Between the Probe and the Pump An experimental study on cardiac performance analysis based on Echocardiography, tissue and laser Doppler

Sammanfattning: Echocardiography is an ultrasound-based bedside, non-invasive and easily available cardiac diagnostic technique visualising the heart’s morphology and function. Quantification of cardiac wall motion can be measured with the tissue Doppler Imaging (TDI) modality which provides in humans a high diagnostic capacity to differentiate healthy from diseased myocardium with reduced function. Heart failure, as a consequence of, for example, myocardial or ischaemic heart disease, demands both bedside and intraoperative diagnostic procedures for myocardial functional and perfusion assessment. In the late stages of heart failure cardiac left ventricular assist devices (LVAD) may be the treatment of choice. Such new technologies are commonly evaluated in large animals before application in humans is accepted.With the aim of evaluating TDI´s applicability and feasibility in a large animal model 21 calves (aged 3 months and weight around 70 kg), were studied with colour TDI (Paper I). Analysis was performed either during coronary artery occlusion when the laser Doppler perfusion imaging technique (LDMP) was refined (Paper II), or after implantation of the LVAD, Heart Mate II® (Papers III, IV). All animals were haemodynamically monitored (pressures, flows, heart rate) and ECG was continuously recorded. Transthoracic and epicardial echocardiography (TTE) were performed before and after sternotomy and intraoperatively during experimental progressive heart failure. Heart chamber dimensions, native stroke volume, systolic and diastolic regional basal myocardial peak velocities (cm/s; systolic S´, early diastolic E´, and atrial A´, strain (%), strain rate (s-1) and displacement (mm) were determined. Second harmonic imaging (SHI) was applied in order to better visualise air bubbles (Paper IV).In Paper I compiled baseline values were established before and after sternotomy for central haemodynamic and echocardiographic parameters, including the TDI myocardial motion variables velocity, strain rate, strain and displacement. Blood pressure and heart rate changed significantly after sternotomy, but the TDI derived data did not change significantly.In Paper II we report that movement artifacts of the laser Doppler myocardial perfusion measurements can be reduced, both when myocardium is normally perfused and during coronary occlusion, by using the TDI velocity registrations showing wall motion to be minimal. The optimum interval depends on the application but late systole as well as late diastole is preferred.After LVAD implantation in Paper III the flow characteristics and myocardial motion during variations in afterload TDI show that myocardial velocities decrease concomitantly with myocardial depression and are significantly correlated to native stroke volume, heart rate, systemic arterial resistance and cardiac output, but not with left ventricular size, fractional shortening or pump speed. Echocardiography together with TDI thereby offers additional means for monitoring and quantifying residual myocardial function during LVAD treatment.SHI is superior in the early detection of single air-bubbles in the ascending aorta prior to significant air embolism during manipulation of the LVAD pump speed, as shown in Paper IV. A prompt decrease in size of the left atrium during speed adjustment may be a warning that massive air embolism is imminent whereas the commonly used left atrial pressure not provide the same warning.