- Email: [email protected]
Usefulness of biplane transesophageal echocardiography in neonates, infants and children with congenital heart disease
Usefulness of Biplane Transesophageal Echocardiography in Neonates, Infants and Children with Congenital Heart Disease Jan Lam, MD, Rodolfo A. Neirotti, MD, Wies J. Lubbers, MD, Mies S. J. Naeff, MD, Connie M. Blom-Muilwijk, MD, Jaap L. Schuller, MD, Fergus J. Macartney, MD, and Cees A. Visser, MD A study was performed to assess the feasibility, additional diaghostic value and potential applitions of biplane transesophageal echocardiom phy in neonates, infants and children. One hum dred thirty-two consecMve studies were attempted in ii1 anesthetized children with congenital heart disease. Longrtudinal and transverse planes werecomparedu!3ing3-
(1) separate
7
mm longitudinal and transverse pediatric trans ducers used sequentiilly; (2) an experimental 9 x 8 mm biplane pediic transducer, and (3) a stae dard adult biplane transducer (12 x 9 or 13 x 9 mm). In all but 1 patient, a probe could be inserted. The longitudinal plane provided superior visualization qf both the right and left ventricular outflow tracts, the interatfial septum, the main puC monary artery, the ascending aorta and the rim coronary artery. In l8 patients (18%), the longitudinal plane provided completely new diagnostic irr fommtion that was not obtained with combined transthoracic and transverse plane tram geal echocardiography. However, the transverse plane was mandatory for demonstration of the 4chamber view, shorkxis cross sections throua the #eat arteries, the distal right pulmonary artery and bifurcation of the left coronary artery. The longitudinal plane is complementa ry to the transverse plane, but cannot substitute for it. (Am J Cardiol1993;72:89+798)
From the Departments of Pediatric Cardiology, Pediatric Cardiac Surgery, Pediatric Cardiac Anesthesiology and Cardiology, Academic Medical Center, Amsterdam, and the Interuniversity Cardiological Institute of the Netherlands (KIN), Utrecht, the Netherlands. Manuscript received January 19, 1993; revised manuscript received May 17, 1993, and accepted May 20. Address for reprints: Jan Lam, MD, Academic Medical Center, GS2 15, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
T
he use of biplane transesophagealechocardiography (TEE) in adults is now well established.ts Although there is a growing interest in the use of TEE in infants and small children,g-‘6 biplane TEE in this age category has been reported only rarely.17-19 Only 1 group of investigators used a real biplane pediatric probe.” This is mainly becausebiplane transducers of a size sufficiently small to be inserted in neonatesare not commercially available. To circumvent this limitation we used 2 separate7 mm pediatric transesophageal transducersthat were introduced sequentially during the same study in neonates,infants and small children. One transducer provided the “conventional” transverse plane, the other the longitudinal plane. In addition, an experimental 9 X 8 mm pediatric biplane probe was used during a short period of the study. Children with a body weight 212 kg were usually studied with adultsized transducers,although there was considerableoverlap between the 2 patient cohorts. This study was performed to determine: (1) the feasibility of this technique, particularly in very small children; (2) the additional diagnostic value of the longitudinal plane; and (3) the potential applications of biplane TEE in the pediatric population. MEWODS From January 1991 to June 1992, 132 studies were attempted in 111patients with congenital heart disease either during cardiac surgery (n = 74), diagnostic (n = 35) or interventional (n = 9) catheterization, or noncardisc surgery (n = 5), or for diagnostic purposes only (n = 9). The equipment used in very small children was the 7 mm 5 mHz Aloka transverse plane transducer (Aloka Ltd., Tokyo), the 7 mm 5 MHz Aloka longitudinal plane transducer or an experimental 9 X 8 mm Aloka biplane pediatric transducer. With these transducers, flexion is only possible in the anteroposteriordirection. The equipment used in children with a bodyweight 22 kg was the 13 X 9 mm 5 MHz ATL transducer connected to an ATL Mark VI or IX echocardiograph (Advanced Technical Laboratories, Bothell, Washington), the 12 X 9 mm Aloka 5 MHz biplane transducer or the aforementioned pediatric transducers. All Aloka transducerswere connected to an Aloka 830 SSD echocardiograph.In the group of patients studied with pediatric probes (n = lOl), age ranged from 18 hours to 18 years. Body weight ranged from 2.3 to 71.0 kg and was <5 kg in 33 patients, 5 to 10 kg in 28, and 10 to 20 kg in 22. All 101 patients were studied with both the longitudinal and transverse plane transducers. BIPLANETRANSESOPHAGEAL ECHOCARDIOGRAPHY699
In addition, in 12 of 101patients, an attempt was made to introduce the pediatric biplane probe, age distribution of these 12 patients was 18 hours to 13 years. Body weight ranged from 3.3 to 40.0 kg and was 40 kg in 7 patients. In the group of patients studied with an adultsized probe (n = 31), age ranged from 2 to 15 years. Body weight ranged from 12 to 65 kg and was ~20 kg in 13 patients. In 21 patients, biplane TEE was performed twice, during heart catheterization and subsequent operation. The patient protile is summarized in Figures 1 and 2. The probes were inserted by the anesthesiologist or pediatric cardiologist at the beginning of the procedure after intubation, either using a laryngoscope or “blindly.” After insertion of the probes, standard scanning planes were obtained as previously described.3 All studies included color and pulsed-wave Doppler examination; in addition, in patients studied with the Aloka equipment, high pulse repetition frequency Doppler examination was performed, which made it possible to record velocities 53.7 m/s. When aortic regurgitation was suspected,color M-mode was performed. In 61 of 63 surgical patients studied with a pediatric single-plane probe, 1 probe was left in situ
throughout the procedure (determined by anticipating which scanning plane would provide optimal information at the end of the operation). In 35 patients undergoing diagnostic heart catheterization, TEE was performed at the beginning of the invasive procedure after intubation (all TEE studies in nonsurgical patients were performed under general anesthesia).In 9 patients undergoing interventional catheterization, the probe was left in situ throughout the procedure; in these cases,a separatemonitor was connectedto the echocardiograph and positioned in the vicinity of the fluoroscopic monitors, thus providing the operator with simultaneous information in both modalities. In all TEE examinations using single-plane probes, 21 exchange of transducers occurred. Contirmation of TEE diagnosis was obtained by angiography or open-heart surgery in 105 of 111patients. Patients undergoing heart surgery received 50 mg/kg of cefalotine intravenously before insertion of the probe. In the other patients, no antibiotic prophylaxis was given. No patient had an esophagealdisorder. In 1 patient with cardiac diseaseand a stricture of the esophagus after surgically repaired esophagealatresia, it was decided not to perform TEE. In 2 other patients, both operated on because of a vascular ring, TEE was not performed, becauseit was thought that entry to the compressedesophagusmight be traumatic. RESULTS In 30 of 31 patients, an adult-sized biplane probe could be inserted. In 1 surgical patient aged 3 years with a body weight of 15 kg, resistance occurred during attemptedpassageof the probe, and it appearedthat the probe was too big for the patient. In the absenceof a smaller probe, surgery was continued without TEE monitoring. The single-plane pediatric probes could be inserted in all patients. In very small children, care had to be taken to prevent accidental extubation of the endotracheal tube during exchange of probes. The 7 mm probes also provided important morphologic information in a few patients with a body weight 171 kg, when no adult-sized probe was available at the time, and precordial echocardiographywas unsatisfactory becauseof
FlGURE2.Boy,~ed5months,[email protected] plens. Pmminent llwbdan v&e (arrow) protwling d#t at&m. COR q comaary; l.A=leftattium.
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PULMONARY VEINS: In 3 patients, partial abnormal venous connection of 1 right pulmonary vein into the right atrium, which was not diagnosed by transthoracic echocardiography,was detectedby TEE. This was only evident using the transverseplane. In the entire group of patients, the longitudinal plane had no advantagein diagnosing abnormalities of the pulmonary veins. CORONARY SLNUS: The coronary sinus was displayed best in the transverse plane. This also applied for patients undergoing intracardiac repair of an atrioventricular septal defect in whom the atria were septatedso that the coronary sinus drained into the left atrium after the repair. In some cases,a prominent Thebesian valve was shown by using the transverseplane. In the longitudinal plane, the coronary sinus was displayed adequately when it was dilated owing to a persistent left superior caval vein. cAv.4LVEINS:The connection of the superior caval vein with the heart was displayed best in the longitudi-
a poor acoustic window. However, in those patients, the imaging of the most anterior part of the heart was not optimal. Color Doppler imaging of the pediatric probes was adequateat a depth 16 cm. The pediatric biplane probe was successfully used in 11of 12 patients, including 1 with a body weight of 3.3 kg. In 1 patient, aged 4 months with a body weight of 4.4 kg, this probe could not be inserted. Because the imaging of the biplane probe was not fully satisfactory,both single-plane transducers were also inserted in all thesepatients. The introduction and manipulation of the pediatric biplane probe were substantially more difficult than were those of the 7 mm single-plane probes. . and atria: Di~aspects:-m ATRIAL APPENDAGES: In a patient with an angiographitally proved left-sided juxtaposition of the atrial appendages,*Othe longitudinal plane provided a longitudinal cross section through both appendages,which displayed the anatomy much better than did the transverse plane (Figure 3). In all the remaining patients, the longitudinal plane was not helpful in detecting abnormalities of the atria1 appendages.
FlwRE4.QM,aged3yean,[email protected] damalse#altlsfect.~ pl;me.m-im sllglitWationuftmnsduce4srevealsthatintwatMseptum binta+andthatatrlalsqvtaldefect@Wffsks lk=tuw rpace between eustachll valve (mww) and inteRMa sep tum.LA=leffeMum;RA=~~atrium;8CV=wperior caval vein.
FlGmE3.Boy,aged6yearr,welglltwkg.-juxt& poslthofatrial -.A,--plane,V---~~rilpt-appencc age(RAA)farmw~.6, lengRudlnal plme dlsphylnglonglhh naIcrosssectionthroughbothabial~s.+=left atrlalappmdage.
.
.__.I
plane. and mitral valve leaflets Coronary sinus (CS) is dilated because of pemistent left superior caval vein. LA = left attfium (distended); LV = left ventricle. BIPLANETRANSESOPHAGEAL ECHOCARDIOGRAPHY 701
nal plane. As expected,21this also applied to a left-sided superior caval vein that descendedin front of the left pulmonary artery, as found in 3 of 3 patients. Using the longitudinal plane, the entranceof the inferior caval vein was marked by the eustachian valve. The inferior caval vein itself was only observed in 1 patient with malposition of the heart; in all other patients, only the confluence with the hepatic veins was observed. In 1 patient, a false-positive image of an atrial septal defect was observed in the longitudinal plane because the area between the eustachianvalve and interatrial septum was mistakenly interpreted to be the defect (Figure 4). In another patient, a Chiari network was displayed best in the longitudinal plane.** Recognition of this structure is important because it precludes performing a clamshell closure of an atrial septal defect.23 THE ATRIAL SEPTUM: The primum and secundumparts of the interatrial septum were profiled better in the longitudinal plane. Defects only visualized in the longitudinal plane were a small secundum-type atrial septal defect in a patient with a double-chamberedright ven-
FlGURE 8. Soy, aged 13 years, plane thrcu@ right venbicular dilatatbn of pulmonay valve DIL). catheter (C) is positionsd valve (snows). G, postdllatation ent scanning plane, increased
wsim 53 lq$ LonfjRudinaI outflow tract (RVGT). Salloon stenosis. A, prsdllatatii (PRE through doming puhnonay (PDST DIL). Sliily difb mobilii of pulmonary valve cusps (anuws). Ao q aorta; LA q left atrium; LVDT = left vetb tkularoutRowtract;PA=pulmunaysutey;RA=ri~at~% urn; RV q @#t ventricle.
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tricle, and a restrictive formen ovale in a patient with mitral atresia. Secundum-typeatria1 septal defects were well displayed in both planes. However, primum- or sinus venosus-typedefects were displayed better in the transverseplane. In 4 of 5 patients undergoing surgical closure of a secundum-typeatria1septal defect, a correct prediction was obtained regarding which defects would also be amenable for clamshell closure based on intraoperative inspection.23In the patient with the wrong prediction, the defect was very close to the inferior caval vein. No patient had a coronary sinus-type atria1septal defect in this series. ATRIOVENTRICULAR VALVE&VENTRICLES AND VENTRICULAR SEPTUM: The size and position of the atrioventricu-
lar valves and junction, and the ventricles were better observed in the 4-chamber view obtained in the transverse plane; therefore, atrioventricular discordance is much more accurately identified in this plane. In cases of tricuspid incompetence,the direction of the jet was better aligned with the Doppler ultrasound beam in the longitudinal than in the transverseview. However, the longitudinal plane could provide a scanning plane through the tricuspid valve in a plane parallel to the annulus. Newly detected defects becoming only apparent in the transverseplane included abnormal attachment of the tricuspid valve to the crest of the interventricular septum in a patient with a ventricular septal defect, and multiplicity of ventricular septal defects in 2 patients. The longitudinal plane provided superior visualization of a supravalvular mitral ring (Figure 5), a small ventricular septal defect in a patient with a double-chambered right ventricle, and a subarterial ventricular septal defect in a third patient. A small residual ventricular septal defect after surgery was displayed equally well in both planes in another patient. In 1 patient operated on because of an aorticopulmonary window, a small muscular ventricular septal defect becameapparentduring follow-up studies,but was overlooked in either plane at the time of the operation. VENTRICULOARTERIAL co~~~cr~o~s: Both outhow tracts were visualized excellently in the longitudinal plane. This applied in particular to the right ventricular outflow
FlouRE7.Girl,~13years,w~s3k&AolticcocvCta thwRhansutysm(A)proximaltonamming.b@tudlM plane. Am 8~88 of nawowln& Ao q aorta proximal coarctation.
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tract, including anterior outlet chambers and conduits between the right ventricle and pulmonary artery. However, in a patient undergoing a Fontan operation with an anterior atriopulmonary anastomosis,this was displayed better in the transverseplane. In 4 of 4 patients with a homograft between the right ventricle and pulmonary artery, the homograft was visualized superiorly in the longitudinal plane. Findings exclusively observed in the longitudinal plane were an acquired subaortic membrane after total correction of an atrioventricular septal defect in 1 patient, and a double-outlet connection to the right ventricle in 1 with atrioventricular discordance. PULMONARYARTERY: In ah patients in whom the main pulmonary artery and right ventricular outiow tract were in the normal position, these structureswere visualized in the longitudinal plane. In 1 patient, this was very helpful in excluding residual obstruction after “debanding” of a previously “banded” pulmonary artery. In the transverse plane, the right ventricular outflow tract was recorded in detail less frequently. In 1 patient with a poor precordial window, severepulmonary valve stenosiswas diagnosed using the longitudinal plane. In 2 patientsundergoingballoon dilatation of the pulmonary valve, the longitudinal plane was very helpful in positioning the balloon and showing increasedmobility of the cusps after the intervention (Figure 6). However, the distal right pulmonary artery was observedbetter in the transverseplane, which often showed the right pulmonary artery up to the superior caval vein. In this way, patency of a Glenn anastomosis could be shown in 1 patient. In 3 of 3 patientswith congenitally correctedtransposition,bifurcation of the pulmonary artery was not shown in either plane. This was possible owing to a learning curve effect, because in recently studied casesnot included in this study, bilkcation was shown in the transverseplane. In all other patients in whom bifurcation was present, it was shown in both planes. In casesof persistentductus arteriosusor aorticopulmonaryshunt, retrogradediastolic flow into the main pulmonary artery was shown more accuratelyin the longitudinal than in the transverseplane. However, a persistent ductus arteriosus in pediatric patients is demonstratedmuch better with precordial echocardiographythan with TEE. In a case of aorticopuhnonary window, this defectwas displayedbetter in the transverseplane. A right upper lobe pulmonary artery was not observedin either plane in any case. AORTA: When the aortic root was in the normal position, the morphology of the cusps was identified accurately in all cases.In most cases,it was visualized equally well in both planes; in some cases,it was observed better in the longitudinal plane. However, the proximal ascendingaorta was visualized much better in the longitudinal plane in all cases.Positive identification of the aortic arch brancheswas only incidentally possible with either technique. In 6 of 6 patients with a coarctation, this was observed in the short-axis view by demonstrating a change in diameter when advancing or withdrawing the probe; only in the last 3 patients with a coarctation was this observedin the longitudinal plane as previously described.24This was possibly due to a learning curve effect. In 1 patient with coarctation, the longitudinal plane revealeda small aneurysmproximal to the nar-
rowing (Figure 7). This aneurysm was documented intraoperatively. CORONARY ARTERIES: In the longitudinal plane, the left coronary artery was observed in a transversecross section; apart from demonstration of its diameter, this had no clinical consequence.The origin of the left coronary artery, including its bifurcation, was observedmuch better in the transverseplane. Only in 2 patients, both with tetralogy of Fallot, was a normal bifurcation of the left coronary artery shown in the longitudinal but not in the transverseplane. The distal circumflex coronary artery was observed frequently in both planes. However, using the longitudinal plane, the right coronary artery was observed in most patients at full length (Figure 8). This was made possible because in the longitudinal plane, a scanning plane could be obtained parallel to the tricuspid annulus. Obtaining such images is not possible in the transverseplane. Using precordial echocardiography in infants, usually a segment of the right coronary artery can be observed, but this is substantially smaller than that found on longitudinal transesophagealscanning. Using the longitudinal plane in 1 patient with transposition of the great arteries, it was prospectively diagnosed that the right and circumflex coronary arteries originated from the sameostium (Figure 9). The ori-
nGUttE8.Gid,agedlweek,we&ht3.lkg.kmspodonof great arteries. A, langltudinal plane showing ri@t coronary artey (amw) over long distance. 6, aortogram of same pa tiint. RA = ri@t atrium. BIPLANETRANSESOPHAGEAL ECHOCARDIOGRAPHY 703
FIGURE 9. Bay, aged l9 hours, weight 3.3 kg. TransposRh of great artehes. A, longitudinal plane, Ion&f axls through right velltlicular outflow tract, revealing oiigln of clwxlmflex comllaly artery &mvs) fmm aorta (Ao). 6, slight mguls tion reveals Mat tight corowq artery mm am-s from same ostium. C, lateral fight ventricular an&#un of same patlent. RV q right ventricle.
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gin of the right coronary artery was shown particularly clearly in casesof tricuspid atresia or hypoplastic right heart syndrome using the longitudinal plane. New dia@~~W i&om~W~ Completely new diagnostic information not provided with transthoracicechocardiography was obtained in 30 patients. Not included in this group of patients are those in whom normal structures were displayed that were not observed with precordial echocardiography,unless this was of clinical relevance (e.g., ruling out of total anomalous pulmonary venous connection). The addition of longitudinal to transverse TEE provided additional information in 18 patients. In this group of patients, 8 had a poor precordial acoustic window. In the remaining 10 patients, the window was satisfactory,but the longitudinal plane provided additional diagnostic information. lntraoperative observations: In a patient scheduled for enucleation of a discrete subaortic stenosis,inspection of the interatrial septum was performed unnecessarily becauseof the aforementionedfalse-positive atrial septal defect. In 5 patients operated on because of various types of atrioventricular septal defects, mild to moderate left atrioventricular valve regurgitation was present before surgery. In all 5 patients, some regurgitation was still present at the end of surgery, but there was no important changein severity as assessedby color Doppler, comparing regurgitant jet areas with the preoperative situation. In all 5 patients, this was thought to be acceptable.In these patients, there was no major discrepancy between the results of assessingmitral regurgitation in the longitudinal or transverseplane. In 1 patient undergoing mitral commissurotomy becauseof congenital mitral stenosis, severe mitral incompetence was present at the end of the procedure, including systolic reversal of flow into the pulmonary veins. After additional valve repair, mild regurgitation persisted.In a patient operatedon becauseof an aortopulmonary window, turbulence was present in the branchesof the pulmonary artery after ligation of the window, as observed in the transverseplane. It was decided to acceptthis sign of obstruction, but during follow-up a gradient in the pulmonary arteries persisted,probably becauseof some kinking of these structures. In a patient operated on becauseof tetralogy of Fallot, a gradient of 35 mm Hg was measuredin the longitudinal plane after repair, and it was decided to accept this residual obstruction. Precordial Doppler studies before discharge revealed a gradient of 40 mm Hg. In 3 patients undergoing an arterial switch operation, wall motion abnormalities were detectedbefore closure of the chest. In 2 of these patients, this observation prompted the surgeon to reinstitiute cardiopulmonary bypass. In these 2 patients, the wall motion abnormalities preceded electrocardiographic changes.All other surgical patients had good ventricular function at the end of the procedure. When monitoring ventricular function during heart surgery in very complex anomalies, one should realize that in certain conditions, satisfactorymyocardial function can coincide with very poor systemicperfusion, as we observed in 1 patient with a univentricular heart, unrestricted pulmonary blood flow and subaortic obstruction who underwent a coarctectomy. SEPTEMBER15, 1993
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Transesophagealmonitoring was performed during interventional catheterizations in 9 patients (2 with pulmonary valvuloplasty, 6 with balloon atrial septostomy, and 1 with blade septostomy). Use of the transverse plane was helpful during atrial septostomy,preventing erroneouspositioning of either the balloon or blade. The transverseplane was chosen becauseit provided a single cross section that showed all structures that were important for prevention of erroneouspositioning of the device, including the pulmonary veins and atrioventricular valves. Becausepatients undergoing atrial septostomy were all neonatesor infants, only single-plane transducers could be used. In the patient studied by biplane TEE during pulmonary balloon valvuloplasty, rapid switching from 1 plane to the other was found to be helpful; this would have been impossible with a singleplane probe. complications: In 1 patient, accidental extubation of the endotracheal tube occurred during exchange of the pediatric probes. This was corrected quickly with reintubation without deterioration in the condition of the patient. Neither blood staining of the probe nor any other complication occurred in any case. DISCUSSION
This study shows that biplane TEE is now also feasible in infants and children provided that 2 separate7 mm transducers are used sequentially. With the use of theseprobes,there is scarcelyany limitation with respect to body size. The main advantageof use of the longitudinal plane during TEE in congenital heart disease appearsto be the accuratevisualization of the right ventricular outflow tract, pulmonary valve and proximal main pulmonary artery (in patients with normally related great arteries). This has important implications from the diagnostic point of view and during interventions such as pulmonary balloon valvuloplasty and surgery of the right ventricular outtlow tract, including insertion of a conduit. The transverseplane is limited for such detailed information. l 6 Potential applications of longitudinal TEE include follow-up of patients with retrostemal conduits and monitoring interventions, including laser valvuloplasty of the pulmonary valve.25Becausethe left ventricular outllow tract and interatrial septum also are well visualized in the longitudinal plane, this approach may be helpful during various interventional procedures including balloon valvuloplasty of the aortic valve and clamshell closure of an atrial septal defect.23The mitral valve can be evaluated in much greater detail with the longitudinal technique. Furthermore, the right coronary artery can be observed at full length in the longitudinal plane, which is not possible in the transverseplane. The limitations of the use of the longitudinal plane alone are its inability to show: (I) the 4-chamber section through the heart; (2) both distal right and left pulmonary arteries in continuity with the bifurcation; and (3) bifurcation of the left coronary artery (with an occasional exception). Becausethe 4-chamber section is very important in congenital heart disease, this view cannot be omitted. Thus, the longitudinal plane is complementary to the transverseplane. Some structures remain difficult
to show with both scanning planes; the right upper lobe pulmonary artery was never recorded, the branches of the aortic arch were shown in somecases,but were very dihicult to identify properly, and continuity between bifurcation of the pulmonary trunk and the complete distal left pulmonary artery was not shown satisfactorily in any plane. Most information regarding the great vessels, which can be obtained in children with suprastemal transthoracicechocardiography,is difficult to obtain with TEE. The use of a 13 X 9 mm biplane TEE probe precludes its use in children with a body weight ~12 kg. The main indication to perform TEE in these small children is perioperatively to conlirm the preoperativediagnosis, evaluate the efficacy of the surgical procedure and monitor ventricular function. However, despite the excellent precordial window in this age group, additional diagnostic information can be obtained, in some cases exclusively, by using the longitudinal plane. Another application of biplane TEE is during interventional catheterization. TEE and x-ray fluoroscopy can be performed simultaneously. Important issues are the prevention of potentially dangerous positioning of guide wires and balloon catheters, and the evaluation of the effectivenessof the procedure.Potentially, TEE can help reduce fluoroscopy time by guiding the placement of guide wires and catheters, particularly when using a biplane probe. Although TEE in children is performed in some institutions without general anesthesia, using ‘ ‘heavy sedation,’ ’ we prefer to perform this investigation under general anesthesia,even in nonsurgical patients. In all patients, the combination of the 2 scanning planesprovided more information than did 1 plane alone. Therefore, exchanges of probes are necessary in the presently described approach. These exchangesare undesirable, particularly after surgical draping. Therefore, the recent introduction of commercially available pediatric biplane probes will contribute to further expansion of the use of biplane TEE in the pediatric age group. Acknowkdgment: We are indebted to A. Wiegman and C. Sakr-Woltz for performing many of the precordial echocardiographic studies, to R.B. A. van den Brink for studying the patient shown in Figure 6, to the many anesthesiologistsfor inserting the transesophageal probes, to E. van de Velde-Visser, A. Ljubic-ten Holte and M. Zuidervaart for preparing the manuscript, to G. J. H. Wentink and WE.M. Kok for preparing the illustrations, and to Aloka/Biomedic, Almere, and Aloka Europe, Hoofddorp, the Netherlands, for supplying the Aloka equipment.
1. Omoto R, Kyo S, Matsamura M, Shah PM, Adachi H, Matwmmaka T. Biplane colour Doppler tramesophageal echocardiography. Its impact on caxJiovascular surgery and further technological progress of the probe, a Matrix phased array biplane probe. E&cardiography 1989;6:423-430. 2. Seward JFI, Khandheria BK, Oh I, Edwards WD, Freeman WK, Tajik AJ. Biplane transesophageal echocardiography: technique, anatomic correlations, image orientation, and clinical applications. Mayo C/in Proc 1990;63:649-680. 2. Bansal RC, Shakudo M, Shah PM, Shah PM. Biplane tramesophageal echocardiography: technique, image orientation and preliminary experience in 131 patients. J Am Sot Echocardiogr 1990;3:348-366. 4. Cohen GI, Ghan KL. Biplane tramesophageal echocardiography: clinical ap-
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7. Omoto R, Kyo S, Matsumura M, Shah PM, Adachi H, Yokote Y, Kondo Y. Evaluation of biplane colour doppler transesophageal echocardiography in 200 consecutive patients. Circuhztion 1992;85:1237-1247. 8. Wang XF, Li 24, Cheng TO, Ding YB, Wang JE, Yang Y. Biplane transesophageal echocardiography: an anatomic-ultrasonic-clinical correlative study. Am Heart J 1992;123:1027-3038. 9. Ritter SB, ‘Ibys D. Pediatric tramesophageal color flow imaging: smaller probes 1989;6:431-440. for smaller hearts. Echocardiography 10. Stllmper 0, Elzenga NJ, Hess J, Sutherland GR. Traosesophageal echocardiography in children with congenital heart disease an initial experience. J Am Coil Cardioi 1990;16:43%l41. u. Sreeram N, Stiimper 0, Kaulitz R, Hess J, Rcelandt JRTC, Sutherland GR. The comparative value of surface and hansesophageal ultrasound in the assessment of congenital abnormalities of the atriovenbicular junction. J Am CON Cardiol 1990; 16:1205-1214. l2. Stilmper 0, Elzenga NJ, Sutherland GR. Left ventricular outflow tract obstmction in childhood improved diagnosis by paediatric tramesophageal echo cardiography. Int J Cardiol 1990;28:107-109. 19. Kaulitz R, Stilmper 0, Geuskens R, Srecmm N, Elzenga NJ, Ghan CK, Bums JE, Godman MI, Hess J, Sutherland GR. We comparative values of the precmdial and tmnsesophageal approaches in the ultrasound evaluation of ahial baffle function following an aterial correction procedure. J Am Coil Cardiol 1990,16:6Cf%694. 14. Lam J, Neimtti RA, Nijveld A, Schuller JL, Blom-Muilwijk CM, Visser CA. Transesophageal echocardiography in paediabic patients: Preliminary results. J Am Sot Echocardiogr 1991;4:43-50.
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1s. Stiimper 0, KaoIitz R, Elzenga NJ, Born N, Rcelandt JRTC, Hess J, Sutherland GR. The value of hansesophageal echocardiography in children with congenital heart disease. J Am Sot Echocardiogr 1991;4:164-176. 16. Stiimper 0, Witsenburg M, Sutherland GR, Cromme-Dijkhuis A, Godman MJ, Hess J. Tramesophageal echocardiogaphic monitoring of interventional cardiac catheterization in children. J Am Co11 Cardiol 1991;18:1506-1514. 17. Omoto R, Kyo S, Matsamura M, Maryama M, Yokote Y. Future technical prospects in biplane tramesophageal echocardiography: of adult and pa&attic biplane matrix protes. Echocardiography 1991;8:713-720. 18. Ritter SB. Tramesophageal real-time echocardiography in infants and children with congenital heart disease. J Am CON Cardiof 1991;18:569-58. IS. Muhiudeen IA, Robertson DA, Silverman NH, Haas GS, Turley K, Cahalan MK. Intmoperative echocardiography for evaluation of congenital heart defects in infants and children. Anesthesiology 199276: 165-172. 20. Hunter AS, Henderson CB, Urquhart W, Farmer MN. Left-sided juxtaposition of the atrial appendages: report of four cases diagnosed by cardiac catheterization and angiocardiography. Br Heart J 1973;35: 1184-l 189. 2l. Podolsky LA, Jacob LE. Schwartz M, Kotler MN, Ioli A. Tramesophageal echocardiography in the diagnosis of the persistent left superior vena cava. J Am Sot Echocardiogr 1992:5: 159-162. 22. Katz ES, Freedberg RS, Rutkovsky L, Martin JC, Kronzon 1. Identification of an unusual right atxial mass as a Chiari network by biplane tmnsesophageal echocar1992;9:273-275. diography. Echocardiography 28. Ferreira SMAG, Ho SY, Anderson RH. Morphological study of defects of the ahial septum within the oval fossa: implications for transcatbeter closure of left-toright shunt. Br Heart J 1992;67:3 16320. 24. Ryan K, Sanyal RS, F’inheim L, Nan& NC. Assessment of aortic coarctation and collateral circulation by biplane transesophageal echocardiography. Echocardiography
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25. Qureshi SA, Rosenthal E, Tynan M, Anjos R, Baker El. Tmnscatbeter laserassisted balloon pulmonaq valve dilatation in pulmonic valve at&a. Am J Cardial 1990;67:428&431.
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(1) separate
7
mm longitudinal and transverse pediatric trans ducers used sequentiilly; (2) an experimental 9 x 8 mm biplane pediic transducer, and (3) a stae dard adult biplane transducer (12 x 9 or 13 x 9 mm). In all but 1 patient, a probe could be inserted. The longitudinal plane provided superior visualization qf both the right and left ventricular outflow tracts, the interatfial septum, the main puC monary artery, the ascending aorta and the rim coronary artery. In l8 patients (18%), the longitudinal plane provided completely new diagnostic irr fommtion that was not obtained with combined transthoracic and transverse plane tram geal echocardiography. However, the transverse plane was mandatory for demonstration of the 4chamber view, shorkxis cross sections throua the #eat arteries, the distal right pulmonary artery and bifurcation of the left coronary artery. The longitudinal plane is complementa ry to the transverse plane, but cannot substitute for it. (Am J Cardiol1993;72:89+798)
From the Departments of Pediatric Cardiology, Pediatric Cardiac Surgery, Pediatric Cardiac Anesthesiology and Cardiology, Academic Medical Center, Amsterdam, and the Interuniversity Cardiological Institute of the Netherlands (KIN), Utrecht, the Netherlands. Manuscript received January 19, 1993; revised manuscript received May 17, 1993, and accepted May 20. Address for reprints: Jan Lam, MD, Academic Medical Center, GS2 15, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
T
he use of biplane transesophagealechocardiography (TEE) in adults is now well established.ts Although there is a growing interest in the use of TEE in infants and small children,g-‘6 biplane TEE in this age category has been reported only rarely.17-19 Only 1 group of investigators used a real biplane pediatric probe.” This is mainly becausebiplane transducers of a size sufficiently small to be inserted in neonatesare not commercially available. To circumvent this limitation we used 2 separate7 mm pediatric transesophageal transducersthat were introduced sequentially during the same study in neonates,infants and small children. One transducer provided the “conventional” transverse plane, the other the longitudinal plane. In addition, an experimental 9 X 8 mm pediatric biplane probe was used during a short period of the study. Children with a body weight 212 kg were usually studied with adultsized transducers,although there was considerableoverlap between the 2 patient cohorts. This study was performed to determine: (1) the feasibility of this technique, particularly in very small children; (2) the additional diagnostic value of the longitudinal plane; and (3) the potential applications of biplane TEE in the pediatric population. MEWODS From January 1991 to June 1992, 132 studies were attempted in 111patients with congenital heart disease either during cardiac surgery (n = 74), diagnostic (n = 35) or interventional (n = 9) catheterization, or noncardisc surgery (n = 5), or for diagnostic purposes only (n = 9). The equipment used in very small children was the 7 mm 5 mHz Aloka transverse plane transducer (Aloka Ltd., Tokyo), the 7 mm 5 MHz Aloka longitudinal plane transducer or an experimental 9 X 8 mm Aloka biplane pediatric transducer. With these transducers, flexion is only possible in the anteroposteriordirection. The equipment used in children with a bodyweight 22 kg was the 13 X 9 mm 5 MHz ATL transducer connected to an ATL Mark VI or IX echocardiograph (Advanced Technical Laboratories, Bothell, Washington), the 12 X 9 mm Aloka 5 MHz biplane transducer or the aforementioned pediatric transducers. All Aloka transducerswere connected to an Aloka 830 SSD echocardiograph.In the group of patients studied with pediatric probes (n = lOl), age ranged from 18 hours to 18 years. Body weight ranged from 2.3 to 71.0 kg and was <5 kg in 33 patients, 5 to 10 kg in 28, and 10 to 20 kg in 22. All 101 patients were studied with both the longitudinal and transverse plane transducers. BIPLANETRANSESOPHAGEAL ECHOCARDIOGRAPHY699
In addition, in 12 of 101patients, an attempt was made to introduce the pediatric biplane probe, age distribution of these 12 patients was 18 hours to 13 years. Body weight ranged from 3.3 to 40.0 kg and was 40 kg in 7 patients. In the group of patients studied with an adultsized probe (n = 31), age ranged from 2 to 15 years. Body weight ranged from 12 to 65 kg and was ~20 kg in 13 patients. In 21 patients, biplane TEE was performed twice, during heart catheterization and subsequent operation. The patient protile is summarized in Figures 1 and 2. The probes were inserted by the anesthesiologist or pediatric cardiologist at the beginning of the procedure after intubation, either using a laryngoscope or “blindly.” After insertion of the probes, standard scanning planes were obtained as previously described.3 All studies included color and pulsed-wave Doppler examination; in addition, in patients studied with the Aloka equipment, high pulse repetition frequency Doppler examination was performed, which made it possible to record velocities 53.7 m/s. When aortic regurgitation was suspected,color M-mode was performed. In 61 of 63 surgical patients studied with a pediatric single-plane probe, 1 probe was left in situ
throughout the procedure (determined by anticipating which scanning plane would provide optimal information at the end of the operation). In 35 patients undergoing diagnostic heart catheterization, TEE was performed at the beginning of the invasive procedure after intubation (all TEE studies in nonsurgical patients were performed under general anesthesia).In 9 patients undergoing interventional catheterization, the probe was left in situ throughout the procedure; in these cases,a separatemonitor was connectedto the echocardiograph and positioned in the vicinity of the fluoroscopic monitors, thus providing the operator with simultaneous information in both modalities. In all TEE examinations using single-plane probes, 21 exchange of transducers occurred. Contirmation of TEE diagnosis was obtained by angiography or open-heart surgery in 105 of 111patients. Patients undergoing heart surgery received 50 mg/kg of cefalotine intravenously before insertion of the probe. In the other patients, no antibiotic prophylaxis was given. No patient had an esophagealdisorder. In 1 patient with cardiac diseaseand a stricture of the esophagus after surgically repaired esophagealatresia, it was decided not to perform TEE. In 2 other patients, both operated on because of a vascular ring, TEE was not performed, becauseit was thought that entry to the compressedesophagusmight be traumatic. RESULTS In 30 of 31 patients, an adult-sized biplane probe could be inserted. In 1 surgical patient aged 3 years with a body weight of 15 kg, resistance occurred during attemptedpassageof the probe, and it appearedthat the probe was too big for the patient. In the absenceof a smaller probe, surgery was continued without TEE monitoring. The single-plane pediatric probes could be inserted in all patients. In very small children, care had to be taken to prevent accidental extubation of the endotracheal tube during exchange of probes. The 7 mm probes also provided important morphologic information in a few patients with a body weight 171 kg, when no adult-sized probe was available at the time, and precordial echocardiographywas unsatisfactory becauseof
FlGURE2.Boy,~ed5months,[email protected] plens. Pmminent llwbdan v&e (arrow) protwling d#t at&m. COR q comaary; l.A=leftattium.
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into
PULMONARY VEINS: In 3 patients, partial abnormal venous connection of 1 right pulmonary vein into the right atrium, which was not diagnosed by transthoracic echocardiography,was detectedby TEE. This was only evident using the transverseplane. In the entire group of patients, the longitudinal plane had no advantagein diagnosing abnormalities of the pulmonary veins. CORONARY SLNUS: The coronary sinus was displayed best in the transverse plane. This also applied for patients undergoing intracardiac repair of an atrioventricular septal defect in whom the atria were septatedso that the coronary sinus drained into the left atrium after the repair. In some cases,a prominent Thebesian valve was shown by using the transverseplane. In the longitudinal plane, the coronary sinus was displayed adequately when it was dilated owing to a persistent left superior caval vein. cAv.4LVEINS:The connection of the superior caval vein with the heart was displayed best in the longitudi-
a poor acoustic window. However, in those patients, the imaging of the most anterior part of the heart was not optimal. Color Doppler imaging of the pediatric probes was adequateat a depth 16 cm. The pediatric biplane probe was successfully used in 11of 12 patients, including 1 with a body weight of 3.3 kg. In 1 patient, aged 4 months with a body weight of 4.4 kg, this probe could not be inserted. Because the imaging of the biplane probe was not fully satisfactory,both single-plane transducers were also inserted in all thesepatients. The introduction and manipulation of the pediatric biplane probe were substantially more difficult than were those of the 7 mm single-plane probes. . and atria: Di~aspects:-m ATRIAL APPENDAGES: In a patient with an angiographitally proved left-sided juxtaposition of the atrial appendages,*Othe longitudinal plane provided a longitudinal cross section through both appendages,which displayed the anatomy much better than did the transverse plane (Figure 3). In all the remaining patients, the longitudinal plane was not helpful in detecting abnormalities of the atria1 appendages.
FlwRE4.QM,aged3yean,[email protected] damalse#altlsfect.~ pl;me.m-im sllglitWationuftmnsduce4srevealsthatintwatMseptum binta+andthatatrlalsqvtaldefect@Wffsks lk=tuw rpace between eustachll valve (mww) and inteRMa sep tum.LA=leffeMum;RA=~~atrium;8CV=wperior caval vein.
FlGmE3.Boy,aged6yearr,welglltwkg.-juxt& poslthofatrial -.A,--plane,V---~~rilpt-appencc age(RAA)farmw~.6, lengRudlnal plme dlsphylnglonglhh naIcrosssectionthroughbothabial~s.+=left atrlalappmdage.
.
.__.I
plane. and mitral valve leaflets Coronary sinus (CS) is dilated because of pemistent left superior caval vein. LA = left attfium (distended); LV = left ventricle. BIPLANETRANSESOPHAGEAL ECHOCARDIOGRAPHY 701
nal plane. As expected,21this also applied to a left-sided superior caval vein that descendedin front of the left pulmonary artery, as found in 3 of 3 patients. Using the longitudinal plane, the entranceof the inferior caval vein was marked by the eustachian valve. The inferior caval vein itself was only observed in 1 patient with malposition of the heart; in all other patients, only the confluence with the hepatic veins was observed. In 1 patient, a false-positive image of an atrial septal defect was observed in the longitudinal plane because the area between the eustachianvalve and interatrial septum was mistakenly interpreted to be the defect (Figure 4). In another patient, a Chiari network was displayed best in the longitudinal plane.** Recognition of this structure is important because it precludes performing a clamshell closure of an atrial septal defect.23 THE ATRIAL SEPTUM: The primum and secundumparts of the interatrial septum were profiled better in the longitudinal plane. Defects only visualized in the longitudinal plane were a small secundum-type atrial septal defect in a patient with a double-chamberedright ven-
FlGURE 8. Soy, aged 13 years, plane thrcu@ right venbicular dilatatbn of pulmonay valve DIL). catheter (C) is positionsd valve (snows). G, postdllatation ent scanning plane, increased
wsim 53 lq$ LonfjRudinaI outflow tract (RVGT). Salloon stenosis. A, prsdllatatii (PRE through doming puhnonay (PDST DIL). Sliily difb mobilii of pulmonary valve cusps (anuws). Ao q aorta; LA q left atrium; LVDT = left vetb tkularoutRowtract;PA=pulmunaysutey;RA=ri~at~% urn; RV q @#t ventricle.
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tricle, and a restrictive formen ovale in a patient with mitral atresia. Secundum-typeatria1 septal defects were well displayed in both planes. However, primum- or sinus venosus-typedefects were displayed better in the transverseplane. In 4 of 5 patients undergoing surgical closure of a secundum-typeatria1septal defect, a correct prediction was obtained regarding which defects would also be amenable for clamshell closure based on intraoperative inspection.23In the patient with the wrong prediction, the defect was very close to the inferior caval vein. No patient had a coronary sinus-type atria1septal defect in this series. ATRIOVENTRICULAR VALVE&VENTRICLES AND VENTRICULAR SEPTUM: The size and position of the atrioventricu-
lar valves and junction, and the ventricles were better observed in the 4-chamber view obtained in the transverse plane; therefore, atrioventricular discordance is much more accurately identified in this plane. In cases of tricuspid incompetence,the direction of the jet was better aligned with the Doppler ultrasound beam in the longitudinal than in the transverseview. However, the longitudinal plane could provide a scanning plane through the tricuspid valve in a plane parallel to the annulus. Newly detected defects becoming only apparent in the transverseplane included abnormal attachment of the tricuspid valve to the crest of the interventricular septum in a patient with a ventricular septal defect, and multiplicity of ventricular septal defects in 2 patients. The longitudinal plane provided superior visualization of a supravalvular mitral ring (Figure 5), a small ventricular septal defect in a patient with a double-chambered right ventricle, and a subarterial ventricular septal defect in a third patient. A small residual ventricular septal defect after surgery was displayed equally well in both planes in another patient. In 1 patient operated on because of an aorticopulmonary window, a small muscular ventricular septal defect becameapparentduring follow-up studies,but was overlooked in either plane at the time of the operation. VENTRICULOARTERIAL co~~~cr~o~s: Both outhow tracts were visualized excellently in the longitudinal plane. This applied in particular to the right ventricular outflow
FlouRE7.Girl,~13years,w~s3k&AolticcocvCta thwRhansutysm(A)proximaltonamming.b@tudlM plane. Am 8~88 of nawowln& Ao q aorta proximal coarctation.
SEPTEMBER15,1993
to
tract, including anterior outlet chambers and conduits between the right ventricle and pulmonary artery. However, in a patient undergoing a Fontan operation with an anterior atriopulmonary anastomosis,this was displayed better in the transverseplane. In 4 of 4 patients with a homograft between the right ventricle and pulmonary artery, the homograft was visualized superiorly in the longitudinal plane. Findings exclusively observed in the longitudinal plane were an acquired subaortic membrane after total correction of an atrioventricular septal defect in 1 patient, and a double-outlet connection to the right ventricle in 1 with atrioventricular discordance. PULMONARYARTERY: In ah patients in whom the main pulmonary artery and right ventricular outiow tract were in the normal position, these structureswere visualized in the longitudinal plane. In 1 patient, this was very helpful in excluding residual obstruction after “debanding” of a previously “banded” pulmonary artery. In the transverse plane, the right ventricular outflow tract was recorded in detail less frequently. In 1 patient with a poor precordial window, severepulmonary valve stenosiswas diagnosed using the longitudinal plane. In 2 patientsundergoingballoon dilatation of the pulmonary valve, the longitudinal plane was very helpful in positioning the balloon and showing increasedmobility of the cusps after the intervention (Figure 6). However, the distal right pulmonary artery was observedbetter in the transverseplane, which often showed the right pulmonary artery up to the superior caval vein. In this way, patency of a Glenn anastomosis could be shown in 1 patient. In 3 of 3 patientswith congenitally correctedtransposition,bifurcation of the pulmonary artery was not shown in either plane. This was possible owing to a learning curve effect, because in recently studied casesnot included in this study, bilkcation was shown in the transverseplane. In all other patients in whom bifurcation was present, it was shown in both planes. In casesof persistentductus arteriosusor aorticopulmonaryshunt, retrogradediastolic flow into the main pulmonary artery was shown more accuratelyin the longitudinal than in the transverseplane. However, a persistent ductus arteriosus in pediatric patients is demonstratedmuch better with precordial echocardiographythan with TEE. In a case of aorticopuhnonary window, this defectwas displayedbetter in the transverseplane. A right upper lobe pulmonary artery was not observedin either plane in any case. AORTA: When the aortic root was in the normal position, the morphology of the cusps was identified accurately in all cases.In most cases,it was visualized equally well in both planes; in some cases,it was observed better in the longitudinal plane. However, the proximal ascendingaorta was visualized much better in the longitudinal plane in all cases.Positive identification of the aortic arch brancheswas only incidentally possible with either technique. In 6 of 6 patients with a coarctation, this was observed in the short-axis view by demonstrating a change in diameter when advancing or withdrawing the probe; only in the last 3 patients with a coarctation was this observedin the longitudinal plane as previously described.24This was possibly due to a learning curve effect. In 1 patient with coarctation, the longitudinal plane revealeda small aneurysmproximal to the nar-
rowing (Figure 7). This aneurysm was documented intraoperatively. CORONARY ARTERIES: In the longitudinal plane, the left coronary artery was observed in a transversecross section; apart from demonstration of its diameter, this had no clinical consequence.The origin of the left coronary artery, including its bifurcation, was observedmuch better in the transverseplane. Only in 2 patients, both with tetralogy of Fallot, was a normal bifurcation of the left coronary artery shown in the longitudinal but not in the transverseplane. The distal circumflex coronary artery was observed frequently in both planes. However, using the longitudinal plane, the right coronary artery was observed in most patients at full length (Figure 8). This was made possible because in the longitudinal plane, a scanning plane could be obtained parallel to the tricuspid annulus. Obtaining such images is not possible in the transverseplane. Using precordial echocardiography in infants, usually a segment of the right coronary artery can be observed, but this is substantially smaller than that found on longitudinal transesophagealscanning. Using the longitudinal plane in 1 patient with transposition of the great arteries, it was prospectively diagnosed that the right and circumflex coronary arteries originated from the sameostium (Figure 9). The ori-
nGUttE8.Gid,agedlweek,we&ht3.lkg.kmspodonof great arteries. A, langltudinal plane showing ri@t coronary artey (amw) over long distance. 6, aortogram of same pa tiint. RA = ri@t atrium. BIPLANETRANSESOPHAGEAL ECHOCARDIOGRAPHY 703
FIGURE 9. Bay, aged l9 hours, weight 3.3 kg. TransposRh of great artehes. A, longitudinal plane, Ion&f axls through right velltlicular outflow tract, revealing oiigln of clwxlmflex comllaly artery &mvs) fmm aorta (Ao). 6, slight mguls tion reveals Mat tight corowq artery mm am-s from same ostium. C, lateral fight ventricular an&#un of same patlent. RV q right ventricle.
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gin of the right coronary artery was shown particularly clearly in casesof tricuspid atresia or hypoplastic right heart syndrome using the longitudinal plane. New dia@~~W i&om~W~ Completely new diagnostic information not provided with transthoracicechocardiography was obtained in 30 patients. Not included in this group of patients are those in whom normal structures were displayed that were not observed with precordial echocardiography,unless this was of clinical relevance (e.g., ruling out of total anomalous pulmonary venous connection). The addition of longitudinal to transverse TEE provided additional information in 18 patients. In this group of patients, 8 had a poor precordial acoustic window. In the remaining 10 patients, the window was satisfactory,but the longitudinal plane provided additional diagnostic information. lntraoperative observations: In a patient scheduled for enucleation of a discrete subaortic stenosis,inspection of the interatrial septum was performed unnecessarily becauseof the aforementionedfalse-positive atrial septal defect. In 5 patients operated on because of various types of atrioventricular septal defects, mild to moderate left atrioventricular valve regurgitation was present before surgery. In all 5 patients, some regurgitation was still present at the end of surgery, but there was no important changein severity as assessedby color Doppler, comparing regurgitant jet areas with the preoperative situation. In all 5 patients, this was thought to be acceptable.In these patients, there was no major discrepancy between the results of assessingmitral regurgitation in the longitudinal or transverseplane. In 1 patient undergoing mitral commissurotomy becauseof congenital mitral stenosis, severe mitral incompetence was present at the end of the procedure, including systolic reversal of flow into the pulmonary veins. After additional valve repair, mild regurgitation persisted.In a patient operatedon becauseof an aortopulmonary window, turbulence was present in the branchesof the pulmonary artery after ligation of the window, as observed in the transverseplane. It was decided to acceptthis sign of obstruction, but during follow-up a gradient in the pulmonary arteries persisted,probably becauseof some kinking of these structures. In a patient operated on becauseof tetralogy of Fallot, a gradient of 35 mm Hg was measuredin the longitudinal plane after repair, and it was decided to accept this residual obstruction. Precordial Doppler studies before discharge revealed a gradient of 40 mm Hg. In 3 patients undergoing an arterial switch operation, wall motion abnormalities were detectedbefore closure of the chest. In 2 of these patients, this observation prompted the surgeon to reinstitiute cardiopulmonary bypass. In these 2 patients, the wall motion abnormalities preceded electrocardiographic changes.All other surgical patients had good ventricular function at the end of the procedure. When monitoring ventricular function during heart surgery in very complex anomalies, one should realize that in certain conditions, satisfactorymyocardial function can coincide with very poor systemicperfusion, as we observed in 1 patient with a univentricular heart, unrestricted pulmonary blood flow and subaortic obstruction who underwent a coarctectomy. SEPTEMBER15, 1993
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Transesophagealmonitoring was performed during interventional catheterizations in 9 patients (2 with pulmonary valvuloplasty, 6 with balloon atrial septostomy, and 1 with blade septostomy). Use of the transverse plane was helpful during atrial septostomy,preventing erroneouspositioning of either the balloon or blade. The transverseplane was chosen becauseit provided a single cross section that showed all structures that were important for prevention of erroneouspositioning of the device, including the pulmonary veins and atrioventricular valves. Becausepatients undergoing atrial septostomy were all neonatesor infants, only single-plane transducers could be used. In the patient studied by biplane TEE during pulmonary balloon valvuloplasty, rapid switching from 1 plane to the other was found to be helpful; this would have been impossible with a singleplane probe. complications: In 1 patient, accidental extubation of the endotracheal tube occurred during exchange of the pediatric probes. This was corrected quickly with reintubation without deterioration in the condition of the patient. Neither blood staining of the probe nor any other complication occurred in any case. DISCUSSION
This study shows that biplane TEE is now also feasible in infants and children provided that 2 separate7 mm transducers are used sequentially. With the use of theseprobes,there is scarcelyany limitation with respect to body size. The main advantageof use of the longitudinal plane during TEE in congenital heart disease appearsto be the accuratevisualization of the right ventricular outflow tract, pulmonary valve and proximal main pulmonary artery (in patients with normally related great arteries). This has important implications from the diagnostic point of view and during interventions such as pulmonary balloon valvuloplasty and surgery of the right ventricular outtlow tract, including insertion of a conduit. The transverseplane is limited for such detailed information. l 6 Potential applications of longitudinal TEE include follow-up of patients with retrostemal conduits and monitoring interventions, including laser valvuloplasty of the pulmonary valve.25Becausethe left ventricular outllow tract and interatrial septum also are well visualized in the longitudinal plane, this approach may be helpful during various interventional procedures including balloon valvuloplasty of the aortic valve and clamshell closure of an atrial septal defect.23The mitral valve can be evaluated in much greater detail with the longitudinal technique. Furthermore, the right coronary artery can be observed at full length in the longitudinal plane, which is not possible in the transverseplane. The limitations of the use of the longitudinal plane alone are its inability to show: (I) the 4-chamber section through the heart; (2) both distal right and left pulmonary arteries in continuity with the bifurcation; and (3) bifurcation of the left coronary artery (with an occasional exception). Becausethe 4-chamber section is very important in congenital heart disease, this view cannot be omitted. Thus, the longitudinal plane is complementary to the transverseplane. Some structures remain difficult
to show with both scanning planes; the right upper lobe pulmonary artery was never recorded, the branches of the aortic arch were shown in somecases,but were very dihicult to identify properly, and continuity between bifurcation of the pulmonary trunk and the complete distal left pulmonary artery was not shown satisfactorily in any plane. Most information regarding the great vessels, which can be obtained in children with suprastemal transthoracicechocardiography,is difficult to obtain with TEE. The use of a 13 X 9 mm biplane TEE probe precludes its use in children with a body weight ~12 kg. The main indication to perform TEE in these small children is perioperatively to conlirm the preoperativediagnosis, evaluate the efficacy of the surgical procedure and monitor ventricular function. However, despite the excellent precordial window in this age group, additional diagnostic information can be obtained, in some cases exclusively, by using the longitudinal plane. Another application of biplane TEE is during interventional catheterization. TEE and x-ray fluoroscopy can be performed simultaneously. Important issues are the prevention of potentially dangerous positioning of guide wires and balloon catheters, and the evaluation of the effectivenessof the procedure.Potentially, TEE can help reduce fluoroscopy time by guiding the placement of guide wires and catheters, particularly when using a biplane probe. Although TEE in children is performed in some institutions without general anesthesia, using ‘ ‘heavy sedation,’ ’ we prefer to perform this investigation under general anesthesia,even in nonsurgical patients. In all patients, the combination of the 2 scanning planesprovided more information than did 1 plane alone. Therefore, exchanges of probes are necessary in the presently described approach. These exchangesare undesirable, particularly after surgical draping. Therefore, the recent introduction of commercially available pediatric biplane probes will contribute to further expansion of the use of biplane TEE in the pediatric age group. Acknowkdgment: We are indebted to A. Wiegman and C. Sakr-Woltz for performing many of the precordial echocardiographic studies, to R.B. A. van den Brink for studying the patient shown in Figure 6, to the many anesthesiologistsfor inserting the transesophageal probes, to E. van de Velde-Visser, A. Ljubic-ten Holte and M. Zuidervaart for preparing the manuscript, to G. J. H. Wentink and WE.M. Kok for preparing the illustrations, and to Aloka/Biomedic, Almere, and Aloka Europe, Hoofddorp, the Netherlands, for supplying the Aloka equipment.
1. Omoto R, Kyo S, Matsamura M, Shah PM, Adachi H, Matwmmaka T. Biplane colour Doppler tramesophageal echocardiography. Its impact on caxJiovascular surgery and further technological progress of the probe, a Matrix phased array biplane probe. E&cardiography 1989;6:423-430. 2. Seward JFI, Khandheria BK, Oh I, Edwards WD, Freeman WK, Tajik AJ. Biplane transesophageal echocardiography: technique, anatomic correlations, image orientation, and clinical applications. Mayo C/in Proc 1990;63:649-680. 2. Bansal RC, Shakudo M, Shah PM, Shah PM. Biplane tramesophageal echocardiography: technique, image orientation and preliminary experience in 131 patients. J Am Sot Echocardiogr 1990;3:348-366. 4. Cohen GI, Ghan KL. Biplane tramesophageal echocardiography: clinical ap-
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plicadons of the long-axis plane. J Am Sot Echocardiogr 1991;4:155-163. 1. Richardson G, Weintraub AR, Schwattz SL, Simonetti J, Clad&a ME, Pandian NG. Biplane tramesophageal echocardiography utiliig transverse and sagittal imaging planes. Ec/uxu~&graphy 1991;8:29%309. 6. Demodt P, Kacenelenbogen R, Bar JP, Salmon K, Peperstraete 8, Verbeet T, Telennans M. Clinical usefulness of biplane traosesophageal echocardiography. Echocardiography
1992;6:251-264.
7. Omoto R, Kyo S, Matsumura M, Shah PM, Adachi H, Yokote Y, Kondo Y. Evaluation of biplane colour doppler transesophageal echocardiography in 200 consecutive patients. Circuhztion 1992;85:1237-1247. 8. Wang XF, Li 24, Cheng TO, Ding YB, Wang JE, Yang Y. Biplane transesophageal echocardiography: an anatomic-ultrasonic-clinical correlative study. Am Heart J 1992;123:1027-3038. 9. Ritter SB, ‘Ibys D. Pediatric tramesophageal color flow imaging: smaller probes 1989;6:431-440. for smaller hearts. Echocardiography 10. Stllmper 0, Elzenga NJ, Hess J, Sutherland GR. Traosesophageal echocardiography in children with congenital heart disease an initial experience. J Am Coil Cardioi 1990;16:43%l41. u. Sreeram N, Stiimper 0, Kaulitz R, Hess J, Rcelandt JRTC, Sutherland GR. The comparative value of surface and hansesophageal ultrasound in the assessment of congenital abnormalities of the atriovenbicular junction. J Am CON Cardiol 1990; 16:1205-1214. l2. Stilmper 0, Elzenga NJ, Sutherland GR. Left ventricular outflow tract obstmction in childhood improved diagnosis by paediatric tramesophageal echo cardiography. Int J Cardiol 1990;28:107-109. 19. Kaulitz R, Stilmper 0, Geuskens R, Srecmm N, Elzenga NJ, Ghan CK, Bums JE, Godman MI, Hess J, Sutherland GR. We comparative values of the precmdial and tmnsesophageal approaches in the ultrasound evaluation of ahial baffle function following an aterial correction procedure. J Am Coil Cardiol 1990,16:6Cf%694. 14. Lam J, Neimtti RA, Nijveld A, Schuller JL, Blom-Muilwijk CM, Visser CA. Transesophageal echocardiography in paediabic patients: Preliminary results. J Am Sot Echocardiogr 1991;4:43-50.
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1s. Stiimper 0, KaoIitz R, Elzenga NJ, Born N, Rcelandt JRTC, Hess J, Sutherland GR. The value of hansesophageal echocardiography in children with congenital heart disease. J Am Sot Echocardiogr 1991;4:164-176. 16. Stiimper 0, Witsenburg M, Sutherland GR, Cromme-Dijkhuis A, Godman MJ, Hess J. Tramesophageal echocardiogaphic monitoring of interventional cardiac catheterization in children. J Am Co11 Cardiol 1991;18:1506-1514. 17. Omoto R, Kyo S, Matsamura M, Maryama M, Yokote Y. Future technical prospects in biplane tramesophageal echocardiography: of adult and pa&attic biplane matrix protes. Echocardiography 1991;8:713-720. 18. Ritter SB. Tramesophageal real-time echocardiography in infants and children with congenital heart disease. J Am CON Cardiof 1991;18:569-58. IS. Muhiudeen IA, Robertson DA, Silverman NH, Haas GS, Turley K, Cahalan MK. Intmoperative echocardiography for evaluation of congenital heart defects in infants and children. Anesthesiology 199276: 165-172. 20. Hunter AS, Henderson CB, Urquhart W, Farmer MN. Left-sided juxtaposition of the atrial appendages: report of four cases diagnosed by cardiac catheterization and angiocardiography. Br Heart J 1973;35: 1184-l 189. 2l. Podolsky LA, Jacob LE. Schwartz M, Kotler MN, Ioli A. Tramesophageal echocardiography in the diagnosis of the persistent left superior vena cava. J Am Sot Echocardiogr 1992:5: 159-162. 22. Katz ES, Freedberg RS, Rutkovsky L, Martin JC, Kronzon 1. Identification of an unusual right atxial mass as a Chiari network by biplane tmnsesophageal echocar1992;9:273-275. diography. Echocardiography 28. Ferreira SMAG, Ho SY, Anderson RH. Morphological study of defects of the ahial septum within the oval fossa: implications for transcatbeter closure of left-toright shunt. Br Heart J 1992;67:3 16320. 24. Ryan K, Sanyal RS, F’inheim L, Nan& NC. Assessment of aortic coarctation and collateral circulation by biplane transesophageal echocardiography. Echocardiography
1992;9:277-285.
25. Qureshi SA, Rosenthal E, Tynan M, Anjos R, Baker El. Tmnscatbeter laserassisted balloon pulmonaq valve dilatation in pulmonic valve at&a. Am J Cardial 1990;67:428&431.
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