Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3677_Библиотеки_им_академика_М_И_Перельмана
.pdf
2.3 Fundamental Aspect ofPediatric TEE
https://t.me/medicina_free
ab
19
c
Fig. 2.8 The upper-esophageal (UE) transesophageal echocardiography (TEE) view is used to
visualize the structures above the heart, such as the great vessels, the aortic arch, and the superior
vena cava. The UE TEE view can help diagnose conditions such as aortic stenosis, aortic dissection, and pulmonary embolism, pulmonary stenosis, among others. (a) The PA view (with a transducer angle of 20°) displays the main pulmonary artery (PA), right PA, left PA, and mid-ascending
aorta (AAo). (b) The RPA view (with a transducer angle of 20°) displays the descending aorta
(DAo), superior vena cava (SVC), right upper pulmonary vein (RUPV), and RPA. (c) The DAo
view (with a transducer angle of 20°) displays the DAo and LPA. (d) The AAo view (with a transducer angle of 20°) displays the AAo and PA
d
20
https://t.me/medicina_free
2 Transesophageal Echocardiography (TEE) forPediatric Congenital Cardiac Surgery…
ab
Fig. 2.9 TEE examination of transgastric (TG) view. (a) The TG mid SAX view displays the
middle left ventricle (LV), middle right ventricle (RV), interventricular septum (IVS), posterior
medial papillary muscle (PM), and anterior lateral papillary muscle (AL). (b) The basal SAX view
illustrates the scallops of mitral valve (MV) (anterior/posterior leaets). (c) The TG LAX view
(with the transducer angle set at 120°) shows the left atrium (LA), LV, MV, and PM and AL
c
2.3.1.1 Additional Left Paracarinal View forVisualizing Left
Pulmonary Artery (LPA)
Furthermore, the TEE imaging of the proximal left pulmonary artery (LPA) is hindered by a “blind spot” caused by the interposition of the left bronchus between the
proximal LPA and the esophagus, resulting from air blockage (Fig.2.10a–c). At the
carinal (C) level, however, the esophagus is positioned dorsally to the left edge of
the carina, between the carina and the descending aorta (Fig.2.10d). By using the
left paracarinal transverse view [16], this limitation can be overcome and the proximal LPA can be clearly seen, which is crucial for diagnostic purposes in cases of
patent ductus arteriosus (PDA) or for its repair through surgery or transcatheter
closure (Fig.2.10d, e).
2.4 Safety andEectiveness ofPediatric TEE
https://t.me/medicina_free
21
a b
d
Fig. 2.10 Shows a left paracarinal view for visualizing the left pulmonary artery (LPA). The
image provides a clear representation of the left pulmonary artery, allowing for accurate assessment and diagnosis. (a) An esophagogram reveals that the left bronchus (LB) lies in front of the
esophagus (ESO) at the upper portion, causing a blind point in the ability of the TEE probe to
visualize the LPA from the esophagus. (b) Cardiac CT image. The red arrow indicates the left
bronchus (LB) which creates a blind spot between the esophagus (*) and the left pulmonary artery
(LPA), hindering the visualization of the latter. On the other hand, the right pulmonary artery
(RPA) can be distinguished clearly from the esophagus. (c) The standard view of the LPA at the
upper esophagus is obstructed by the left bronchus. (d) Cardiac CT at the level of the carina (C)
demonstrates the esophagus (*) located dorsally to the left edge of the carina and between the
carina and the descending aorta (DAO). In this left paracarinal view, the LPA can be delineated
from the esophagus. (e) TEE image of the UE AAo SAX view reveals that the left pulmonary
artery (LPA) can be delineated by avoiding the left bronchus (LB) through the use of the left paracarinal transverse view
e
c
2.4 Safety andEffectiveness ofPediatric TEE
While pediatric TEE plays a signicant role in CHD surgery and catheter interventions, it is considered semi-invasive, particularly in pediatric patients, nonetheless it
is safer compared to other diagnostic techniques. Consequently, the insertion and
handling of the ultrasound probe during the procedure can result in related injuries
to the gastroesophageal system, as well as potential compromise to the cardiovascular and respiratory systems. Despite the rarity of such complications, they can be
fatal if not prevented or promptly treated. To minimize the risk, it is essential to
employ strategies for the prevention of these complications. Comprehensive
22
https://t.me/medicina_free
2 Transesophageal Echocardiography (TEE) forPediatric Congenital Cardiac Surgery…
multiplane TEE examinations are performed according to guidelines established by
the American Society of Echocardiography (ASE) and the Society of Cardiovascular
Anesthesiologists (SCA) [7, 8].
2.5 Potential Complications Associated withPediatric TEE
2.5.1 Gastrointestinal Injury
TEE injury is a consistent major upper gastrointestinal (UGI) complication, accounting for 1.2% of such cases [17]. Hematoma (Fig.2.11a), bleeding (Fig.2.11b), and
perforation [18] are possible esophageal injuries that are due to the small diameter
of the esophagus in pediatric patients, particularly when using TEE.Small children,
especially, may experience injury from improper insertion, inexperience, or hastily
a
Fig. 2.11 (a) A patient-reported difculty swallowing after undergoing cardiac surgery. Upon
examination via panendoscopy, a large hematoma was discovered in the lower esophageal area
(Eso). (b) Shows a 4-year-old female patient with tetralogy of Fallot who underwent surgical
repair. Postsurgery, persistent esophageal bleeding was observed, and panendoscopy revealed erosion and bleeding lesions at the gastroesophageal junction (GEJ) (indicated by arrows in the two
upper diagrams). Hemostasis was achieved by applying two hemoclips (H) in the two lower
diagrams
2.5 Potential Complications Associated withPediatric TEE
https://t.me/medicina_free
b
23
Fig. 2.11 (continued)
withdrawn TEE probe. Additionally, peptic ulcer or gastroesophageal reux can
cause inammation or bleeding in the esophagus, particularly during heparization
in cardiopulmonary bypass. The contributing factors to TEE-related esophageal
injury may be due to prolonged exion of the probe or mobilization in a locked
position, particularly during prolonged cardiopulmonary bypass with nonpulsatile
ow or excessive heat, which can lead to ischemic esophageal injury.
2.5.2 Airway Compression
Compression of the trachea or bronchial tree can obstruct ventilation.
1. Patients with congenital heart conditions, such as tetralogy of Fallot (TOF) or
pulmonary atresia, have a high rate of tracheobronchomalacia (as shown in
24
https://t.me/medicina_free
2 Transesophageal Echocardiography (TEE) forPediatric Congenital Cardiac Surgery…
Fig.2.12), which is easily compressed by the rigid TEE probe in the esophagus,
leading to airway obstruction.
2. An aneurysm in the pulmonary artery due to tetralogy of Fallot with an absent
pulmonary valve can also result in tracheal and esophagus compression (as
shown in Fig.2.12a).
3. In infants with a double aortic arch or a left pulmonary sling, tracheal stenosis
may occur near the carina, away from the tip of the endotracheal tube. If necessary, intubating only one lung which can relieve such atypical airway obstruction
is recommended (as shown in Fig.2.12b).
4. Children with congenital heart disease (CHD) have a higher incidence of tracheobronchial anomalies [19] (as stated in Fig.2.12c). These anomalies, combined with extrinsic compression or an undiagnosed condition, can result in
signicant perioperative morbidity. Physicians should be vigilant for signs of
cardiorespiratory compromise and take prompt action when necessary.
It is important to note that if airway obstruction occurs after the insertion of a
TEE probe, the probe should be immediately removed.
a
Fig. 2.12 (a) Contrast-enhanced cardiac CT image displayed by a lung window shows a nasogas-
tric (NG) tube compresses on the ventral membranous portion of the trachea (T) (black arrow) in
a 4-month-old male infant with diagnosed as tetralogy of Fallot (TOF) with tracheomalacia. (b–b2)
Depicts a 7-month-old child with TOF and an absent pulmonary valve (PV) before surgical repair.
The multislice CT reconstruction shows a large right pulmonary artery (RPA) aneurysm compressing the carina, right bronchus (arrows in b and b1), and esophagus, resulting in respiratory distress
and potentially hindering the insertion of a transesophageal echocardiogram (TEE) probe (b2).
The TEE probe was introduced after a sternotomy was performed. (abbreviation: T, trachea; RB,
Right bronchus; C, Carina; UE, upper esophagus; LE, lower esophagus; * indicates middle esophagus). (c–c1) Depicts an infant experiencing respiratory distress due to a double aortic arch. The
bronchogram in the left plane shows the double aortic arch forming a vascular ring and compressing the carina region. To address this, single-lung intubation was performed using an endotracheal
tube with multiple handmade holes at its tip, which ensured that the tube passed through the distal
stenosis at the carina and allowed gas to reach the other lung, as seen in c1. (d) Depicts an infant
with a ventricular septal defect (VSD) and a 3D trachea, which shows an abnormal narrowing of
the left bronchus
cc
2.5 Potential Complications Associated withPediatric TEE
https://t.me/medicina_free
25
bb1
d
b2
1
Fig. 2.12 (continued)
26
https://t.me/medicina_free
2 Transesophageal Echocardiography (TEE) forPediatric Congenital Cardiac Surgery…
2.5.3 Desaturation andSystemic Hypotension
Newborns with Total Anomalous Pulmonary Venous Connection (TAPVC) have a
congenital heart defect where the four pulmonary veins are not properly connected
to the left atrium. Instead, they form a conuence known as the Pulmonary Venous
Conuence (PVC) which is located behind the left atrium and can be easily compressed by the rigid TEE probe inserted into the esophagus. This compression can
lead to hypotension or desaturation [20] (as shown in Fig.2.13).
Fig. 2.13 Depicts a baby with total anomalous pulmonary venous connection (TAPVC). The
transesophageal echocardiogram (TEE) image in the left diagram shows the pulmonary venous
conuence (PVC) located behind the left atrium (LA), marked by a small “LA.” The cardiac CT in
the right diagram shows the PVC arising from both the left and right pulmonary veins, tting
closely against the back of the esophagus. Hence, placement of the TEE probe in the esophagus
will compress the PVC, leading to desaturation. (Note: The “#” indicates the left atrium and the
“*” indicates the nasogastric tube)
2.5 Potential Complications Associated withPediatric TEE
https://t.me/medicina_free
27
2.5.4 Systemic Hypotension
It is recommended to withdraw the TEE probe after the surgical repair of Coarctation
of the aorta (CoA) due to the risk of hypotension. This is because the repaired aorta
can be easily compressed by the rigid TEE probe in the esophagus. CoA is a condition in which the aorta is abnormally narrowed, but it can be treated successfully
with surgery (as shown in Fig.2.14).
Fig. 2.14 Depicts a child with a coarctation of the aorta (CoA) who underwent angioplasty repair
(as shown in left diagram). The insertion of a transesophageal echocardiogram (TEE) through the
esophagus can result in systemic hypotension due to compression of the surgical ap, as depicted
in the right diagram
2 Transesophageal Echocardiography (TEE) forPediatric Congenital Cardiac Surgery…
https://t.me/medicina_free
28
2.6 Contraindication forPediatric TEE (Refer toTable 2.1)
The use of TEE in cardiac surgery has been reported to result in major injury in
approximately one out of every 1000 patients [21]. Although such incidents are
relatively uncommon, they can occur due to problems during probe insertion or
manipulation. These complications can include oropharyngeal trauma, arrhythmias,
and disruptions to both respiratory and cardiac function. These contraindications
are listed in Table2.1.
Table 2.1 Contraindication in TEE used in pediatric patients
Absolute contraindications Relative contraindications
Esophageal pathology
Fistula to trachea
Stricture
Infection
Bleeding
Trauma
Tumor
Diverticulum
Poor airway control
Respiratory distress (e.g., vascular ring)
a
TAPVC total anomalous pulmonary venous connection
b
CoA coarctation of the aorta
Specic lesions
a
TAPVC
b
CoA
Severe coagulopathy or thrombocytopenia
History of esophageal surgery
Соседние файлы в папке Библиотека им академика М.И. Перельмана