Transesophageal echocardiography in evaluation and management after a Fontan procedure

Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to assess the immediate (5 patients) or intermediate (13 patients) results after a Fontan-type procedure. The findings were correlated with precordial echocardiographic (all patients) and cardiac catheterization (11 patients) data. Atrial shunting was documented by transesophageal studies in three patients (precordial in one patient). In two patients it was confirmed by cardiac catheterization; the third underwent reoperation based on the transesophageal study alone. Pulmonary artery obstruction was documented in three patients (precordial in one patient) and was confirmed by subsequent cardiac catheterization in all. Evaluation of anterior Fontan connections was successful in 5 of 8 patients (precordial in 6 of 8), and posterior connections in 10 of 10 patients (precordial in 5 of 10). A Glenn shunt could be evaluated in eight of nine patients (precordial in three of nine). Thrombus formation was detected by transesophageal studies in three patients (precordial in one patient); repeat studies were used to evaluate thrombolytic therapy in two. Atrioventricular valvular regurgitation (11 of 18 patients) was better defined by transesophageal than by precordial studies (5 of 18). A coronary artery fistula was identified in two cases (precordial in none). Transesophageal pulsed Doppler interrogation of pulmonary artery and pulmonary vein flow patterns consistently allowed a detailed evaluation of the Fontan circulation. Transesophageal echocardiography is an important diagnostic and monitoring technique after the Fontan procedure. In this series, it was far superior to precordial ultrasound evaluation and of substantial additional value to cardiac catheterization.     

The value of 2-D Doppler echocardiography in the evaluation of asymptomatic patients with Mustard operation for transposition of the great arteries.

2-D Doppler echocardiography was used to assess the occurrence of haemodynamic abnormalities in 45 asymptomatic patients, aged 4 to 16 years (median 7.4) after a Mustard operation for transposition of the great arteries. The findings were compared with those derived from cardiac catheterization. Thirty-five cardiac lesions were correctly diagnosed by 2-D Doppler echocardiography in 23 patients, but on six occasions, minor abnormalities were missed. 2-D Doppler echocardiography demonstrated systemic venous pathway obstruction of more than 3 mmHg at cardiac catheterization in nine patients, and in five of the six patients with pulmonary venous channel obstruction. A left ventricular outflow tract obstruction (pressure difference greater than 15 mmHg) was diagnosed correctly by Doppler echocardiography in seven patients. Baffle leakage was found in two patients with a left to right shunt of 25% or more of pulmonary blood flow, but was missed in five out of nine patients with small shunts. Tricuspid regurgitation was well defined in eight patients. The absence of symptoms and a routine examination after a Mustard operation do not rule out haemodynamic abnormalities. However, these, with the possible exception of minor baffle leakage, can be detected by 2-D Doppler echocardiography.     

Comparative value of transthoracic and transesophageal echocardiography in the assessment of congenital abnormalities of the atrioventricular junction

Information obtained from transthoracic and transesophageal echocardiography (two-dimensional echocardiography with spectral Doppler and color flow imaging) was compared in 17 patients with major congenital abnormalities of the atrioventricular (AV) junction (10 discordant AV connections, 1 criss-cross connection, 5 absent right connections and 1 absent left connection). The findings by either technique were correlated with findings at cardiac catheterization (12 patients) and at surgery (5 patients). In two of six patients with an absent AV connection as defined by transthoracic echocardiography, transesophageal imaging demonstrated an imperforate AV valve. In 11 of 11 patients with a discordant or criss-cross connection, assessment of AV valve and ventricular morphology (by defining the chordal attachments of both AV valves) was possible with transesophageal echocardiography (3 of 11 patients by transthoracic echocardiography); chordal straddling was detected in 1 patient and excluded in 3 others with an associated inlet ventricular septal defect. Anomalous pulmonary venous connection (one patient), atrial septal defect (three patients) and subpulmonary stenosis (five patients) were better assessed by transesophageal imaging, and atrial appendage morphology could be demonstrated in all. The transesophageal technique was less useful in demonstrating the anterior subaortic infundibulum or aortopulmonary shunt (two patients). Although systemic ventricular function could be assessed by either method with use of short-axis M-mode scans, transesophageal pulsed Doppler interrogation of AV valve and pulmonary venous flow patterns provided clues to diastolic dysfunction of the systemic ventricle.     

Transesophageal contrast echocardiography and color flow mapping: methods of choice for the detection of shunts at the atrial level?

The detection of shunts at the atrial level is important, and a reliable means of diagnosis is required. Precordial contrast echocardiography is usually performed to detect such shunts. To investigate the advantages of transesophageal echocardiographic techniques, we studied 167 consecutive patients with both precordial and transesophageal echocardiography, using two-dimensional imaging with contrast techniques (with and without a Valsalva maneuver) and color flow mapping. A patent foramen ovale was diagnosed in 31 patients, an atrial septal defect in 11 (7 with bidirectional shunts), and a pulmonary arteriovenous fistula in 3 patients. All right-to-left shunts were detected with transesophageal contrast echocardiography. With these results used as the gold standard, the sensitivity of combined precordial techniques was 37% and that of transesophageal color flow mapping 46%. All left-to-right shunts were detected by transesophageal color flow mapping. With these results used as the gold standard, the sensitivities of both precordial color flow mapping and a transesophageal negative right atrial contrast study were 27%. We conclude that transesophageal contrast echocardiography is the echocardiographic method of choice for the detection of a right-to-left shunt at the atrial level, which cannot be excluded by negative results on precordial study or on transesophageal color flow map study. A left-to-right shunt at this level is best detected by transesophageal color flow mapping.     

Evaluation of left atrial filling using systolic pulmonary venous flow velocity measurements in patients with atrial fibrillation

Background: The pattern of pulmonary venous flow velocity is useful for understanding the hemodynamic relationship between the left atrium and left ventricle in patients with a variety of diseases, and the systolic flow wave, in particular, is considered a clinically important parameter that reflects left atrial filling. Hypothesis: The study was undertaken to determine whether systolic pulmonary venous flow velocity patterns can be used to evaluate left atrial filling in patients with atrial fibrillation. Methods: We performed transesophageal pulsed Doppler echocardiography and cardiac catheterization in 34 patients with chronic atrial fibrillation (10 with hypertrophic cardiomyopathy, 5 with dilated cardiomyopathy, 7 with previous myocardial infarction, and 12 with isolated atrial fibrillation) and 15 normal controls in sinus rhythm. Results: Mean pulmonary capillary wedge pressure, V-wave height in the pulmonary capillary wedge pressure curve, and left ventricular end-diastolic pressure were significantly higher in the hypertrophic cardiomyopathy and dilated failing heart (previous myocardial infarction and dilated cardiomyopathy) groups than in the isolated atrial fibrillation and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, and percent left atrial emptying fraction were significantly lower in the dilated failing heart group than in the isolated atrial fibrillation, hypertrophic cardiomyopathy, and normal groups. The peak velocity and time-velocity integral of the systolic pulmonary venous flow velocity, percent left atrial emptying fraction, and V-wave height were comparatively constant when the preceding R-R intervals were relatively stable in the isolated atrial fibrillation group and in 4 of the 10 patients with hypertrophic cardiomyopathy. However, changes in these variables correlated with the preceding R-R interval in all patients with dilated failing hearts and in 6 of the 10 patients with hypertrophic cardiomyopathy. Conclusion: Transesophageal pulsed Doppler echocardiographic measurements of systolic pulmonary venous flow velocity are valid indicators of left atrial filling in patients with atrial fibrillation.     

Detection of caval obstruction by magnetic resonance imaging after intraatrial repair of transposition of the great arteries

Vena caval obstruction may cause significant morbidity after intraatrial repair of transposition of the great arteries (TGA). Two noninvasive methods of diagnosing vena caval obstruction were compared with cardiac catheterization. Echocardiographically gated magnetic resonance imaging (MRI) and echocardiographic evaluation (2-dimensional saline contrast echocardiography and pulsed Doppler flow measurement) were performed on 15 patients 0.7 to 13.5 years after intraatrial repair of TGA (8 Mustard, 7 Senning). At catheterization, complete superior vena cava or partial caval obstruction (gradient greater than 5 mm Hg from cava to systemic venous atrium) was present in 7 of 15 patients. Superior vena cava obstruction was directly visualized by MRI in both patients with catheterization-proved complete superior vena cava occlusion. A dilated azygous/hemiazygous venous complex (greater than or equal to 5 mm cross-sectional diameter) was seen by MRI in 5 of 7 patients with complex or partial vena caval obstruction and in no patient without vena caval obstruction. MRI showed superior vena caval dilatation (ratio of superior vena caval diameter to aortic diameter greater than 1.45) in 3 of 5 patients with partial vena caval obstruction and in 0 of 8 without vena caval obstruction. Direct visualization of narrowing within the atrium was unreliable for any MRI plane because of the 3-dimensional nature of the intraatrial baffle. Two-dimensional saline contrast echocardiography, successfully performed in 12 of 15 patients, detected complete superior vena caval obstruction only in the 2 patients with catheterization-proved complete superior vena cava occlusion. Contrast echocardiography failed to identify any of the 5 patients with partial vena caval obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)     

The flail mitral valve: echocardiographic findings by precordial and transesophageal imaging and Doppler color flow mapping

To determine the echocardiographic and Doppler characteristics of mitral regurgitation associated with a flail mitral valve, precordial and transesophageal echocardiography with pulsed wave and Doppler color flow mapping was performed in 17 patients with a flail mitral valve leaflet due to ruptured chordae tendineae (Group I) and 22 patients with moderate or severe mitral regurgitation due to other causes (Group II). Echocardiograms were performed before or during cardiac surgery; cardiac catheterization was also performed in 28 patients (72%). Mitral valve disease was confirmed at cardiac surgery in all patients. By echocardiography, the presence of a flail mitral valve leaflet was defined by the presence of abnormal mitral leaflet coaptation or ruptured chordae. Using these criteria, transesophageal imaging showed a trend toward greater sensitivity and specificity than precordial imaging in the diagnosis of flail mitral valve leaflet. By Doppler color flow mapping, a flail mitral valve leaflet was also characterized by an eccentric, peripheral, circular mitral regurgitant jet that closely adhered to the walls of the left atrium. The direction of flow of the eccentric jet in the left atrium distinguished a flail anterior from a flail posterior leaflet. By transesophageal echocardiography with Doppler color flow mapping, the ratio of mitral regurgitant jet arc length to radius of curvature was significantly higher in Group I than Group II patients (5.0 +/- 2.3 versus 0.7 +/- 0.6, p less than 0.001); all of the Group I patients and none of the Group II patients had a ratio greater than 2.5.(ABSTRACT TRUNCATED AT 250 WORDS)     

Concealed left atrial membrane: Pitfalls in the diagnosis of cor triatriatum and supravalve mitral ring

Cor triatriatum and supravalve mitral ring are forms of congenital left ventricular inflow obstruction produced by membranes within the left atrium. Typically, these defects occur as isolated anomalies with manifestations of pulmonary venous obstruction. Four children are presented whose left atrial membrane was associated with other significant cardiac defects, including, in one patient each, simple coarctation of the aorta, sinus venosus atrial septal defect, tricuspid atresia and complex coarctation of the aorta syndrome. The patient with the latter defect had undergone previous pulmonary arterial banding. None of these patients demonstrated significant pulmonary venous obstruction at cardiac catheterization. All patients had a normal value for either pulmonary arterial diastolic or pulmonary arterial wedge pressure. Three mechanisms explained the lack of pulmonary venous obstruction: (1) a large cross-sectional area of membrane openings, (2) an atrial septal defect that was confined to the pulmonary venous chamber and decompressed it by allowing blood to escape into the right atrium, and (3) decreased pulmonary blood flow. The diagnosis was facilitated by two dimensional echocardiography. Accurate diagnosis of left atrial membrane in the setting of other cardiac defects is of practical significance because pulmonary venous obstruction may occur after surgery for the associated defects.     

Pulmonary venous obstruction in patients with transposition of the great arteries

We report two cases of complete transposition of the great arteries with pulmonary venous obstruction which was diagnosed by intraoperative transesophageal echocardiography, but was not detected by transthoracic echocardiography and cardiac catheterization. The pulmonary venous obstruction was relieved simultaneously with arterial switch operation. The intraoperative transesophageal echocardiography has great contribution for thorough evaluation of the pulmonary venous return of the patients.     

Pulmonary venous and systemic ventricular inflow obstruction in patients with congenital heart disease: detection by combined two-dimensional and Doppler echocardiography

Obstruction to pulmonary venous return may be associated with a number of congenital cardiovascular abnormalities occurring both before and after surgery. Hemodynamic assessment by cardiac catheterization is often difficult. A noninvasive method for detection and quantitation of obstruction to systemic ventricular inflow would be clinically useful. Two-dimensionally directed pulsed and continuous wave Doppler echocardiography was performed before cardiac catheterization in 31 patients thought clinically to have possible obstruction to left ventricular inflow or pulmonary venous return. Primary diagnoses included transposition of the great arteries after the Mustard or Senning procedure in nine patients, total anomalous pulmonary venous connection in nine (in two after surgical repair), cor triatriatum in eight (in four after surgical repair), congenital mitral stenosis in four (in one after surgical repair) and mitral atresia in one. Severe obstruction was defined as a mean pressure gradient at catheterization of greater than or equal to 16 mm Hg at any level of the pulmonary venous return or of the systemic ventricular inflow. Severe obstruction was predicted if Doppler examination measured a flow velocity of greater than or equal to 2 m/s across any area of inflow obstruction. At catheterization, 12 patients (39%) had severe obstruction to left ventricular inflow or pulmonary venous return and all obstructions were correctly detected by Doppler echocardiography. The site of pulmonary venous obstruction was localized by two-dimensionally directed pulsed Doppler study. Patients with a lesser degree of obstruction had a lower Doppler velocity, but none had a maximal Doppler velocity of greater than or equal to 2 ms/s.(ABSTRACT TRUNCATED AT 250 WORDS)     

Estimation of mean left atrial pressure from transesophageal pulsed Doppler echocardiography of pulmonary venous flow

To determine whether pulmonary venous flow and mitral inflow measured by transesophageal pulsed Doppler echocardiography can be used to estimate mean left atrial pressure (LAP), we prospectively studied 47 consecutive patients undergoing cardiovascular surgery. We correlated Doppler variables of pulmonary venous flow and mitral inflow with simultaneously obtained mean LAP and changes in pressure measured by left atrial or pulmonary artery catheters. Among the pulmonary venous flow variables, the systolic fraction (i.e., the systolic velocity-time integral expressed as a fraction of the sum of systolic and early diastolic velocity-time integrals) correlated most strongly with mean LAP (r = -0.88). Of the mitral inflow variables, the ratio of peak early diastolic to peak late diastolic mitral flow velocity correlated most strongly with mean LAP (r = 0.43), but this correlation was not as strong as that with the systolic fraction of pulmonary venous flow. Similarly, changes in the systolic fraction correlated more strongly with changes in mean LAP (r = -0.78) than did changes in the ratio of peak early diastolic to peak late diastolic mitral inflow velocity (r = 0.68). We conclude that in the surgical setting observed, pulmonary venous flow from transesophageal pulsed Doppler echocardiography can be used to estimate mean LAP. This technique may provide a rapid, simple, and relatively noninvasive means of gauging this variable in patients undergoing intraoperative transesophageal echocardiography.     

Echocardiographic localization of interatrial baffle after mustard operation for dextrotransposition of the great arteries

The position of the interatrial baffle was determined by echocardiography in 11 patients with complete transposition of the great arteries who had undergone the Mustard operation. The location of the interatrial baffle and the newly created systemic venous atrium and the pulmonary venous atrium behind the pulmonary arterial root was established by echocardiographic contrast studies during cardiac catheterization. Angiographic analysis indicated that the segments of the systemic and pulmonary venous atria seen behind the pulmonary arterial root in the echocardiogram were, respectively, the superior limb of the systemic venous atrium and the posterior segment of the pulmonary venous atrium. The area of mitral-pulmonary valve continuity in the echocardiogram was used as a reference point for dimensional measurements of the systemic and pulmonary venous atria. It is suggested that longitudinal measurements of these structures by echocardiogram may help evaluate their growth in size. Fine to coarse fibrillatory movements of the atrioventricular valves and, more frequently, of the mitral valve were seen in the majority of patients.     

Transoesophageal echocardiographic evaluation of atrial morphology in children with congenital heart disease.

In a prospective study, atrial morphology was evaluated by both transoesophageal and precordial echocardiography in 86 unoperated children with congenital heart disease (age range = 0.2 to 14.8 years, mean = 3.8 years) to determine what advantages, if any, might be inherent in the transoesophageal approach. The information derived from both ultrasound approaches was correlated and compared to information obtained during subsequent cardiac catheterization (78 patients) and, or, surgical inspection (53 patients). Atrial appendage morphology and hence atrial situs was determined by transoesophageal echocardiography in every case (82 solitus, two right atrial isomerism, two left atrial isomerism). In addition, the transoesophageal approach indicated left juxtaposition in four patients, compared to only one by precordial examination. Probe patency of the foramen ovale was correctly predicted in 21 patients by transoesophageal imaging, but in only 10 by precordial imaging. In two children significant secundum defects, undetected by the precordial route, were identified. Multiple atrial septal defects were correctly defined in four patients by transoesophageal study but in only one by precordial study. Sinus venosus defects were documented in four by the transoesophageal approach, but in only one by the precordial. Primum defects were equally well documented (nine patients) by either technique, but the associated valve leaflet morphology was better documented by transoesophageal study in 5/9. A subtotal cor triatriatum was diagnosed in one child only by transoesophageal investigation. Transoesophageal echocardiography allows a much more detailed evaluation of atrial morphology than precordial imaging even in infants. It provides direct diagnosis of atrial situs, detection of juxtaposed atrial appendages and improved demonstration or definitive exclusion of atrial septal defects.     

Cardiological diagnosis in arterial embolism]

Potential cardiac sources of arterial embolism are in particular thrombi within the left atrium or ventricle, or attached to a prosthetic valve, intracardiac tumors, and vegetations due to endocarditis. Patent foramen ovale and atrial septal defect may lead to paradoxical embolism, and spontaneous echo contrast within the heart has to be considered as a parameter of increased thromboembolic risk. In rare cases, atrial septal aneurysm, mitral valve prolapse or annulus calcification and calcified aortic stenosis has to be taken into consideration. Current method of choice for diagnosis of these abnormalities is echocardiography. When the transthoracic approach fails, transesophageal echocardiography (TEE) leads to a definite diagnosis in most cases. Precordial echocardiography allows the detection of left ventricular thrombi with a sensitivity ranging between 72 and 95%, and monoplane TEE does usually not increase these numbers. In contrast, thrombi within the left atrium and particularly in the left atrial appendage can be detected with a significantly higher detection rate when TEE is used. The same is true for spontaneous echo contrast in the left atrium, a phenomenon which is almost exclusively diagnosed by TEE, as well as for endocarditis associated vegetations that can be identified by TEE with a sensitivity higher than 90%. Patient foramen ovale is usually diagnosed by precordial contrast echocardiography combined with a Valsalva maneuver; color Doppler or contrast TEE allows to increase the detection rate. In the diagnosis of prosthetic valve attached thrombi and vegetations, TEE is clearly superior compared to the precordial examination, at least concerning prosthetic devices in mitral position. If echocardiography fails to identify a potential cardiac source of embolism, other techniques don't add significant information in most cases. Detection of a potential source of embolism, however, does not necessarily prove that the particular finding represents the true etiology of an embolic event; results of all clinical and technical examinations have to be evaluated in a critical synopsis. In addition, proper therapeutic consequences in quite a number of abnormalities considered as potential cardiac sources of embolism are not yet defined.     

Echocardiographic guidance during placement of the buttoned double-disk device for atrial septal defect closure

The usefulness of two-dimensional and Doppler echocardiography during buttoned double-disk device closure of an atrial septal defect was evaluated in 20 consecutive patients at the time of interventional catheterization. Transesophageal echocardiography was used in 11 patients (ages 5 to 62 years, weights 20 to 91 kg). Because of the size of the available transesophageal echo probe, transthoracic echocardiography was used in the remaining 9 patients (ages 4 to 5.5 years, weights 14 to 21 kg). In the transesophageal echo group, 1 patient was found to have no atrial septal defect despite a previous diagnosis by transthoracic echocardiography, 3 patients had atrial septal defects too large for closure despite attempts in 2, and 7 patients had transesophageal echo guided device placement. All of these 7 patients had small residual shunts by color Doppler, 2 had unusual arm positions, and 2 had surgical removal of the device due to embolization to the pulmonary artery in 1 and failure to obtain close approximation of the occluder and counteroccluder in 1. In the transthoracic echo group, 2 patients had atrial septal defects too large for closure, 1 patient had no femoral venous access, and 6 patients had transthoracic echo guided device placement. All of these 6 patients had small residual shunts by color Doppler and 3 of the 6 had unusual arm positions. For atrial septal defect sizing, transesophageal echo measurements correlated with catheter balloon size more closely than did transthoracic echo measurements (r 2 = 0.97 vs 0.86).(ABSTRACT TRUNCATED AT 250 WORDS)     

Study of the infradiaphragmatic total anomalous pulmonary venous connection with cross-sectional and pulsed Doppler echocardiography

We studied neonates with the infradiaphragmatic form of total anomalous pulmonary venous drainage by a combination of cross-sectional echocardiography and pulsed Doppler ultrasound. The diagnosis by ultrasound was made prospectively in all six patients. Three large vascular channels could be observed passing through the diaphragm from the subcostal parasagittal plane. The vessels were identified as the descending aorta (to the left), the inferior vena cava (to the right), and the anomalous pulmonary venous channel (in the center). The vessels were insonated in turn, with pulsed Doppler ultrasound, and the characteristic normal flow signals in the aorta and inferior vena cava were obtained. The signal from the anomalous pulmonary vein was a continuous venous signal, the direction of flow being away from the heart. Pulsed Doppler ultrasound allows accurate recognition of the anomalous pulmonary venous channel without the use of contrast echocardiography.     

An echocardiographic study of perimembranous ventricular septal defect with left ventricular to right atrial shunting

Twenty nine patients with isolated perimembranous ventricular septal defects were investigated by M mode, cross sectional, and pulsed Doppler echocardiography. Tricuspid valve anomalies were present in all six patients with a left ventricular-right atrial shunt but in only six (26%) of 23 patients who had interventricular shunts only. Systolic flutter of the tricuspid valve was shown in five (83%) of the six patients with a ventriculoatrial shunt but not in the other patients. Systolic turbulence in both the right ventricle and right atrium was detected by Doppler echocardiography only in patients with ventriculoatrial shunting. A perimembranous ventricular septal defect with left ventricular to right atrial shunt can be diagnosed by its combined M mode, cross sectional, and pulsed Doppler echocardiographic features.     

An echocardiographic study of perimembranous ventricular septal defect with left ventricular to right atrial shunting.

Twenty nine patients with isolated perimembranous ventricular septal defects were investigated by M mode, cross sectional, and pulsed Doppler echocardiography. Tricuspid valve anomalies were present in all six patients with a left ventricular-right atrial shunt but in only six (26%) of 23 patients who had interventricular shunts only. Systolic flutter of the tricuspid valve was shown in five (83%) of the six patients with a ventriculoatrial shunt but not in the other patients. Systolic turbulence in both the right ventricle and right atrium was detected by Doppler echocardiography only in patients with ventriculoatrial shunting. A perimembranous ventricular septal defect with left ventricular to right atrial shunt can be diagnosed by its combined M mode, cross sectional, and pulsed Doppler echocardiographic features.     

Transesophageal echocardiography in children with congenital heart disease: an initial experience

Transesophageal echocardiography with a single plane (transverse axis), dedicated pediatric probe was performed prospectively in 25 anesthetized children undergoing routine cardiac catheterization or intracardiac surgery, to assess the potential role of this technique in the initial diagnosis, perioperative management and postoperative follow-up of children with congenital heart disease. The group ranged in age from 1 year to 14.8 years (mean 6.1) and weight from 6.5 to 52 kg (mean 22.4). Studies were successful in all patients and no complications were encountered. The results of the transesophageal studies (combined imaging, color flow mapping and pulsed wave Doppler sampling) were correlated both with the results of prior precordial studies and the information obtained at cardiac catheterization. Transesophageal echocardiography provided a more detailed evaluation of the morphology and function of systemic and pulmonary venous return, the atria, interatrial baffles, atrioventricular valves and the left ventricular outflow tract. Additional information was obtained in 15 patients (60%). Problem areas for single plane transesophageal imaging were the apical interventricular septum, the right ventricular outflow tract and the left pulmonary artery. The intraoperative use of transesophageal echocardiography allowed assessment of the surgical repair and monitoring of ventricular function and volume status while the patient was weaned from cardiopulmonary bypass. Transesophageal echocardiography in pediatric patients is of additional value in three main areas: 1) the precise morphologic diagnosis of congenital heart disease, 2) perioperative monitoring, and 3) postsurgical follow-up.     

The value of 2-D Doppler echocardiography in the evaluation of asymptomatic patients with Mustard operation for transposition of the great arteries

2-D Doppler echocardiography was used to assess the occurrenceof haemodynamic abnormalities in 45 asymptomatic patients, aged4 to 16 years (median 7·4) after a Mustard operationfor transposition of the great arteries. The findings were comparedwith those derived from cardiac catheterization. Thirty-fivecardiac lesions were correctly diagnosed by 2-D Doppler echocardiographyin 23 patients, but on six occasions, minor abnormalities weremissed. 2-D Doppler echocardiography demonstrated systemic venouspathway obstruction of more than 3 mmHg at cardiac catheterizationin nine patients, and in five of the six patients with pulmonaryvenous channel obstruction. A left ventricular outflow tractobstruction (pressure difference > 15 mmHg) was diagnosedcorrectly by Doppler echocardiography in seven patients. Baffleleakage was found in two patients with a left to right shuntof 25% or more of pulmonary bloodflow, but was missed in fiveout of nine patients with small shunts. Tricuspid regurgitationwas well defined in eight patients, The absence of symptomsand a routine examination after a Mustard operation do not ruleout haemodynamic abnormalities. However, these, with the possibleexception of minor baffle leakage, can be detected by 2-D Dopplerechocardiography.