Right ventricular function assessment by transesophageal echocardiography in lung transplantation: Preoperative, intraoperative, and postoperative considerations.

BACKGROUND

Right ventricular (RV) function is a key determinant of outcomes in lung transplantation, particularly in patients with pre-existing pulmonary hypertension. The RV is uniquely sensitive to perioperative hemodynamic stressors, including ischemia-reperfusion injury, abrupt afterload changes, and allograft implantation.

PURPOSE: This review aims to summarize the perioperative echocardiographic assessment of RV function in lung transplantation, emphasizing the role of transesophageal echocardiography (TEE) in evaluating RV performance and guiding intraoperative management.

METHODS

A comprehensive synthesis of recent literature was performed, focusing on echocardiographic parameters relevant to RV evaluation during the preoperative, intraoperative, and postoperative phases of lung transplantation. Both conventional and advanced imaging modalities were reviewed.

DISCUSSION: TEE provides real-time insights into RV adaptation and dysfunction. Key parameters include fractional area change, tricuspid annular plane systolic excursion (TAPSE), tricuspid annular velocity (S'), and speckle-tracking-derived strain. Three-dimensional echocardiography enhances volumetric and geometric assessment, while venous congestion indices such as the Venous Excess Ultrasound (VExUS) score offer indirect hemodynamic evaluation. Intraoperatively, dynamic monitoring supports optimization of preload, afterload, and inotrope therapy. Postoperative complications-such as RV outflow tract obstruction and pulmonary vascular anastomotic dysfunction-require prompt recognition. Persistent RV dysfunction despite afterload reduction may reflect intrinsic myocardial disease.

CONCLUSION

Comprehensive echocardiographic evaluation throughout all perioperative phases is essential for optimizing RV performance and improving outcomes in lung transplantation. Future studies should aim to standardize RV assessment protocols and validate multimodal imaging approaches for perioperative clinical decision-making.