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Ann Thorac Surg 2005;80:56-59
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Predictive Value of Intraoperative Transesophageal Echocardiography in Complete Atrioventricular Septal Defect

^a Department of Thoracic and Cardiovascular Surge ry, Department of Pediatrics,Sejong General Hospital, Sejong Heart Institute, Bucheon, Korea
^b Department of Thoracic and Cardiovascular Surgery, Clinical Research Institute, Seoul National University Hospital, Seoul, Korea, Korea

Accepted for publication January 20, 2005.

^_* Address reprint requests to Dr Woong-Han Kim, Department of Thoracic and Cardiovascular Surgery, Clinical Research Institute, Seoul National University, College of Medicine, Seoul National University Children’s Hospital, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744, Korea; (Email: woonghan{at}korea.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: Intraoperative transesophageal echocardiography and follow-up transthoracic echocardiography have been useful in assessing cardiac function in complete atrioventricular septal defects. However, it has been suggested that a discrepancy exists between intraoperative and postoperative findings, and that intraoperative findings cannot reliably predict long-term results. This study aims to determine whether this discrepancy exists and to assess whether it is possible to predict follow-up results using intraoperative transesophageal echocardiography.

METHODS: A retrospective analysis was made in 35 patients who underwent biventricular repair by one surgeon between November 1997 and January 2004. All patients received intraoperative transesophageal echocardiography and follow-up transthoracic echocardiography at 19.1 ± 18.02 months (range, 7 days to 5 years; median, 15.1 months).

RESULTS: In left-sided atrioventricular valve regurgitation, 34.3% (12 of 35) of patients showed discrepancy during follow-up, and 28.6% (10 of 35) showed progression of regurgitation (from grade I to II). In right-sided atrioventricular valve, 11.4% (4 of 35) of patients showed discrepancy, 9.6% (3 of 35) showed progression of regurgitation (from grade I to II).

CONCLUSIONS: In complete atrioventricular septal defects, intraoperative transesophageal echocardiography did not show the same findings as that of follow-up transthoracic echocardiography in some cases. However, this discrepancy is not so great as to require reoperation in early to midterm follow-up. Therefore, intraoperative transesophageal echocardiography may be used as tool to predict durability of surgical results and to decrease the incidence of reoperation in complete atrioventricular septal defects.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Since the first successful repair of a complete atrioventricular septal defect (C-AVSD) by Lillehei and colleagues [1] using controlled cross-circulation in 1954, operative results have been improving owing to technical refinement and a better understanding of the pathophysiology of C-AVSD. However, early mortality rates are still reported as ranging between 8.7% and 15% [2–4], its main cause being reoperation [3–5]. The causes of reoperation are left atriventricular valvular regurgitation (MR), left ventricular outflow tract obstruction (LVOTO), residual ventricular septal defect (VSD), and permanent pacemaker insertion [5, 6]. Therefore, this suboptimal repair of C-AVSD is a problem that needs to be solved to reduce operative death and reoperation.

Intraoperative transesophageal echocardiography (TEE) has helped to improve surgical outcomes by providing the surgeon with instant, real-time information about cardiac structure and valvular function [7, 8]. However, it has been suggested that a significant discrepancy exists between intraoperative findings by TEE and follow-up findings by transthoracic echocardiography (TTE) [6, 7, 9]. Therefore, intaoperative TEE might not always be predictive of follow-up findings [7, 9].

This study aims to determine whether a discrepancy between intraoperative TEE and follow-up TTE exists and to ascertain whether it is possible to predict follow-up outcomes by the use of intraoperative TEE.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
A retrospective analysis was made of 35 patients who underwent biventricular repair of a C-AVSD by one surgeon (W.H.K.) between November 1997 and January 2004. All patients received intraoperative TEE and corresponding follow-up TTE. Follow-up was completed in January 2004 for 34 patients (mean follow-up time 36.9 ± 21.0 months, range, 5.7 months to 6.2 years). The patients consisted of 12 males and 23 females. The median age at the time of repair was 5.4 months (range, 47 days to 31 years). Twenty patients (57%) underwent repair at less than 6 months of age. The mean weight of the patients was 9.0 ± 12.1 kg (range, 3.2 kg to 59 kg; median, 5.3 kg). Eleven patients (31.4%) had Down syndrome.

The C-AVSD was of the following types: Rastelli A in 24 patients (68.6%), type B in 3 patients (8.5%), and type C in 8 patients (22.9%). Associated cardiac defects are summarized in Table 1.

Echocardiographic Studies
Intraoperative TEE was performed just after weaning from cardiopulmonary bypass, before chest closure. An Acuson V705B Bi-Plane transesophageal TEE probe for Acuson 128XP system (Malvern, PA) was used with color Doppler flow imaging at 5 MHz. Follow-up TTE studies were performed with a Sequoia 256-7V3C probe for Acuson Sequoia system with color Doppler flow imaging at 5 MHz. The mean interval between intraoperative TEE and follow-up TTE was 19.1 ± 18.02 months (range, 7 days to 5 years; median, 15.1 months). Evaluation of echocardiography was performed by four pediatric cardiologists, but no statistical blinding techniques were employed. Atrioventricular valvular regurgitation assessed by echocardiography was graded as grade I (mild), grade II (mild to moderate), grade III (moderate), and grade IV (severe) according to standard methods [10].

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Return to Bypass
Of the 35 patients, cardiopulmonary bypass was reinitiated in 4 patients (11.4%) to repair regurgitation of atrioventriuclar valve or residual defects. Two patients had grade III MR and right atrioventricular valvular regurgitation (TR) on initial intraoperative TEE, and showed improvement to grade I MR and TR after further repair. One patient with residual VSD leakage and 1 patient with right ventricular outflow tract obstruction found on initial intraoperative TEE showed no defect after further repair. One patient with moderate left atrioventricular valvular stenosis on initial intraoperative TEE showed no significant stenosis after further surgery (Table 2).

As for TR, none of the 35 patients left the operating room with more than grade II. Follow-up TTE studies found that of the 34 patients with grade I or less revealed by intraoperative TEE, 31 patients maintained the same level of regurgitation, but increased regurgitation to grade II occurred in 3. One patient who was initially grade II regurgitation by intraoperative TEE improved to grade I or less regurgitation on follow-up TTE study. Overall, 31 of the 35 patients (88.6%) had no change in the grade of right atrioventricular valvular regurgitation at follow-up. Regarding the rest of the patients (11.4%) who had a discrepancy at follow-up, 1 patient (25%) had improvement, and 3 patients (75%) had increased TR by one grade.

In residual VSD leakage, none of the 35 patients left the operating room with above mild leakage. Intraoperative TEE showed that no VSD leakage was noted in 27 patients, and minimal residual VSD was noted in 8. Follow-up TTE studies revealed that the minimal residual VSD was closed spontaneously in all 8 patients.

In residual ASD, intraoperative TEE showed that no ASD leakage was noted in 33 patients, and minimal residual ASD was noted in 2. Follow-up TTE studies revealed that the minimal residual ASD was closed spontaneously in both patients.

One patient with mild mitral stenosis had progression to moderate mitral stenosis, and in 2 patients, LVOTO was newly developed at follow-up TTE (Table 3).

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
Intraoperative TEE is considered a reliable method for detecting defects in C-AVSD. In particular, TEE can grade MR or TR, which is a major cause of late reoperation. However, it has been proposed that intraoperative TEE is not always predictive of follow-up findings. Lee and colleagues [7] reported short-term discrepancy between intraoperative and postoperative findings in the grade of MR in 21 of 47 patients (47%) with C-AVSD (follow-up median interval 5 days; range, 1 to 174). And Bando and associates [6] reported that of the 203 children with AVSD who underwent surgery, 132 patients (65.0%) had long-term change in the grade of MR at follow-up (median interval 7.1 years; range, 2.2 months to 19.5 years). Our study shows that the discrepancy rate between introperative TEE and follow-up TTE was 34.3%, which suggested better predictability of the intraoperative TEE in evaluating follow-up results.

The rate of progress of MR at follow-up TTE in the study mentioned above [7] was 38%. In our study, the rate of progression was 28.6%, which was rather lower than the other study. In general, ventricular function is not fully recovered at the time of weaning from cardiopulmonary bypass. The grade of MR and TR changes dramatically according to preload, afterload, and myocardial function after C-AVSD repair [12]. As a result, echocardiographic findings of atrioventricular valvular regurgitation in the operating room may be underestimated. Therefore, this change in hemodynamics may be considered a major cause of the discrepancy between intraoperative and postoperative echocardiographic findings. The discrepancy between the two modalities is also attributed partly to the use of inotropics, filling pressures, ventricular function, atriventricular synchrony in immediate postoperative period and suture line tension adjustment, postrepair ventricular volume and function changes, healing, scarring, and growing during follow-up. In the present study, for 10 of the 35 patients, MR progressed; however, no one underwent reoperation. In other words, the progression was not so significant clinically as to require reoperation. Therefore, intraoperative TEE can predict if there will be significant atrioventricular valvular regurgitation that will require reoperation during the follow-up period in C-AVSD. In addition, the present study shows that intraoperative TEE can predict more accurately the follow-up results in TR, residual VSD, and ASD in C-AVSD.

In 12 patients, the C-AVSD was repaired by direct closure of the VSD followed by pericardial patch closure of the primum ASD. This technique did not result in postoperative LVOTO and residual VSD in our series. This technique made no differences comparing it with the other repair techniques during the early to midterm period. This technique, first done by Wilcox and coworkers [13], was performed for a balanced C-AVSD with a VSD located beneath the inferior bridging leaflet mainly, with no potential LVOTO in echocardiography. This modified technique resulted in equivalent outcomes compared with the two- or one-patch technique [14]. It also did not increase the incidence of LVOTO and residual VSD postoperatively.

In conclusion, intraoperative TEE does not always show the same findings as follow-up TTE in patients with C-AVSD. In spite of this discrepancy, however, none of our cases resulted in reoperation in early to midterm follow-up (1- to 2-year follow-up). Therefore, intraoperative TEE may be used as tool to predict durability of surgical results and to decrease the incidence of reoperation in C-AVSD.

Limitations
The evaluation of MR or TR by intraoperative TEE is confounded by the labile hemodynamic milieu of the operating room. Also, this study was a retrospective study in which the median follow-up was relatively short. Echocardiography was performed by four pediatricians, but statistical blinding techniques were not applied to our study.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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2. Crawford Jr FA, Stroud MR. Surgical repair of complete atrioventricular septal defect Ann Thorac Surg 2001;72:1621-1629.[Abstract/Free Full Text]
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4. Al-Hay AA, MacNeill SJ, Yacoub M, Shore DF, Shinebourne EA. Complete atrioventricular septal defect, down syndrome, and surgical outcomerisk factors. Ann Thorac Surg 2003;75:412-421.[Abstract/Free Full Text]
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6. Bando K, Turrentine MW, Sun K, et al. Surgical management of complete atrioventricular septal defects. A twenty-year experience J Thorac Cardiovasc Surg 1995;110:1543-1554.[Abstract/Free Full Text]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hyun Koo Kim Woong-Han Kim Jae Young Lee Ki Young Jang Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kim, H. K. Articles by Jang, K. Y. Search for Related Content PubMed PubMed Citation Articles by Kim, H. K. Articles by Jang, K. Y. Related Collections Congenital - cyanotic Related Article