The role of intraoperative TOE in congenital cardiac surgery

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1 The role of intraoperative TOE in congenital cardiac surgery Justiaan Swanevelder Dept of Anaesthesia Groote Schuur and Red Cross War Memorial Children s Hospitals University of Cape Town, South Africa

2 Paediatric cardiac anaesthesia: balancing risk and outcome..no one is unfit for anaesthesia and surgery it is simply a question of ascribing an individual risk and potential benefit to the planned procedure within the individualized context. Wolf AR. Br J Anaesth 2012;109(1):12-15

3 Haemodynamic monitor vs diagnostic tool

4 Benefit paediatric cardiac surgery Study N New info Change SX Medical Rx Kaushal % Pre 3% Post 6.6% Randolf % Bettex % 12.7% 19.4% Ma Pre 9.4% Post 16.3% Pre 6.6% Post 3.7% Intraoperative TOE and epicardial echo very useful!

5 Practical issues Patient-probe mismatch Paediatric probe ( Minimulti )- 3-20kg Adult probe > 20kg Epicardial scan < 3kg Neonatal probe ( Micro ) < 3kg 3D probe? Scohy TV, et al. Image quality using a micromultiplane transesophageal echocardiographic probe in older children during cardiac surgery. Eur J Anaesthesiology 2009;26:445-7

6 Neonatal microprobe Scohy TV, et al. Image quality using a micromultiplane transesophageal echocardiographic probe in older children during cardiac surgery. Eur J Anaesthesiology 2009;26:445-7

7 Intra-operative scanning conditions Time constraints Probe insertion ECG electrodes Electrocautery Cardiopulmonary bypass Pathology and Procedure? Cardiorespiratory compromise? Ayres NA, et al. Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease. J Am Soc Echocardiogr 2005;18(1):91-8 Andropoulos DB, et al. The effect of transesophageal echocardiography on ventilation in small infants undergoing cardiac surgery. Anesth Analg 2000;90:47-9 Andropoulos DB, et al. The effect of transesophageal echocardiography on hemodynamic variables in small infants undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2000;14:133-5

8 Who is responsible? Stevenson JG. Adherence to physician training guidelines for pediatric transesophageal echocardiography affects the outcome of patients undergoing repair of congenital cardiac defects. J Am Soc Echocardiogr 1999;12: Stevenson JG. Performance of intraoperative transesophageal echocardiography by anesthesiologists and echocardiographers: training and availability are more important than hats. J Am Soc Echocardiogr 1999;12: Ayres NA, et al. Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease. J Am Soc Echocardiogr 2005;18(1):91-8

9 Guidelines for performing a comprehensive intraoperative multiplane TEE examination: Recommendations of the ASE Council on intraoperative echocardiography and the SCA Task Force for certification in Shanewise JS, et al. Anesth Analg 1999;89: perioperative TEE ALSO: Flachskampf FA, et al. Guidelines from the working group: Recommendations for performing transoeophageal echocardiography. Eur J Echocardiography 2001;2:8-21

10 Cardiac development and foetal circulation Moorman A, et al. Heart 2003 Jul;89(7): Development of the heart: (1) formation of the cardiac chambers and arterial trunks

11 Segmental analysis of congenital heart morphology Step 1: Atrial arrangement (according to atrial appendages) atrial situs atrial morphology veno-atrial connections Drawings: S Yen Ho Shinebourne EA, et al. Segmental analysis of congenital heart morphology. Br Heart J 1976;38:327-40

12 Segmental analysis of congenital heart morphology Dextrocardia Drawing: Dr S Yen Ho Shinebourne EA, et al. Segmental analysis of congenital heart morphology. Br Heart J 1976;38:327-40

13 Segmental analysis of congenital heart morphology Step 2: Drawings: S Yen Ho Atrioventricular connection biventricular or univentricular connections concordant or discordant AV valve morphology Shinebourne EA, et al. Segmental analysis of congenital heart morphology. Br Heart J 1976;38:327-40

14 Segmental analysis of congenital heart morphology Step 3: Ventricles - morphology Drawings: S Yen Ho Shinebourne EA, et al. Segmental analysis of congenital heart morphology. Br Heart J 1976;38:327-40

15 Segmental analysis of congenital heart morphology Step 4: Drawings: S Yen Ho Ventriculo-arterial connection concordant or discordant outflow tract morphology VA valve morphology great arteries Shinebourne EA, et al. Segmental analysis of congenital heart morphology. Br Heart J 1976;38:327-40

16 Segmental analysis of congenital heart morphology Step 5: Associated malformations/anomalies Shinebourne EA, et al. Segmental analysis of congenital heart morphology. Br Heart J 1976;38:327-40

17 Shunts at Atrial Level 1. PFO 2. Secundum Atrial Septal Defect (Fossa Ovalis Defect) 3. SVC Sinus Venosus Defect 4. IVC Sinus Venosus Defect 5. Primum Atrial Septal Defect 6. Atrio-Ventricular Septal Defect Drawing: Dr S Yen Ho

18 Ostium Secundum ASD

19 Ostium Secundum ASD

20 Ostium Secundum ASD Taniguchi M, et al. Application of real-time three-dimensional transesophageal echocardiography using a matrix array probe for transcatheter closure of atrial septal defect. J Am Soc Echocard 2009;22:

21 Ostium Secundum ASD Taniguchi M, et al. Application of real-time three-dimensional transesophageal echocardiography using a matrix array probe for transcatheter closure of atrial septal defect. J Am Soc Echocard 2009;22:

22 Amplatz device Patient from cardiac catheter suite in serious trouble

23 Sinus venosus ASD - superior

24 Sinus venosus ASD - superior Drawing: Dr S Yen Ho

25 Sinus venosus ASD - superior Drawing: Dr S Yen Ho

26 Sinus venosus ASD - superior Drawing: Dr S Yen Ho

27 64 yr old female MR, TR ASD closure 45 yrs ago! Now progressively short of breath, symptomatic

28 Sinus venosus ASD - inferior

29 Acyanotic Heart Disease L to R Shunts at Ventricular Level 1. Perimembranous 2. Apical Muscular and Multiple Muscular 3. Doubly Committed Sub-Arterial 4. Associated with Aortic Regurgitation

30 Perimembranous VSD

31 Septum primum ASD bridging leaflets Drawing: Dr S Yen Ho

32 AVSD / AV canal Eisenmenger Drawing: Dr S Yen Ho

33 Cyanotic Heart Disease R to L shunts 1. Tetralogy of Fallot 2. Transposition of Great Arteries 3. Tricuspid Atresia/ Univentricular Heart 4. Total Anomalous Pulmonary Venous Drainage 5. Pulmonary Stenosis/Atresia with or without VSD 6. Truncus arteriosus

34 18 months child with Tetralogy of Fallot Perimembranous VSD, overriding aorta, RVH, infundibular RVOTO

35 18 months child with Tetralogy of Fallot Perimembranous VSD, overriding aorta, RVH, infundibular RVOTO

36 BP 80/40, heart rate 130 bpm, Hb 13%, SpO 2 85% After 20 minutes: blood pressure 50/20, heart rate 105 bpm, SpO 2 60% Action: phenylephrine (5 micrograms/kg), atropine 0.02mg/kg Right to left Left to right

37 Intracardiac shunt Qp/Qs calculation Qp/Qs = π x (RVOT d ) 2 x VTI RVOT π x (LVOT d ) 2 x VTI LVOT 2 2 Ratio more than 1.8:1 = severe L to R shunt Ratio less than 1 = R to L shunt Valdes-Cruz LM, et al. A pulsed Doppler echocardiographic method for calculating pulmonary and systemic blood flow in atrial level shunts: validation studies in animals and initial human experience. Circulation 1984;69:80-86

38 Outflow Lesions 1. Pulmonary Valve and Infundibular Stenosis 2. Aortic Valve Stenosis 3. Sub-Valvular Aortic Stenosis 4. Supra-Valvular Aortic Stenosis

39 Differential diagnosis of AS LVOT obstruction sub-valvular muscular stenosis sub-aortic membrane

40 Congenital Valve Lesions 1. Aortic Lesions Valve a) Bicuspid with Stenosis b) Regurgitation Aortic Root Pathology 2. Mitral Valve Regurgitation, Stenosis Cleft, Prolapse 3. Tricuspid Valve Ebstein s Anomaly Isolated TR 4. Pulmonary Valve Regurgitation

41 Intact atrial septum - cleft left AV valve! Drawings: Dr S Yen Ho Abadir S, et al. Isolated cleft of the mitral valve: distinctive features and surgical management. Ann Thorac Surg 2009;88:839-49

42 Arterial trunks AP Window

43 Does intraoperative 3D TOE make a difference in congenital heart surgery? Scohy TV, et al. Usefulness of intraoperative real-time 3D transesophageal echocardiography in cardiac surgery. J Card Surg 2008;23:784-6 Bharucha T, et al. Impact of multiplanar review of three-dimensional echocardiographic data on management of congenital heart disease. Ann Thorac Surg 2008;86: Baker GH, et al. Usefulness of live three-dimensional transesophageal echocardiography in a congenital heart disease center. Am J Cardiol 2009;103:1025-8

44 Morgan GJ, et al. Just pretty pictures or a useful clinical tool? Eur J Echocardiogr 2008;9: Doddamani S, et al. Demonstration of left ventricular outflow tract eccentricity by realtime 3D echocardiography: implications for the determination of aortic valve area. Echocardiography 2007;24:860-66

45 Morgan GJ, et al. Just pretty pictures or a useful clinical tool? Eur J Echocardiogr 2008;9: Armen TA, et al. Three dimensional echocardiographic evaluation of an incidental quadricuspid aortic valve. Eur J Echocardiogr 2008;9:318-20

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