Utility of a standardized postcardiopulmonary bypass epicardial echocardiography protocol for stage I Norwood palliation

Abstract

Objective Stage 1 Norwood palliation is one of the highest risk procedures in congenital cardiac surgery. Patients with superior technical performance scores have more favorable outcomes. Intraoperative epicardial echocardiography may allow the surgeon to address residual lesions prior to leaving the operating room, resulting in improved technical performance. The ability of intraoperative epicardial echocardiography to visualize the relevant anatomy and its association with outcomes is not known. Design A standardized intraoperative epicardial echocardiography protocol was developed and performed at the conclusion of Stage 1 Norwood palliation. Data pertaining to visualization of relevant anatomy, and comparison of intraoperative echocardiogram findings with other post-operative investigations was performed. Clinical outcomes, including technical performance, were collected. A historical cohort who received either no echocardiogram or a non-standardized examination was used as a comparison group. Results Thirty on-protocol and 30 pre-protocol patients, 22 of whom had a non-standardized intraoperative epicardial echocardiogram, were studied. Compared with pre-protocol, visualization of the relevant anatomy was significantly increased for the Damus-Kaye-Stansel anastomoses (93% vs. 68% P=0.03) and branch pulmonary arteries (70% vs. 36%, P=0.02). One residual lesion requiring immediate operative reintervention was diagnosed in the pre-protocol group. There were 5 patients in each cohort with residual lesions during the post-operative hospitalization that were not appreciated on the intraoperative echocardiogram. Technical performance, rates of reintervention and clinical outcomes were not significantly different between the two groups. Conclusions Intraoperative epicardial echocardiography is technically feasible and increases visualization of the relevant anatomy. Larger investigations may be warranted to determine if there is clinical benefit to such an approach.

Application of the Boston Technical Performance Score to intraoperative echocardiography

“…Recognition of the limitations of echocardiography, on which the TPS is based, may inform decision-making to use alternative imaging modalities including CT, MRI or angiography in patients at high risk of shunt-related complications. This has been supported by the recent publication from the Boston group in Norwood patients (10).…”

The role of intraoperative epicardial echocardiography in pediatric cardiac surgery

“…Advantages of IEE are timely and accurate decision making, especially in cases where significant residual lesions are present. As a result, the patient is reoperated on during the same procedure, avoiding excessive complications and cost …”

“…However, inappropriate probe size for newborns and infants, inappropriate anatomy of the jaw, macroglossia, and potential procedural complications (eg, esophageal trauma, arrhythmia) limit TEE application. Intraoperative epicardial echocardiography (IEE) might be a simple but effective alternative to TEE …”

“…Intraoperative epicardial echocardiography (IEE) might be a simple but effective alternative to TEE. 3,4 In this study, we evaluate the IEE findings and potential effects of these findings on decision making about congenital heart surgery patients in a tertiary cardiac center. Our aim was to evaluate the indications, results, and complications of IEE in detail, and also to discuss the alterations in diagnosis and treatment strategy after IEE.…”

“…There are, unfortunately, limitations to the application of the TEE probe, especially in pediatrics. IEE might be an effective alternative to TEE,3,9,10 particularly in the following cases: (1) where use of the TEE is impractical due to low body weight, micrognathia, macroglossia, or other such conditions;(2) where visualization with TEE is either difficult or insufficient (such as in the evaluation of the pulmonary artery bifurcation, branch pulmonary arteries, or apical muscular VSD); or (3) when the TEE probe is not available 3,9,10. In the study published by Muhiudeen et al, the results of 50 infants and children with congenital cardiac shunt lesions for whom TEE and IEE were used during the same procedure were compared.…”