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. 2017 May;12(3):350-356.
doi: 10.1111/chd.12450. Epub 2017 Feb 16.

Utility of a standardized postcardiopulmonary bypass epicardial echocardiography protocol for stage I Norwood palliation

Kenan W D Stern  1   2 , Kimberlee Gauvreau  1   2 , Sitaram Emani  3   4 , Tal Geva  1   2
Affiliations

Utility of a standardized postcardiopulmonary bypass epicardial echocardiography protocol for stage I Norwood palliation

Kenan W D Stern et al. Congenit Heart Dis. 2017 May.

Abstract

Objective: Stage 1 Norwood palliation is one of the highest risk procedures in congenital cardiac surgery. Patients with superior technical performance scores have more favorable outcomes. Intraoperative epicardial echocardiography may allow the surgeon to address residual lesions prior to leaving the operating room, resulting in improved technical performance. The ability of intraoperative epicardial echocardiography to visualize the relevant anatomy and its association with outcomes is not known.

Design: A standardized intraoperative epicardial echocardiography protocol was developed and performed at the conclusion of Stage 1 Norwood palliation. Data pertaining to visualization of relevant anatomy, and comparison of intraoperative echocardiogram findings with other postoperative investigations was performed. Clinical outcomes, including technical performance, were collected. A historical cohort who received either no echocardiogram or a nonstandardized examination was used as a comparison group.

Results: Thirty on-protocol and 30 preprotocol patients, 22 of whom had a nonstandardized intraoperative epicardial echocardiogram, were studied. Compared with preprotocol, visualization of the relevant anatomy was significantly increased for the Damus-Kaye-Stansel anastomosis (93% vs. 68% P = .03) and branch pulmonary arteries (70% vs. 36%, P = .02). One residual lesion requiring immediate operative reintervention was diagnosed in the preprotocol group. There were 5 patients in each cohort with residual lesions during the postoperative hospitalization that were not appreciated on the intraoperative echocardiogram. Technical performance, rates of reintervention and clinical outcomes were not significantly different between the two groups.

Conclusions: Intraoperative epicardial echocardiography is technically feasible and increases visualization of the relevant anatomy. Larger investigations may be warranted to determine if there is clinical benefit to such an approach.

Keywords: Epicardial echocardiography; intraoperative echocardiography; protocol; stage I Norwood procedure.

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Conflict of interest statement

Conflicts of Interest: The authors have no relevant conflicts of interest to disclose.

Figures

Figure 1
Figure 1. Rates of visualization of the relevant anatomy
Rates of visualization of the relevant anatomy were higher in on-protocol patients, though this only reached statistical significant for the Damus-Kaye-Stansel (DKS) anastomosis and the branch pulmonary arteries. Within the on-protocol cohort, structures visualized with the greatest frequency were the DKS (93%) and proximal aortic arch (90%). The Distal aortic arch was imaged in 80% of patients. Structures seen with the least frequency were coronary flow (57%) and the source pulmonary blood flow (PBF) (43%). The atrial septum and the branch pulmonary arteries were imaged in 77% and 70% of patients, respectively.
Figure 2
Figure 2. Postoperative survival
Follow-up was until time of bidirectional Glenn, death or subsequent intervention if bidirectional Glenn was not performed. Median follow-up duration was 174 days in the pre-protocol cohort and 151 in the on-protocol cohort. Survival was not significantly different between the groups by Kaplan-Meier estimate.
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