Assessment of ventricular septal defect closure by intraoperative epicardial ultrasound

Abstract

Intraoperative epicardial two-dimensional echocardiographic imaging, color flow mapping and contrast echocardiography were used in 31 patients after patch closure of a ventricular septal defect to determine their respective values in the assessment of residual shunting after cardiopulmonary bypass and for the prediction of long-term results. Epicardial imaging showed no incidence of patch dehiscence. Residual shunting detected by color flow mapping or contrast echocardiography was graded into one of four categories (0 to III). Real time analysis of color flow mapping studies suggested no shunting (grade 0) in 2 patients, grade I shunting in 20, grade II in 8 and grade III in 1; contrast studies suggested grade 0 in 15, grade I in 6, grade II in 8 and grade III in 2. Interobserver variation in real time encoding of grade I or II shunting was 25% by color flow mapping and 6% by contrast echocardiography. Subsequent frame by frame analysis revealed that both diastolic and early systolic right ventricular turbulence gave rise to false positive results during real time analysis of color flow mapping studies. Color flow mapping allowed exact localization of residual shunting, whereas contrast echocardiography allowed better semiquantification. Postbypass results were correlated in 30 patients with late postoperative precordial studies (mean interval 7.5 months). Persistent shunts were found in 6 (20%) of 30 patients. No patient required reoperation for residual shunting. The predictive value of immediate grade I or II shunting as a marker for persistent long-term shunting was poor, whereas both patients with immediate grade III shunting had shunt persistence, indicating that immediate revision should be considered in such patients. Intraoperative epicardial ultrasound is valuable for the immediate exclusion of important residual shunting after ventricular septal defect closure. Maximal information is obtained when color flow mapping and contrast echocardiography are used in combination.

Intraoperative echocardiography in children

“…Do diagnostického pfiínosu "pre-bypass" POE byly zpoãátku vkládány velké nadûje. (8,11,16,17) Zvy‰ující se kvalita standardního pfiedoperaãního transthorakálního vy‰etfiení omezila "pre-bypass" POE na vyuÏití v ojedinûl˘ch speciálních indikacích. (11,12,18) Doporuãujeme ji provádût pfiedev‰ím k detailnímu ozfiejmûní poãtu a polohy mnohoãetn˘ch nebo atypick˘ch defek-tÛ komorového septa pfied jejich plánovan˘m chirur-gick˘m uzávûrem.…”

Transesophageal echocardiography in congenital heart disease

“…Thus, we recommend the use of contrast echocardiographic studies for the rapid identification and semiquantification of residual shunting following closure of ventricular septal defects. 21 Hand-agitated saline and blood is injected into the left atrial line, while a high esophageal view of both the aortic root and the right ventricular outflow tract is imaged.…”