Intraoperative Echocardiography for Evaluation of Congenital Heart Defects in Infants and Children

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Abstract
To determine the accuracy, utility, and limitations of intraoperative transesophageal echocardiography (TEE) in infants and children, we performed prebypass and postbypass TEE in 90 children undergoing surgical repair of congenital heart lesions, comparing the results to those obtained using intraoperative epicardial echocardiography and pre- and postoperative precordial echocardiography. Patients ranged in age from 4 days to 21 yr (mean 4.1 yr) and in weight from 3 to 68 kg (mean 15.4 kg). Prebypass, we obtained high-quality, two-dimensional TEE images in 86 patients, with correction of the preoperative precordial diagnosis in 3 and confirmation of the preoperative diagnosis in the rest. Adequate epicardial images were obtained in 78 patients, with confirmation of the preoperative diagnosis in all. Shunt lesions that were well delineated prebypass by both TEE and epicardial imaging included interatrial, interventricular, and atrioventricular septal defect lesions. TEE failed to detect the exact size and location of lesions involving the right ventricular outflow tract, i.e., doubly committed subarterial (supracristal) ventricular septal defects. Regurgitant lesions (n = 30) were identified and their severity evaluated in all patients by both TEE and epicardial imaging. Obstructive lesions (n = 33), excluding those involving the right ventricular outflow tract, were well defined by both echocardiographic approaches. Postbypass, we obtained high-quality, two-dimensional, color and Doppler TEE images in 86 patients and epicardial images in 78 patients. Compared with postoperative precordial imaging, TEE accurately showed the absence of hemodynamically significant shunt lesions in each of the 64 patients who had definitive shunt repairs, falsely overestimated the degree of postbypass valvular regurgitation 5 of the 30 patients with valvular regurgitation, and could not identify the degree of pulmonic insufficiency in 7 patients with tetralogy of Fallot. Results from epicardial echocardiography concurred with TEE results and accurately detected the presence or absence of all residual shunts and regurgitation, as well as the severity of residual defect. Mild residual obstruction was detected accurately by both TEE and epicardial imaging, except that TEE could not fully assess those involving the right ventricular outflow tract. We conclude that TEE provides accurate imaging of important morphologic and flow features of most pediatric congenital heart lesions and provides an accurate assessment of the surgical repair. It may improve diagnostic accuracy in some patients who have undergone precordial echocardiography and has the advantage of offering accuracy equal to that obtained using epicardial echocardiography.

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