Role of intraoperative ultrasound examination in patients undergoing a Fontan-type procedure

Experience with intraoperative ultrasound in paediatric cardiac surgery

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.

Intraoperative transesophageal echocardiography in congenital heart disease

This article reviews the use of intraoperative echocardiography during repair of congenital heart defects. Although initial experience was generated using epicardial transducers, there has been a trend in recent years toward the use of transesophageal echocardiography (TEE) in the operating room. This has encouraged increased involvement from cardiologists and anesthesiologists. New probe designs have provided biplane imaging via the TEE approach in infants weighing more than 2.5 kg. Smaller infants may still require epicardial imaging, so it is helpful for surgeons to maintain some skill in this technique. This article reviews the utility of intraoperative echocardiography for various congenital heart defects by providing examples from our experience at Duke University Medical Center since 1987 with close to 2,000 cases. Furthermore, we review and report for the first time our experience with TEE since 1993 in the operating room during infant heart surgery (493 patients). Along with this experience, we provide a review of important series in the literature to outline recommendations for the use of echocardiography during infant heart repair.

Transoesophageal echocardiography in congenital heart disease

The development of paediatric transoesophageal ultrasound imaging represents an important advance in the diagnosis and management of the patient with congenital heart disease. Although primary diagnostic transoesophageal studies are seldom indicated in infants and unoperated children, they have an important role in the older child, especially where there has been prior cardiac surgery. Diagnostic studies are most appropriate for abnormalities of venous return, the atria, atrioventricular valves and the left ventricular outflow tract. Two other important areas in which transoesophageal imaging is playing an increasing role in the management of the paediatric patient is in monitoring of surgical repair.