | ||||||
| Dobutamine 5 mcg/min | ||||||
| Dobutamine 10 mcg/min | ||||||
| Dobutamine 20 mcg/min |
B. Echo Conclusions:
C. Stress Conclusions:
– A limited heart rate response was achieved– There is no ECG or Echocardiographic evidence of inducible ischemia with low-dose dobutamine.– This study is non-diagnostic for ischemia– Despite a > 20% increase in the stroke volume with dobutamine, there was no significant change in the aortic valve area. This indicates a severe low-flow, low-gradient aortic stenosis.
• MitraClip® Procedure
2D, Doppler, and 3D transesophageal echocardiogram performed intraoperatively for the guidance of transcatheter mitral valve repair with MitraClip®.
PRE-PROCEDURE TEE:
– Normal left ventricular size and systolic function. Estimated ejection fraction is 60%.
– Right ventricle is mildly dilated with mildly reduced systolic function
– Prolapse with partial flail P2 scallop resulting in severe eccentric anteriorly directed mitral regurgitation. There is also mild prolapse of the P3 scallop.
– Inadequate coaptation of the tricuspid leaflets resulting in severe tricuspid regurgitation
– Sclerodegenerative valve disease with mild aortic regurgitation
– Severe biatrial enlargement
PROCEDURAL TEE:
– Patient underwent transseptal puncture in the superior posterior portion of the atrial septum with appropriate distance from the mitral valve annulus (4.0 cm)
– A single clip was placed in the center of the mitral regurgitant jet anchoring the A2 and P2 scallops of the mitral valve.
– Following clip placement, the mitral regurgitation was reduced to mild to moderate and there was no evidence of significant mitral stenosis.
– Following removal of the transseptal catheter, there was 6 x 6 mm iatrogenic atrial septal defect in the thick portion of the septum with left to right shunting by color Doppler and a Vmax of 1.46m/s.
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