Impact of perioperative transesophageal echocardiography on tetralogy of fallot total repair

IntroductionPrevious studies have suggested that in cardiac surgical patients, TEE provides essential information before and after cardiopulmonary bypass regarding cardiac performance, valve function, and congenital anomalies. Significant residual abnormalities may be missed during TOF surgical repair. The result is often post-operative morbidity and mortality and sometimes the need for reoperation.ObjectivesTo determine impact and accuracy of perioperative TEE in assessment of patients undergoing TOF total repair.MethodsThe study included 50 patients with TOF referred to Cardiothoracic Surgery Department Ain Shams University Hospitals for total repair. Each patient was subjected to history taking, clinical examination, routine preoperative investigations, preoperative TTE, perioperative TEE and Post recovery TTE.ResultsOur study population included 45 (90%) pediatric patients and 5(10%) adults. Youngest was 1year 2 months old and oldest was 25 years old. Their weight ranged from 8 to 85Kg. TEE was feasible in 49 cases (98%) while the pediatric probe failed to be introduced in only one patient. TEE was able to visualize LM coronary artery in 96% of cases, and visualized RCA in 70% of cases. TEE newly detected a case with separate ostea of LAD and LCX. Only one patient developed non sustained runs of SVTThere was significant difference between TEE and TTE as regard IAS visualization (P value <0.0001). All our patients had only subaortic VSD except 4 patients. Three had doubly commited subarterial VSD seen by both TTE and TEE, while one patient had subaortic VSD with inlet extension, which was visualized only by TEE. Postoperative TEE detected residual small VSD in 29 cases of whom 14 cases had the VSD closed spontaneously by the time of TTE. TEE missed small residual VSD in 3 cases. In one case postoperative TEE showed a serpignous mid muscular VSD which was not detected preoperatively.There was moderate agreement between TEE and TTE regarding overriding of aortic valve (weighted Kappa 0.580). There was strong agreement between TTE and TEE in assessment of postoperative PR (r o.8594, P<0.0001).Preoperative TEE showed major impact in 2 cases (4%). In one case total repair was decided instead of shunt operation. While in the other TEE newly detected TV chordae attached to IVS crest with inlet extension of VSD. Preoperative TEE had minor impact in 29 cases (59%) by adding new information which did not alter surgical plan, as visualization of coronaries and IAS.TEE showed major postoperative impact in 2 cases (4%) in the form of second run of CPB and RVOT reconstruction. Minor impact in the form of detection of relieved RVOT obstruction, absence of residual shunts, preserved biventricular function in 47 cases (94%).ConclusionTEE imaging is a safe, feasible, and accurate tool for anatomical, hemodynamic, and functional assessment in patients with TOF during surgical repair. TEE offers the advantage of permitting visualization of the operative procedure in real time and provides guidance for the surgeon in making decisions inside the operating room

Impact of prosthesis oversizing on clinical outcomes of transcatheter aortic valve implantation using a self-expandable Evolut R valve

Abstract Background Transcatheter Aortic Valve Implantation (TAVI) has a growing target population after being indicated even in low-surgical-risk patients with severe symptomatic aortic stenosis. However, postoperative outcomes can be compromised due to para-valvular leakage (PVL). A lot of procedural steps have been investigated to decrease this partially avoidable operational hazard. Oversizing is a main technique to decrease the PVL, despite being itself a risky step. Many studies have been conducted to identify the optimum degree of oversizing. However, studies about oversizing by more than 20% are scarce. We aimed to evaluate the safety and efficacy of oversizing equal to or more than 20%. Results 209 patients who underwent TAVI using the self-expandable valve Evolut R were initially included. 66 patients were excluded because of the baseline conduction disturbance and lack of sufficient data, so 143 patients, 60 females and 83 males, were enrolled in our study as two groups based on the degree of oversizing: Group A included 97 patients with an oversizing index (OI) of less than 20%, and Group B included 46 patients with an OI of 20% or more. We conducted a new technique for more accurate measuring of the OI in the context of the implantation depth, and our patients were categorized using this technique. Our findings have met our primary end point in terms of the safety and efficacy of oversizing by 20% or more. There was no significant difference between both groups in terms of new-onset conduction disturbance (NOCD), with zero cases of annular rupture or coronary encroachment. In terms of efficacy, The incidence of significant PVL (grade 2 or more) in group B was less than in group A (P value 0.007). The ROC curve found that the minimum depth of implantation-derived oversizing (DIDO) to predict no significant PVL was less than 17%. Conclusion Prosthesis oversizing by 20% using the self-expandable Evolut R valve is safe and effective, with no significant effect on the conduction system, coronary encroachment, or annular injury, and warrants a greater reduction in the incidence of significant PVL