HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Keiichi Fujiwara Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Komai, H. Articles by Uemura, S. Search for Related Content PubMed PubMed Citation Articles by Komai, H. Articles by Uemura, S.

J Thorac Cardiovasc Surg 1999;118:758-759
© 1999 Mosby, Inc.

BRIEF COMMUNICATIONS

THE BENEFITS OF SURGICAL ATRIAL SEPTOSTOMY GUIDED BY TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN PEDIATRIC PATIENTS

From the Departments of Thoracic and Cardiovascular Surgery and Pediatrics, Wakayama Medical College, Wakayama, Japan.

Presented at the Seventh Annual Meeting of the Asian Society for Cardiovascular Surgery, Singapore, May 28–June 1, 1999.

Address for reprints: H. Komai, MD, Department of Thoracic and Cardiovascular Surgery, Wakayama Medical College, 811-1, Kimiidera, Wakayama, Japan 641-0012.

With the recent developments of smaller probes, transesophageal echocardiography (TEE) has become a safe and beneficial tool for diagnosing and monitoring heart disease in small children. At some institutes, TEE is also used for catheter intervention of congenital heart disease. We successfully performed closed atrial septostomy in 2 children using TEE during the operation.

Clinical summaries

PATIENT 1.
Soon after birth, a boy was found to have a double-outlet right ventricle, pulmonary atresia, ventricular septal defect, and patent ductus arteriosus. He had undergone a right modified Blalock-Taussig shunt at the age of 4 months. One year after the operation, follow-up echocardiography revealed mitral stenosis (parachute mitral valve) and significant left atrial dilatation. Eventually he was referred to the surgical team because of the development of heart failure. He had tachypnea, cold sweats, and mild cyanosis. A continuous heart murmur was audible at the right sternal border. As the left ventricle was not large enough to tolerate systemic circulation, we thought the only way to save his life was to perform atrial septostomy, even though the 2-ventricle repair might fail in the future. From the preoperative echocardiographic findings the atrial septum was thick and no atrial communication was present. Thus we planned surgical septostomy instead of catheter intervention.

At the time of the operation, he was 1 year 7 months old and weighed 6.9 kg. After the induction of anesthesia and intratracheal intubation, a pediatric biplane TEE transducer probe (V 705B, Acuson Corporation, Mountain View, Calif) was inserted without any difficulty. The TEE probe was 9.5 mm wide at the transducer portion (the widest part). The probe was connected to an Acuson computed sonography 128XP echocardiography system and monitored. A median sternotomy was performed and a purse-string suture was placed on the right atrial wall just posterior to the appendage. A small microsurgery scalpel was inserted through the purse-string suture to the right atrium and proceeded to the center of the atrial septum, guided by a longitudinal atrial TEE view (Fig 1). The atrial septum appeared projected convexly toward the right atrial cavity, indicating high left atrial pressure. When the tip of the scalpel reached the septum, it had to be pushed hard. The septum was so thick that a great deal of effort was needed to make a small incision. The scalpel was then removed and our septostomy knife was inserted to widen the incision. After additional bougienage, a 4.5-mm incision was made and observed by color Doppler echocardiography through TEE (Fig 2). The septum projection was reduced, showing that the left atrial pressure had decreased with the left-to-right shunt at the atrial level. We could evaluate the effects of each procedure accurately with TEE. Recovery was uneventful after the operation, and the symptoms of heart failure disappeared.

View larger version (106K): [in this window] [in a new window]   Fig. 1. The TEE during atrial septostomy. Although the septum was thick and difficult to incise, the scalpel accurately proceeded toward the septum under TEE guidance. SC, Scalpel; SPT, atrial septum.

View larger version (102K): [in this window] [in a new window]   Fig. 2. A postoperative view of the transesophageal Doppler echocardiogram showing the left-to-right shunt flow through the incision made in the septum. RA, Right atrium; LA, left atrium.

Discussion.

With the recent advance in miniaturizing probes, TEE has been used in infants and even newborn patients. ^1,2 In contrast to its use in adults, TEE has been used effectively for monitoring congenital heart disease in children, rather than diagnosing it. TEE during catheter intervention has been reported and shown to be an accurate and safe tool. ³ Intraoperative use of TEE has been widely accepted in adults and is now being extended to children. ^4,5 In the present cases, we chose TEE-guided closed atrial septostomy because the septum was too thick to perforate by means of the transcatheter method. Like others, we always try to avoid the use of extracorporeal circulation for palliative procedures. With the help of real-time TEE imaging, we easily recognized where the knife was proceeding in the atrial cavity, what size of incision we obtained, and how effective the procedure was during the operation. As in patient 2, not only could we perform the procedure safely, but we were also able to evaluate the results immediately and institute additional procedures when appropriate. Although this method is not applicable in many patients, we believe it should be the method of choice in patients who need atrial septostomy.

References

1. Weintraub R, Shiota T, Elkadi T, et al. Transesophageal echocardiography in infants and children with congenital heart disease. Circulation 1992;86:711-22. [Abstract/Free Full Text]
   
2. Lam J, Neirotti RA, Hardjowijono R, Plom-Muilwijk CM, Schuller JL, Visser CA. Transesophageal echocardiography with the use of a four-millimeter probe. J Am Soc Echocardiogr 1997;10:499-504. [Medline]
   
3. Douglas D, Fyfe DA. Use of miniature biplane transesophageal echocardiography during pediatric atrial catheter interventional procedures. Am Heart J 1996;132:179-86. [Medline]
   
4. Kyo S, Omoto R, Matsumura M, Shah P, Ito H. Intraoperative transesophageal echocardiography in pediatric patients. J Thorac Cardiovasc Surg 1990;99:373-5.
   
5. Stevenson JG. Role of intraoperative transesophageal echocardiography during repair of congenital cardiac defects. Acta Paediatr 1995;410(Suppl):23-33.
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Keiichi Fujiwara Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Komai, H. Articles by Uemura, S. Search for Related Content PubMed PubMed Citation Articles by Komai, H. Articles by Uemura, S.