European Journal of Echocardiography 2007 8(4):241-246; doi:10.1016/j.euje.2007.02.011
Copyright © 2007, The European Society of Cardiology
Intraoperative evaluation of micromultiplane transesophageal echocardiographic probe in surgery for congenital heart disease
Thierry V. Scohya,*,
Diederik Gommersa,
A. Derk Jan ten Harkelb,
Yvon Derycka,
Jackie McGhiec and
Ad.J.J.C. Bogersd
aDepartment of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
bDepartment of Pediatric Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
cDepartment of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
dDepartment of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
Received 5 February 2007; accepted after revision 14 February 2007.
t.scohy{at}erasmusmc.nl
* Corresponding author: Department of Anesthesiology, Room Bd 581, Erasmus Medical Center, P.O. BOX 2040, 3000 CA Rotterdam, The Netherlands. Tel.: +31 324 7351 9413.
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Abstract
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Introduction In the last years, transesophageal transducers
for multiplane Doppler echocardiography have demonstrated their
superior imaging performance in pediatric patients undergoing
cardiac surgery. To date, the size of these probes has limited
their use in neonates and small children. New technologies allowing
performing TEE in smaller patients are therefore promising.
Methods We report our clinical experience with the Oldelft micromultiplane TEE probe (8.2–7mm diameter tip with a 5.2mm diameter shaft) specifically meant for use in neonates.
Results Forty-two patients were examined intra-operatively using the micromulti TEE harmonic transducer. Patients examined ranged in age from 4days to 6years and ranged in weight from 2.5 to 23.8kg. In two patients we had to adapt ventilatory settings because of increased airway resistance after probe insertion. In 3 patients surgical re-intervention was performed due to TEE assessment immediately after weaning from bypass. In two patients significant obstruction of the right ventricular outflow tract was still present after Fallot correction, and one patient had an additional muscular ventricular septal defect still present after VSD closure.
Conclusions The micromulti TEE harmonic transducer provided excellent diagnostic intra-operative TEE in neonates and small children without major complications, special attention should be taken for ventilatory parameters in neonates less than 3kg.
Keywords: TEE; Neonates; Small children
Financial support: There was no financial support for this study. 
Conflict of interest: There was no conflict of interest.
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Introduction
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The role of transesophageal echocardiography (TEE) during surgery
for congenital cardiac disease to define complex anatomical
structures, functional abnormalities, and to monitor hemodynamics
is well established.
1,2 Until 1990, intraoperative evaluation
of infants and children undergoing congenital heart surgery
was not feasible with TEE because probe sizes were too large.
1 It is not surprising that inability to pass the TEE probe and
complications as esophageal trauma, airway compromise, and aortic
compression occur predominantly in smaller children.
3 The subsequent
development of miniaturized single- and bi-plane probes (from
9mm down to 3.3mm diameter) has generated a number of studies,
which have demonstrated that TEE can be performed safely in
the pediatric population.
4–6 However, the use of a mini
multiplane TEE probe (10.7–8.0mm diameter tip with a 7.4mm
diameter shaft) is still limited to children above the weight
of 5kg.
7 A multiplane TEE probe for neonates and small children
which obtains images in several planes is an obvious advantage,
certainly considering the complexity of the intracardiac defects.
8–10 In this study we evaluated the clinical and diagnostic ability
of the Oldelft micromulti TEE probe (8.2–7mm diameter
tip with a 5.2mm diameter shaft) in neonates and infants undergoing
cardiac surgery to provide data on safety and visability.
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Methods
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Forty-two consecutive neonates and infants undergoing surgery
for congenital cardiac defects at the Erasmus MC Thoraxcentrum
were included. All patients undergo routinely TEE during cardiac
surgery. Since the availability of the Oldelft micromultiplane
TEE probe the weight limit has dropped to 2.5kg.
Before induction of anesthesia, all patients were monitored with a five-lead, two-channel electrocardiogram, non-invasive blood pressure measurement, and pulse oximetry. After the insertion of a peripheral venous line, general anesthesia was induced with midazolam 0.2mg/kg, sufentanil 2mcg/kg and pancuronium 0.15mg/kg. Patients were nasotracheally intubated and pressure controlled ventilated (PCV) using a Siemens 900C ventilator. Anesthesia was maintained with midazolam 0.1mg/kg per hour and sufentanil 1mcg/kg per hour. Invasive monitoring via a femoral arterial line and an internal jugular central venous catheter was performed, and a Foley bladder catheter and rectal temperature probe were inserted. The lubricated Oldelft micromultiplane TEE probe was inserted blindly with or without a jaw thrust of the mandible or under direct laryngoscopic view. During insertion of the TEE probe special attention was payed to tidal volume and dampening of the arterial waveform.3 TEE examinations were performed using Philips iE 33 ultrasound system (Philips, Andover, MA, USA) equipped with 2D, pulsed, continuous, and color Doppler capabilities. All TEE examinations were conducted by the same anaesthesiologist in presence of a second anaesthesiologist who was responsible for the care of the patient.
TEE probe
The micromulti TEE Transducer is a miniature, phased array ultrasound (center frequency 7.5MHz/bandwidth >40%/48 elements/0.1mm pitch) multiplane TEE probe, developed for neonates and small children. The micromultiplane TEE transducer consists of an octagonal 48-element array, 5.0mm elevation, 4.77mm lateral aperture, rotatable through 180° mounted on the distal end of a gastroscope. The micromulti TEE Transducer uses a flexible shaft with a thickness of max 5.2mm, with a length of 70cm, with a bending neck capable of articulating in the anterior and posterior directions (120°±10° upward anterior, 90°±10° backward posterior). The bending neck has a diameter of 5.6mm and a length of 40mm. The bead on the transition to the shaft has a diameter of 6.2mm. The tip is 8.2mm wide, 7.0mm thick and has a length of 24.0mm. Fig. 1 shows a comparison of an adult, the mini multiplane and the micro multiplane TEE probe tips.
Complete TEE examination took place before cardiopulmonary bypass
(CPB). After the initial examination, the probe was advanced
into the stomach and left in an unlocked position during the
procedure; the ultrasound emission was turned off during bypass.
The TEE assessment of the surgical repair occurred immediately
after weaning from CPB.
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Results
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Demographic data are summarized in
Table 1. Patients examined
ranged in age from 4days to 6years and ranged in weight from
2.5 to 23.8kg.
Table 1 also lists the diagnostic information
concerning patients who were evaluated before, during and after
surgery.
None of the patients was excluded beforehand. There were two
patients with complications related to introduction of the probe
or its use during the surgical procedure. Patient 1 had an increased
airway resistance with increased air leak after introduction
of the micromulti TEE probe, the problem was solved by increasing
PEEP level from 4 to 6cm H
2O and increasing peak inspiratory
pressure from 10 to 14cm H
2O above PEEP. Patient 6 had increased
airway resistance after introducing the probe, withdrawal of
the nasal endotracheal tube for 0.5cm, and PEEP increase from
4 to 8cm H
2O and peak pressure increase from 10 to 18cm H
2O
solved the problem. In both patients we noticed no further difficulties
during TEE examination.
In three patients surgical re-intervention during the continued procedure was decided after intra-operative TEE assessment of the initial repair. Case 21 and 31 had significant RVOT obstruction (continuous-wave Doppler velocities of 4.0m/s) after correction, therefore widening of the RVOT (CW velocities 1.4m/s and 2.0m/s) was performed. Case 14 showed an additional muscular VSD after VSD correction, which was closed subsequently. This reintervention rate is comparable to the 5–10% as reported earlier in pediatric cardiac surgery after TEE assessment.
In two of the larger patients (case 40 and 42, body weight 20 and 24kg) we had poor quality images.
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Discussion
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TEE has become the standard of care in many institutions performing
pediatric cardiac surgery, to evaluate the surgical repair after
weaning from cardiopulmonary bypass. The cardiac performance
can be assessed and possible residual lesions can be immediately
corrected.
11 As surgical techniques have improved, greater numbers
of neonatal and small patients are referred for repair of complex
intracardiac defects. TEE is frequently used in this population.
Due to the relatively large size and rigid nature of TEE probes,
airway complications, inadvertent extubation, and insertion
failures have been reported to occur predominantly in smaller
patients.
3 Until recently a safe investigation with multiplane
technique in neonates and infants was limited to children of
5kg or more.
7 The Oldelft micromultiplane TEE probe provided
excellent diagnostic intra-operative TEE in neonates and small
children without major complications, this probe allows multiplane
imaging in neonates and smaller children and provides additional
and clear information, with less manipulation than would be
required for biplane visualization. This is illustrated in
Figs. 2–7
.
In
Fig. 2 we measured a flow velocity of 4m/s with continuous
wave (CW) Doppler in the pulmonary artery after surgical repair,
with the simplified modification of the Bernoulli equation (
P=4
xV2)
the estimated instantaneous systolic gradient would be 64mmHg.
Fig. 3 shows an overriding aorta and VSD in TOF.
Fig. 4 shows
the RVOT and the pulmonary artery. In
Fig. 5 we measured the
velocity time integral (VTI) with CW Doppler in a transgastric
long-axis view of the aortic valve.
Fig. 6 shows color Doppler
flow in the left coronary artery (LCA) and
Fig. 7 shows a transgastric
long-axis view of the aortic valve.
In this study we were able to acquire useful images in children
down to a weight of 2.5kg, however in two of the larger children
(case 40 and 42) we noticed poor quality images. Although in
two children ventilatory problems occur they could be resolved
by changing ventilatory settings.
In conclusion the Oldelft micromultiplane TEE probe examinations provided excellent diagnostic intraoperative TEE assessment in neonates as small as 2.5kg without major complications. In larger children (>20kg) however we noticed poor image quality, further investigation will have to confirm this.
Immediate TEE assessment of the surgical repair after weaning from bypass may prevent unplanned reoperations in the early and late post operative period. In the smallest infants attention should be payed to ventilatory settings during and after introduction of the micromulti TEE probe. Furthermore intra-operative TEE assessment also provided additional information concerning cardiac performance. This information assisted in taking the appropriate decisions for optimal pharmacologic treatment during weaning of bypass. Intraoperative TEE monitoring is recommended in all cases.
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Notes
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Financial support: There was no financial support for this study.
Conflict of interest: There was no conflict of interest.
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References
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Abstract
Introduction
