Anesthetic management for cardiac surgery for adult congenital heart disease : The role of intraoperative TEE

Abstract

 The number of patients with adult congenital heart disease (ACHD) in Japan has dramatically increased. Anesthesiologists, therefore, are often tasked to provide anesthetic management for ACHD patients requiring cardiac surgery. Intraoperative transesophageal echocardiography (TEE) is a useful modality for evaluating surgical competence and cardiac function in this population during cardiac surgery. Yet devices or materials implanted in previous surgeries often impede the view of the heart intraoperatively.

 TEE checkpoints for total cavo-pulmonary connection (TCPC) conversion include detection of stenotic lesions in the Fontan circuit and evaluation of both atrioventricular valve function and ventricular function. These points are same as those for TCPC in small children.

 Right ventricular function can be a major concern for us in tailoring anesthetic management for patients with CHD. The challenge often goes beyond the complex shape of the right ventricle (RV). Huge dilation of the RV and/or the artificial materials implanted earlier make it difficult to visualize the RV itself and to evaluate the size and contractility of the RV. Several metrics such as the RV myocardial performance index and velocity of tricuspid annular systolic motion are available for this purpose. None of the methods, however, is sufficient in itself to reliably evaluate RV function for every case in this population. Oftentimes the direction of the ultrasound cannot be accurately aligned to the tissue movement or blood flow by the TEE approach. Intraoperative RV function should be evaluated comprehensively by a combination of methods suitable for the case at hand.