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Ann Thorac Surg 1999;68:536
© 1999 The Society of Thoracic Surgeons
a Division of Pediatric Cardiology University of Minnesota Box 94 Mayo, 420 Delaware St SE Minneapolis, MN 55455, USA
Invited commentary
Cardiovascular operations without preoperative cardiac catheterization began two generations ago, when physical findings, electrocardiogram, and chest roentgenogram were the sole preoperative evaluation methods in children with an atrial septal defect, patent ductus arteriosus, or coarctation of the aorta. In the next generation of pediatric cardiologists, this practice spread to more complicated lesions by combining anatomic data from two-dimensional echocardiographic imaging with flow and pressure dynamics from Doppler echocardiography. This technique required careful echocardiographic studies tracing every detail of cardiovascular anatomy. Cardiac catheterization was done in fewer patients until interventional procedures were developed. The present generation of pediatric cardiologists is trained in both technologies, and the two methods are used in combination. Noninvasive evaluation now determines when cardiac catheterization must be used. This reduces risk by shortening procedures and decreasing contrast load. A marriage of the two technologies, with cardiac catheterization for selected indications, provides the safest preoperative evaluation.
The issue, then, is defining when cardiac catheterization is needed. Echocardiographic evaluation is only as good as the information available (garbage in, garbage out). Accuracy depends on high-quality images (top-of-the-line equipment with high-frequency probes, good penetration which makes the newborn infant an ideal candidate, and a cooperative patient) and the experience of the pediatric sonographer and echocardiographer. When necessary information cannot be determined noninvasively, cardiac catheterization should be used to provide it. Each institution must have its own approach, as determined by physician experience and resources. It is important that the approach to each patient is controlled by medical indications determined by a team of cardiologists and surgeons. There is no place for pressure from competition or third-party payers in decisions on whether to perform an invasive evaluation.
Studies defining the accuracy of noninvasive evaluation are important. Pfammatter and associates reported the accuracy of preoperative diagnosis in 142 patients who had clinical and echocardiographic assessment and 67 who also had diagnostic cardiac catheterization. An undiagnosed finding was discovered perioperatively in 8.5% of patients who had noninvasive procedures only and in 6% of patients who also had catheterization. An exact comparison between groups cannot be made, because patients were not randomly assigned to treatment, but accurate noninvasive preoperative evaluation is clearly possible in many patients. The surgeon and cardiologist must recognize the limitations of preoperative evaluation both of the techniques and quality of information and with consideration of the type of congenital heart disease. Some conditions might be difficult to detect using either approach, and an unrecognized patent ductus arteriosus with high pulmonary artery pressure or an intramural coronary artery might have to be dealt with perioperatively.
Related Article
Ann. Thorac. Surg. 1999 68: 532-536.
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