A 66-year-old man with ischemic cardiomyopathy was admitted for management of worsening heart failure and implantation of a HeartWare (HeartWare International, Framingham, MA) left ventricular assist device (LVAD) as a bridge to heart transplantation. Written consent was obtained from the patient for publication of this report.A complete transesophageal echocardiography (TEE) examination was performed with the Philips iE33 xMA-TRIX Ultrasound (Philips Healthcare, Andover, MA) and, most notably, revealed a dilated left ventricle with severe hypokinesis and severe tricuspid regurgitation. A HeartWare LVAD was implanted, and a tricuspid annuloplasty was performed. After bypass, 2-dimensional TEE imaging revealed proper inflow cannula orientation at the left ventricular apex with no evidence of obstruction. Color Doppler, however, revealed a continuous artifact that extended the length of the color sector, from the LVAD inflow cannula toward the origin of the imaging sector ( Fig. 1A; Supplemental Digital Content 1, Video 1, http:// links.lww.com/AA/B73). The use of spectral Doppler with both pulsed wave and continuous wave (CW) demonstrated an artifact that precluded interrogation of the inflow cannula velocities (Fig. 1B). The alignment of the impeller and the associated artifact with the coaptation point of the mitral valve made evaluation of the mitral valve challenging. Unobstructed laminar flow was seen at the site of the outflow graft anastomosis in the ascending aorta. Despite HeartWare LVAD implantation and tricuspid valve annuloplasty, the right ventricle became dilated, and the tricuspid valve regurgitation remained moderate to severe. The tricuspid valve was then replaced, and a right ventricular assist device was placed for support.
DISCUSSIONThe HeartWare LVAD is a third-generation, centrifugal, continuous-flow device 1 (Fig. 2) that was approved by the Food and Drug Administration in November 2012 as bridge to transplant therapy. It has 3 basic components: a short metallic inflow cannula inserted into the left ventricular apex, a magnetically and hydrostatically levitated impeller attached to the inflow cannula, and an outflow graft that courses along the right anterolateral cardiac border ECHO ROUNDS E Figure 1. A, Side-by-side 2D and color Doppler interrogation of the HeartWare left ventricular assist device (LVAD) in the midesophageal 4-chamber view. Note the continuous artifact that extends vertically from the LVAD inflow cannula for the length of the color sector. This artifact is not present when 2-dimensional imaging is used (Supplemental Digital Content 1, Video 1, http://links.lww.com/AA/ B73). B, Continuous-wave Doppler interrogation of the HeartWare LVAD. The artifact precludes interrogation of the true inflow velocity. LV = left ventricle; LA = left atrium; RV = right ventricle.Video 1. Two-dimensional, color Doppler, and side-by-side interrogation of HeartWare left ventricular assist device (LVAD) in the midesophageal 4-chamber view. Note the continuous artifact that extends vertically fro...