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Transesophageal Echocardiography in Pediatric Congenital Cardiac Surgery and Catheter Intervention

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Transesophageal Echocardiography in Pediatric

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Over the past 25 years, we have successfully carried out over 3000 surgeries for congenital heart diseases (CHD), over 5000 pediatric catheter interventions and over 10,000 computed tomography (CT) or magnetic resonance imaging (MRI). This book provides a review of our experience using intraoper...

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Transesophageal
Echocardiography in Pediatric
Congenital Cardiac Surgery
and Catheter Intervention

Shen-Kou Tsai
Jou-Kou Wang
Shyh-Jye Chen

123

,Transesophageal Echocardiography
in Pediatric Congenital Cardiac Surgery
and Catheter Intervention

,Shen-Kou Tsai • Jou-Kou Wang
Shyh-Jye Chen

Transesophageal
Echocardiography
in Pediatric Congenital
Cardiac Surgery and
Catheter Intervention

,Shen-Kou Tsai, MD, PhD Jou-Kou Wang, MD, PhD
Professor, Anesthesiologist Professor of Pediatrics, School of Medicine
Cheng Hsin General Hospital National Taiwan University
Professor of Anesthesiology Pediatric Cardiologist
School of Medicine National Taiwan University Hospital
National Taiwan University, and Hospital Taipei, Taiwan
Taipei, Taiwan

Shyh-Jye Chen, MD, PhD
Professor and Chairman
Department of Medical Imaging/Center
of Radiation Protection
National Taiwan University Hospital
Director, Department of Radiology
School of Medicine
National Taiwan University
Taipei, Taiwan

ISBN 978-981-99-6581-6 ISBN 978-981-99-6582-3 (eBook)
https://doi.org/10.1007/978-981-99-6582-3

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore
Pte Ltd. 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
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The publisher, the authors, and the editors are safe to assume that the advice and information in this book
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Paper in this product is recyclable

,Preface

Over the past 25 years, we have successfully carried out over 3000 surgeries for
congenital heart diseases (CHD), over 5000 pediatric catheter interventions and
over 10,000 computed tomography (CT) or magnetic resonance imaging (MRI).
This book provides a review of our experience using intraoperative transesophageal
echocardiography (TEE) in various pediatric surgeries including congenital heart
surgeries, catheter interventions, and hybrid surgeries.
TEE monitoring plays a crucial role in providing essential information for the
surgeon throughout each procedure. From pre-operative planning to real-time assis-
tance during the surgery, TEE helps confirm intended results and identify any resid-
ual lesions that may require additional surgical intervention. Intraoperative TEE can
significantly reduce the risk of unintended surgical events (Part I).
Catheter-based interventions and hybrid surgeries are alternative treatments for
CHD. By combining TEE with fluoroscopy, the risk of radiation exposure for chil-
dren can be reduced. TEE images provide important information for preoperative
patient selection, guide the entire procedure, and confirm the correct deployment of
devices. This book also explores the growing complexity and diversity of CHD
catheter interventions (Part II).
To effectively use intraoperative TEE images for monitoring and guidance dur-
ing a procedure, it is important for the provider to be familiar with current surgical
methods and catheter-based procedures. This book presents various CHD surgical
methods using actual intraoperative photographs to enhance understanding of how
to use TEE images to assess the completeness of the procedure. We also provide
pre- and postoperative images, such as cardiac CT, MRI, or 3D reconstructions, to
complement TEE images.
This book is both comprehensive and practical, providing well-documented fig-
ures that clearly illustrate the complex anatomy of various CHD. This makes it a
valuable resource for perioperative management. Transesophageal echocardiogra-
phy plays a crucial role in providing essential information for perioperative decision-
making and fosters effective teamwork among pediatric cardiologists, surgeons,
anesthesiologists, radiologists and intensivists by employing a common language.
We would like to express our sincere gratitude to our team of pediatric cardiolo-
gists (Hung-Chi Lue, Mei-Hwan Wu), surgeons (Chung-I Chang, Ing-Sh Chiu,
Yieh-Sharng Chen Shu Chien Huang), anesthesiologists (Ming-Jiuh Wang, Chi-
Hsiang Huang, Su-Man Lin, Ching Huei Ou), and illustrators (Yea-Wen Lee, Yung

v

,vi Preface

Wei Huang). Additionally, we extend our thanks to Dr. Jui-Yu Hsu, a pediatric car-
diologist and Dr. Ching Huei Ou, who not only contributed significantly to the prep-
aration of most of the manuscripts but also provided numerous special requests for
the production of this book. Their invaluable knowledge, extensive experience, and
expertise have been generously shared in this book with the aim of improving
healthcare delivery and clinical outcomes

Shen-Kou Tsai
Jou-Kou Wang
Shyh-Jye Chen

,Contents

Part I Introduction of Transesophageal Echocardiography (TEE)
for Pediatric Congenital Heart Diseases
1
Overview of Pediatric Echocardiography�� 3
References�� 7
2
Transesophageal Echocardiography (TEE) for Pediatric
Congenital Cardiac Surgery and Catheter Intervention�� 9
2.1 The History and Development of Pediatric TEE�� 9
2.1.1 The Evolutionary Development of Pediatric TEE
Transducers �� 9
2.1.2 The Current TEE Transducer for Infants in Pediatrics �� 11
2.2 Indication of TEE�� 15
2.2.1 Indication of the Pediatric TEE Monitoring
of Congenital Heart Surgery �� 15
2.2.2 Pediatric TEE Guidance of Cardiac Catheter Intervention�� 15
2.3 Fundamental Aspect of Pediatric TEE�� 16
2.3.1 Key Views in Pediatric TEE Imaging �� 16
2.4 Safety and Effectiveness of Pediatric TEE �� 21
2.5 Potential Complications Associated with Pediatric TEE�� 22
2.5.1 Gastrointestinal Injury�� 22
2.5.2 Airway Compression�� 23
2.5.3 Desaturation and Systemic Hypotension�� 26
2.5.4 Systemic Hypotension�� 27
2.6 Contraindication for Pediatric TEE
(Refer to Table 2.1) �� 28
2.7 Recommendations for Pediatric TEE (Refer to Table 2.2) �� 29
2.8 Conclusion�� 30
References�� 31

Part II TEE Monitoring of Pediatric Congenital Cardiac Surgery
3 Septal Defects �� 35
3.1 Atrial Septal Defect (ASD)�� 35
3.2 Ventricular Septal Defect (VSD)�� 44

vii

,viii Contents

4 Valvular Abnormalities of Atrioventricular Connections�� 55
4.1 Tricuspid Atresia (TA)�� 55
4.2 Ebstein’s Anomaly�� 58
4.3 Mitral Atresia (MA) with Hypoplastic Left Heart Syndrome
(HLHS) �� 60
4.3.1 Mitral Atresia [1, 2]�� 60
4.3.2 Mitral Atresia (MA) with Hypoplastic Left Heart
Syndrome (HLHS)�� 63
5
Anomalies of the Great Vessels & Ventriculoarterial Connections �� 71
5.1 (A). Abnormal Connections between Great Arteries
and Ventricles�� 71
5.1.1 Transposition of the Great Arteries (TGA) �� 71
5.1.2 Transposition of the Great Arteries (TGA)
with Ventricular Septal Defect (VSD)�� 84
5.1.3 Truncus Arteriosus (TrA) and Hemitruncus Arteriosus�� 91
5.1.4 Congenital Aortic Stenosis (AS)�� 95
5.1.5 Tetralogy of Fallot (TOF) �� 101
5.1.6 Pulmonary Atresia with Intact Ventricular Septum
(PA-IVS) �� 107
5.2 (B). Vascular Abnormalities�� 112
5.2.1 Coarctation of the Aorta (CoA)�� 112
5.2.2 Interrupted Aortic Arch (IAA)�� 113
5.2.3 Double Aortic Arch (DAA)�� 113
5.2.4 The Aortapulmonary Window (APW)�� 114
5.2.5 Diverticulum of Kommerell (KD)�� 114
5.2.6 Patent Ductus Arteriosus (PDA) �� 116
5.2.7 Left Pulmonary Artery Sling (LPAS)�� 120
5.2.8 Anomalous Origin of the Left Coronary Artery
from the Pulmonary Artery (ALCAPA)�� 122
5.2.9 Total Anomalous Pulmonary Venous Connection
(TAPVC) �� 123
5.2.10 Complex Partial Anomalous Pulmonary Venous
Connection (PAPVC)�� 127
6 Cardiac Chamber Anomalies�� 131
6.1 Cor Triatriatum�� 131
6.2 Right Atrial Isomerism (RAI) �� 133
6.3 Double-Chambered Right Ventricle (DCRV) �� 135
6.4 Double Outlet Right Ventricle (DORV)�� 138
6.5 Univentricular Heart (Single Ventricle, SV) �� 145
6.6 Double Inlet of Left Ventricle (DILV)�� 147
6.6.1 L-TGA, Hypoplastic Left-Sided Morphological Right
Ventricle (RV), Atrial Septal Defect (ASD),
and Ventricular Septal Defect (VSD)�� 147

,Contents ix

6.6.2 L-TGA with Pulmonary Atresia/VSD (PA/VSD)
and ASD�� 148
6.6.3 Holmes Heart�� 150
6.7 Double Inlet of Right Ventricle (DIRV)�� 151
6.7.1 With Systemic Outflow Obstruction �� 151
7
Miscellaneous Congenital Heart Diseases�� 153
7.1 Primary Neonatal Cardiac Tumors�� 153
7.2 Congenital Right Coronary Artery Aneurysm with a Fistula
to the Right Heart Chamber�� 155
7.3 Pediatric Heart Transplant�� 158
7.4 Situs Inversus, DIRV with VSD�� 161
7.5 Congenital Giant Left Atrial Appendage Aneurysm�� 162

Part III TEE Guidance of Pediatric Catheter Intervention
8 Septal Defects �� 167
8.1 Imaging Modality Monitoring During Transcatheter
Intervention Procedure for Septal Defects�� 167
8.2 Transcatheter Closure of Patent Foramen Ovale (PFO)�� 172
8.3 Transcatheter Closure of Atrial Septal Defect (ASD)�� 173
8.4 Transcatheter Closure of Ventricular Septal Defect (VSD)�� 193
8.4.1 Catheterization Procedure�� 193
8.4.2 Device Used�� 194
8.4.3 Transcatheter Closure of Outlet VSD �� 197
8.4.4 Transcatheter Closure of Muscular VSD�� 201
8.4.5 Device-Related Complications �� 208
9
Unusual Shunt and Fistula�� 211
9.1 Aorta-Right Atrial Tunnel (ARAT)�� 211
9.2 Ruptured Sinus of Valsalva Aneurysm (RSVA)�� 213
9.3 Aorto-Left Ventricular Tunnel (ALVT)�� 217
9.4 Aortic Injury During Electrophysiological Studies (EPSs)�� 220
9.5 Patent Ductus Arteriosus (PDA) �� 222
10 Postoperative Residual Defect�� 225
10.1 Residual ASD�� 226
10.2 Residual VSD�� 227
10.3 Recurrent PDA�� 228
10.4 Fenestration Closure �� 229
11
Hybrid Procedure for Congenital Heart Diseases (CHDs)�� 231
11.1 Perventricular Device Closure of VSDs�� 231
11.2 Hybrid Procedure for Newborn Baby with Complex CHDs�� 233
11.2.1 Hybrid Procedure of Surgical Bilateral Pulmonary
Artery Banding and Percutaneous Patent Ductus
Arteriosus (PDA) Stenting in a Newborn with
Hypoplastic Left Heart Syndrome (HLHS)�� 233

, x Contents

11.2.2 A Hybrid Procedure of Trans-Right Ventricular
Outflow Tract (Trans-RVOT) Pulmonary
Valvuloplasty in a Newborn with Critical
Pulmonary Stenosis�� 234
11.2.3 A Hybrid Procedure of Blade Atrioseptostomy
in an Infant with Mitral Atresia and Severely
Restrictive Atrial Septal Defect (ASD)�� 235
12 Valvular Abnormalities�� 239
12.1 Percutaneous Trans-Septal Mitral Valvuloplasty Used for
Treating Congenital Mitral Stenosis in Infants and Children �� 239
12.1.1 Congenital Mitral Stenosis (MS)�� 239
12.1.2 Mitral Stenosis in a 6-Year-Old Children �� 241
12.2 Transcatheter Pulmonary Valve Implantation (TPVI)
in Patients with Right Ventricular Outflow Tract
Dysfunction After Surgical Correction of Tetralogy
of Fallot�� 242

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