Update on the Practical Role of Echocardiography in Selection, Implantation, and Management of Patients Requiring Left Ventricular Assist Device Therapy.

The LVAD is a temporary or permanent option for patients with advanced heart failure who are unresponsive to other therapy. Use of the device has its own risks, and implantation remains a complex procedure. Transthoracic and transesophageal echocardiography are useful tools for patient evaluation and monitoring both peri- and postoperatively, as we previously presented. Assessment of left and right ventricular function, complications such as thrombus formation or intracardiac shunting, and valvular disease are all important in this assessment. This also aids in predicting postoperative complications. Placement of the device is confirmed intraoperatively, and subsequent ramp studies are used to determine optimal device settings. Right ventricular (RV) failure is the most common postoperative complication and preoperative evaluation of its function is crucial. Studies suggest that tricuspid annular plane systolic excursion, RV fractional area change, and RV global longitudinal strain are strong predictors of RV failure; LV ejection fraction, size, and end-diastolic diameter are also important markers. Aortic regurgitation and mitral stenosis must always be corrected prior to LVAD placement. However, direct visualization before and after implantation, especially to rule out potential contraindications such as thrombi, cannot be overemphasized. Ramp studies remain an integral part of device optimization and may result in greater myocardial recovery than previously realized.