Mechanical flow obstruction after heart transplantation diagnosed by TEE

Abstract

We report a case of mechanical flow obstruction after heart transplantation caused by a prominent left atrium suture with a "pursestring" effect. The diagnosis was achieved by transesophageal echocardiography. The mean transstenotic gradient was measured at 13 mm Hg. Because of the profound hemodynamic and multisystemic failure, no surgical correction was attempted. The postmortem examination confirmed the stenosis at the level of the left atrium.

Sonolucent Space Posterior to Left Atrium: Unusual Echocardiographic Appearance in a Cardiac Transplant Patient

“…In apical views, both atria appear unduly long due to confluence of donor and recipient atria. A local narrowing at the site of the suture line joining the donor and the recipient atria has been variously described as an “hour‐glass” or “snowman” configuration, 4 “acquired cor triatriatum” 5 or “purse‐string effect.” 6 Extremely rare instances of hemodynamically important stenosis of the left atrium at the suture line have been reported 5–8 . The patient we report here represents yet another left atrial abnormality following cardiac transplantation, which presented an echocardiographic appearance not hitherto reported, to our knowledge.…”

“…6 Extremely rare instances of hemodynamically important stenosis of the left atrium at the suture line have been reported. [5][6][7][8] The patient we report here represents yet another left atrial abnormality following cardiac transplantation, which presented an echocardiographic appearance not hitherto reported, to our knowledge.…”

Dilated Cardiomyopathy and Myocarditis

“…TEE and transthoracic echo can demonstrate obstruction at the inferior vena cava-RA junction [92], superior vena cava [93] (Fig. 33.11), and within the left atrium leading to pulmonary venous obstruction [94,95]. Additionally, there is a higher incidence of left atrial thrombi in biatrial cardiac transplant as diagnosed by TEE [96,97], including 15% with evidence of acute arterial embolic events [97].…”

The Role of Intraoperative Transesophageal Echocardiography in Heart Transplantation

“…This obstruction precipitated failure of the heart, and the patient subsequently died. 8 Recognition of this possible complication with intraoperative TEE might have avoided mortality in this instance. Occasionally, the atrial anastomoses can protrude into the atria and resemble mass lesions.…”

“…Thrombus formation on a prominent suture line also may result in in ow obstruction. 8 Law et al reported a case of a 13-year-old boy with an acquired form of cor triatriatum, with supramitral valve obstruction (mean left atrial pressure 5 28 mmHg) from hypertrophied native atrial tissue that was diagnosed by TEE in the intensive care unit (ICU) several hours after the patient underwent heart transplantation. 9 Fortunately, early surgical resection of the hypertrophied atrial septum and atrial wall corrected the anatomic obstruction and improved the hemodynamics in this case, and the patient survived.…”