A systematic approach to epicardial echocardiography in pediatric cardiac surgery: An important but underutilized intraoperative tool.
TL;DR: In this paper, the authors describe the technique of epicardial echocardiography and the various views that have been found useful for a complete postsurgical evaluation, and the limitations of the technique are also discussed.
Abstract: Intraoperative echocardiography is an integral component of the peri-operative management of pediatric heart disease. It confirms the adequacy of surgery, identifies residual lesions, and can provide useful hemodynamic data. It, therefore, helps to decide on the need for revision of repair and guides the postoperative management strategy. Intraoperative echocardiography is done with the use of either an epicardial probe or a transesophageal probe. Epicardial echocardiography is a simple, useful modality and has the ability to perform imaging in cases where transesophageal echocardiography cannot be easily performed, for example, in low birth weight babies. We attempt to describe in detail the technique of epicardial echocardiography and the various views that we have found useful for a complete postsurgical evaluation. The limitations of the technique are also discussed in detail.
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TL;DR: In this article , the authors provide an overview of this important and relevant topic and discuss strategies for managing these patients, and implanting clinicians should carefully assess for valve abnormalities that may need repair and impact device selection and cannulation strategy to effectively support this diverse population.
Abstract: Ventricular assist devices have become a valuable tool in the treatment of heart failure in children. The use of ventricular assist devices has decreased mortality in children with end-stage heart failure awaiting transplant. It is not uncommon for children with end-stage heart failure associated with cardiomyopathy or congenital heart disease to have significant systemic semilunar and atrioventricular valve regurgitation, which can impact the efficiency and efficacy of hemodynamic support provided by a ventricular assist device. Therefore, implanting clinicians should carefully assess for valve abnormalities that may need repair and impact device selection and cannulation strategy to effectively support this diverse population. The purpose of this review is to provide an overview of this important and relevant topic and to discuss strategies for managing these patients.
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165 citations
TL;DR: The incidence of complications during pediatric transesophageal echocardiography is low, and failure to insert the probe and airway complications occurred predominantly and significantly in smaller subjects.
Abstract: The purpose of this study was to tabulate the complications encountered in 1650 patients who underwent pediatric transesophageal echocardiography. The occurrence of complications and their type and severity were prospectively recorded. The patients had a mean age of 3.6 years (range 1 day to 21 years) and a mean weight of 17.2 kg (range 1.6 to 118 kg). Of the 1650 cases, 1534 were intraoperative. Most patients studied (97%) had congenital heart disease. Complications occurred in 52 (3.2%) of the 1650 patients. Failure to insert the probe occurred in 13 (0.8%) patients; if those cases are not counted as complications, the incidence of overall complications falls to 2.4%. Airway obstruction occurred in 14 (1%) patients, right mainstem advancement of the endotracheal tube in 3 (0.2%), inadvertent tracheal extubation in 8 (0.5%), vascular compression in 10 (0.6%), and single additional complications in 4 (0.2%). No significant bleeding, arrhythmias, esophageal injuries, or deaths occurred. Failure to insert the probe and airway complications occurred predominantly and significantly in smaller subjects. It is concluded that the incidence of complications during pediatric transesophageal echocardiography is low.
117 citations
TL;DR: It is demonstrated that intraoperative transesophageal echocardiographic findings before and after cardiopulmonary bypass consistently defined important morphologic, color and pulsed Doppler ultrasound features of most congenital shunt lesions.
94 citations
TL;DR: A comprehensive examination protocol for the intraoperative interrogation of cardiac structures using an epicardial/epiaortic echocardiographic approach is developed and may be useful for cardiac surgeons and anesthesiologists seeking to use this technique as a cardiac imaging modality that is complementary to TEE.
74 citations
TL;DR: Patients who left the operating room with no problems of concern by echo-DCFI had a greater than 90% likelihood of a long-term acceptable outcome compared to patients who had any problem of concern whose long- term likelihood of an acceptable outcome approached 50% (p less than 0.0125).
Abstract: Surgical repair of congenital cardiac defects (CCD) has undergone a remarkable evolution in the past decade. Major defects are now often completely corrected in early infancy with continually improving rates of survival. It has become clear that the next major focus will be improvements in the long-term quality of life and this has promoted many innovations in surgical technique and approach. One advance is the use of intraoperative echo with Doppler color flow imaging (echo-DCFI) to evaluate the exactness of operative repair. Aside from anecdotal reports, very little information is available regarding the interpretation of images produced by this technology in the operating room. Furthermore there have been no studies addressing the predictive value of intraoperative echo-DCFI findings with respect to outcome for patients undergoing repair of CCD. The prospective data obtained by following the course of 273 patients receiving intraoperative echo-DCFI has been reviewed after repair of a variety of CCD (age range, 1 to 53 years; mean 5.3 years; smallest patient, 1.8 kg). Forty-seven patients (17%) had initially unacceptable results, by echo, at the completion of their repair. Eighteen of these patients (7% of entire series) had no clinical problems and the defects were discernible only by echo. Twenty-six patients with initially unacceptable results had their repairs revised in the operating room and left with an acceptable result by echo. Twenty-one patients were allowed to leave the operating room with echo-discernible defects. Follow-up of these patients demonstrated a significantly higher (p less than 0.006) rate of reoperation (42% vs. 3%) and of early death (29% vs. 10%) for those patients whose defects were left unrepaired compared to those whose problems were corrected before leaving the operating room. Sixty-eight patients (25%) had some alteration of ventricular function (compared to their prebypass evaluation) at the completion of their repair. Regardless of whether the dysfunction was limited to the right ventricle, left ventricle, or was biventricular, patients in this group had a significantly higher incidence (p less than 0.004) of early, but not late, death compared to patients without alteration of ventricular function (35% vs. 4%). Patients who left the operating room with no problems of concern by echo-DCFI had a greater than 90% likelihood of a long-term acceptable outcome compared to patients who had any problem of concern (residual defect, anatomic or technical imperfection, ventricular dysfunction, and so on) whose long-term likelihood of an acceptable outcome approached 50% (p less than 0.0125).(ABSTRACT TRUNCATED AT 400 WORDS)
61 citations