Anesth Analg 2003;97:1617-1619
© 2003 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Transnasal Placement of Biplane Transesophageal Echocardiography Probe Intraoperatively in an Adolescent with Congenital Heart Disease
Lori A. Aronson, MD FAAP
From the Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
Address correspondence and reprint requests to Lori A. Aronson, MD, FAAP, Cincinnati Children’s Hospital Medical Center, Department of Anesthesia, 3333 Burnet Ave, Cincinnati, OH 45229. Address email to Lori.Aronson{at}cchmc.org
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Abstract
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Intraoperative transesophageal echocardiography (TEE) is frequently used in children with congenital heart disease (CHD). Although transnasal TEE is being used in various settings in the adult population, there are no descriptions of its use intraoperatively in patients with CHD. This report describes the successful use of transnasal TEE after multiple unsuccessful transoral attempts in an adolescent male undergoing subaortic stenosis repair.
IMPLICATIONS: Transnasal transesophageal echocardiography (TEE) is being used in various settings in the adult population. The author describes its use intraoperatively in an adolescent undergoing surgery for congenital heart disease after unsuccessful transoral attempts.
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Introduction
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Intraoperative transesophageal echocardiography (TEE) is frequently used for infants and children undergoing repair of congenital heart disease (CHD). Intraoperative TEE identifies residual cardiac defects requiring reoperation in 7.4%–8.2% of children with CHD (1–3). Smaller transnasal TEE probes have been used for critically ill adults and during stress testing (4–6), but there are no reports of its use for patients with CHD. This is a report of intraoperative transnasal placement of a biplane TEE probe in an adolescent with CHD after failed transoral attempts with multiplane and biplane probes.
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Case Report
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An 18-yr-old, ASA physical status II, 121-kg, 196-cm male with subaortic stenosis (SAS) was scheduled for elective repair. Physical examination was within normal limits except for a III/VI systolic murmur at the right and left upper sternal borders and a Mallampati Class III airway because of a large tongue. Transthoracic echocardiography identified a subaortic membrane with a 45 mm Hg gradient, mild aortic insufficiency (AI), and increased left ventricular (LV) mass.
The patient had an unremarkable IV induction, grade 2 laryngoscopy, and uncomplicated oral intubation on the first attempt. After appropriate venous and arterial access was obtained, the patient was positioned with a shoulder roll in slight head extension. Despite mechanical maneuvers (decreased extension, jaw thrust, head elevation, and direct laryngoscopy with cuff deflation), neither the multiplane or pediatric biplane TEE probes (models 21364A and 21366A; Philips, Andover, MA) were successfully inserted orally. The patient’s medical history did not suggest esophageal diverticuli, strictures, or vascular rings that might restrict probe advancement. Direct laryngoscopy showed no deviation of the piriform fossae; however, the acute angle of the probe, which was unable to be maneuvered past the level of the glottic opening, was visualized. Because of the small size of the pediatric probe, the size of our patient, and the requirement of an intraoperative study, a transnasal approach was attempted and successful on the first pass (perhaps as a result of better alignment). Given the need for heparinization before cardiopulmonary bypass (CPB) and recognizing the possibility of epistaxis with insertion of the probe, 0.5 mL of 0.5% phenylephrine was applied to the right nares for vasoconstriction. The probe was well lubricated and advanced without resistance. There were no complications and adequate images were obtained. The postrepair intraoperative TEE revealed no significant LV outflow tract gradient (13 mm Hg) and mild AI (Fig. 1). The patient recovered uneventfully and was discharged home on atenolol for persistent hypertension. There were no reports of postoperative dysphagia, epistaxis, or other complications.
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Figure 1. Postrepair intraoperative transnasal transesophageal echocardiography image. View of left ventricular outflow tract (LVOT) and aortic valve (AV) after resection of subaortic membrane and septal myomectomy. Minimal residual peak gradient of 12.7 mm Hg and peak velocity of 178 cm/s after subaortic membrane resection.
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Discussion
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Intraoperative echocardiography has become indispensable for children with CHD, confirming or identifying new defects in the pre-CPB period as well as evaluating significant residual defects requiring reoperation. TEE, whether oral or transnasal, is limited by the size of the patient, esophageal anomalies, and potential difficult insertion. Muhiudeen et al. (7) evaluated the accuracy, utility, and limitations of intraoperative uniplane TEE versus epicardial echocardiography (EE) and transthoracic imaging in children with CHD. EE advantages include no limitation on minimum patient size and excellent image quality, and EE should remain an alternative to TEE. TEE, however, played an important role in patient management without interrupting the surgical procedure, allowing for continuous monitoring and avoiding potential arrhythmias, hypotension, and contamination of the surgical field that can occur with EE. A study of 230 infants and children with CHD found 17 of 227 patients (7.5%) returned to CPB for residual lesions; of 28 children with SAS as a primary diagnosis, 9 (32%) underwent revision based on TEE (1). Bengur et al. (2) demonstrated an 8.1% incidence (40 of 493) of residual defects requiring reoperation; 34 of the 40 defects that required reoperation (85%) were based primarily on TEE data. They concluded that TEE was indicated for repairs of most forms of complex CHD including SAS.
TEE has had important diagnostic as well as therapeutic impact in adult postoperative cardiac patients in the intensive care setting (8). Voci and Marino (9) showed that a miniaturized monoplanar TEE probe could yield good image quality with better patient compliance scores in critically ill adults. The transnasal approach represents one of the latest advances in adult echocardiography; the transnasal monoplanar TEE probe has an imaging head sized 7.3 x 6 x 21 mm and a shaft diameter of 6 mm (6–8), comparable to an 18F nasogastric tube (6 mm). The Philips pediatric biplane probe used in this patient has a maximum diameter of 8 mm as compared with the adult multiplane probe tip maximum diameter of 15 mm. The transnasal approach using the currently available probes can only be used in patients able to accept the equivalent of a 6.0-mm nasotracheal tube (outer diameter, 8.2 mm). Thus, this technique is limited by the size of the patient.
Transnasal TEE in healthy adults undergoing upright exercise stress testing allows for continuous visualization of the LV (4). A multicenter study (5) evaluated transnasal TEE for 194 examinations, most of intensive care unit (ICU) and mechanically ventilated patients; 25% of the examinations lasted longer than 60 minutes. Intubation was successful in 88% of attempts; 12% had minor nasal bleeding not requiring intervention. No vasoconstrictor was used, and nasal bleeding was more likely with difficult or unsuccessful intubation. Greim et al. (6) studied transnasal TEE in mechanically ventilated patients under deep and mild sedation in the ICU. The probe was successfully inserted in 90% of patients (38/42). With nasal application of 1% xylometazolin, 13 of 38 patients (31%) developed nasal bleeding and one required nasal tamponade. However, 18 examinations (47%) yielded information that led to a change in patient management. The incidence of epistaxis from transnasal TEE insertion is comparable to that of nasotracheal intubation at 26%–43% without use of a vasoconstrictor (10,11). Given the inherent risk of epistaxis with nasal instrumentation, it is recommended that a topical vasoconstrictor be applied to the nasal mucosa to minimize this risk, especially previous heparinization for CPB.
Intraoperative TEE is useful for children with CHD and can positively affect outcome. Transnasal TEE has been demonstrated to be safe and easy to perform in intubated adult patients. The probe the author inserted transnasally was only 2 mm larger than the prototype transnasal probe and had biplane capability, allowing for better assessment of the LV outflow tract. This is the first report of intraoperative transnasal TEE in an adolescent with CHD after unsuccessful transoral attempts with adult omniplane and pediatric biplane probes.
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Acknowledgments
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The author would like to thank Drs. Joel Gunter, Kenneth Goldschneider, and David Porembka for their helpful comments prior to submission of this manuscript.
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References
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- Stevenson JG, Sorensen GK, Gartman DM, et al. Transesophageal echocardiography during repair of congenital heart defects: identification of residual problems necessitating reoperation. J Am Soc Echocardiogr 1993; 6: 356–65.[Medline]
- Bengur AR, Li JS, Herlong JR, et al. Intraoperative transesophageal echocardiography in congenital heart disease. Semin Thorac Cardiovasc Surg 1998; 10: 255–64.[Medline]
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- Schmidlin D, Schuepbach R, Bernard E, et al. Indications and impact of postoperative transesophageal echocardiography in cardiac surgical patients. Crit Care Med 2001; 29: 2143–8.[ISI][Medline]
- Voci P, Marino P. Transesophageal echocardiography in critically-ill patients using a miniaturized probe: feasibility, efficacy, and indications. Cardiologia 1996; 41: 855–9.[Medline]
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Accepted for publication June 24, 2003.
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Abstract
Introduction
