A transesophageal echocardiography probe causes airway obstruction in an older child

Two unusual complications associated with cardiopulmonary bypass for pediatric cardiac surgery detected by transesophageal echocardiography after decannulation

We describe two rare cases of complications associated with cannulation for cardiopulmonary bypass during pediatric cardiac surgery detected by transesophageal echocardiography (TEE). The first patient (a 20-month-old boy, 11 kg) was scheduled for complete repair of an atrial septal defect and partial anomalous pulmonary venous connection. After decannulation of the superior vena cava, a mosaic jet was observed by means of TEE. The second patient (an 11-month-old boy, 6.4 kg), with a double outlet right ventricle, was scheduled for a hemi-Fontan procedure. After decannulation of the ascending aorta, high blood flow velocity of 4 m x s(-1) was detected by TEE. Intraoperative TEE was useful for early detection of complications associated with cardiopulmonary bypass cannulation during pediatric cardiac surgery.

Hypopharyngeal Perforation Near-Miss During Transesophageal Echocardiography

OBJECTIVES/HYPOTHESIS

The traditional blind passage of a transesophageal echocardiography probe transorally through the hypopharynx is considered safe. Yet, severe hypopharyngeal complications during transesophageal echocardiography at several institutions led the authors to investigate whether traditional probe passage results in a greater incidence of hypopharyngeal injuries when compared with probe passage under direct visualization.

STUDY DESIGN

Randomized, prospective clinical study.

METHODS

In 159 consciously sedated adults referred for transesophageal echocardiography, the authors performed transesophageal echocardiography with concomitant transnasal videoendoscopic monitoring of the hypopharynx. Subjects were randomly assigned to receive traditional (blind) or experimental (optical) transesophageal echocardiography. The primary outcome measure was frequency of hypopharyngeal injuries (hypopharyngeal lacerations or hematomas), and the secondary outcome measure was number of hypopharyngeal contacts.

RESULTS

No perforation occurred with either technique. However, hypopharyngeal lacerations or hematomas occurred in 19 of 80 (23.8%) patients with the traditional technique (11 superficial lacerations of pyriform sinus, 1 laceration of pharynx, 12 arytenoid hematomas, 2 vocal fold hematomas, and 1 pyriform hematoma) and in 1 of 79 patients (1.3%) with the optical technique (superficial pyriform laceration) (P =.001). All traumatized patients underwent flexible laryngoscopy, but none required additional intervention. Respectively, hypopharyngeal contacts were more frequent with the traditional than with the optical technique at the pyriform sinus (70.0% vs. 10.1% [P =.001]), arytenoid (55.0% vs. 3.8% [P =.001]), and vocal fold (15.0% vs. 3.86% [P =.016]).

CONCLUSION

Optically guided trans-esophageal echocardiography results in significantly fewer hypopharyngeal injuries and fewer contacts than traditional, blind transesophageal echocardiography. The optically guided technique may result in decreased frequency of potentially significant complications and therefore in improved patient safety.

Intraoperative transoesophageal echocardiography in a low birth weight neonate with atrioventricular septal defect

An 18-day-old male neonate (45 cm, 1.8 kg) with a history of cyanosis and congestive heart failure from an atrioventricular septal defect (AVSD) with a large left-to-right shunt was scheduled for surgical repair of the AVSD. After routine induction of anaesthesia with fentanyl and vecuronium, a 4.5-mm diameter transoesophageal echocardiography (TOE) probe was inserted into the oesophagus, and systematic echocardiographic evaluation was performed during surgery. After cardiopulmonary bypass was stopped, intraoperative TOE revealed mild residual mitral valve regurgitation. Because good left ventricular wall motion was confirmed and haemodynamic parameters were stable, cardiopulmonary bypass was not reinitiated. The patient's cardiac output was low in the postoperative intensive care unit. TOE was performed the next day to detect the source of this problem, revealed severe regurgitation compared with that observed intraoperatively. TOE was useful for evaluation of the residual mitral valve regurgitation, and we reconfirmed the importance of continuous monitoring even in a low birthweight neonate undergoing repair of a complete AVSD.

Intraoperative transoesophageal echocardiography for paediatric cardiac surgery--an audit of 200 cases

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.