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Puchalski MD, Lui GK, Miller-Hance WC, Brook MM, Young LT, Bhat A, Roberson DA, Mercer-Rosa L, Miller OI, Parra DA, Burch T, Carron HD, Wong PC. Guidelines for Performing a Comprehensive Transesophageal Echocardiographic. J Am Soc Echocardiogr 2019; 32:173-215. [DOI: 10.1016/j.echo.2018.08.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Levin DN, Taras J, Taylor K. The cost effectiveness of transesophageal echocardiography for pediatric cardiac surgery: a systematic review. Paediatr Anaesth 2016; 26:682-93. [PMID: 27177602 DOI: 10.1111/pan.12920] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intraoperative transesophageal echocardiography (ITEE) for pediatric cardiac surgery has been described as clinically efficacious and cost-effective. There are a small number of publications supporting these claims. AIMS The objectives were to assess the quality of the research, the variability of results across studies and, if possible, to make a consensus statement based on the results. METHODS In March 2015, a systematic search of MEDLINE and MEDLINE In-Process, EMBASE, and the National Health Service Economic Evaluation Database was performed. The search was supplemented with a review of Health Technology Assessment reports through the Centre for Reviews and Dissemination database. English language articles including any quantitative economic evaluation were included. The quality of each study was assessed using the British Medical Journal economic evaluation quality checklist. Data extracted included the main outcomes from each study, study methodologies, itemized costs, sensitivity ranges, biases, and delayed reoperation prevented with ITEE. When possible, a cost-savings per ITEE was calculated to facilitate comparison across studies and used to create a synthesis of the results. RESULTS Seven studies met the inclusion criteria; of these, five were included in the synthesis of results. The cost-savings per ITEE ranged from $194 to $4910 with a mean of $1930 (95%CI: $845 to $3015) (2015 USD). Prevented delayed reoperation rates using ITEE ranged from 2.8% to 10%. Earlier studies were of poorer quality (scores 8-17) and more recent studies were of higher quality (scores 22-25). Methodologies used were either retrospective chart reviews (57%) or prospective observational studies (43%) with a range of approaches to estimate costs. CONCLUSION ITEE for pediatric cardiac surgery is effective and cost-saving. This is a validation of the current practice patterns. These finding may influence the expansion of the use of this technology.
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Affiliation(s)
- David N Levin
- London School of Hygiene and Tropical Medicine and London School of Economics, London, UK.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Jillian Taras
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katherine Taylor
- Department of Anesthesia, Hospital for Sick Children, Toronto, ON, Canada
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Abstract
OBJECTIVES Trans-oesophageal echocardiographic imaging is valuable in the pre- and post-operative evaluation of children and adults with CHD; however, the frequency by which trans-oesophageal echocardiography guides the intra-operative course of patients is unknown. METHODS We retrospectively reviewed 1748 intra-operative trans-oesophageal echocardiograms performed between 1 October, 2005 and 31 December, 2010, and found 99 cases (5.7%) that required return to bypass, based in part upon the intra-operative echocardiographic findings. RESULTS The diagnoses most commonly requiring further repair and subsequent imaging were mitral valve disease (20.9%), tricuspid valve disease (16.0%), atrioventricular canal defects (12.0%), and pulmonary valve disease (14.1%). The vast majority of those requiring immediate return to bypass benefited by avoiding subsequent operations and longer lengths of hospital stay. A total of 14 patients (0.8%) who received routine imaging required further surgical repair within 1 week, usually due to disease that developed over ensuing days. Patients who had second post-operative trans-oesophageal echocardiograms in the operating room rarely required re-operations, confirming the benefit of routine intra-operative imaging. CONCLUSIONS This study represents a large single institutional review of intra-operative trans-oesophageal echocardiography, and confirms its applicability in the surgical repair of patients with CHD. Routine imaging accurately identifies patients requiring further intervention, does not confer additional risk of mortality or prolonged length of hospital stay, and prevents subsequent operations and associated sequelae in a substantial subset of patients. This study demonstrates the utility of echocardiography in intra-operative monitoring of surgical repair and highlights patients who are most likely to require return to bypass, as well as the co-morbidities of such manipulations.
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Abstract
Echocardiography has revolutionized the management of pediatric and adult heart disease, especially in the diagnosis of congenital heart defects. Although the early methods of echocardiography (M-mode and Doppler imaging) were limited in their ability to define the defect in question, the advent of 2D, and now 3D, imaging have clearly equaled or surpassed traditional methods of diagnosis (e.g., noninvasively obtained plain chest radiographs and electrocardiograms) and invasive tests (e.g., cardiac catheterization and angiography). Confidence in the images obtained using echocardiography has continued to increase, with many patients referred for corrective or palliative surgery on the basis of echocardiographic imaging alone. Echocardiography has eliminated the need, decreased the frequency, or improved the timing or performance of invasive studies in other patients. Specifically, it is used to definitively diagnose a cardiac defect and any associated lesions. It will also provide quantitative information for the assessment of the hemodynamic severity of the lesion. This review outlines the manner in which echocardiography is used to plan and guide congenital heart surgery or intervention, along with some of the advantages and disadvantages (pitfalls) of which to be aware. The use of echocardiography within the cardiac catheterization or surgical theater, as well as in the intensive care unit, is discussed, as is the use of echocardiography as a means of monitoring recovery and follow-up following cardiac surgery. Finally, the authors discuss who is best qualified or suited to perform these tests.
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Affiliation(s)
- Omar Khalid
- University of Chicago Childrens Hospital, Chicago, IL 60637, USA.
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Abstract
Transesophageal echocardiography (TEE) plays an important role in the anatomical, functional, and hemodynamic assessment of patients with congenital heart disease (CHD). This imaging approach has been applied to both children and adults with a wide range of cardiovascular malformations. Extensive clinical experience documents significant contributions, particularly in the perioperative setting. In fact, in the current medical era, many consider this technology to be an essential adjunct to surgical and anesthetic management in CHD. This review focuses on the applications of TEE in patients with tetralogy of Fallot (TOF), the most common form of cyanotic heart disease. Emphasis is given to the perioperative use of this imaging modality and benefits derived during the prebypass and postbypass periods. Limitations and pitfalls relevant to the TEE assessment in patients with this anomaly are also addressed.
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The impact of additional epicardial imaging to transesophageal echocardiography on intraoperative detection of residual lesions in congenital heart surgery. J Thorac Cardiovasc Surg 2012; 143:361-7. [DOI: 10.1016/j.jtcvs.2011.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 05/09/2011] [Accepted: 06/07/2011] [Indexed: 11/23/2022]
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Echocardiography in the Adult with Congenital Heart Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Balmer C, Barron D, Wright JGC, de Giovanni JV, Miller P, Dhillon R, Brawn WJ, Stümper O. Experience with intraoperative ultrasound in paediatric cardiac surgery. Cardiol Young 2006; 16:455-62. [PMID: 16984697 DOI: 10.1017/s1047951106000618] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2006] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative ultrasound was introduced to evaluate the adequacy of repair after surgical repair of congenital cardiac malformations. Our purpose was to review the evolution of this technique at our centre. METHODS We evaluated all intraoperative ultrasound studies undertaken between 1997 and 2002, reviewing the data from 1997 through 2001 retrospectively, but undertaking a prospective audit of studies undertaken from 2002 onwards. In all, we carried out a total number of 639 intraoperative ultrasound studies, from a possible 2737 cardiac operations (23.3%), using the epicardial approach in 580 (90.7%), and transoesophageal ultrasound in the other 59 patients (9.3%). Median age was 0.6 years, with an interquartile range from 0.06 to 3.6 years. RESULTS The findings obtained using intraoperative ultrasound influenced the surgical management in 63 of the 639 patients (9.9%), suggesting the need for additional surgery in 26, adjustment of the band placed round the pulmonary trunk in 16, preoperative assessment of the cardiac malformation in 5, and confirming the need for prolonged support with cardiopulmonary bypass for impaired ventricular function in 16. There were 18 early reoperations, 5 of which may have been predicted by intraoperative ultrasound. Of the 183 studies reviewed prospectively in 2002, it was not possible to obtain the complete range of views in 8 (4.4%), while in 27 patients (14.7%), the postoperative findings using transthoracic interrogation differed from the findings obtained immediately following bypass. CONCLUSION Intraoperative ultrasound is an important technique for monitoring the results of complex congenital cardiac surgery. The immediate recognition of significant lesions, together with multidisciplinary discussion, allows for improved management and prevention of early surgical reintervention.
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Affiliation(s)
- Christian Balmer
- The Heart Unit, Birmingham Children's Hospital-NHS Trust, Birmingham, United Kingdom
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Ayres NA, Miller-Hance W, Fyfe DA, Stevenson JG, Sahn DJ, Young LT, Minich LL, Kimball TR, Geva T, Smith FC, Rychik J. Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease. J Am Soc Echocardiogr 2005; 18:91-8. [PMID: 15637497 DOI: 10.1016/j.echo.2004.11.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Aronson LA. Transnasal Placement of Biplane Transesophageal Echocardiography Probe Intraoperatively in an Adolescent with Congenital Heart Disease. Anesth Analg 2003; 97:1617-1619. [PMID: 14633530 DOI: 10.1213/01.ane.0000086729.89284.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Intraoperative transesophageal echocardiography (TEE) is frequently used in children with congenital heart disease (CHD). Although transnasal TEE is being used in various settings in the adult population, there are no descriptions of its use intraoperatively in patients with CHD. This report describes the successful use of transnasal TEE after multiple unsuccessful transoral attempts in an adolescent male undergoing subaortic stenosis repair. IMPLICATIONS Transnasal transesophageal echocardiography (TEE) is being used in various settings in the adult population. The author describes its use intraoperatively in an adolescent undergoing surgery for congenital heart disease after unsuccessful transoral attempts.
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Affiliation(s)
- Lori A Aronson
- From the Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Koinig H, Schlemmer M, Keznickl FP. Occlusion of the right subclavian artery after insertion of a transoesophageal echocardiography probe in a neonate. Paediatr Anaesth 2003; 13:617-9. [PMID: 12950863 DOI: 10.1046/j.1460-9592.2003.00958.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present a case of occlusion of the right arm's blood supply in a neonate with a lusorian artery, a rare anomaly of the right subclavian artery, after insertion of a transoesophageal echocardiography (TOE) probe and discuss the impact of a lusorian artery on intraoperative TOE monitoring.
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Affiliation(s)
- Herbert Koinig
- Departments of Cardiothoracic Anaesthesia & Intensive Care Medicine, University of Vienna, Vienna, Austria.
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Bruce CJ, O'Leary P, Hagler DJ, Seward JB, Cabalka AK. Miniaturized transesophageal echocardiography in newborn infants. J Am Soc Echocardiogr 2002; 15:791-7. [PMID: 12174348 DOI: 10.1067/mje.2002.120978] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND METHODS A miniaturized 5.5 to 10 MHz, phased-array, single longitudinal plane transducer mounted on a 3.3-mm diameter catheter (miniaturized transesophageal echocardiography [TEE]) may overcome mechanical limitations of standard pediatric transesophageal probes. We evaluated whether the miniaturized TEE probe could define clinically relevant anatomy in 17 infants who weighed less than 6 kg. RESULTS Twenty-two studies were performed in 17 infants without complication, weighing 2.1 to 5.6 kg. Twenty of twenty-two studies were diagnostic. Pediatric biplane TEE was not possible in 13 studies. Lack of horizontal plane imaging with miniaturized TEE made evaluation difficult in patients with atrioventricular septal defect. CONCLUSION Miniaturized TEE provided diagnostic intraoperative TEE in the majority of infants studied and may allow broader and safer application of TEE to neonates and small infants.
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Affiliation(s)
- Charles J Bruce
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Abstract
BACKGROUND The objective of this study was to assess the outcome of complete atrioventricular septal defect repair from 1981 to 2000. METHODS One hundred seventy-two consecutive patients with atrioventricular septal defect were operated on by a single surgeon using a consistent operative technique (single patch; "cleft" closure). The patients' age range was from 5 weeks to 9 years (mean, 10.8 +/- 1.2 months). RESULTS Overall operative mortality was 15 of 172 (8.7%) and this decreased significantly from 12 of 73 (16.4%) in the first decade to 3 of 99 (3.0%) in the second decade (p = 0.0021) with no operative deaths in the last 51 patients. Operative mortality was related to decade of operation (p = 0.0021) and to use of crystalloid cardioplegia (p = 0.0047) by univariate analysis, and to decade of operation (p = 0.0016) and postoperative time on ventilator (p = 0.0023) by multivariate analysis. Actuarial long-term survival including operative deaths was 79.0% +/- 3.8% at 15 years. Ten of 157 (6.4%) operative survivors have undergone reoperation for late mitral regurgitation (9 mitral valve repair, 1 mitral valve replacement) with one death. Four of 8 patients surviving late mitral valve replacement have subsequently required mitral valve repair. Freedom from late reoperation for severe mitral regurgitation was 89.9% +/- 3.1% at 15 years. Freedom from late reoperation for mitral regurgitation did not decrease in the second decade (84.2% +/- 6.6% at 10 years) versus the first decade (94.5% +/- 3.1%) (p = 0.0679). CONCLUSIONS Although operative mortality for repair of atrioventricular septal defect has decreased dramatically during the past decade, the incidence of late reoperation for mitral regurgitation has not improved, and better techniques to eliminate late mitral regurgitation are needed.
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Affiliation(s)
- F A Crawford
- Department of Surgery, Medical University of South Carolina, Charleston 29425, USA.
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Jaggers J, Ungerleider RM. Cardiopulmonary bypass in infants and children. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2001; 3:82-109. [PMID: 11486188 DOI: 10.1053/tc.2000.6033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiopulmonary bypass (CPB) systems have evolved from futuristic visions of surgical pioneers to a safe and efficient tool in the therapy of treatment of cardiac disorders. There are many significant differences in the physiology between neonates and adult patients. There are currently very few congenital cardiac malformations that cannot be addressed effectively with surgical therapy. Yet, the necessity of CPB in the repair of these patients can still result in significant morbidity. A clearer understanding of the effects of CPB, hypothermia, and circulatory arrest is evolving and there is a considerable amount of research in these areas. It seems likely that modification of current CPB systems, minimization of exposure, and surgical techniques to avoid or limit the adverse effects may reduce mortality and morbidity in the future. The problems faced in these complex patients and procedures require that infant and neonatal cardiac surgery be performed in specialized centers with a multidisciplinary approach and specialized personnel. Future improvements in technology will likely result in improved long term outcome for children with congenital cardiac disease. Copyright 2000 by W.B. Saunders Company
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Affiliation(s)
- James Jaggers
- Division of Thoracic Surgery, Pediatric Cardiac Surgery, Duke University Medical Center, Durham, NC
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Sheil ML, Baines DB. Intraoperative transoesophageal echocardiography for paediatric cardiac surgery--an audit of 200 cases. Anaesth Intensive Care 1999; 27:591-5. [PMID: 10631412 DOI: 10.1177/0310057x9902700606] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report out initial experience with intraoperative transoesophageal echocardiography (TOE) in 200 patients undergoing repair of congenital heart disease. Complications associated with probe insertion precluded a full study in 11 patients (5.5%) and included airway obstruction (n = 6), inability to pass the probe (n = 4) and vascular compression (n = 1). The preoperative diagnosis was confirmed by TOE in 176 of 189 cases (93%) with minor variances in 12 (6.3%) and one major variance (additional large muscular ventricular septal defect (VSD)). Unexpected abnormalities not diagnosed preoperatively were found at surgery in four cases (2%) and were all of trivial operative significance. Postoperative studies showed no residual defect in 96 (51%) and trivial or mild residual defects in 72 patients (38%). There were moderate or severe residual defects in 21 cases (11%). Ten cases (5.3%) returned to bypass for further surgery, with eight achieving complete or adequate amelioration. In six of the 10 cases, return to bypass was prompted by the TOE examination alone. There was one re-operation in the postoperative period for a VSD patch dehiscence. Routine TOE offers significant advantages in the management of patients undergoing repair of congenital heart disease, particularly in postoperative assessment. Careful monitoring of perfusion and ventilation is required, particularly during probe insertion in children weighing 5 kg or less.
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Affiliation(s)
- M L Sheil
- Royal Alexandra Hospital for Children, Westmead, Sydney, New South Wales
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Ramamoorthy C, Lynn AM, Stevenson JG. Pro: transesophageal echocardiography should be routinely used during pediatric open cardiac surgery. J Cardiothorac Vasc Anesth 1999; 13:629-31. [PMID: 10527237 DOI: 10.1016/s1053-0770(99)90020-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- C Ramamoorthy
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA
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