The Use of Intraoperative Echocardiography with Doppler Color Flow Imaging in the Repair of Congenital Heart Defects

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Abstract
Surgical repair of congenital cardiac defects has undergone a remarkable evolution in the past decade. Major defects are now often completely corrected in early infancy with continually improving rates of survival. It has become clear that the next major focus will be improvements in the long‐term quality‐of‐life and this has prompted many innovations in surgical technique and approach. One advance is the use of intraoperative echocardiography with Doppler color flow imaging to evaluate the exactness of operative repair. Aside from anecdotal reports, very little information is available regarding the interpretation of images produced by this technology in the operating room. Furthermore, there have been no studies addressing the predictive value of intraoperative echocardiography with Doppler color flow imaging findings with respect to outcome for patients undergoing repair of congenital cardiac defects. The prospective data obtained by following the course of 273 patients receiving intraoperative echocardiography with Doppler color flow imaging has been reviewed after repair of a variety of congenital cardiac defects (age range 1–53 years; mean 5.3 years; smallest patient 1.8 kg). The average time required to perform a complete intraoperative echocardiography with Doppler color flow imaging evaluation was 3.64 ± 1.73 minutes. Except for mild ectopy induced by pressure from the transducer, complications of the procedure were minimal. Echocardiography with Doppler color flow imaging revealed previously unsuspected details of the anatomy in 21% of patients and in 47% of patients, it was felt that the prebypass echocardiography with Doppler color flow imaging impacted in some way on planning of the operative procedure. Echocardiography with Doppler color flow imaging was 2.5 times more likely to provide help in planning the operation if a previously unrecognized anatomical finding was disclosed. Postbypass evaluation revealed that 47 patients (17%) had initially unacceptable results, by echocardiography, at the completion of their repair. Eighteen of these patients (7% of the entire series) had no clinical problems and the defects were discernible only by echocardiography. Twenty‐six patients with initially unacceptable results had their repairs revised in the operating room and left with an acceptable result by echocardiography. Twenty‐one patients were allowed to leave the operating room with echocardiographically discernible defects. Follow‐up of these patients demonstrated a significantly higher (P < 0.006) rate of reoperation (42% vs 3%) and an early death (29% vs 10%) for those patients whose defects were left unrepaired compared to those whose problems were corrected before leaving the operating room. Sixty‐eight patients (25%) had some alteration of ventricular function (compared to their prebypass evaluation) at the completion of their repair. Regardless of whether the dysfunction was limited to the right ventricle, left ventricle, or was biventricular, patients in this group had a significantly higher incidence (P < 0.004) of early, but not late, death compared to patients without alteration of ventricular function (35% vs 4%). Patients who left the operating room with no problems of concern by echocardiography with Doppler color flow imaging had a > 90% likelihood of a long‐term acceptable outcome compared to patients who had any problem of concern, whose long‐term likelihood of an acceptable outcome approached 50% (P < 0.0125). The results of this study demonstrate that echocardiography with Doppler color flow imaging can provide useful information to surgeons at the time of repair for congenital cardiac defects.