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Intraoperative transesophageal echocardiography (TEE) in patients with congenital heart disease. Its impact on the immediate and late follow-up period
368
Abstracts
6B
Withdrawn by authors' request
6C
INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOG R A P H Y (TEE) IN PATIENTS W I T H C O N G E N I T A L H E A R T DISEASE. ITS I M P A C T ON T H E I M M E D I A T E AND LATE F O L L O W - U P PERIOD. Tamara Martins MD, Alvaro Moraes MD, Caio Medeiros M D Miguel Barbero-Marcial MD, Jogo Sbaan MD, Giovanni Cerri MD, Giovanni Bellotti MD, Adib Jatene MD, Fulvio Pileggi MD. HEART INSTITUTE - UNIVERSITY OF SAO PAULO - BRAZIL.
Journal o f the American Society o f Echocardiography May lune 1996
Oral Abstract Session 7 3 - D Echocardiography 7A
THREE-DIMENSIONAL RECONSTRUCTION OF THE MITRAL ANNULUS: COMPARISON OF NORMAL ADULTS VERSUS PATIENTS WITH ISCHEMIC MITRAL REGURGITATION G. Bashein MD Phi), B. Munt MD, M.E. Legget MB ChB, R.W. Martin PhD, F.H. Sheehan MD, X.N. Li MD, E.L. Bolsnn MS, D.F. Leotta MS, M. Sivarajan MD, C.M. Otto MD University of Washington, Seattle, WA. We hypothesized that mitral regurgitation (MR) in ischemic heart disease (IHD) is associated with a more planar, less saddleshaped annulus. Six normals and 4 IHD patients with moderate to severe MR without mitral leaflet pathology were studied under general anesthesia during suspended mechanical ventilation. The mitral annulus was scanned with a multiptane transesophageal probe rotated through 24-33 planes. T h e annulus was manually outlined using custom software enabling interactive threedimensional visualization and editing, and then fitted using a 5harmonic Fourier series in each of the three spatial coordinates. The point-to-point path length was used as the indepeMent variable. Annulus height was calculated as the distance from its highest to lowest point. * means+SD Normal* lschemic* p Height Diastole, cm .gl-+.10 .49+.22 .002 Height Systole, cm .80+.15 .62+_.20 .12 Change in Height, cm .11+.16 -.13-+.18 .06 Area Diastole, cm 2 8.6+_1.4 11.1-+6.1 .47 Area Systole, cm2 8.9+1.8 12.7+_8.1 .42 Major Axis Diastole, cm 3.7-+.44 4.1-+I.1 .48 Major Axis Systole, cm 3.5-.35 4.1+1.4 .45 These data suggest that in normal subjects the mitral ammlus remains non-planar during systole and diastole, and the annular area does not change significantly. Patients with IHD and MR have a more planar mitral annulus compared with normal subjects. The saddle-shaped structure may be important biomechanically for valve function, and is modified in IHD with MR.
7B
INTRAOPERATIVE THREE DIMENSIONAL TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN M1TRAL VALVE REPAIR OF MITRAL VALVE PROLAPSE: COMPARISON TO QUADRILATERAL TISSUE RESECTION. Christian S. Breburda, MD, Hiroya Kondo, MD, Brian Griffin, MD, Delos M Cosgrove III, MD, James D. Thomas, MD, The Cleveland Clinic Foundation, Cleveland, OH
To compare the follow-up ofpts who underwent surgery monitored by TEE (Group A) with those who were not (Group B), 83 pts were studied: Group A-44 pts (4 days-29 years, 3-60 kg, 26 males), and Group B-39 pts (8 months-32 years, 5-69 kg, 25 males) Group A defects were: ventricular septal defect (VSD)=8; atrial septal defect (ASD)=3; atrial ventricular septal defect (AVSD)=4; discret subaortic stenosis (SS)=5; Tetralogy of Faltot (TOF)=6; transposition of great arteries (TGA)=5 and others=7. Group B defects were: VSD=I4; ASD-5; AVSD=3; SS-4; TOF-5 and others=7. There was no differences concerning age, weight and sex distribution for both groups. Intraoperative TEE detected 5 (11%) important residual defects (RD) after post-pump evaluation: 2 with right ventricular outflow tract (RVOT) obstruction in TOF; 2 detachment of portion of the patch in AVSD and 1 previous Blalock pervious, that were corrected in the same operative time. No significant RD were detected in 9 pts (20%). In the late follow-up, these defects were followed by transthoracic echocardiography (TTE), with no re-operation. In Group B TTE detected, in the immediate follow-up, 6 (15%) important RD (3 RVOT obstruction; 2 VSD and I supra-valvar pulmonary stenosis) and 14 (36%) with no significant RD. There was a higher rate of residual RVOT obstruction and VSD in Group B. After 12-18 months, all pts were in functional class I despite 3 re-operations in Group B. In conclusion intraoperative TEE allowed an adequate analysis of the RD to correct them on the same sugery; and, at least in this study, it avoided re-operations in this follow-up period.
6D
ROLE OF INTRAOPERATIVETRANSESOPHAGEALECHOCARDIOGRAPHY IN CONGENITALCARDIACSURGERY:THE TCH EXPERIENCE LI Bezold MD, R Pigantelli MD, CA Altman MD, TF Feltes MD, RJ GajarskiMD~ GW Vick MD, PhD, NA AyresMD, Texas Children's Hospital,HoustonTX. lntraoperative transesophagealechocardiography(ITEE) is becoming the standard of care during surgery for congenital heart disease (CHD). The role of ITEE, especially in infants, continues to be refined, aIlowingimprovedpt selection which is desirable in tiffs era of cost-consciousness and limited resources. We sought to further define the role of ITEE by retrospectivereview of 341 studies performedat Texas Children's Hospital (1990-95). Data regarding diagnostic information, impact on surgical managementand outcome,and complicationswere analyzed. Results: Pts ranged from 2.5-128 kg (mean ll.2 kg), and from 2 days - 49 yr (mean 4 yr). Biplane probes were used in 313 pts (92%), with adult probes routinely used in pts _>15kg. Similar to most tertiary-centers, complex diagnoses predominated, but common lesions were well represented Minor diagnostic changes occurred in 45 pts (13%). Prebypass ITEE findings altered planned surgical procedures in 32 pts (9.4%), most frequeutly involving VSDs with associated obstructivelesions, subaortic stanosis, and atriovantricularvalve (AVV) dysfunction. 28 pts (8.2%) underwentimmediate reoperation, with ITEE providing useful information for surgical revision, most comranniy demonstrating residual AVV regurgitation or obstructed veturicular outflows, Fontan or Glenn circuits. primary diagnoses in pts requiring reoperation were VSD with associated lesions, AVV dysfunction, atrioventricular canal (AVC) defects, and complex single ventricles. In the subset of neonatal pts (16 arterial switches, 5 TAPVR repairs, 7 systemic outflow obstruction repairs) ITEE provided limited 1low anatomic information that affected the surgical approach, however provided important data on ventricular volume, function and suspected coronary insufficiency of clinical importance during weaning from CPB and in the early postoperative period. In contrast, ITEE had limited impact in uncomplicated ASD and VSD repairs. No major complications occurred,but 5 studies (1.5%) were terminated due to possible airway compression(withoutsequelae)in infants weighing < 4 kg. Conclusions: Our large series confirms the safety and clarifies the role of ITEE in the management of CHD. ITEE is clearly indicated in surgery involving single ventricles, complex lesions, complicated VSDs, left or right ventricular outflow obstructions, AVV and AVC repairs, In neonates and small infants ITEE is safe and provides clinically important data, particularly during weaning from CPB and in the early postoperativeperiod. Our data do not support routine use of ITEE in simple ASD or VSD repairs.
The utilization of intraoperative three-dimensinnal transesophageal echocardiography (3DE) in mitral valve repair (MVRep) is undetermined. To evaluate the location, area and volume of mitral valve prolapse (MVP) with correlation to the size of the resected valvular tissue we examined 14 pts (11 males, mean age 59.9, range 27-70) intranperatively pro and post mitral valve repair. Rotational respiratory and ECG gated 2D TEE images were acquired at every 3 degrees (from 0-180) using an omniplane TEE orobe. A surglcal view from the left atrium on the mitral valve was chosen for intranperative dynamic 3DE (TomTec) reconstmctinn. The mitral valve apparatus was electronically extracted and prolapse quantitated by manual tracing of 1 mm slices. Results: Dynamic 3DE was accomplished in all patients. Intranperative artifact reduced 3DE quality ofaquisition in n=4 (28%) pre and n=3 (23%) post MVRep. Comparing 3DE to 2DE detected additional prolapse areas of the same leaflet, n=4 (28%) and & t h e other leaflet, n=5 (36%). In one patient requiring a prosthesis 75% of the leaflet prolapsed (3D volume 15 ml) compared to a mean of 55% MVP area in the 13 MVR pts (mean 3 D '~ p3o,~,~ ° volume 7.4 ml). Average 3D ~] . . . . . . prolapse volume (3PV) was 0m, : 8.3 ±1.9 ml (SE). 3D prolaps~ o / area (3PA) was 4.3 ~ 0.9 cm ~ , = o . ~ versus 7 ± 1.2 cm resected 2i oo • ,,o.oo9 tissue area (p < 0004, t-test) *, with shown regression line . . R e.j e c t e d . M~tral V a t v e T; l ~ u * A r e a ,',in e m 2 2'° Conclusions: 1. Intraoperative 3DE in MVR is feasible and locates additional prolapse areas when compared to 2D TEE. 2. The resected tissue area is significantly larger than 3DE prolapse area. 3. 3DE may facilitate surgical planning for MV repair versus MV prosthesis by assessing 3D prolapse volume and area.
Abstracts
6B
Withdrawn by authors' request
6C
INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOG R A P H Y (TEE) IN PATIENTS W I T H C O N G E N I T A L H E A R T DISEASE. ITS I M P A C T ON T H E I M M E D I A T E AND LATE F O L L O W - U P PERIOD. Tamara Martins MD, Alvaro Moraes MD, Caio Medeiros M D Miguel Barbero-Marcial MD, Jogo Sbaan MD, Giovanni Cerri MD, Giovanni Bellotti MD, Adib Jatene MD, Fulvio Pileggi MD. HEART INSTITUTE - UNIVERSITY OF SAO PAULO - BRAZIL.
Journal o f the American Society o f Echocardiography May lune 1996
Oral Abstract Session 7 3 - D Echocardiography 7A
THREE-DIMENSIONAL RECONSTRUCTION OF THE MITRAL ANNULUS: COMPARISON OF NORMAL ADULTS VERSUS PATIENTS WITH ISCHEMIC MITRAL REGURGITATION G. Bashein MD Phi), B. Munt MD, M.E. Legget MB ChB, R.W. Martin PhD, F.H. Sheehan MD, X.N. Li MD, E.L. Bolsnn MS, D.F. Leotta MS, M. Sivarajan MD, C.M. Otto MD University of Washington, Seattle, WA. We hypothesized that mitral regurgitation (MR) in ischemic heart disease (IHD) is associated with a more planar, less saddleshaped annulus. Six normals and 4 IHD patients with moderate to severe MR without mitral leaflet pathology were studied under general anesthesia during suspended mechanical ventilation. The mitral annulus was scanned with a multiptane transesophageal probe rotated through 24-33 planes. T h e annulus was manually outlined using custom software enabling interactive threedimensional visualization and editing, and then fitted using a 5harmonic Fourier series in each of the three spatial coordinates. The point-to-point path length was used as the indepeMent variable. Annulus height was calculated as the distance from its highest to lowest point. * means+SD Normal* lschemic* p Height Diastole, cm .gl-+.10 .49+.22 .002 Height Systole, cm .80+.15 .62+_.20 .12 Change in Height, cm .11+.16 -.13-+.18 .06 Area Diastole, cm 2 8.6+_1.4 11.1-+6.1 .47 Area Systole, cm2 8.9+1.8 12.7+_8.1 .42 Major Axis Diastole, cm 3.7-+.44 4.1-+I.1 .48 Major Axis Systole, cm 3.5-.35 4.1+1.4 .45 These data suggest that in normal subjects the mitral ammlus remains non-planar during systole and diastole, and the annular area does not change significantly. Patients with IHD and MR have a more planar mitral annulus compared with normal subjects. The saddle-shaped structure may be important biomechanically for valve function, and is modified in IHD with MR.
7B
INTRAOPERATIVE THREE DIMENSIONAL TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN M1TRAL VALVE REPAIR OF MITRAL VALVE PROLAPSE: COMPARISON TO QUADRILATERAL TISSUE RESECTION. Christian S. Breburda, MD, Hiroya Kondo, MD, Brian Griffin, MD, Delos M Cosgrove III, MD, James D. Thomas, MD, The Cleveland Clinic Foundation, Cleveland, OH
To compare the follow-up ofpts who underwent surgery monitored by TEE (Group A) with those who were not (Group B), 83 pts were studied: Group A-44 pts (4 days-29 years, 3-60 kg, 26 males), and Group B-39 pts (8 months-32 years, 5-69 kg, 25 males) Group A defects were: ventricular septal defect (VSD)=8; atrial septal defect (ASD)=3; atrial ventricular septal defect (AVSD)=4; discret subaortic stenosis (SS)=5; Tetralogy of Faltot (TOF)=6; transposition of great arteries (TGA)=5 and others=7. Group B defects were: VSD=I4; ASD-5; AVSD=3; SS-4; TOF-5 and others=7. There was no differences concerning age, weight and sex distribution for both groups. Intraoperative TEE detected 5 (11%) important residual defects (RD) after post-pump evaluation: 2 with right ventricular outflow tract (RVOT) obstruction in TOF; 2 detachment of portion of the patch in AVSD and 1 previous Blalock pervious, that were corrected in the same operative time. No significant RD were detected in 9 pts (20%). In the late follow-up, these defects were followed by transthoracic echocardiography (TTE), with no re-operation. In Group B TTE detected, in the immediate follow-up, 6 (15%) important RD (3 RVOT obstruction; 2 VSD and I supra-valvar pulmonary stenosis) and 14 (36%) with no significant RD. There was a higher rate of residual RVOT obstruction and VSD in Group B. After 12-18 months, all pts were in functional class I despite 3 re-operations in Group B. In conclusion intraoperative TEE allowed an adequate analysis of the RD to correct them on the same sugery; and, at least in this study, it avoided re-operations in this follow-up period.
6D
ROLE OF INTRAOPERATIVETRANSESOPHAGEALECHOCARDIOGRAPHY IN CONGENITALCARDIACSURGERY:THE TCH EXPERIENCE LI Bezold MD, R Pigantelli MD, CA Altman MD, TF Feltes MD, RJ GajarskiMD~ GW Vick MD, PhD, NA AyresMD, Texas Children's Hospital,HoustonTX. lntraoperative transesophagealechocardiography(ITEE) is becoming the standard of care during surgery for congenital heart disease (CHD). The role of ITEE, especially in infants, continues to be refined, aIlowingimprovedpt selection which is desirable in tiffs era of cost-consciousness and limited resources. We sought to further define the role of ITEE by retrospectivereview of 341 studies performedat Texas Children's Hospital (1990-95). Data regarding diagnostic information, impact on surgical managementand outcome,and complicationswere analyzed. Results: Pts ranged from 2.5-128 kg (mean ll.2 kg), and from 2 days - 49 yr (mean 4 yr). Biplane probes were used in 313 pts (92%), with adult probes routinely used in pts _>15kg. Similar to most tertiary-centers, complex diagnoses predominated, but common lesions were well represented Minor diagnostic changes occurred in 45 pts (13%). Prebypass ITEE findings altered planned surgical procedures in 32 pts (9.4%), most frequeutly involving VSDs with associated obstructivelesions, subaortic stanosis, and atriovantricularvalve (AVV) dysfunction. 28 pts (8.2%) underwentimmediate reoperation, with ITEE providing useful information for surgical revision, most comranniy demonstrating residual AVV regurgitation or obstructed veturicular outflows, Fontan or Glenn circuits. primary diagnoses in pts requiring reoperation were VSD with associated lesions, AVV dysfunction, atrioventricular canal (AVC) defects, and complex single ventricles. In the subset of neonatal pts (16 arterial switches, 5 TAPVR repairs, 7 systemic outflow obstruction repairs) ITEE provided limited 1low anatomic information that affected the surgical approach, however provided important data on ventricular volume, function and suspected coronary insufficiency of clinical importance during weaning from CPB and in the early postoperative period. In contrast, ITEE had limited impact in uncomplicated ASD and VSD repairs. No major complications occurred,but 5 studies (1.5%) were terminated due to possible airway compression(withoutsequelae)in infants weighing < 4 kg. Conclusions: Our large series confirms the safety and clarifies the role of ITEE in the management of CHD. ITEE is clearly indicated in surgery involving single ventricles, complex lesions, complicated VSDs, left or right ventricular outflow obstructions, AVV and AVC repairs, In neonates and small infants ITEE is safe and provides clinically important data, particularly during weaning from CPB and in the early postoperativeperiod. Our data do not support routine use of ITEE in simple ASD or VSD repairs.
The utilization of intraoperative three-dimensinnal transesophageal echocardiography (3DE) in mitral valve repair (MVRep) is undetermined. To evaluate the location, area and volume of mitral valve prolapse (MVP) with correlation to the size of the resected valvular tissue we examined 14 pts (11 males, mean age 59.9, range 27-70) intranperatively pro and post mitral valve repair. Rotational respiratory and ECG gated 2D TEE images were acquired at every 3 degrees (from 0-180) using an omniplane TEE orobe. A surglcal view from the left atrium on the mitral valve was chosen for intranperative dynamic 3DE (TomTec) reconstmctinn. The mitral valve apparatus was electronically extracted and prolapse quantitated by manual tracing of 1 mm slices. Results: Dynamic 3DE was accomplished in all patients. Intranperative artifact reduced 3DE quality ofaquisition in n=4 (28%) pre and n=3 (23%) post MVRep. Comparing 3DE to 2DE detected additional prolapse areas of the same leaflet, n=4 (28%) and & t h e other leaflet, n=5 (36%). In one patient requiring a prosthesis 75% of the leaflet prolapsed (3D volume 15 ml) compared to a mean of 55% MVP area in the 13 MVR pts (mean 3 D '~ p3o,~,~ ° volume 7.4 ml). Average 3D ~] . . . . . . prolapse volume (3PV) was 0m, : 8.3 ±1.9 ml (SE). 3D prolaps~ o / area (3PA) was 4.3 ~ 0.9 cm ~ , = o . ~ versus 7 ± 1.2 cm resected 2i oo • ,,o.oo9 tissue area (p < 0004, t-test) *, with shown regression line . . R e.j e c t e d . M~tral V a t v e T; l ~ u * A r e a ,',in e m 2 2'° Conclusions: 1. Intraoperative 3DE in MVR is feasible and locates additional prolapse areas when compared to 2D TEE. 2. The resected tissue area is significantly larger than 3DE prolapse area. 3. 3DE may facilitate surgical planning for MV repair versus MV prosthesis by assessing 3D prolapse volume and area.