Intraoperative Epicardial Echocardiography Research Articles

Intraoperative epicardial echocardiography or transoesophageal echocardiography in CHD: how much does it matter?

Intraoperative imaging determines the integrity of surgical repairs. Transoesophageal echocardiography represents standard care for intraoperative imaging in CHD. However, some conditions preclude its use, and epicardial echocardiography is used alternatively. Minimal literature exists on the impact of epicardial echocardiography versus transoesophageal echocardiography. We aimed to evaluate accuracy between the two modalities and hypothesised higher imaging error rates for epicardial echocardiography. We retrospectively reviewed all epicardial echocardiograms performed over 16 years and compared them to an age- and procedure-matched, randomly selected transoesophageal echocardiography cohort. We detected un- or misidentified cardiac lesions during the intraoperative imaging and evaluated patient outcomes. Data are presented as a median with a range, or a number with percentages, with comparisons by Wilcoxon two-sample test and Fisher's exact test. Totally, 413 patients comprised the epicardial echocardiography group with 295 transoesophageal echocardiography matches. Rates of imaging discrepancies, re-operation, and incision infection were similar. About 13% of epicardial echocardiography patients had imaging discrepancies versus 16% for transoesophageal (p = 0.2352), the former also had smaller body sizes (p < 0.0001) and more genetic abnormalities (33% versus 19%, p < 0.0001). Death/mechanical support occurred more frequently in epicardial echocardiography patients (16% versus 6%, p < 0.0001), while hospitalisations were longer (25 versus 19 days, p = 0.0003). Diagnostic accuracy was similar between patients undergoing epicardial echocardiography and transoesophageal echocardiography, while rates of death and mechanical support were increased in this inherently higher risk patient population. Epicardial echocardiography provides a reasonable alternative when transoesophageal echocardiography is not feasible.

A valuable echocardiographic indicator for the optimal tightness of bilateral pulmonary artery banding.

The optimal tightness of bilateral pulmonary artery banding (BPAB) is considered to balance not only systemic-to-pulmonary blood flow but also each pulmonary blood flow, which is still challenging. To achieve them, we adopt the end-diastolic velocity (EDV) to the peak systolic velocity (PSV) ratio at BPAB with intraoperative epicardial echocardiography. We evaluated the usefulness of the EDV to PSV ratio and the patient outcomes. 34 patients underwent BPAB with this indicator and using a looped polytetrafluoroethylene suture. The PSV and the EDV to PSV ratio with echocardiography were measured in the intraoperative, early postoperative and late postoperative period. Lung perfusion scintigraphy was performed to quantify flow to each lung. There were 3 early deaths (< 30days). Two patients required re-BPAB due to hypoxia. The intraoperative EDV to PSV ratios in the right and left were almost equal (0.50 ± 0.07 versus 0.51 ± 0.06, P = 0.73). There was no significant difference in the right and left EDV to PSV ratios throughout the postoperative course. The right PSV was smaller than the left PSV due to the Doppler angle intraoperatively (2.78 ± 0.57 versus 3.02 ± 0.50, P = 0.030). In addition, the PSV changed significantly until the late postoperative period (P < 0.001). Lung perfusion scintigraphy revealed only two patients had perfusion abnormalities. Our clinical outcomes are satisfactory with low early mortality and a low rate of re-BPAB. The EDV to PSV ratio can be a reliable indicator to assess flow distribution to each lung and may be a valuable adjunct to achieve balanced systemic to pulmonary flow.

Additive value of intraoperative hemodynamic monitoring to epicardial echocardiography during surgical repair of children with congenital heart disease

Aim The aim was to evaluate the additive value of intraoperative hemodynamic monitoring to epicardial echocardiography on the surgical outcome in children undergoing surgical correction of congenial heart disease. Patients and methods This study was conducted on 238 children with congenital heart disease who were enrolled for surgical correction. They were arranged in two groups: group A included 159 children in whom e-echo was used to detect intraoperative residual lesions while group B included 79 patients in whom e-echo and intraoperative hemodynamic monitoring using oxygen saturation step-up and intracardiac pressures after disconnection of cardiopulmonary bypass to detect residual shunt flow and outflow tract obstruction were used; revision of bypass was done when significant lesions were detected for repair. The follow-up echocardiography showed no significant residual lesions and complications in the subgroup of patients who had both epicardial monitoring and hemodynamic studies, in contrast to other groups of patients in whom19 patients had residual lesions and complications. Conclusions Routine use of intraoperative epicardial echocardiography allows detection of majority of residual defects after bypass; however, addition of other intraoperative monitoring tools like hemodynamic pressure measurement and oxygen saturation step-up can result in the detection of more residual lesions with revision of bypass, thus saving these patients from reoperation and postoperative complications.

The role of intraoperative epicardial echocardiography in pediatric cardiac surgery.

Our aim was to evaluate the findings and the role of intraoperative epicardial echocardiography (IEE) in the management of pediatric cardiac surgery patients. Patients evaluated with IEE between December 2015 and December 2017 were analyzed retrospectively. Demographic data, preoperative transthoracic echocardiography (TTE), and IEE reports were evaluated. A total of 410 patients evaluated by IEE were included in the study. Of these, 52% were women, and 48% were men. The median age was 8.5months (range: 1month-7years), and median body weight was 7.1kg (range: 3.3-61kg). The most common diagnoses were tetralogy of Fallot (TOF; n=148), ventricular septal defect (VSD; n=117), atrial septal defect (ASD; n=57), and complete atrioventricular septal defect (AVSD; n=48). There were minor residual lesions not requiring reestablishment of cardiopulmonary bypass (CPB) in 16.6% (n=68), while major residual lesions requiring return to CPB were determined in 5.1% (n=21). Major residual lesions were detected in 7 patients with TOF (4 severe right ventricular outflow tract obstructions, 2 pulmonary artery stenosis, 1 residual VSD shunt), 6 patients with VSD (hemodynamically significant residual shunts), and 5 patients with complete AVSD (3 left atrioventricular valve regurgitations, 1 right atrioventricular valve regurgitation, 1 left ventricular outflow tract obstruction). Transient bradycardia was observed in 5 patients. Intraoperative epicardial echocardiography provides good guidance during congenital heart surgery. IEE helps to clarify the surgical planning and decreases morbidity and mortality due to unnecessary invasive procedures, especially for pathologies involving the pulmonary artery and its branches, as well as for apical ventricular septal defects.

Role of real-time three-dimensional epicardial echocardiography in a novel transcatheter treatment techniques of mitral regurgitation:an acute in vivo animal study

Objective To evaluate the usefulness of real-time three-dimensional intraoperative epicardial echocardiography (RT-3D IEE) in the process of transapical mitral valve repair and a new device′s efficacy in an animal model. Methods Acute mitral regurgitation (MR) was induced in 18 anesthetized domestic pigs as MR group by cutting chordae supporting the segment of the leaflet (A2, n=9; P2, n=8; P3, n=1), while 15 pigs received no cutting chordae were chosed as normal mitral valve (NMV) group.The ValveClamp procedures were then transapically performed either on the prolapsing segment (MR group) or A2/P2 segment (NMV group) respectively solely under 3D epicardial echocardiographic guidance. Epicardial echocardiography was obtained before and after transcatheter interventions. Thirty days later all pigs were humanely killed to verify the location of implanted devices. Results In normal group, the preoperative max and mean mitral valve pressure gradient was higher than postoperative those (P 0.05). The autopsy report demonstrated that all ValveClamp devices were precisely placed to clamp either the prolapsing segments (MR group) of mitral valve or A2/P2 segments (NMV group), respectively. Conclusions Real-time three-dimensional epicardial echocardiography can independently monitor the new transcatheter mitral repair technique-ValveClamp, facilitating the overall procedure. Transapical implantation of ValveClamp device under epicardial echocardiographic guidance is effective in reducing acutely induced mitral regurgitation. Key words: Echocardiography, intraoperative epicedial; Transcatheter mitral valve repair; Mitral regurgitation

Epicardial 15-MHz Echocardiography for Effective Repair of Coronary Arteriovenous Fistula

In the era of catheter intervention, the surgical repair of coronary arteriovenous fistula needs to be free from residual shunt. Intraoperative epicardial 15-MHz echocardiography helps to find the residual shunt after ligation or obliteration of anomalous vessels. Here we report our method of the echo-assisted surgical repair of coronary arteriovenous fistula in 7 adult patients. The method made the operation for coronary arteriovenous fistula free from residual shunt, but care should be taken to the development of new vessels after the operation.

Clinical study of graft-left anterior descending artery assessment in off-pump coronary artery bypass grafting with intraoperative epicardial echocardiography

Objective To study the clinical value of intraoperative epicardial echocardiography (IEE) in assessing graft-left anterior descending artery (LAD) of off-pump coronary artery bypass grafting (OPCABG). Methods IEE was used to detecte graft vessels anastomosis in 53 patients with OPCABG-LAD. Two-dimensional grey ultrasound and color Doppler ultrasound was used to show whether there was abnormal echo in proximal and distal lumen, measuring diameter and rate of stenosis. Pulse Doppler ultrasound was used to observe the blood flow spectrum. Intraoperative transient blood flow meter (TTFM) was employed to measure the pulsatility index and flow volume. Results Among the 53 patients with OPCABG-LAD, 38 cases were left internal mammary artery graft (LIMA), 15 cases were saphenous vein graft (GSV). Pulsatility index and flow volume showed normal by TTFM. The detection rates of graft vessels-LAD anastomosis in proximal and distal segment were 100% using IEE, including 10 cases anastomotic plaques and 10 cases proximal plaques. Comparison of blood flow parameter of graft by IEE and TTFM in operation, there was no significant difference in LIMA grafts (P=0.091), but the correlation was statistically significant (r=0.809, P<0.001); the difference in GSV grafts had no statistical significance (P=0.821), but the correlation was statistically significant (r=0.684, P=0.005). Conclusions IEE clearly displays the lumen of graft vessel and LAD, and measures the hemodynamic indexes. It provides an intuitive, accurate and convenient method for detecting the patency of the graft vessels during OPCABG. Key words: Echocardiography; Coronary artery bypass, off-pump; Left anterior descending artery; Graft vessel

Utility of a standardized postcardiopulmonary bypass epicardial echocardiography protocol for stage I Norwood palliation.

Stage 1 Norwood palliation is one of the highest risk procedures in congenital cardiac surgery. Patients with superior technical performance scores have more favorable outcomes. Intraoperative epicardial echocardiography may allow the surgeon to address residual lesions prior to leaving the operating room, resulting in improved technical performance. The ability of intraoperative epicardial echocardiography to visualize the relevant anatomy and its association with outcomes is not known. A standardized intraoperative epicardial echocardiography protocol was developed and performed at the conclusion of Stage 1 Norwood palliation. Data pertaining to visualization of relevant anatomy, and comparison of intraoperative echocardiogram findings with other postoperative investigations was performed. Clinical outcomes, including technical performance, were collected. A historical cohort who received either no echocardiogram or a nonstandardized examination was used as a comparison group. Thirty on-protocol and 30 preprotocol patients, 22 of whom had a nonstandardized intraoperative epicardial echocardiogram, were studied. Compared with preprotocol, visualization of the relevant anatomy was significantly increased for the Damus-Kaye-Stansel anastomosis (93% vs. 68% P = .03) and branch pulmonary arteries (70% vs. 36%, P = .02). One residual lesion requiring immediate operative reintervention was diagnosed in the preprotocol group. There were 5 patients in each cohort with residual lesions during the postoperative hospitalization that were not appreciated on the intraoperative echocardiogram. Technical performance, rates of reintervention and clinical outcomes were not significantly different between the two groups. Intraoperative epicardial echocardiography is technically feasible and increases visualization of the relevant anatomy. Larger investigations may be warranted to determine if there is clinical benefit to such an approach.

Preliminary evaluation of a microtransesophageal probe in neonates and young infants undergoing surgery for congenital heart disease.

Background:The larger size of the currently available transesophageal echocardiography (TEE) probes limits their use to relatively older infants undergoing cardiac surgery. In very young neonates and infants, epicardial echocardiogram is used to assess postoperative residual defects. Recently, a miniaturized microTEE probe compatible in neonates has been introduced for clinical use. We evaluated the use of this probe in small infants undergoing cardiac surgery.Materials and Methods:Thirty-three consecutive neonates and infants undergoing cardiac surgery at our institution were included in the study. Intraoperative echocardiography with Philips s8-3t microTEE probe done using IE33 platform was utilized to study the preoperative anatomy and assess postoperative results.Results:Thirty-three patients aged 3 days-2 years (mean 5.1 months) and weighing 2.5-11 kg (mean 4.4 kg) underwent perioperative evaluation using the microTEE probe. Good quality two-dimensional and color Doppler images were obtained in all patients. There were no complications related to the probe insertion or manipulation. The findings on microTEE led to revision of surgery in five patients. Certain echocardiographic parameters that could never be recorded with epicardial echocardiogram could be easily seen in microTEE.Conclusion:On preliminary evaluation, the microTEE probe provided good quality images in very small infants who were not amenable for transesophageal echocardiographic evaluation so far. The probe could be used safely in small infants without complications. It appears to be a promising imaging modality in the perioperative assessment of young infants undergoing cardiac surgery, in whom intraoperative epicardial echocardiography is currently the only tool.

Accuracy of Intraoperative Epicardial Echocardiography in the Assessment of Surgical Repair of Congenital Heart Defects confirmed.

Objective:To determine the accuracy of epicardial echocardiography in detecting residual lesions after surgical repair of congenital heart defects. To determine the sensitivity, specificity, positive predictive valve, negative predictive valve, and false negative and false positive percentage of the same.Materials and Methods:One year hospital-based prospective study of epicardial echocardiography in patients undergoing cardiopulmonary bypass for surgical correction of congenital heart defects in children and adults.Results:Epicardial echocardiography was done in 158 patients. Residual lesions were detected in 38 patients by epicardial echocardiography. In 28 of these cases the residual lesions were significant. In 24 of them immediate reoperation was done with good outcome. Epicardial echo has high sensitivity, specificity, positive and negative predictive valve, in detecting residual lesion with congenital heart defects.Conclusion:Routine use of intraoperative epicardial echocardiography allows detection of majority of residual defects. It has high accuracy. There were no complications associated with use of epicardial echocardiography. The use of transesophageal echocardiography (TEE) can be avoided in small children and neonates undergoing cardiac surgery.

Impact of Intraoperative Epicardial Real-Time Three-Dimensional Echocardiography as a Surgical Guide on Systemic Atrioventricular Valve Plasty of Congenital Heart Disease

The aim of the study is to assess the feasibility and accuracy of intraoperative epicardial RT3DE (IERT3DE) for obtaining anatomical information of systemic atrioventricular valve as a surgical guide in congenital heart disease.

Safety and efficacy of sonicated albumin microspheres in perfusion and vein graft patency assessments

This study was designed to identify a concentration of sonicated albumin microspheres that is safe, useful in determining graft patency, and provides an estimate of regional myocardial perfusion. The study included 8 patients between 50 and 72 years of age who were undergoing coronary artery bypass grafting. All patients were hemodynamically stable with left ventricular ejection fractions greater than or equal to 0.35. None had congestive heart failure or myocardial infarction within 4 months prior to the study. All had normal baseline neurologic and renal functions, and none had experienced allergic reactions to blood products or contrast dyes. A standard median sternotomy was performed for exposure of the heart at surgery, and saphenous veins were harvested and used for grafting. Intraoperative epicardial echocardiography (EE), always in the left ventricle short-axis at midpapillary level, was performed before and after grafting to determine regional myocardial wall motion. Sonicated albumin microspheres were prepared and injected into a single vein graft using an 18-gauge needle; 20 x 10(6), 100 x 10(6), and 200 x 10(6) microspheres were injected into the first graft sequentially. All other vein grafts were injected once with the dose that gave optimal contrast enhancement in the initial graft studied. In each patient, a minimum of 3 and maximum of 5 injections were performed, and graft perfusion was studied using EE. Graft flow, blood pressure, and electrocardiographic (ECG) measurements were continuously monitored, with a final EE performed after weaning the patient off cardiopulmonary bypass to assess wall motion. Preliminary results showed that no patient had adverse effects during or after the study and all remained hemodynamically stable.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of Intra-Operative Epicardial Three-Dimensional Echocardiography to Guide Aortic Valve Repair in Children

The aim of this study was to determine the additional important information obtained on prebypass epicardial 3-dimensional imaging (E-3D) compared with transesophageal 2-dimensional echocardiography (TEE-2D) in young patients who undergoing aortic valve repair. From January 2004 to May 2007, all patients who underwent reconstructive surgery of the native aortic valve and intraoperative TEE-2D and E-3D were retrospectively reviewed. Thirteen structural anatomic variables of the aortic valve for TEE-2D and E-3D were evaluated, scored, and compared (by a blinded observer) with intraoperative surgical findings. Nineteen patients underwent valve repair. The median age at surgery was 10 years (range 1 day to 24 years). The primary aortic valve disease was regurgitation (n = 19), and 2 patients had additional valvar stenosis. TEE-2D and E-3D were able to detect 82% (n = 204) and 91% (n = 225), respectively, of the intraoperative findings (n = 247) (p = 0.006). Individual evaluation scores were higher for E-3D (median 12, interquartile range 11 to 13) than for TEE-2D (median 11, interquartile range 10 to 12) (p = 0.01) compared with surgical findings (score 13). Differences in detection sensitivity occurred for commissural fusion (n = 7), leaflet perforation or deficiency (n = 5), and leaflet prolapse (n = 2). TEE-2D was more likely to have false-negative findings than E-3D (36 vs 16 findings, p = 0.001). In conclusion, intraoperative E-3D provides additional important information over TEE-2D for aortic valve repair in young patients. Such 3-dimensional echocardiographic imaging has become an important intraoperative modality for valve repair at the investigators' institution.

Guidelines for the Performance of a Comprehensive Intraoperative Epiaortic Ultrasonographic Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons

Guidelines for the Performance of a Comprehensive Intraoperative Epiaortic Ultrasonographic Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons

Alcohol septal ablation versus surgical myectomy: a patient with obstructive HCM

A 42-year-old woman with a 20-year history of obstructive hypertrophic cardiomyopathy was referred for alcohol septal ablation following a worsening of symptoms, which had persisted despite medical treatment. Physical examination, electrocardiography, rest-exercise Doppler and two-dimensional echocardiography, coronary angiography, intracoronary myocardial contrast echocardiography, and intraoperative transesophageal and epicardial echocardiography. Symptomatic obstructive hypertrophic cardiomyopathy. The patient was deemed unsuitable for alcohol septal ablation and underwent surgical myectomy guided by intraoperative echocardiography.

Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

TABLE OF CONTENTSIntroduction 921General Guidelines 922Training and Certification 922Indications for TEE 923Management of Patient Sedation 927Sedation and Anesthesia 929Probe Insertion Techniques 930Instrument Controls 930Instrument Manipulation 931Comprehensive Imaging Examination 932ME Views 932TG

Guidelines for Performing a Comprehensive Epicardial Echocardiography Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Scott T. Reeves, MD, FASE, Kathryn E. Glas, MD, FASE, Holger Eltzschig, MD, Joseph P. Mathew, MD, FASE, David S. Rubenson, MD, FASE, Gregg S. Hartman, MD, and Stanton K. Shernan, MD, FASE, for the Council for Intraoperative Echocardiography of the American Society of Echocardiography, Charleston, South Carolina; Atlanta, Georgia; Tubingen, Germany; Durham, North Carolina; La Jolla, California; and Lebanon, New Hampshire

Epicardial Real-Time Three-Dimensional Echocardiography in Cardiac Surgery: A Preliminary Experience

Intraoperative two-dimensional transesophageal echocardiography (2DTEE) is a widely accepted method to guide cardiac valve surgery. The aim of our study was to evaluate the feasibility, effectiveness, and incremental value of intraoperative epicardial real-time three-dimensional echocardiography (RT3DE). Thirty consecutive patients (18 aortic and 12 mitral valve diseases) underwent intraoperative 2DTEE and RT3DE before and after cardiopulmonary bypass. Five observers compared independently 2DTEE to live and full volume images and to the surgical view, to assess the incremental value of RT3DE in depicting the different anatomic structures. Epicardial RT3DE was feasible in all patients. Qualitative evaluation determined RT3DE superiority in depicting aortic cusp morphologic lesions; left ventricular outflow tract spatial relationships with mitral apparatus and aortic root; and both anterior and posterior mitral leaflet scallops, particularly posterior commissure. In our study, epicardial RT3DE has been demonstrated to improve morphologic definition of anatomic valvular lesions and their relationship with cardiac adjacent structures. It may be a valid substitute when the 2DTEE approach is contraindicated, or it could have a complementary role, coupled with 2DTEE, to give additional information for surgical planning.

Live three-dimensional paediatric intraoperative epicardial echocardiography as a guide to surgical repair of atrioventricular valves

Real-time three dimensional echocardiography is increasingly used for imaging patients with congenital cardiac malformations. One of the limitations of a transthoracic approach is that intervening structures can impact on the quality of the images obtained. We hypothesised that, during surgery, epicardial three-dimensional echocardiography would provide images of high quality. We report our findings in eight children or young adults, with weights ranging from 2.8 to 70 kilograms, in whom we used this approach. In all cases, we obtained images of good quality, which could be analysed rapidly in the operating room. Of the eight cases, seven had echocardiographic findings which matched exactly the surgical findings. The remaining child had been diagnosed echocardiographically with a cleft in the aortic leaflet of the mitral valve, but was found at surgery to have a double orifice in the valve.

A Comparative Study of Imaging Techniques in Aortic Dissection, DeBakey Type I: Intraoperative Live Three- Dimensional Epicardial Echocardiography, Multiplane Transesophageal Echocardiography, and Multislice Computed Tomography

Objective To compare the accuracy of intraoperative live 3-dimensional epicardial echocardiography, multiplane transesophageal echocardiography (TEE), and multislice computed tomography (MSCT) imaging in the detection of thoracic aortic dissection, site of intimal tear, and involvement of arch vessel. Methods Of 24 patients studied from October 2003 to September 2004, 12 had aortic dissection. They were examined preoperatively with contrast material-enhanced MSCT and multiplane TEE. Intraoperative live 3-dimensional epicardial echocardiographic evaluation of the ascending aorta and arch was performed. Imaging results in terms of detection of aortic dissection, site of intimal tear, and involvement of coronary arteries and arch vessels were confirmed at intraoperative exploration by the operating surgeon as the reference standard. Results Sensitivity in the detection of thoracic aortic dissection was 100% for all techniques. Specificity was 92%, 92%, and 100% for live 3-dimensional epicardial echocardiography, multiplane TEE, and MSCT imaging, respectively. In the assessment of aortic arch vessel involvement, sensitivity was 92%, 58%, and 92%, and specificity was 75%, 50%, and 83%, respectively. For the detection of the site of intimal tear, sensitivity was 92%,92%, and 58%, and specificity was 83%,75%, and 50%, respectively. Conclusion Intraoperative live 3-dimensional epicardial echocardiography is as valuable as multiplane TEE and MSCT imaging in the detection of thoracic aortic dissection. In the assessment of the aortic arch vessel involvement, MSCT and live 3-dimensional epicardial echocardiography are superior (P &lt; 0.05), whereas live 3-dimensional epicardial echocardiography and TEE are superior in detection of site of intimal tear (P &lt; 0.05).