The Journal of Thoracic and Cardiovascular Surgery, Vol 98, 90-99, Copyright © 1989 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
Intraoperative prebypass and postbypass epicardial color flow imaging in the repair of atrioventricular septal defects
RM Ungerleider, JA Kisslo, WJ Greeley, P Van Trigt and DC Sabiston Jr
Department of Surgery, Duke University Medical Center, Durham, NC 27710.
The use of intraoperative epicardial Doppler echocardiography with color
flow imaging both before and after cardiopulmonary bypass to assist repair
of congenital heart defects in infants and small children has not been
reported. To demonstrate its simplicity and utility, we obtained
immediately prebypass and postbypass examinations from 18 consecutive
patients undergoing repair of atrioventricular septal defects between March
1987 and March 1988 (aged newborn to 3 years, smallest 2.4 kg, 11 patients
less than 1 year old). Direct application of a sterile transducer to the
epicardial surface eliminates any restriction imposed by the
transesophageal approach, and the routine use of color flow imaging enables
the operating surgeon to directly evaluate intracardiac anatomy and flows
in a variety of orientations. Average examination time was 3.95 +/- 1.96
minutes. Prebypass studies disclosed that a short-axis inspection through
the common atrioventricular valve orifice produced a unique visualization
of the dynamic commitments of atrioventricular valve tissue throughout
systole and diastole that was helpful in planning valve allocation during
repair. In addition, echocardiography demonstrated features not previously
appreciated in seven of 18 patients (39%). In all, image quality and
resolution were vastly superior to preoperative chest wall studies.
Postbypass studies revealed significant residual interventricular shunts in
two of 18 patients (11%). Views obtained from various orientations directed
specific and efficient repair immediately so that all patients left the
operating room with documented, surgically acceptable results. Comparison
of ventricular function between prebypass and postbypass studies enabled
appropriate application of pharmacologic agents in the operating room if
necessary. All patients survived their operation. There have been two late
deaths, and 16 patients are alive and doing well (follow-up: 9 to 21
months). These experiences indicate that intraoperative epicardial Doppler
color flow imaging (1) can be easily learned and applied by the surgeon,
(2) enhances the repair of atrioventricular septal defect by providing
unique spatial, anatomic, and flow information in the beating heart at the
time of repair, (3) increases confidence of a surgically acceptable repair
before the patients leave the operating room, (4) guides specific surgical
or anesthetic adjustments to optimize results, and (5) works as a valuable
aid that may help reduce poor results in the repair of complex congenital
cardiac lesions.
