How to cite this article: Jain PK, Malik V, Kapoor PM. Transesophageal echocardiography for minimally invasive cardiac surgery-atrial septal defect closure. Ann Card Anaesth 2016;19:527-9
How to cite this URL: Jain PK, Malik V, Kapoor PM. Transesophageal echocardiography for minimally invasive cardiac surgery-atrial septal defect closure. Ann Card Anaesth [serial online] 2016 [cited 2021 Sep 28];19:527-9. Available from: https://www.annals.in/text.asp?2016/19/3/527/185549
Evaluation of the atria and interatrial septum
Determine types: Ostium secundum defect [Video 1]/ostium primum defect/sinus venosus atrial septal defect (ASD)/coronary sinus (CS) type ASD
Determine - size, shape, number, and location of any atrial/ventricular communication present; and the direction of shunt flow [Figure 1]
Rule out - partial anomalous pulmonary venous connection, left superior vena cava (LSVC)
Transesophageal echocardiography (TEE) views: Mid-esophageal aortic valve short axis (ME AoV SAX) view, ME modified bicaval view/ME bicaval view
Superior vena cava (SVC) cannula through the right internal jugular vein approach: Bicaval or modified bicaval view [Video 1] - best suits the purpose. Venous cannula should be kept at least 2 cm above the right atrium-SVC junction for adequate SVC snaring
Real-time assistance for arterial cannulation and antegrade cardioplegia delivery
Guidewire for endovascular - real-time assisted balloon catheter insertion in Asc ascending aorta is a must; so also measurement of aortic root diameter, correct placement of endovascular balloon, and its proper inflation
TEE views: ME long axis (LAX) view, ME AoV LAX view [Figure 3].
Figure 3: Mid-esophageal long axis view, mid esophageal aortic valve long axis view
Real-time assistance for coronary sinus cannulation and retrograde cardioplegia delivery
CS is visible in the high ME4C view/ME bicaval view/the classical ME4C view with slight retroflexion [Video 2]
Normal CS diameter is 7-15 mm and diameter >15 mm is suggestive of LSVC presence. Uninterrupted retrograde cardioplegia delivery requires a patent and unobstructed CS and the absence of LSVC.
Weaning from cardiopulmonary bypass and post cardiopulmonary bypass period
TEE is valuable during weaning from cardiopulmonary bypass (CPB) since removal of intracavitary air, and visual assessment of cardiac function during minimally invasive cardiac surgery is not possible due to limited exposure
Confirm the adequacy of surgical repair and absence of residual anatomic defects (ME4C view, ME bicaval, or modified bicaval view) [Figure 4].
Figure 4: Confirm the adequacy of surgical repair and absence of residual anatomic defects (ME4C view, mid-esophageal bicaval, or modified bicaval view)
Left ventricular systolic function - ejection fraction calculation using Simpson's method [Figure 5] and observing for the presence of any regional wall motion abnormalities [Video 3]
Left ventricular diastolic function - by pulse wave Doppler and tissue Doppler Imaging
Patients with severe ventricular systolic or diastolic dysfunction may not tolerate the prolonged CPB and aortic cross-clamp times
TEE views: ME4C view/ME2C/ME LAX views.
Figure 5: Left ventricular systolic function-ejection fraction calculation using Simpson's method
When the shunt flow is right to left or bidirectional - suggests significant pulmonary hypertension or significant impairment of right ventricular (RV) compliance - a contraindication for ASD and patent foramen ovale closure
TEE views:
Upper esophageal pulmonary artery LAX view [Figure 6]/transgastric RV basal view - interrogate spectral profile of forward and regurgitant (if any) flow across pulmonary valve
ME RV inflow-outflow view/ME modified bicaval tricuspid valve view [Figure 7] - tricuspid regurgitation (TR) jets are well aligned with the insonation beam and allows precise measurement of maximum TR velocity, right ventricular systolic pressure (≈pulmonary artery systolic pressure).
Figure 6: Upper esophageal pulmonary artery long axis view
Correspondence Address: Pawan Kumar Jain Senior Resident, Department of Cardiac Anaesthesia, CTC, All India Institute of Medical Sciences, New Delhi India
Source of Support: None, Conflict of Interest: None
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