Transesophageal echocardiographic assessment of right ventricular function in heart transplantation: Preoperative, intraoperative, and postoperative considerations.

Right ventricular (RV) dysfunction remains a major contributor of morbidity and mortality after heart transplantation, and yet its perioperative assessment is both technically challenging and frequently inconsistent. Transesophageal echocardiography (TEE) provides for continuous evaluation of RV structure and function and is uniquely positioned to guide real-time clinical decision-making across the course of transplant care. This review presents a clinically focused, multiparametric framework for TEE-based RV assessment in the preoperative, intraoperative, and postoperative realm. Key quantitative measures including fractional area change, tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (S'), 3-dimensional RV ejection fraction, and RV longitudinal strain provide complementary but incomplete assessments of RV performance. Reliance on any single parameter is insufficient, particularly in the transplanted heart, where altered geometry, loading conditions, and surgical factors significantly influence measurement accuracy. Integration of these indices with qualitative assessment is critical for accurate interpretation. TEE plays a critical role in defining preoperative RV function and pulmonary vascular burden, guiding intraoperative management, including de-airing and graft assessment, and enabling early detection of complications such as primary graft dysfunction and RV failure. A structured, multifaceted TEE evaluation may reduce diagnostic variability, enhance hemodynamic management, and improve transplant outcomes.