Video Commentary 1
Transesophageal echocardiography for minimally invasive cardiac surgery‑atrial septal defect closure Pawan Kumar Jain, Vishwas Malik, Poonam Malhotra Kapoor Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
Evaluation of the atria and interatrial septum • Determine types: Ostium secundum defect [Video 1]/ostium primum defect/ sinus venosus atrial septal defect (ASD)/ coronary sinus (CS) type ASD • Determine ‑ size, shape, number, and location of any atrial/ventricular communication present; and the direction of shunt flow [Figure 1] • Rule out ‑ partial anomalous pulmonary venous connection, left superior vena cava (LSVC) • Transesophageal echocardiography (TEE) views: Mid‑esophageal aortic valve short axis (ME AoV SAX) view, ME modified bicaval view/ME bicaval view [Figure 2].
Access this article online
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.185549 Quick Response Code:
Real‑time assistance for venous cannulation • A must for accurate percutaneous placement of: • Superior vena cava (SVC) cannula through the right internal jugular vein approach: Bicaval or modified bicaval view [Video 1] ‑ best suits the purpose. Venous cannula should be kept at least 2 cm above the right atrium‑SVC junction for adequate SVC snaring Real‑time assistance for arterial cannulation and antegrade cardioplegia delivery • Guidewire for endovascular – real‑time assisted balloon catheter insertion in Asc ascending aorta is a must; so also measurement of aortic root diameter, correct placement of endovascular balloon, and its proper inflation • TEE views: ME long axis (LAX) view, ME AoV LAX view [Figure 3].
© 2016 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow
Figure 1: Determine- size, shape, number and location of any atrial / ventricular communication present; and the direction of shunt flow
Figure 2: Mid‑esophageal aortic short axis view, mid‑esophageal modified bicaval view/mid esophageal bicaval view
Video 1: Superior vena cava cannula through the right internal jugular vein approach: Bicaval or modified bicaval view Address for correspondence: Dr. Pawan Kumar Jain, Senior Resident, Department of Cardiac Anaesthesia, CTC, All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]
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Video Commentary
Real‑time assistance for coronary sinus cannulation and retrograde cardioplegia delivery • CS is visible in the high ME4C view/ME bicaval view/the classical ME4C view with slight retroflexion [Video 2] • Normal CS diameter is 7–15 mm and diameter >15 mm is suggestive of LSVC presence. Uninterrupted retrograde cardioplegia delivery requires a patent and unobstructed CS and the absence of LSVC. Weaning from cardiopulmonary bypass and post cardiopulmonary bypass period • T E E i s v a l u a b l e d u r i n g w e a n i n g f r o m cardiopulmonary bypass (CPB) since removal of intracavitary air, and visual assessment of cardiac function during minimally invasive cardiac surgery is not possible due to limited exposure • Confirm the adequacy of surgical repair and absence of residual anatomic defects (ME4C view, ME bicaval, or modified bicaval view) [Figure 4]. Assessment of ventricular function • Left ventricular systolic function ‑ ejection fraction calculation using Simpson’s method [Figure 5] and observing for the presence of any regional wall motion abnormalities [Video 3] • Left ventricular diastolic function ‑ by pulse wave Doppler and tissue Doppler Imaging • Patients with severe ventricular systolic or diastolic dysfunction may not tolerate the prolonged CPB and aortic cross‑clamp times • TEE views: ME4C view/ME2C/ME LAX views. Assessment of pulmonary hypertension • W h e n t h e s h u n t f l o w i s r i g h t t o l e f t o r bidirectional ‑ suggests significant pulmonary hypertension or significant impairment of right ventricular (RV) compliance ‑ a contraindication for ASD and patent foramen ovale closure • TEE views: • Upper esophageal pulmonary artery LAX view [Figure 6]/transgastric RV basal view ‑ interrogate spectral profile of forward and regurgitant (if any) flow across pulmonary valve • M E RV i n f l o w ‑ o u t f l o w v i e w / ME modified bicaval tricuspid valve
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Figure 3: Mid‑esophageal long axis view, mid esophageal aortic valve long axis view
Figure 4: Confirm the adequacy of surgical repair and absence of residual anatomic defects (ME4C view, mid-esophageal bicaval, or modified bicaval view)
Figure 5: Left ventricular systolic function‑ejection fraction calculation using Simpson’s method
Annals of Cardiac Anaesthesia | Jul-Sep-2016 | Vol 19 | Issue 3
Video Commentary
Figure 6: Upper esophageal pulmonary artery long axis view
Video 2: Coronary sinus is visible in the high ME4C view/ mid‑esophageal bicaval view/the classical ME4C view with slight retroflexion
view [Figure 7] ‑ tricuspid regurgitation (TR) jets are well aligned with the insonation beam and allows precise measurement of maximum TR velocity, right ventricular systolic pressure (≈pulmonary artery systolic pressure).
Annals of Cardiac Anaesthesia | Jul-Sep-2016 | Vol 19 | Issue 3
Figure 7: Mid‑esophageal right ventricular inflow‑outflow view/ mid esophageal modified bicaval tricuspid valve view
Video 3: Observing for presence of any regional wall motion abnormalities
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. Cite this article as: Jain PK, Malik V, Kapoor PM. Transesophageal echocardiography for minimally invasive cardiac surgery-atrial septal defect closure. Ann Card Anaesth 2016;19:527-9.
529
Transesophageal echocardiography for minimally invasive cardiac surgery‑atrial septal defect closure Pawan Kumar Jain, Vishwas Malik, Poonam Malhotra Kapoor Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
Evaluation of the atria and interatrial septum • Determine types: Ostium secundum defect [Video 1]/ostium primum defect/ sinus venosus atrial septal defect (ASD)/ coronary sinus (CS) type ASD • Determine ‑ size, shape, number, and location of any atrial/ventricular communication present; and the direction of shunt flow [Figure 1] • Rule out ‑ partial anomalous pulmonary venous connection, left superior vena cava (LSVC) • Transesophageal echocardiography (TEE) views: Mid‑esophageal aortic valve short axis (ME AoV SAX) view, ME modified bicaval view/ME bicaval view [Figure 2].
Access this article online
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.185549 Quick Response Code:
Real‑time assistance for venous cannulation • A must for accurate percutaneous placement of: • Superior vena cava (SVC) cannula through the right internal jugular vein approach: Bicaval or modified bicaval view [Video 1] ‑ best suits the purpose. Venous cannula should be kept at least 2 cm above the right atrium‑SVC junction for adequate SVC snaring Real‑time assistance for arterial cannulation and antegrade cardioplegia delivery • Guidewire for endovascular – real‑time assisted balloon catheter insertion in Asc ascending aorta is a must; so also measurement of aortic root diameter, correct placement of endovascular balloon, and its proper inflation • TEE views: ME long axis (LAX) view, ME AoV LAX view [Figure 3].
© 2016 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow
Figure 1: Determine- size, shape, number and location of any atrial / ventricular communication present; and the direction of shunt flow
Figure 2: Mid‑esophageal aortic short axis view, mid‑esophageal modified bicaval view/mid esophageal bicaval view
Video 1: Superior vena cava cannula through the right internal jugular vein approach: Bicaval or modified bicaval view Address for correspondence: Dr. Pawan Kumar Jain, Senior Resident, Department of Cardiac Anaesthesia, CTC, All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]
527
Video Commentary
Real‑time assistance for coronary sinus cannulation and retrograde cardioplegia delivery • CS is visible in the high ME4C view/ME bicaval view/the classical ME4C view with slight retroflexion [Video 2] • Normal CS diameter is 7–15 mm and diameter >15 mm is suggestive of LSVC presence. Uninterrupted retrograde cardioplegia delivery requires a patent and unobstructed CS and the absence of LSVC. Weaning from cardiopulmonary bypass and post cardiopulmonary bypass period • T E E i s v a l u a b l e d u r i n g w e a n i n g f r o m cardiopulmonary bypass (CPB) since removal of intracavitary air, and visual assessment of cardiac function during minimally invasive cardiac surgery is not possible due to limited exposure • Confirm the adequacy of surgical repair and absence of residual anatomic defects (ME4C view, ME bicaval, or modified bicaval view) [Figure 4]. Assessment of ventricular function • Left ventricular systolic function ‑ ejection fraction calculation using Simpson’s method [Figure 5] and observing for the presence of any regional wall motion abnormalities [Video 3] • Left ventricular diastolic function ‑ by pulse wave Doppler and tissue Doppler Imaging • Patients with severe ventricular systolic or diastolic dysfunction may not tolerate the prolonged CPB and aortic cross‑clamp times • TEE views: ME4C view/ME2C/ME LAX views. Assessment of pulmonary hypertension • W h e n t h e s h u n t f l o w i s r i g h t t o l e f t o r bidirectional ‑ suggests significant pulmonary hypertension or significant impairment of right ventricular (RV) compliance ‑ a contraindication for ASD and patent foramen ovale closure • TEE views: • Upper esophageal pulmonary artery LAX view [Figure 6]/transgastric RV basal view ‑ interrogate spectral profile of forward and regurgitant (if any) flow across pulmonary valve • M E RV i n f l o w ‑ o u t f l o w v i e w / ME modified bicaval tricuspid valve
528
Figure 3: Mid‑esophageal long axis view, mid esophageal aortic valve long axis view
Figure 4: Confirm the adequacy of surgical repair and absence of residual anatomic defects (ME4C view, mid-esophageal bicaval, or modified bicaval view)
Figure 5: Left ventricular systolic function‑ejection fraction calculation using Simpson’s method
Annals of Cardiac Anaesthesia | Jul-Sep-2016 | Vol 19 | Issue 3
Video Commentary
Figure 6: Upper esophageal pulmonary artery long axis view
Video 2: Coronary sinus is visible in the high ME4C view/ mid‑esophageal bicaval view/the classical ME4C view with slight retroflexion
view [Figure 7] ‑ tricuspid regurgitation (TR) jets are well aligned with the insonation beam and allows precise measurement of maximum TR velocity, right ventricular systolic pressure (≈pulmonary artery systolic pressure).
Annals of Cardiac Anaesthesia | Jul-Sep-2016 | Vol 19 | Issue 3
Figure 7: Mid‑esophageal right ventricular inflow‑outflow view/ mid esophageal modified bicaval tricuspid valve view
Video 3: Observing for presence of any regional wall motion abnormalities
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. Cite this article as: Jain PK, Malik V, Kapoor PM. Transesophageal echocardiography for minimally invasive cardiac surgery-atrial septal defect closure. Ann Card Anaesth 2016;19:527-9.
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