Does intraoperative transesophageal echocardiography predict pulmonary valve dysfunction during the Ross procedure?

Anesthetic management for severe aortic regurgitation in an infant repaired by Ross procedure

We report the anesthetic management of a 7-month-old male infant with severe aortic regurgitation (AR) scheduled for the Ross procedure. To the best of our knowledge, this is the first report from the viewpoint of anesthetic management for the Ross procedure performed in an infant. He had been suffering from severe AR that occurred suddenly when he was 5 months old. The cause of the AR was considered to be spontaneous rupture of a fenestrated aortic valve, owing to congenital tissue defect in part of the aortic valvular leaflet. The Ross procedure was scheduled to be performed under general anesthesia using deep hypothermic cardiopulmonary bypass (CPB). Continuous infusion of nitroglycerin was started during CPB and continued after CPB to dilate the newly implanted coronary arteries for the prevention of myocardial ischemia and to decrease afterload and pulmonary vascular resistance. Weaning from CPB was performed without difficulty, but after the prolonged CPB he had a bleeding tendency that needed transfusion and a hemostatic drug. Monitoring with transesophageal echocardiography was very useful for evaluating myocardial ischemia, and for assessing the procedure and the completion of surgical repair. His postoperative course was uneventful and he was discharged on the 25th postoperative day.

Intraoperative monitoring with transesophageal echocardiography: indications, risks, and training

There are benefits and risks to the use of TEE. The benefits are derived from the physiologic information that TEE provides, which may not be as readily obtained by any other technique. The risks of TEE are those related to mechanical trauma from the probe, as well as those of an incorrect TEE interpretation by the echocardiographer. Intraoperative TEE is a powerful monitoring and diagnostic tool. Performance of TEE requires special skills. As has been discussed, training guidelines exist. As more clinical studies are published, the indications for intraoperative TEE are likely to expand. Class-I recommendations for intraoperative echocardiography have been listed. The authors have discussed some of the issues involved with each class-I indication. Performance of the TEE is not an end in itself and should not distract the anesthesiologist from the primary goal of patient care. With proper training and experience, the anesthesiologist may learn how to use TEE to improve patient care.