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    Abstract
   Introduction
   Case report
   Discussion
   Acknowledgment
    References
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Table of Contents
CASE REPORT  
Year : 2014  |  Volume : 17  |  Issue : 4  |  Page : 296-298
A proposed method to visualize the ductus arteriosus on transesophageal echocardiography


Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Submission12-Dec-2013
Date of Acceptance24-Apr-2014
Date of Web Publication1-Oct-2014
 

   Abstract 

The ductus arteriosus occupies a uniquely privileged position in the management of heart disease; it initiated not only the surgical management of congenital lesions but also the percutaneous management of this subset. During trans-thoracic echocardiography (TTE) the ductus is often visualized using 'high' parasternal (or the 'ductal' view) or suprasternal windows. It is generally agreed that imaging ductus during transesophageal echo (TEE) can be sub-optimal. During TEE imaging, visualization of the ductus arteriosus is obscured by the acoustic impedance offered by the left main bronchus; adjunct techniques such as insertion of a saline filled balloon in this airway have been used. We describe a simple maneuver that allows visualization of the patent ductus arteriosus during TEE imaging without the use of any adjuncts.

Keywords: Ductus arteriosus; Modified upper esophageal view; Transesophageal echocardiography

How to cite this article:
Gogia R, Kumar B, Jayant A. A proposed method to visualize the ductus arteriosus on transesophageal echocardiography. Ann Card Anaesth 2014;17:296-8

How to cite this URL:
Gogia R, Kumar B, Jayant A. A proposed method to visualize the ductus arteriosus on transesophageal echocardiography. Ann Card Anaesth [serial online] 2014 [cited 2022 Aug 19];17:296-8. Available from: https://www.annals.in/text.asp?2014/17/4/296/142068



   Introduction Top


The patent ductus arteriosus (PDA) occupies a uniquely privileged position in the management of heart disease; it initiated not only the surgical management of congenital lesions, but also the percutaneous management of this subset. [1] In transthoracic echocardiography (TTE), the ductus is visualized using "high" parasternal (or the "ductal" view) or suprasternal windows. [2] It is generally agreed that imaging ductus during transesophageal echocardiography (TEE) can be suboptimal. [3] During TEE, visualization of the ductus arteriosus (DA) is obscured by the acoustic impedance offered by the left main bronchus. Adjunct techniques such as insertion of a saline filled balloon in the left main bronchus have been used. [3] We describe a simple maneuver that allows visualization of the PDA during TEE imaging.


   Case report Top


A 12-year-old female patient was diagnosed preoperatively with a PDA and subaortic membrane with a mean gradient of 40 mmHg and an echocardiographically normal aortic valve. She was scheduled for PDA ligation and subaortic membrane resection. Following induction of general anesthesia, a pediatric TEE probe (S7-3t, Philips, Andover MA, USA) was inserted for TEE imaging. To visualize the ductus during 2-dimensional (D) echocardiography examination, initially, the left subclavian artery was visualized [4] using upper esophageal aortic arch long axis view at an angle of 40-60°. From this point, the probe was advanced 1 to 2 cm, the multiplane angle returned to 0°, the probe is gently anteflexed and gradually turned to the right. Video Loop 1 and [Figure 1] show the image obtained wherein the aorta, the dilated main pulmonary artery, the proximal left pulmonary artery (LPA) and the echo dropout in the form of the ductus are clearly visualized. The patient underwent a median sternotomy and the ductus was ligated, postligation, the same TEE views were used to verify the completeness of ligation [Loop 2]. In the same sitting, the patient underwent subaortic membrane resection and was weaned off cardiopulmonary bypass with minimal inotropic support. TEE imaging of the left ventricular outflow after hemodynamic stabilization showed no residual obstruction. She had an uneventful postoperative recovery.
Figure 1: Ductus as visualized on 2-dimensional echocardiography (LB: Left main-stem bronchus, LPA: Left pulmonary artery, DTA: Descending thoracic aorta)

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   Discussion Top


The PDA is a persistent vascular connection between the aortic isthmus and the proximal LPA. [2] Arising from the posterosuperior aspect of the junction of the pulmonary trunk and the LPA it then courses posteriorly and slightly leftward to join the aorta at its isthmus. The LPA arises from the pulmonary trunk in the concavity of the aortic arch in front of the left main bronchus, is attached to the undersurface of the aortic isthmus by the ligamentum arteriosus (the obliterated DA) and then quickly spirals over the top of this bronchus to reach the back of the airway and the hilum of the left lung [5] and because of the intervening left bronchus imaging of the LPA on TEE is often the echo cardiographer's Achilles heel. [6],[7]

The key to demonstrate the ductus on 2D echocardiography is a delineation of the pulmonary trunk and the proximal LPA. It is generally believed that this may not be always obtainable on TEE or more readily obtained with additional measures such as a fluid filled balloon in the left main bronchus. [3] Yet others have suggested that the LPA need not be visualized at all to investigate the ductus on TEE. This places an excessive reliance on color Doppler investigation of the distal pulmonary trunk; [8],[9] while Color Doppler of the distal pulmonary artery is readily obtainable and is supportive, it is not definitive in the delineation of a ductus. A recent review suggests the importance of visualizing the aorta and the pulmonary artery concurrently, but probably applies only to the postsubclavian position of the ductus. [10] Our alternative perspective is also validated by the need to obtain a "high" parasternal short axis ("ductal") view rather than a standard parasternal short axis view in trans-thoracic imaging of the DA; this view optimally traces the pulmonary artery bifurcation and the descending aorta simultaneously. [2] In the variegated landscape of congenital heart disease, there is a subset of patients who will have a large ductus, but with reversal of flow (from right to left) in which case the ductus can easily be confused with the flow in either the pulmonary artery or the proximal descending aorta; [2] since our proposed view simultaneously views both the descending aorta and the origin of the LPA it could potentially be useful as it can show the ductus (on 2D echocardiography) as a communication between these two structures. However, since this is an isolated case report it will need prospective validation.

The use of adjuncts such as a balloon in the left main bronchus filled with saline offering a hitherto unavailable acoustic window is attractive, but often not practical (considering the additional needs for bronchoscopy, sizing balloons, keeping them right where they should be) in the pediatric population. Instead of attempting to see through the left main bronchus, we instead seek to go beyond it (just distal to the origin of the left subclavian artery); from this distal position, mild anteflexion and rightward rotation brings the distal pulmonary trunk, the proximal LPA and the aortic isthmus in one composite view however, Doppler interrogation and the resultant interpretation using this technique may be inadequate and must take into account imprecise beam orientation, the vicinity of many major vascular structures such as the LPA. The aortic isthmus and the left subclavian artery whose individual flows could contaminate the ductal flow spectrum in addition to the conventional problems of aliasing. Thus, beyond identification of the ductus itself, conclusions on the directionality of ductal flow should not be based on this imaging alone. When anteflexing the probe, care has to be exercised in avoiding excessive anteflexion which would lead to visualizing the airway instead of the more anteriorly placed LPA and can also cause esophageal injury. The view so obtained is different from the standard upper esophageal aortic arch short axis view; [5] the orthogonal cut at the multiplane angle of around 90° in this image passes through the left main bronchus and obscures the LPA (ultrasound emanating from the esophagus is poorly conducted by the left main bronchus and cannot image the LPA, which is exactly anterior to this structure). This schematic is further explained diagrammatically in [Figure 2]. It is also mandatory to ensure that anteflexion is a brief maneuver and that the probe is returned to neutral as soon as the necessary images are obtained. While this index patient had a PDA allowing elaboration, we have quite consistently used this view in both adults and pediatric patients to visualize the proximal LPA and its confluence with the pulmonary trunk (so as to examine a disease subset such as proximal LPA stenosis and the adequacy of its repair in Tetralogy of Fallot).

Preoperative TTE should be necessary and sufficient to rule in or rule out a ductus for children presenting for open heart procedures. There will be however some patients in whom preoperative TTE has missed out on some of these details. It is precisely this void in the continuum of cardiac care that intraoperative TEE has filled. [11] While not suggesting that intraoperative TEE replace preoperative TTE in delineating this condition definitively, we propose a simple maneuver that can adequately image the PDA without the use of any adjuncts on TEE. The imaging maneuver suggested can also potentially image left sided modified Blalock-Taussig shunts (BTS) [Colour Doppler of a patent left sided modified BTS) Loop 3] and LPA origin stenosis. We are able to view the LPA in a majority of patients using this method in diverse subsets ranging from Tetralogy of Fallot to chronic thromboembolic pulmonary hypertension. Further, if the proximal LPA is not visualized on TEE, the TEE imaging should be considered insufficient to rule out the presence of a PDA.
Figure 2: Schematic of imaging method (LPA: Left pulmonary artery, MPA: Main pulmonary artery)

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   Acknowledgment Top


The authors gratefully acknowledge the assistance in producing Figures from the Art Division, Department of Experimental Medicine, PGIMER, Chandigarh.

 
   References Top

1.Kouchokos NT, Blackstone EH, Hanley FL, Doty DB, Karb RP. Patent ductus arteriosus. 3 rd ed., Ch. 23. Kirklin/Barratt-Boyes Cardiac Surgery. Philadelphia: Churchill Livingstone; c2003. p. 928-45.  Back to cited text no. 1
    
2.Tacy TA. Abnormalities of the ductus arteriosus and pulmonary arteries. In: Lai WM, Mertens LL, Cohen MS, Geva T, editors. Echocardiography in Pediatric and Congenital Heart Disease. Chicester: Wiley-Blackwell; c2009. p. 283-96.  Back to cited text no. 2
    
3.Song H, Liu F, Dian K, Liu J. Echo rounds: Intraoperative transesophageal echocardiography-guided patent ductus arteriosus ligation in an asymptomatic nonbacterial endocarditis patient. Anesth Analg 2010;111:878-80.  Back to cited text no. 3
    
4.Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64.  Back to cited text no. 4
    
5.McMinn RM. Thorax. Last's Anatomy. 9 th ed., Ch. 4. New York: Churchill Livingstone; c1994. p. 241-94.  Back to cited text no. 5
    
6.Phoon CK, Rutkowski M. Transesophageal imaging of the mid to distal left pulmonary artery in congenital heart disease. J Am Soc Echocardiogr 1999;12:663-8.  Back to cited text no. 6
    
7.Guardado J, Cotrim C, Simões O, Almeida S, Ialá M, Lopes L, et al. Left pulmonary artery evaluation through transesophageal echocardiography. Rev Port Cardiol 2006;25:409-15.  Back to cited text no. 7
    
8.Takenaka K, Sakamoto T, Shiota T, Amano W, Igarashi T, Sugimoto T. Diagnosis of patent ductus arteriosus in adults by biplane transesophageal color Doppler flow mapping. Am J Cardiol 1991;68:691-3.  Back to cited text no. 8
    
9.Gologorsky E, Gologorsky A, Barron ME, Salerno TA. Patent ductus arteriosus revisited: Myths and misconceptions. Anesth Analg 2011;113:425.  Back to cited text no. 9
[PUBMED]    
10.Vegas A, Jerath A. Upper esophageal transesophageal echocardiography views pathology. Anesth Analg 2012;115:511-6.  Back to cited text no. 10
    
11.Bettex DA, Schmidlin D, Bernath MA, Prêtre R, Hurni M, Jenni R, et al. Intraoperative transesophageal echocardiography in pediatric congenital cardiac surgery: A two-center observational study. Anesth Analg 2003;97:1275-82.  Back to cited text no. 11
    

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Correspondence Address:
Aveek Jayant
Nehru Hospital Level 4, Postgraduate Institute of Medical Education and Research, Sector 12,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.142068

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    Figures

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