Scohy, T.V.

Intraoperative transesophageal echocardiography for mediastinal mass surgery improves anesthetic management in pediatric patients (Article)

2011-12-01T00:00:00Z

Peri-operative Anesthetic Innovations During Pediatric Cardiac Surgery (Doctoral Thesis)

2011-10-28T00:00:00Z

Congenital heart disease (CHD) refers to a series of birth defects that aff ect the heart and thoracic vessels, aff ecting 6 to 8 out of 1,000 babies being born. In 40% of these children no treatment is indicated because of minimal eff ect on hemodynamics and outcome. In 60% treatment will be required; about half of them will require urgent surgery after birth, while the other half will probably require surgery or medication at some point during childhood. Due to advances in heart surgery, 85% of children with congenital heart disease will survive into adulthood. Although CHD has been recognized for centuries, therapeutic options were not available until the 20th century. Until the late 1930s little advances were made in cardiac surgery due to a lack of refi nement in anesthesia and problems related to now routine perioperative support techniques, such as blood transfusion and mechanical ventilation. After the fi rst successful ligation of a patent ductus arteriosus in 1938, a lot of new operations found their origin. In 1949 perioperative mortality, approached 14.5%. In the 1950s extracorporeal circulation made its entry. The introduction of new anesthetic drugs and the use of prostaglandins to maintain ductal patency and pulmonary blood fl ow was one of the most important advances of the 1970s. In the late 1970s cardioplegia solutions were introduced. During the 1980s sufentanil and midazolam off ered alternatives to potent volatile anesthetics, although hospital mortality was still 6%. From the 1990s miniaturizing components of the cardiopulmonary bypass circuit reduced priming volumes, producing less coagulation factor dilution and further improvement in patient outcome. During the past two decades, mortality after surgery for congenital cardiac disease has decreased dramatically and is now reported to be 4% in the European Association for Cardio-thoracic Surgery and the Society of Thoracic Surgeons Congenital Heart Surgery Database, the focus of clinical research and eff orts to improve quality has now shifted to that of the minimization of morbidity.

Intraoperative glycemic control without insulin infusion during pediatric cardiac surgery for congenital heart disease (Article)

2011-08-01T00:00:00Z

Summary Background: Many studies are reporting that the occurrence of hyperglycemia in the postoperative period is associated with increased morbidity and mortality rates in children after cardiac surgery for congenital heart disease. This study sought to determine blood glucose levels in standard pediatric cardiac anesthesiological management without insulin infusions. Methods: The study population consisted of 204 consecutive pediatric patients aged from 3 days to 15.4 years undergoing open cardiac surgery for congenital heart disease between June 2007 and January 2009. Glucose-containing fluids were not administrated intraoperatively, and all patients received high dose of opioids (sufentanil 10 mcg·kg-1) and steroids (30 mg·kg-1methylprednisolone) iv. Glucose levels were measured before CPB, 10 min after initiation of CPB, every hour on CPB, post-CPB, and on arrival at intensive care unit (ICU). Results: Intraoperatively, only one patient had a glucose level <50 mg·dl-1(=34.2 mg·dl-1), 57/204 patients (27.9%) had at least one intraoperative glucose >180 mg·dl-1, but only 12 patients (5.8%) had a glucose level >180 mg·dl-1at ICU arrival. Thirty-day mortality was 1.5% (3/204). Younger age, lower body weight, and lower CPB temperature were associated with hyperglycemia at ICU arrival, as were higher RACHS and Aristotle severity scores. Conclusion: A conventional (no insulin, no glucose) anesthetic management seems sufficient in the vast majority of patients (96.5%). Special attention should be paid to small neonates with complex congenital heart surgery, in whom insulin treatment may be contemplated.

Three-dimensional transesophageal echocardiography: Diagnosing intraoperative pulmonary artery thrombus (Article)

2011-05-01T00:00:00Z

A 61-year-old patient with the diagnosis of acute heart failure based on severe mitral valve insufficiency due to chordae rupture was scheduled for surgery. Intraoperatively, a standard two-dimensional transesophageal echocardiogram (2D-TEE) examination, revealed severe mitral valve regurgitation due to a prolaps with chordal rupture and an echo dense structure in the pulmonary artery (PA). Because it was not possible to visualize this echo dense structure fully with 2D-TEE we performed a three-dimensional transesophageal echocardiogram (3D-TEE). On the basis of the clear demonstration on 3D-TEE of an at least 6-cm thrombus in the PA we decided to remove the thrombus prior to proceeding with the mitral valve repair. We conclude that 3D-TEE can alter surgical management and provide more valuable information on PA thrombus than that obtained by 2D-TEE.

Feasibility of real-time three-dimensional transesophageal echocardiography in type a aortic dissection (Article)

2010-07-01T00:00:00Z

Transesophageal echocardiography (TEE) is the fastest method for diagnosing aortic dissection type A and allows 3D TEE, even in hemodynamically instable patients. 3D TEE may provide additional information on aortic morphology, the involvement of coronary arteries by the dissection and aortic valve function. In this regard 2D and 3D TEE might become the diagnostic method of choice in hemodynamically instable patients.

Relevance of colloid oncotic pressure regulation during neonatal and infant cardiopulmonary bypass: a prospective randomized study (Article)

2010-01-01T00:00:00Z

Objective: In neonatal and infant cardiac surgery with cardiopulmonary bypass (CPB), hemodilution with reduction of plasma albumin concentration and low colloid oncotic pressure (COP) are the main factors associated with tissue edema and postoperative weight gain. The aim of our study was to evaluate the influence of two different COP regulatory strategies on post-bypass body weight gain, fluid balance, and clinical outcomes. Methods: Seventy elective patients with body weight < 10 kg underwent first-time cardiac surgery with CPB and were randomized into two groups. The standard COP group received 0.5 g kg-1 of human albumin in the priming and, during CPB, albumin was added to maintain the COP > 15 mmHg. In the high COP group, albumin concentration in the priming was 5% and, during CPB, the COP was maintained above 18 mmHg. All patients were monitored before, during and until 24 h postoperatively. Data were collected on body weight gain, COP, albumin concentration, fluids transfusion, blood loss, urine production and laboratory results. Results: Patients' demographics and operative data were comparable. Although the high COP group had perioperatively significantly higher COP and albumin concentration than the standard COP group, no significant difference was found in the body weight gain. There were also no significant differences between the groups with respect to fluid balance, urine output and blood loss. However, the high COP group had significantly shorter postoperative duration of mechanical ventilation (10 h vs 14 h, p = 0.02) and lower plasma lactate concentration post operation (1.1 mmol l-1 vs 1.4 mmol l-1, p = 0.046). Conclusions: The COP regulatory strategy for neonatal and infant CPB, based upon the 5% concentration of albumin in the priming and a COP target of 18 mmHg during bypass, better preserves the plasma albumin concentration within the physiological range and stabilizes the colloid pressure than the standard strategy (0.5 g kg-1 albumin in the priming and bypass COP target at 15 mmHg). Nevertheless, only the lower postoperative plasma lactate concentration and the shorter duration of mechanical ventilation in the high COP group indicated the potential clinical benefit of this new strategy.

Rapid method for intraoperative assessment of aortic coarctation using three-dimensional echocardiography (Article)

2009-12-01T00:00:00Z

Aims The availability of three-dimensional (3D) echography with its multiplanar review analysis software on board now allows detailed examination in assessing morphological details. We evaluated the feasibility of 3D echography in assessing intraoperative morphological details of aortic coarctation (CoA) and its repair.Methods and resultsNine consecutive children scheduled for surgery of CoA were intraoperatively evaluated. Intraoperative 3D data sets were taken and analysed online before resection of the coarctation, showing the cross-sectional area (CSA) of the proximal aorta, coarctation, and the distal descending aorta. After resection of the coarctation and extended end-to-end anastomosis, a 3D data set was recorded to analyse the CSA of the anastomosis. In nine out of nine consecutive procedures, intraoperative 3D echography permitted comprehensive viewing and measuring of CoA and its repair. In three out of nine surgical procedures, intraoperative 3D echography provided additional information to support surgical decision-making. ConclusionIntraoperative 3D echography is a feasible non-invasive imaging modality for intraoperative assessment of CoA and its repair, which provides useful additional information.

Alveolar recruitment strategy and PEEP improve oxygenation, dynamic compliance of respiratory system and end-expiratory lung volume in pediatric patients undergoing cardiac surgery for congenital heart disease (Article)

2009-12-01T00:00:00Z

Objective: Optimizing alveolar recruitment by alveolar recruitment strategy (ARS) and maintaining lung volume with adequate positive end-expiratory pressure (PEEP) allow preventing ventilator-induced lung injury (VILI). Knowing that PEEP has its most beneficial effects when dynamic compliance of respiratory system (Crs) is maximized, we hypothesize that the use of 8 cm H2O PEEP with ARS results in an increase in Crs and end-expiratory lung volume (EELV) compared to 8 cm H2O PEEP without ARS and to zero PEEP in pediatric patients undergoing cardiac surgery for congenital heart disease. Methods: Twenty consecutive children were studied. Three different ventilation strategies were applied to each patient in the following order: 0 cm H2O PEEP, 8 cm H2O PEEP without an ARS, and 8 cm H2O PEEP with a standardized ARS. At the end of each ventilation strategy, Crs, EELV, and arterial blood gases were measured. Results: EELV, Crs, and PaO2/FiO2ratio changed significantly (P < 0.001) with the application of 8 cm H2O + ARS. Mean PaCO2- PETCO2difference between 0 PEEP and 8 cm H2O PEEP + ARS was also significant (P < 0.05). Conclusion: An alveolar recruitment strategy with relative high PEEP significantly improves Crs, oxygenation, PaCO2- PETCO2difference, and EELV in pediatric patients undergoing cardiac surgery for congenital heart disease.

Measurement of end-expiratory lung volume in intubated children without interruption of mechanical ventilation (Article)

2009-10-01T00:00:00Z

Purpose: Monitoring end-expiratory lung volume (EELV) is a valuable tool to optimize respiratory settings that could be of particular importance in mechanically ventilated pediatric patients. We evaluated the feasibility and precision of an intensive care unit (ICU) ventilator with an in-built nitrogen washout/washin technique in mechanically ventilated pediatric patients. Methods: Duplicate EELV measurements were performed in 30 patients between 5 kg and 43 kg after cardiac surgery (age, median + range: 26, 3-141 months). All measurements were taken during pressure-controlled ventilation at 0 cm H2O of positive end-expiratory pressure (PEEP). Results: Linear regression between duplicate measurements was excellent (R2= 0.99). Also, there was good agreement between duplicate measurements, bias ± SD: -0.3% (-1.5 mL) ± 5.9% (19.2 mL). Mean EELV ± SD was 19.6 ± 5.1 mL/kg at 0 cm H2O PEEP. EELV correlated with age (p < 0.001, r = 0.92, R2= 0.78), body weight (p < 0.001, r = 0.91, R2= 0.82) and height (p < 0.001, r = 0.94, R2= 0.75). Conclusion: This ICU ventilator with an in-built nitrogen washout/washin EELV technique can measure EELV with precision, and can easily be used for mechanically ventilated pediatric patients.

A New Transesophageal Probe for Newborns (Article)

2009-10-01T00:00:00Z

Current transesophageal probes are designed for adults and are used both in the operating theatre for monitoring as well as in the outpatient clinic for patients with specific indications, like obesity, artificial valves, etc. For newborns (<5 kg), transesophageal echocardiography (TEE) is not possible because the current probes are too big for introducing them into the esophagus. There is a clear need for a small probe in newborns that are scheduled for complicated cardiac surgery and catheterization. We present the design and realization of a small TEE phased array probe with a tube diameter of 5.2 mm and head size of only 8.2-7 mm. The number of elements is 48 and the center frequency of the probe is 7.5 MHz. A separate clinical evaluation study was carried out in 42 patients (Scohy et al. 2007). (E-mail: n.dejong@erasmusmc.nl).

Three-dimensional transesophageal echocardiography: Diagnosing the extent of pericarditis constrictiva and intraoperative surgical support (Article)

2009-05-01T00:00:00Z

The traditional two-dimensional transthoracic echocardiography (2DTTE) has limitations in demonstrating the extent of pericardial thickening in constrictive pericarditis (CP) because of poor transmission of ultrasound through the thickened anterior pericardial structures. We describe a case of CP, of unknown etiology, in which transesophageal 3DTEE equalled the accuracy of cardiac magnetic resonance in demonstrating the extent of pericardial thickening in CP.

Image quality using a micromultiplane transesophageal echocardiography probe in older children during cardiac surgery (Article)

2009-05-01T00:00:00Z

Intraoperative transesophageal echocardiography is beneficial for hemodynamic stabilization during left ventricular assist device implantation in children (Article)

2009-04-01T00:00:00Z

Background: Mechanical circulatory support, with a left ventricular assist device (LVAD) is used in an increasing number of children for treatment of advanced heart failure as bridge-to-transplant. To date no data are available and no studies have defined the role of intraoperative transesophageal echocardiography (TEE) for hemodynamic stabilization during Centrimag Levitronix centrifugal pump implantation in children. Methods: Children with therapy resistant heart failure, undergoing LVAD implantation using Berlin Heart Excor pediatric cannula connected to a Levitronix Centrifumag pump, are intraoperatively monitored using an Oldelft micromultiplane TEE. Intraoperative TEE is specially used to monitor right ventricular (RV) and left ventricular (LV) function, correct position of the cannulas and response to pharmacological treatment. Results: In five consecutive patients RV function was assessed by TEE after starting LVAD Levitronix centrifugal pump. Initial RV failure presents with RV dilation and LV collapse. After titration of vasopressor and inotropic agents, RV contractility improved and thereby the filling of the LV. In one child, despite those measures the RV showed no improvement by TEE and a Levitronix right ventricular assist device to support the RV function was implanted as well. All patients could hemodynamically be stabilized before transport to the intensive care unit. Conclusion: The complex interaction of the RV and LV function and correct positioning of the cannula, during LVAD implantation in children with end-stage cardiac failure is improved by simultaneous visualization of cardiac performance of both ventricles and cannula positioning by means of intraoperative multiplane TEE.

Intraoperative real time three-dimensional transesophageal echocardiographic measurement of hemodynamic, anatomic and functional changes after aortic valve replacement (Article)

2009-01-01T00:00:00Z

The traditional intraoperative two-dimensional transesophageal echocardiography (2DTEE) has limitations in measuring left ventricular ejection fraction (LVEF) because measurements rely on geometric assumptions. The availability of online software and real time three-dimensional transesophageal echocardiography (RT3D-TEE) makes intraoperative LVEF measurements fast and easy. This is the first report of intraoperative measurement of LVEF and aortic valve area (AVA) by RT3-DTEE in a patient who received transcatheter-based transapical aortic valve implantation.

Usefulness of intraoperative real-time 3D transesophageal echocardiography in cardiac surgery (Article)

2008-11-01T00:00:00Z

Background: Recent advances in three-dimensional (3D) echocardiography allow to obtain real-time 3D transesophageal (RT3DTEE) images intraoperatively. Methods: Preoperative transthoral echocardiography (TTE) revealed: hypertrophic ventricular septum (TTE:19.3 mm), systolic anterior motion (SAM) not causing obstruction and malcoaptation of the anterior mitral valve leaflet (AMVL), and posterior mitral valve leaflet (PMVL) with severe mitral regurgitation. Results: Intraoperative TEE with a x7-2t MATRIX-array transducer (Philips, Andover, MA, USA) with a transducer frequency of x7-2 t mHz, connected to a iE33 (Philips), shows us that the main mechanism and site of regurgitation was an AMVL cleft. We also measured a 24.3-mm thickness of the ventricular septum and analyzing the 3D full volume acquisition revealed that there was no SAM. Conclusion: Intraoperative RT3DTEE permitted comprehensive 3D viewing of the mitral valve revealing the mechanism of mitral valve regurgitation, SAM, and the exact width of the hypertrophic ventricular septum.

Intraoperative cell salvage in infants undergoing elective cardiac surgery: a prospective trial (Article)

2008-08-01T00:00:00Z

Background: For a long time intraoperative cell salvage was considered not to be applicable in paediatric patients due to technical limitations. Recently, new autotransfusion devices with small volume centrifugal bowls and dedicated paediatric systems allow efficient blood salvage in small children. The purpose of this prospective non-randomised study was to determine the impact of intraoperative cell salvage on postoperative allogeneic blood products transfusion in infant patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: Two consecutive cohorts (122 patients) were studied. The first cohort underwent procedures between January 2004 and July 2005 with only blood salvage from the residual volume. The second cohort consisted of patients operated on from August 2005 to December 2006, with additional use of intraoperative cell salvage. The following variables were analysed: peri- and postoperative blood loss, transfusion of homologous blood products and cell salvage product, haematological and coagulation data, measured before, during and after the operation. Results: Additional intraoperative cell salvage significantly enhanced the amount of cell saving product available for transfusion (183 ± 56 ml vs 152 ± 57 ml, p = 0.003) and significantly more patients in this group received the cell saving product postoperatively. Consequently, allogeneic blood transfusion was significantly reduced in volume as well as in frequency. We did not observe any adverse effects of intraoperative cell salvage. Conclusion: Intraoperative cell salvage, employed as an adjuvant technique to the residual volume salvage in infants undergoing first time cardiac surgery with cardiopulmonary bypass, was a safe and effective method to reduce postoperative allogeneic blood transfusion. Considering current cell salvage related expense and the cost reduction achieved by diminished allogeneic transfusion, intraoperative cell salvage in infants demonstrated no economic benefit.

Intraoperative real time three-dimensional transesophageal echocardiographic evaluation of right atrial tumor (Article)

2008-07-01T00:00:00Z

Right atrial myxomas are uncommon heart tumors that can simulate nonspecific symptoms, such as fever, paroxysmal palpitations, chronic anemia, weight loss, and may escape timely diagnosis until the development of severe complications due to embolism. We present a patient with a history of palpitations. In search for the source of palpitations, a 2D transthoracic echocardiography was performed, showing a right atrial mass. Real time three-dimensional transesophageal echocardiography (RT3DTEE) was performed intraoperative and demonstrated very accurate information about the size and the morphology of the tumor. This is the first case report of a right atrial myxoma visualized intraoperatively by RT3DTEE.

Intraoperative evaluation of micromultiplane transesophageal echocardiographic probe in surgery for congenital heart disease (Article)

2007-08-01T00:00:00Z

Introduction: In the last years, transesophageal transducers for multiplane Doppler echocardiography have demonstrated their superior imaging performance in pediatric patients undergoing cardiac surgery. To date, the size of these probes has limited their use in neonates and small children. New technologies allowing performing TEE in smaller patients are therefore promising. Methods: We report our clinical experience with the Oldelft micromultiplane TEE probe (8.2-7 mm diameter tip with a 5.2 mm diameter shaft) specifically meant for use in neonates. Results: Forty-two patients were examined intra-operatively using the micromulti TEE harmonic transducer. Patients examined ranged in age from 4 days to 6 years and ranged in weight from 2.5 to 23.8 kg. In two patients we had to adapt ventilatory settings because of increased airway resistance after probe insertion. In 3 patients surgical re-intervention was performed due to TEE assessment immediately after weaning from bypass. In two patients significant obstruction of the right ventricular outflow tract was still present after Fallot correction, and one patient had an additional muscular ventricular septal defect still present after VSD closure. Conclusions: The micromulti TEE harmonic transducer provided excellent diagnostic intra-operative TEE in neonates and small children without major complications, special attention should be taken for ventilatory parameters in neonates less than 3 kg.

Effects of cardiopulmonary bypass circuit reduction and residual volume salvage on allogeneic transfusion requirements in infants undergoing cardiac surgery (Article)

2007-06-01T00:00:00Z

Cardiopulmonary bypass in children may cause severe hemodilution and can lead to excessive perioperative blood loss and high transfusion requirements. Minimization of cardiopulmonary bypass circuit and salvage of red blood cells from the residual volume after the procedure are widely utilized to reduce allogeneic transfusion. We evaluated the effectiveness of those measures introduced in infant cardiac surgery in our institution. This retrospective observational study included 148 consecutive infants between 1 and 12 months of age, with a body weight <10 kg, who underwent an elective cardiac operation between 1997 and 2005. Patients were divided into three groups defined by the circuit prime volume; 700 ml (Group 1), 450 ml (Group 2) and 330 ml (Group 3). In Group 1 residual volume after perfusion was discarded and in Groups 2 and 3 was processed in a cell saving device. Analyzed variables were: perioperative blood loss, transfusion of homologous blood products and cell salvage product, and hematology data. Reduction of the circuit volume significantly diminished use of red blood cell concentrates from 1.6 units to 0.8 units (P<0.0001), and fresh frozen plasma from 1.3 units to 0.4 units (P<0.0001). Utilization of the cell salvage product reduced significantly (P=0.023) the postoperative need for homologous blood transfusion. Therefore, both measures proved to be effective in reducing homologous blood transfusion in infant cardiac surgery.

Three-dimensional transesophageal echocardiography in Ebstein's anomaly (Article)

2007-05-01T00:00:00Z

Three-dimensional (3D) transthoracic echocardiography has advantages over traditional two-dimensional (2D) echocardiography in visualizing tricuspid valve morphology in Ebstein's anomaly. We describe the application of intra-operative 3D transesophageal echocardiography during a tricuspid valve repair procedure in a patient with Ebstein's anomaly. Intra-operatively three-dimensional transesophageal echocardiography (3D TEE) data sets revealed morphology and function of the tricuspid valve, right ventricle outflow tract (RVOT) and pulmonary valve before and after repair. Tricuspid valve leaflet morphology and coaptation as visualized with 3D TEE proved to be consistent with intra-operative findings. Analysis of the tricuspid valve, RVOT and pulmonary valve in the multi-planar review (MPR) mode revealed a bicuspid pulmonary valve, which had not been noticed on the preoperative 2D echocardiographic work-up. In this patient with Ebstein's anomaly, 3D TEE provided additional information on morphology and function of tricuspid valve, RVOT and pulmonary valve.

Virtual reality 3D echocardiography in the assessment of tricuspid valve function after surgical closure of ventricular septal defect (Article)

2007-03-12T00:00:00Z

Background. This study was done to investigate the potential additional role of virtual reality, using three-dimensional (3D) echocardiographic holograms, in the postoperative assessment of tricuspid valve function after surgical closure of ventricular septal defect (VSD). Methods. 12 data sets from intraoperative epicardial echocardiographic studies in 5 operations (patient age at operation 3 weeks to 4 years and bodyweight at operation 3.8 to 17.2 kg) after surgical closure of VSD were included in the study. The data sets were analysed as two-dimensional (2D) images on the screen of the ultrasound system as well as holograms in an I-space virtual reality (VR) system. The 2D images were assessed for tricuspid valve function. In the I-Space, a 6 degrees-of-freedom controller was used to create the necessary projectory positions and cutting planes in the hologram. The holograms were used for additional assessment of tricuspid valve leaflet mobility. Results. All data sets could be used for 2D as well as holographic analysis. In all data sets the area of interest could be identified. The 2D analysis showed no tricuspid valve stenosis or regurgitation. Leaflet mobility was considered normal. In the virtual reality of the I-Space, all data sets allowed to assess the tricuspid leaflet level in a single holographic representation. In 3 holograms the septal leaflet showed restricted mobility that was not appreciated in the 2D echocardiogram. In 4 data sets the posterior leaflet and the tricuspid papillary apparatus were not completely included. Conclusion. This report shows that dynamic holographic imaging of intraoperative postoperative echocardiographic data regarding tricuspid valve function after VSD closure is feasible. Holographic analysis allows for additional tricuspid valve leaflet mobility analysis. The large size of the probe, in relation to small size of the patient, may preclude a complete data set. At the moment the requirement of an I-Space VR system limits the applicability in virtual reality 3D echocardiography in clinical practice.

Anaesthesiological and ventilatory precautions during cardiac surgery in Steinert's disease: A case report (Article)

2007-01-01T00:00:00Z

Myotonic dystrophia type I or Steinert's disease is a progressive multisystemic-inherited neuromuscular disease. Higher sensitivity to sedatives, anaesthetic, and neuromuscular blocking agents may result in cardiovascular and respiratory complications. We describe the anaesthesiological and ventilatory measures in a 43-year-old patient with Steinert's disease successfully undergoing cardiac surgery.