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PEDIATRIC ANESTHESIA

Intraoperative Evaluation of Pulmonary Artery Flow During the Fontan Procedure by Transesophageal Doppler Echocardiography

Department of Anesthesiology, Tokushima University School of Medicine, 3-18-15 Kuramoto, Tokushima, 770-8503 Japan

Address correspondence and reprint requests to Shinji Kawahito, MD, PhD, Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030. Address e-mail to kawahito @bcm.tmc.edu.

After the Fontan procedure, pulmonary artery (PA) flow is maintained without right ventricular pump function. We evaluated intraoperative PA flow velocity patterns using transesophageal Doppler echocardiography (TEE) immediately after cardiopulmonary bypass (CPB) in patients during Fontan or hemi-Fontan procedures. We studied 10 patients with single-ventricle physiology (age range, 5 mo to 3 yr 1 mo). Anesthesia was induced and maintained with fentanyl. After induction of anesthesia, a pediatric TEE probe was inserted into the esophagus. All patients had surgical repair involving direct anastomosis of the right atrium to the PA. Immediately after completion of CPB, adequacy of the atriopulmonary anastomosis was assessed and PA flow velocity was recorded. In all patients, the atriopulmonary anastomosis was clearly defined using a single-plane TEE probe, and PA flow recording was completed successfully. Intraoperative PA flow velocities showed two distinct patterns. Biphasic forward flows with peak velocities during systole and diastole were observed in six patients. The remaining four patients showed forward flows with flow reversals. The four patients demonstrating flow reversals showed significantly reduced fractional shortening (26.5 ± 2.1% vs 35.5 ± 6.3%) and larger pressure gradient between the right atrium and left atrium (10.8 ± 1.3 mm Hg vs 8.0 ± 0.9 mm Hg) when compared to those without reverse flow. Two patients with reverse flow required reoperation because of hypotension. Because PA flow is influenced by pulmonary vascular resistance and left ventricular function, TEE assessed intraoperative PA flow should be further evaluated as a useful predictor of surgical outcome after a Fontan procedure.

Implications: We evaluated intraoperative pulmonary artery flow velocity patterns with transesophageal Doppler echocardiography (TEE) in patients during a Fontan procedure. Because pulmonary artery flow is influenced by pulmonary vascular resistance and ventricular function, intraoperative evaluation of pulmonary artery flow using TEE should be further evaluated as a predictor of surgical outcome after a Fontan procedure.

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