Dr. Yasser Salem

1. Intra-operative echocardiography in pediatric cardiac surgery Dr. Yasser Salem

5. Left to right shuntPathology of shunt flow Atrial or ventricular shunts Great artery shunts All shunts ↑RV filling ↑Pulmonary blood flow ↑LA and LV blood flow ↓Diastolic BP ↓Coronary perfusion pressure ↑RVEDV and ↑RVEDP Pulmonary edema ↑LVEDV and ↑LVEDP RV failure ↑PVR Myocardial ischemia LV failure Pulmonary hypertension Shunt reversal Eisenmenger’s syndrome RV hypertrophy Pressure RV > LV

6. Left to right shuntPathology of shunt flow • Avoid increase in pulmonary flow • Avoid decrease in systemic flow • Avoid extensive diastolic hypotension • Avoid increase in total blood volume • Avoid decrease in PVR • Enhance the use of vasoconstrictors

7. Mixing lesions • Qp/Qs dependent upon PVR SVR balance • Hypoxemia and its consequences

8. Mixing lesions • Qp/Qs dependent upon PVR SVR balance • Hypoxemia and its consequences Adjust PVR SVR balance to gain optimal oxygen delivery

9. Obstructive lesions • Qp decreased • Hypoxemia • RV hypertrophy • RV dysfunction • TR • Qs decreased • Low CO • Hypotension • Coronary perfusion decreased • LV failure Avoid SVR decrease Maintain preload Maintain PDA patency • Avoid increase PVR • Hyperoxia • Hyperventilation • Avoid decrease PVR • Relative hypoxia • Relative hypercarbia

10. Atrial switch • RV facing systemic pressure • Pulmonary hypertension may be present • Baffle may leak or obstruct flow • Suture line near the SA node Functional consideration: Preoperative assesment: • Evaluation of RV function • Evaluation of pulmonary pressure • Evaluation of baffle status • Evaluation of arrhythmias and pacemaker

11. Single ventricle physiology • Backward effect • Need for higher SVC pressure to drive shunt flow • Systemic venous congestion • Forward effect • Non pulsatile pulmonary flow • Left atrial filling totally dependent on pulmonary flow • Systemic hypotension

12. Single ventricle physiology • Pitfalls • Saturation is not sytemic pressure dependent • Saturation is pulmonary pressure dependent • All circulatory and ventilatory support should be directed to: • Lower PVR • Higher SVR • Higher Rt filling pressure (within limits)

13. Determinants of cardiac output

14. Demons Angels • Septal aneurysm • Persistent left SVC • Interrupted IVC • Restrictive VSD • High pressure gradient across VSD • Law pressure gradient across left or right obstructive lesions • Atralization of the RV • Parachute mitral valve • Interrupted aortic arch • Non-restrictive VSD • Law pressure gradient across VSD • High pressure gradient across left or right obstructive lesions

16. Planes of TEE

17. A. Trans-gastric Views

18. A. Trans-gastric Views

19. B. Mid Trans-esophageal Views

20. C. Upper Trans-esophagealAortic level Out flow tract view

21. C. Upper Trans-esophagealVascular level

22. Doppler study

24. Pre & Post bypass data(lesion oriented) • ASD • VSD • AV canal • Aortic stenosis • Tetralogy of Fallot • TGA • Single ventricle

25. Objectives

26. Pre-bypass Define location and size of defect Evaluate pulmonary venous drainage Assessment of atrioventricular valve regurgitation Baseline determination of ventricular function Post-bypass Residual shunt Atrioventricular valve regurgitation Ventricular function Superior vena cava obstruction Pulmonary venous obstruction ASD Sinus venosus type

27. Pre-bypass Define location and size of defect Evaluate for additional intracardiac shunts Investigate for associated pathology Baseline determination of ventricular function Post-bypass Residual shunt Atrioventricular valve regurgitation, aortic insufficiency Right ventricular pressure Ventricular function VSD Muscular Doubly committed

28. Pre-bypass Define location, size and type of defects Evaluate for additional septal defects Assessment of atrioventricular valve Interrogation of ventricular outflows Baseline determination of ventricular function Post-bypass Residual shunts Residual/new atrioventricular valve regurgitation Mitral inflow obstruction Left ventricular outflow tract obstruction Atrioventricular valve stenosis Ventricular function AV canal defect

29. Pre-bypass Evaluate location and severity of obstruction (subvalvar, valvar, supravalvar) Define aortic valve anatomy Evaluate for aortic regurgitation Assess for ventricular hypertrophy and function Post-bypass Residual outflow obstruction or aortic insufficiency New ventricular septal defect Mitral regurgitation Ventricular function Aortic stenosis

33. Ross procedure • Aortic stenosis or insufficiency • Right ventricular outflow tract conduit (for stenosis/regurgitation) • Global and segmental left ventricular function

34. Ross procedure

35. Pre-bypass Define size and location of septal defects Evaluate right ventricular outflow tract (subvalvar, valvar and supravalvar regions) Define morphology, obstruction, gradients Determine size of pulmonary arteries Evaluate aortic valve competence/aortic override Evaluate origin and course of coronary arteries Baseline determination of ventricular function Post-bypass Residual ventricular septal defect or unmasked defects Residual right ventricular outflow tract obstruction Pulmonary regurgitation Right ventricular systolic pressure can be assessed by using the tricuspid regurgitant jet Right and left ventricular function Tetralogy of Fallot

36. C. Upper Trans-esophagealAortic level

38. Pre-bypass Evaluate ventriculoarterial relationships and intracardiac shunts (location, size, flow direction, relation to outflows) Assessment of outflow tract obstruction Evaluate A.V. and semilunar valves Evaluate origin and course of coronary arteries Assessment of septal geometry (as an indicator of ventricular pressures) Evaluate ventricular sizes and function Post-bypass Neo-aortic and pulmonic anastomoses (for stenosis) Semilunar valve competence Outflow tracts (for obstruction) A.V. valve regurgitation Residual intracardiac shunts Coronary flow Global and segmental left ventricular function TGA

39. Pre-bypass Evaluate morphologic type Assess atrioventricular and semilunar valves, inflows and outflows Interrogate for adequacy of interatrial communication if indicated Evaluate prior surgical interventions Assess ventricular function Post-bypass Flow in Fontan/Glenn connections Evaluate Fontan fenestration if performed Atrioventricular valve regurgitation Atrial septum for evidence of obstruction (if stenosis/atresia of atrioventricular valve) Ventricular function Single ventricle

40. THANK YOU