PEDIATRIC CARDIOLOGY

BRIEF REVIEW Table 2. PEDIATRIC TEE CONTRAINDICATIONS

Absolute
Review and Update of Pediatric 1. Esophageal obstruction or stricture
Transesophageal Echocardiography 2. Active gastrointestinal bleeding
3. Perforated viscus
Timothy M. Cordes, MD, Section of Pediatric Cardiology, Indiana University School of 4. Unrepaired tracheoesophageal fistula
Medicine, Indianapolis, Indiana 5. Severe respiratory decompensation
6. Inadequate control of the airway
Relative
ransesophageal echocardiography (TEE) in infants,
T children and adolescents has made dramatic ad-
vances over the past 10 years. Early reports of the
pediatric application of single plane TEE began appearing in
1. Esophageal varices
2. Esophageal diverticulum
3. Cervical spine injury or deformity
4. Oropharyngeal distortion or deformity
1989 (1). Initial technology was limited to transverse plane 5. Postesophageal surgery
6. Severe coagulopathy
images. Subsequently, a monoplane probe with longitudinal
orientation was developed to overcome limitations of single
transverse plane imaging. Rapidly, by the early 1990s, the
development and use of biplane transesophageal probes to return to bypass for repair of residual defects in approxi-
occurred. Currently, miniaturization has led to small bi- mately 7– 8% of cases or more. Although pediatric transtho-
plane transesophageal probes (approximately 7–10 mm in racic echocardiography provides excellent and sufficient an-
diameter) that are appropriate for use in infants and small atomic and hemodynamic detail for presurgical evaluation
children. Still smaller biplane and multiplane probes are and planning in most cases, prebypass intraoperative TEE
being developed. Today, TEE is a common and invaluable may be useful in providing additional information in some
diagnostic tool of the pediatric cardiologist. cases (i.e., suboptimal transthoracic images). Prebypass TEE
Commonly accepted indications and contraindications may also allow more accurate pre and postoperative com-
for pediatric TEE are listed in Tables 1 and 2, respectively parisons of specific lesions, such as regurgitant or stenotic
(2). Specific guidelines and recommendations that address valve repair. Prebypass pediatric TEE was found to alter the
training for and performance of TEE have been published planned procedure in 11 of 104 patients in one study by
and summarized in previous reviews (3). O’Leary et al. (5). Rosenfeld et al. (6) evaluated the accuracy
Initial use of TEE was primarily performed in the operat- of residual defects found during immediate postbypass TEE.
ing room as an alternative to epicardial echocardiography. They compared the TEE findings with immediate postby-
Today, in pediatric patients, intraoperative imaging is still pass right or left ventricular outflow pressure gradients by
the most common application of TEE. It is seen as an pullback in the operating room, direct surgical inspection of
important means of assessing the adequacy of the surgical residual ventricular septal defects, pulmonary artery satura-
repair or palliation and to identify residual defects. It also tion and transthoracic echocardiogram performed within 40
provides additional information regarding cardiac function days of the operation. Although TEE was found to be very
and hemodynamics. Early studies have detailed the value of reliable for identifying residual ventricular septal defects,
postbypass TEE with regard to identification of residual mitral stenosis and mitral or aortic regurgitation (97–100%
lesions and/or the need to perform additional surgical palli- agreement with other data), the severity of residual right and
ation or repair (4). As described by Stevenson et al. (4) this left ventricular outflow obstruction was less reliable (87%
and other studies found an alteration in surgical plan or need and 96% agreement, respectively). Additionally in this
study, of the 11 patients that required immediate surgical
revision, TEE confirmed and quantified suspected residual
lesions in seven and identified unsuspected lesions in four.
Table 1. PEDIATRIC TEE INDICATIONS
Transesophageal echocardiography can also provide valu-
1. When transthoracic image/study quality is unsatisfactory able assessment of cardiac function during and immediately
2. When transthoracic window is impeded or unobtainable (i.e.,
following weaning from cardiopulmonary bypass (7). Many
intraoperative, catheterization laboratory, etc.)
3. Intraoperative evaluation, especially when residual cardiac abnormalities studies have viewed the identification of significant residual
are anticipated or suspected cardiac lesions as the quantifiable benefit to intraoperative
4. Intraoperative monitoring of ventricular function for patients with TEE. However, a more difficult to measure but perhaps
congenital heart disease undergoing noncardiac surgery equally significant value of intraoperative TEE is the imme-
5. Guidance of interventional procedures during cardiac catheterization diate feedback to the surgeon regarding the surgical pallia-
6. When vegetations or masses (which may be poorly-imaged from tion or repair and the early postoperative baseline for com-
transthoracic windows) are suspected to be present
parison with future studies.

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Published by Elsevier Science Inc. PII S1062-1458(99)00020-3
 PEDIATRIC CARDIOLOGY

The use of TEE has been previously described in a variety with biplane TEE. Lam et al. (15) reported the use of a 4 mm
of interventional procedures, including atrial and ventricu- diameter 17 element transverse monoplane TEE probe with
lar septal defect device closures, pulmonary and aortic bal- satisfactory results. Future potential applications being ex-
loon valvuloplasty, Brockenbrough transeptal procedures plored include dynamic three-dimensional TEE and fetal
and more. It continues to be increasingly valuable in the TEE using an intravascular ultrasound probe (16,17). Pedi-
catheterization laboratory as an adjunct to interventional atric transesophageal echocardiography has become a rou-
procedures. Several recent studies have reported the use and tine and integral part of pediatric cardiology. It is accepted as
benefit of TEE in Fontan fenestration closure and evaluation a reliable and valuable supplement to other diagnostic mo-
and guidance for dilation of systemic and pulmonary venous dalities. Continued technological advances and develop-
pathway obstructions in patients with Mustard or Senning ment promises an expanding role for and utility of pediatric
repair (8 –10). Kantoch et al. (11) compared the use of TEE TEE.
in radiofrequency (RF) catheter ablation of left-sided path-
ways with standard RF catheter ablation without TEE. They
found that TEE was beneficial in performing transeptal
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11. Kantoch M, Frost G, Robertson M. Use of transesophageal echocardi-
transthoracic echocardiograms are frequently complete and ography in radiofrequency catheter ablation in children and adolescents.
of excellent quality in children in the outpatient setting. For Can J Cardiol 1998;14:519 –23.
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ography with the use of a four-millimeter probe. J Am Soc Echocardiogr geal and intracardiac echocardiography utilizing intravascular ultrasound
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17. Kohl T, Szabo Z, VanderWall K, et al. Experimental fetal transesopha- Barnhill Drive, Riley Research Building 104, Indianapolis, IN 46202.

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