Initial clinical trial of substernal epicardial echocardiography: SEEing a new window to the postoperative heart.

BACKGROUND: Postoperative echocardiography windows are often of poor quality because of intervening air spaces around the heart and great vessels. We assessed the utility of a new commercially available adult chest drainage tube that has been modified with the addition of a sterile sleeve to accommodate the introduction of a nonsterile pediatric transesophageal echocardiography (TEE) probe. The TEE probe lies in a substernal epicardial position on the postoperative heart allowing one to perform substernal epicardial echocardiography (SEE). METHODS: Informed consent was obtained from 21 consecutive adult cardiac operation patients. At the completion of the operation the SEE drainage tube was inserted through the rectus muscle and into the pericardium. After chest closure, all patients underwent a full echo examination using an Acuson pediatric biplane probe in the SEE position. Views obtained and ease of insertion were judged on a 1 to 10 (worst to best) scale. RESULTS: Full SEE examinations were completed in an average of 12 minutes. Ease of probe entry and manipulation was excellent (ratings of 9.3 and 9.6, respectively). The quality of the anatomic images was also excellent. Substernal epicardial echocardiography tube positioning was integral to the orientation of the images obtained. There were no complications related to the placement of the SEE tubes or TEE probes. In 4 of 21 patients (19%) the SEE methodology was used serially in the intensive care unit to accurately assess ventricular function and filling during weaning of an intraaortic balloon and inotropic agents. CONCLUSIONS: Substernal epicardial echocardiography is a safe and highly effective methodology for the serial echocardiographic assessment of the postoperative heart.

Substernal epicardial echocardiography: a new ultrasonic window to the postoperative heart.

Echocardiographic examination of the postoperative cardiac surgery patient is often problematic because of a poor acoustic window that requires imaging by transesophageal echocardiography. Furthermore, no available echocardiographic methods exist for simple ongoing beat-to-beat assessment of postoperative left ventricular size and function. We designed a modification of a mediastinal drain to allow a transesophageal echocardiography probe to be placed adjacent to the epicardial surface of the heart. After chest closure in a series of 13 patients, we were able to obtain 5- and 7-MHz epicardial images of high quality in both short- and long-axis planes, which also allowed Doppler examination of aortic, mitral, and tricuspid valves in 10 patients. This technique was suitable for prolonged and serial assessment of left ventricular size and function. Though preliminary, these observations suggest that this new substernal epicardial echocardiographic window to the postoperative heart offers a potential for prolonged monitoring of cardiac function as well as rapid and accurate diagnosis in problematic patients.

The contribution of echocardiography to the community practice of cardiology. A prospective study.

The utility of echocardiography in a clinical office practice was assessed by prospectively studying 93 patients. Each patient was examined by a cardiologist and a diagnosis and management plan was outlined. An M-mode and 2D echocardiogram was then obtained and interpreted by a second cardiologist without knowledge of the clinical findings. Patients were then categorized as follows: group 1, clinical and echo diagnosis agree, management unchanged (67 patients); group 2, clinical and echo diagnosis agree, management changed (two patients); group 3, clinical and echo diagnosis disagree, management unchanged (16 patients); and group 4, clinical and echo diagnosis disagree, management changed (eight patients). Echocardiography significantly altered management of 11 percent of patients, provided additional important information in 48 percent, and confirmed the clinical impression in 74 percent of patients. It was particularly helpful in determining left ventricular structure and function, valvular anatomy, and in the diagnosis of clinically unsuspected idiopathic hypertrophic subaortic stenosis.