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Advances in transesophageal echocardiography: Impact of a changing technology or children with congenital heart disease
joung.
pediilmc
cdrdialag~sn
from ,he mugmg
Advances in Transesop Echocardiography: Impact of a Changing Technology o With Congenital Heart
HI@I re~~~1uvm qmenral culor “w
F. FELTES.
MD.
caiduc
,,~uc!“re\.
provdc
teooardue \e, For the last 2 decades. advances in echocnrdtography
impact on the chnical practice of cardIor adult,.
abilities of ~ranxerophagcal
cardiography
have evolved
among cardiologists nologic
advance
scrutiny.
have
In the Iat
rapidly.
i years. the ccho-
a, bar itb Qopular~?
treating adults. Becaux in echocardiography
each new Iech-
bong,
we are yet agam faced with
a pcrtod
the question.
of Do
pediatric patients stand 10 benefit fmm thn new technology’! Transesophageal echocardiography that conventional don and Doppler hampered
The findme
transthoracic ultrasound image resoluassessment of the hear1 we frequenrly
in adult
new approaches.
in adul8.
patienls
has prompted
Because of it? retmcardiac
G scnrch
for
loulion.
the
esophagus has been rccogmzed as providing an ~lremat~ve “window” (I). In 1980. Matsumot” et al. 121 ruccessfully monitored left ventricular Qerf”rmsnce with USCoi a wan
and improved.
high re~olul~on car-
diac assessmenl by means of the lransesophageal became possible by the late 1980s 01. Reccnlly.
appruach the intro-
duction of biplane oansesophageal echucardiography ha\ made scanning possible in both Ihe tmnsverie and verucal olanes of the heart ,4,. In adults. tran,e,“phageal echocarbiography has overcome such ullrasound bx~&r\ ~IL chehl wall impedance and prosthetic valve shielding to grci~ti~
on accurate
Echocard~qraphx
immcdtstc
_
surccr~ (that ii.
imagmg and interrogative
approach.
Doppler
and
pediatric wI,enls.
and the surgical management
Qlcx and increa~mg~y recant
eval~atmn
c”icardiah
o”n Irransrhoiaclci
made a substardial
wo-dimeowmal.
of chtl-
dren atth congeniml heart disease have become m”re com-
FACC
ologists treating children
largely been prowled
wxJv can be achieved I” mat
Yet buth the msdul
I” TIMOTHY
hne
of the tmnsrhoractc
iim,an”“s
ficla ~~enhtv. Therefore.
of a commercially
inmwophaeeai
echocardiogmphx
ing ~20 k: I\ rcportedlg rnphi
crucial
IO sxolore
echocardlog-
I” uch
children imaging
\ttth a linnied prccurdial
m
Fmm a techntcal smndavailable
bin&e-plane
probe 1x1children ueigh-
not vgmficantly
(101. Applicauon
c”n~cnt~“nai
it is
we of wansesophageal echocardiogphy
parrag?
in adult\
after
cathelenza-
and. at least m theory.
as Irans;sophegeal
chddren to d&c is limited (10-17) pomt.
of ihe
of hemodynamlcs
and mlcrvenr~“nal
are cumbersome
Imaging rys~cm, &h
raph) The rcpurlcd
imaging
rechmqoes designed
different from rhal
of ~ransesophageal ohocardiog
has been considcrcd techmques.
an adjunct t”
panicularly
in padents
window or complex anatomy.
such
a, tho,e i\ho hiwe had the procedure (I 11. Transesophdwl echvcardugraphv has also been mlroduced in the catheterizillion iabwatory 1” enhance naping of the alrial seplum in p;n~emx underg”ing transcatheter closure of an amal seplnl dcfccl In pahcnt, nelghmg 40 kg. the experience wilh tnob-
,1?,.
cwph+eeni cchuurdiography I$ even m”re limited and largely rcwicled iu the ox of pr”u”type pediatric probe? not yet available 10 the pracreing cardtologlst (131. Indicatlom for iranresophagsal echocardiography m these pstienls remam I” be defined. The present study. Ln fhls issue ofthe Journal. Stumper et .I,_ dacribc their initial experience with tnnsesophageal echocw+~ogr~ph) (prototype smgle-plane probe1 in 22 children undergomg mtervcnlional cardiac catheterization. These ,nver,,gat”rs are 1” be congratulated for their conlin-
i ISI
ued p,oncermg iturk ,11.16) wth lransesoQhageal echocardiography in chddren with cungemtal heart disease. But. :dthough
,hc,r rep””
rr;m\esophage;d
describes
echocardiography
some of the first
“ses of
m the catheterization
lab-
aramry and is therefore an important contribution. the place
procedure requires endotncheal
and we of general anesthesia.
Although
in-
in this
the inveshgalors encountered no complicalions with pamy of ihc probe (maximal duneter IO mm) in children weighmg as ihttle a, 9.5 kg. they idenllfy. from their IDIal rlnertence of 268 sludies. four “adems who had iomplicar~ rton, , IS), Traneesaphageal e;hocardiagraphy accurately characterized the atriovenmcular anntomy of the patients in
this study. including that of one patient with a previously ““dngnosed a~nai septal defect. but ” faded t” provide adequate viwalizatio” ofthe pulmonary valve. right ventricular outflaw tract and proximal descending aorta. Areas of systemic venous obstruction in palients with a Mustard re”au were identifird. hut ““or alienment of the Doooler ads to blood flow faded Id predici the prssrure g&lent before and ailrr baboon dilation. On the basis of these data, the advantages of tranrerophageat echocardiography over standard catheterization techniques (oximetry. angiography and pressure monitaris) are doubtful and seem to be outwkighed by the the&tic risk of the procedure. The additwn of biplane imaging and continuous wave Doppler ultrasound will undoubtedly “vercome these limitations. One unique feature of tranresophageal echocardiography alreadv available that the invertieatorr identifv is the abilitv to m&itor amtic valve morpi&ogy and ihe degree df regurgitation between balloon dilations, thus providing the interventionalist with immediate feedback. The future of transesophagealechocardiography in childre”. This orocedure is alreadv orovidine imcoriant information withbut the need for g&al a”es&e& in our older patients with limited echocwdiographic windows. Biplane imaging will soon allow multiple tomographic views of cardiac structure and complete characterization of flow patterns in sw”“tic and regurgitant lesions. Transesophageat cchacardiography may help t” limit or eliminate the need for diagnostic catheterization in the postoperative patient with complex anatomy. With the addition of continuous wave Doppler ultrasound to these probes, instantaneous assess. ment of balloon dilation and surgical correction may bec”me z reality. Because definitive surgical repair and catheter intervcntion arc being performed on younger and smaller children wth congenital heart disease, it is this group of patienls thal the technology must target before transesophagealechocardiography alters the pmct!ce of the pedntric cardiologist. More flexible gartroscopes, miniaturization of transducers, addition ofcantinuaus wave Doppler and biplane technology to probes that can he accommodated by the esophagus of small patients must be developed for the technique to make a lasting unpact. Transenaphageal echocardiography has the potential to make a rigniticant contribution to the management of children with congenital heart disease.Tcch”&ic advancesi” the technique will SO”” make complex analysis of cardiac btruct”re and Row dynamics a reality in older pediatric patients. Techniques for transesophagealechocardiography in younger children and infants are now being explored. Report> like that of Stlimper et al. (IS) wdl help 10establish
the necessarvindications and methcds for the vrrocedurein pediatric paiients. Tranaesophagcal echocardiography is poised LOmake its tong awaited m”ve int” the practice of pediatric cardiology.
pediilmc
cdrdialag~sn
from ,he mugmg
Advances in Transesop Echocardiography: Impact of a Changing Technology o With Congenital Heart
HI@I re~~~1uvm qmenral culor “w
F. FELTES.
MD.
caiduc
,,~uc!“re\.
provdc
teooardue \e, For the last 2 decades. advances in echocnrdtography
impact on the chnical practice of cardIor adult,.
abilities of ~ranxerophagcal
cardiography
have evolved
among cardiologists nologic
advance
scrutiny.
have
In the Iat
rapidly.
i years. the ccho-
a, bar itb Qopular~?
treating adults. Becaux in echocardiography
each new Iech-
bong,
we are yet agam faced with
a pcrtod
the question.
of Do
pediatric patients stand 10 benefit fmm thn new technology’! Transesophageal echocardiography that conventional don and Doppler hampered
The findme
transthoracic ultrasound image resoluassessment of the hear1 we frequenrly
in adult
new approaches.
in adul8.
patienls
has prompted
Because of it? retmcardiac
G scnrch
for
loulion.
the
esophagus has been rccogmzed as providing an ~lremat~ve “window” (I). In 1980. Matsumot” et al. 121 ruccessfully monitored left ventricular Qerf”rmsnce with USCoi a wan
and improved.
high re~olul~on car-
diac assessmenl by means of the lransesophageal became possible by the late 1980s 01. Reccnlly.
appruach the intro-
duction of biplane oansesophageal echucardiography ha\ made scanning possible in both Ihe tmnsverie and verucal olanes of the heart ,4,. In adults. tran,e,“phageal echocarbiography has overcome such ullrasound bx~&r\ ~IL chehl wall impedance and prosthetic valve shielding to grci~ti~
on accurate
Echocard~qraphx
immcdtstc
_
surccr~ (that ii.
imagmg and interrogative
approach.
Doppler
and
pediatric wI,enls.
and the surgical management
Qlcx and increa~mg~y recant
eval~atmn
c”icardiah
o”n Irransrhoiaclci
made a substardial
wo-dimeowmal.
of chtl-
dren atth congeniml heart disease have become m”re com-
FACC
ologists treating children
largely been prowled
wxJv can be achieved I” mat
Yet buth the msdul
I” TIMOTHY
hne
of the tmnsrhoractc
iim,an”“s
ficla ~~enhtv. Therefore.
of a commercially
inmwophaeeai
echocardiogmphx
ing ~20 k: I\ rcportedlg rnphi
crucial
IO sxolore
echocardlog-
I” uch
children imaging
\ttth a linnied prccurdial
m
Fmm a techntcal smndavailable
bin&e-plane
probe 1x1children ueigh-
not vgmficantly
(101. Applicauon
c”n~cnt~“nai
it is
we of wansesophageal echocardiogphy
parrag?
in adult\
after
cathelenza-
and. at least m theory.
as Irans;sophegeal
chddren to d&c is limited (10-17) pomt.
of ihe
of hemodynamlcs
and mlcrvenr~“nal
are cumbersome
Imaging rys~cm, &h
raph) The rcpurlcd
imaging
rechmqoes designed
different from rhal
of ~ransesophageal ohocardiog
has been considcrcd techmques.
an adjunct t”
panicularly
in padents
window or complex anatomy.
such
a, tho,e i\ho hiwe had the procedure (I 11. Transesophdwl echvcardugraphv has also been mlroduced in the catheterizillion iabwatory 1” enhance naping of the alrial seplum in p;n~emx underg”ing transcatheter closure of an amal seplnl dcfccl In pahcnt, nelghmg 40 kg. the experience wilh tnob-
,1?,.
cwph+eeni cchuurdiography I$ even m”re limited and largely rcwicled iu the ox of pr”u”type pediatric probe? not yet available 10 the pracreing cardtologlst (131. Indicatlom for iranresophagsal echocardiography m these pstienls remam I” be defined. The present study. Ln fhls issue ofthe Journal. Stumper et .I,_ dacribc their initial experience with tnnsesophageal echocw+~ogr~ph) (prototype smgle-plane probe1 in 22 children undergomg mtervcnlional cardiac catheterization. These ,nver,,gat”rs are 1” be congratulated for their conlin-
i ISI
ued p,oncermg iturk ,11.16) wth lransesoQhageal echocardiography in chddren with cungemtal heart disease. But. :dthough
,hc,r rep””
rr;m\esophage;d
describes
echocardiography
some of the first
“ses of
m the catheterization
lab-
aramry and is therefore an important contribution. the place
procedure requires endotncheal
and we of general anesthesia.
Although
in-
in this
the inveshgalors encountered no complicalions with pamy of ihc probe (maximal duneter IO mm) in children weighmg as ihttle a, 9.5 kg. they idenllfy. from their IDIal rlnertence of 268 sludies. four “adems who had iomplicar~ rton, , IS), Traneesaphageal e;hocardiagraphy accurately characterized the atriovenmcular anntomy of the patients in
this study. including that of one patient with a previously ““dngnosed a~nai septal defect. but ” faded t” provide adequate viwalizatio” ofthe pulmonary valve. right ventricular outflaw tract and proximal descending aorta. Areas of systemic venous obstruction in palients with a Mustard re”au were identifird. hut ““or alienment of the Doooler ads to blood flow faded Id predici the prssrure g&lent before and ailrr baboon dilation. On the basis of these data, the advantages of tranrerophageat echocardiography over standard catheterization techniques (oximetry. angiography and pressure monitaris) are doubtful and seem to be outwkighed by the the&tic risk of the procedure. The additwn of biplane imaging and continuous wave Doppler ultrasound will undoubtedly “vercome these limitations. One unique feature of tranresophageal echocardiography alreadv available that the invertieatorr identifv is the abilitv to m&itor amtic valve morpi&ogy and ihe degree df regurgitation between balloon dilations, thus providing the interventionalist with immediate feedback. The future of transesophagealechocardiography in childre”. This orocedure is alreadv orovidine imcoriant information withbut the need for g&al a”es&e& in our older patients with limited echocwdiographic windows. Biplane imaging will soon allow multiple tomographic views of cardiac structure and complete characterization of flow patterns in sw”“tic and regurgitant lesions. Transesophageat cchacardiography may help t” limit or eliminate the need for diagnostic catheterization in the postoperative patient with complex anatomy. With the addition of continuous wave Doppler ultrasound to these probes, instantaneous assess. ment of balloon dilation and surgical correction may bec”me z reality. Because definitive surgical repair and catheter intervcntion arc being performed on younger and smaller children wth congenital heart disease, it is this group of patienls thal the technology must target before transesophagealechocardiography alters the pmct!ce of the pedntric cardiologist. More flexible gartroscopes, miniaturization of transducers, addition ofcantinuaus wave Doppler and biplane technology to probes that can he accommodated by the esophagus of small patients must be developed for the technique to make a lasting unpact. Transenaphageal echocardiography has the potential to make a rigniticant contribution to the management of children with congenital heart disease.Tcch”&ic advancesi” the technique will SO”” make complex analysis of cardiac btruct”re and Row dynamics a reality in older pediatric patients. Techniques for transesophagealechocardiography in younger children and infants are now being explored. Report> like that of Stlimper et al. (IS) wdl help 10establish
the necessarvindications and methcds for the vrrocedurein pediatric paiients. Tranaesophagcal echocardiography is poised LOmake its tong awaited m”ve int” the practice of pediatric cardiology.