Role of intraoperative transesophageal echocardiography in pediatric cardiac surgery

Background: Intraoperative transesophageal echocardiography [TEE] has a major role in detecting residual lesions during and/or after pediatric cardiac surgery

Methods: All pediatric patients who underwent cardiac surgery between July 2001 and December 2008 were reviewed. The records of surgical procedure, intraoperative TEE, and predischarge transthoracic echocardiograms were reviewed to determine minor and major residual cardiac lesions after surgical repair

Results: During the study period, a total of 2268 pediatric cardiac patients were operated in our center. Mean age was 21 months [from 1 day to 14 years]. Of these patients, 1016 [48%] had preoperative TEE and 1036 [46%] were evaluated by intraoperative echocardiography [TEE or epicardial study]. We identified variations between TEE and preoperative transthoracic echocardiography in 14 patients [1.3%]. Only one surgical procedure was cancelled after atrial septal defect exclusion. The other 13 patients had minor variation from their surgical plan. Major residual lesions requiring surgical revision were detected in 41 patients [3.9%], with the following primary diagnoses: tetralogy of Fallot in 12 patients [29%], atrioventricular septal defect in seven patients [17%], ventricular septal defect in seven patients [17%], double outlet right ventricle in two patients [5%], Shone complex in two patients [5%], subaortic stenosis in two patients [5%], mitral regurgitation in two patients [5%], pulmonary atresia in two patients [5%], and five patients [12%] with other diagnoses

Conclusion: Intraoperative TEE has a major impact in pediatric cardiac surgery to detect significant residual lesions. Preoperative TEE has a limited role in case of a high quality preoperative transthoracic echocardiography. We recommend routine use of intraoperative TEE during and/or after intracardiac repair in children

Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery

Chylothorax is the accumulation of chyle in the pleural cavity, which usually develops after disruption of the thoracic duct along its intra-thoracic route. In the majority of cases, this rupture is secondary to trauma [including cardio thoracic surgeries]. Chylothorax is a potentially serious complication after cardiovascular surgeries that require early diagnosis and adequate management. This study aims to determine the risk factors and the impact of chylothorax on the early postoperative course after pediatric cardiac surgery. A retrospective study of all cases complicated with chylothorax after pediatric cardiac surgery was conducted at King Abdulaziz Cardiac Center between January 2007 and December 2009. There were 1135 cases operated on during the study period. Of these, 57 cases [5%] were complicated by chylothorax in the postoperative period. Thirty patients [54%] were males, while 27 [47%] were females. Ages ranged from 4 to 2759 days. The most common surgeries complicated by chylothorax were the single ventricle repair surgeries [15 cases, 27%]; arch repairs [10 cases, 18%]; ventricular septal defect repairs [10 cases, 18%]; atrioventricular septal defect repairs [7 cases, 12%]; arterial switch repair [6 cases, 11%], and others [8 cases, 14%]. The intensive care unit [ICU] and the length of hospital stays were significantly longer in the chylothorax group. Additionally, some early postoperative parameters such as incidence of sepsis, ventilation time, and inotropes duration and number were higher in the chylothorax group. Chylothorax after pediatric cardiac surgery is not a rare complication. It occurs more commonly with single ventricle repair and aortic arch repair surgeries, and has a significant impact on the postoperative course and post operative morbidity

Ultrasound guided vascular access in pediatric cardiac critical care

Safely obtaining vascular access in the pediatric population is challenging. This report highlights our real-world experience in developing a safer approach to obtaining vascular access using ultrasound guidance in children and infants with congenital heart disease. As part of a quality initiative, we prospectively monitored outcomes of all vascular access attempts guided by ultrasound from January 2010 to September 2010. Variables monitored included age, weight, the time from first needle puncture to wire insertion, site of insertion, number of attempts, type of line, and complications. There were 77 attempts [15 arterial and 62 venous] to obtain vascular access in 43 patients. The mean age was 15 months [6 days-11 years; median 2.5 months]. The mean weight was 7.2 kg [2-46 kg, median 3.8]. Success rates were 93% and 95% for arterial and venous cannulation, respectively. Mean time from first needle puncture to wire insertion was 3.9 min [0.5-15 min, median 2 min]. Fifty-five [75%] central line cannulations were successful from the first puncture; 17[23%] were successful from the second puncture; and one case [2%] required three punctures. Thirty patients [45%] weighed less than 3.5 kg. This lower body weight did not affect success rate, which was unexpectedly high [96.6%]. There were no associated complications. Ultrasound guided vascular cannulation in critically ill pediatric patients is safe, effective and efficient. This approach had a high success rate, and was associated with zero complications in our setting

Dextrocardia, aortopulmonary window with transposition of the great arteries, case report

Transposition of the great arteries [D-TGA] in combination with aortopulmonary window [APW] is a very rare entity and carries high morbidity and mortality. Only few cases have been reported with this association. We report the first case of D-TGA and APW with mirror image dex-trocardia which was repaired successfully