Transoesophageal echocardiographic monitoring of pulmonary venous obstruction induced by sternotomy closure during infant heart transplantation

The safe use of intraoperative transesophageal echocardiography in the management of total anomalous pulmonary venous connection in newborns and infants: a case series

BACKGROUND

Intraoperative transesophageal echocardiography (TEE) is useful in evaluating the repair of lesions in patients with congenital heart disease. But the use of TEE in infants with total anomalous pulmonary venous connection (TAPVC) remains unclear. We reviewed the safety and efficacy of intraoperative TEE during TAPVC repair.

METHODS

Twenty-eight consecutive 1 day to 7 month-old infants with TAPVC (14 supracardiac, six intracardiac and eight infracardiac type) had surgical repair with intraoperative TEE monitoring.

RESULTS

Four patients received immediate surgical revision after primary surgery for residual anastomotic stenosis diagnosed by TEE. In addition, two unsuspected ventricular septal defects and three persistent ductus arteriosus were detected before surgery. Eight infants (29%) had hypotension and hypoxemia associated with TEE probe insertion before surgery, but this hemodynamic disturbance returned to baseline value after withdrawing the TEE probe from the esophagus. However, these eight patients had uneventful TEE probe insertion following sternotomy. The mechanism was probably because of the reduction of intrathoracic pressure when the chest was opened.

CONCLUSIONS

TEE probe insertion in TAPVC patients may pose a potential risk of compression of pulmonary venous confluence resulting in hemodynamic instability. Therefore, we suggest that the use of TEE in such TAPVC patients appears to be safer after sternotomy.

[Preoperative evaluation and perioperative management of patients with increased cardiovascular risk]

Due to the increasing age in western countries, combined with high rates of major surgical interventions in high-risk patients, perioperative reduction of cardiovascular complications becomes increasingly more important for perioperative physicians. After identifying patients with increased perioperative risk, specific interventions need to be considered to reduce their risk for cardiovascular complications, either by perioperative medical therapy or specific treatment options (e.g. coronary intervention). Several trials have demonstrated an effect of perioperative beta-blocker-therapy in reducing cardiovascular complications among high-risk patients. Additionally, several monitoring techniques are effective in detecting cardiovascular complications. Nevertheless, it remains unclear whether they are associated with a measurable improvement of outcome. Based on the ACC/AHA-guidelines, the present review describes a stepwise approach to surgical patients to identify perioperative risks, based on specific patient related risk factors, the kind of surgery and on the specific setting (emergency versus elective surgery). In addition, strategies to reduce perioperative cardiovascular complications are discussed.

Anaesthetic and perioperative management of paediatric organ recipients in nontransplant surgery

The number and success rate of paediatric organ transplantation continue to improve yearly, and the number of transplanted children presenting for either elective or emergency nontransplant surgery is expected to increase accordingly. The general considerations related to any transplant recipient are the physiological and pharmacological problems of allograft denervation, the side effects of immunosuppression, the risk of infection, and the potential for rejection. Preoperative assessment of transplant recipients undergoing non-transplant surgery should focus on graft function, the risk of infection, and function of other organs. Local, regional, or general anaesthesia can be safely delivered to transplant recipients. Specific anaesthetic considerations related to the type of transplantation, have an impact directly on anaesthetic and perioperative management. Since anaesthetists and surgeons in hospitals who are not involved in transplantations, may be required to manage paediatric transplant recipients, the reviews of the existing experience in this field will be valuable tools in their hands.