Newsletter

TEE in Congenital Heart Disease: Dr. Fyfe's Response

Thank you for the opportunity to comment on your "President's Message" about TEE in pediatrics. I am sure your pointing out the significance of Dr. Stevenson's study will stimulate many new readers and educate them about the inherent conflict of trying to perform intraoperative TEE in congenital heart patients while simultaneously trying to provide attentive anesthetic care. I don't think it matters who does the TEE, be they anesthesiologist or cardiologist as long as they are fully conversant with congenital heart echocardiography and its postoperative manifestations.

Perhaps it would be worthwhile reviewing what we mean by congenital heart surgery TEE. It is not only a matter of looking at left ventricular contractility, assessing whether the heart is full or empty, demonstrating whether there is air in the LV and evaluating the degree of mitral regurgitation. The important aspects are the detailed demonstration of the usually multiple congenital abnormalities. The precise anatomy of each region which requires surgical modification must be defined. Anticipatory guidance about the impact of the surgery should be attempted not only on the region which is to be operated upon, but also on contiguous and remote structures which may be negatively impacted by the physical and hemodynamic effects of the surgery. Post operative residua such as residual defects or inadequacies of the surgical repair, in the context of flow pathways which themselves are often unique, must be carefully evaluated, and severity evaluated. The intraoperative echocardiographer, therefore, must be as skilled or more so than the pediatric cardiologist who sent the patient to the operating room in the first place. In our group of seventeen pediatric cardiologists, all of whom have done full fellowships, which included rigorous echo training, only three echo specialists perform TEE. Each of these physicians have extensive experience and have gained the surgeons' confidence to accurately interpret the intraoperative studies. This degree of subspecialization is, I believe, essential for correct interpretation of these studies.

When we started formulating the guidelines for TEE in children several years ago, it was after many of us had completed our own informal training in TEE. We all had similar concerns, the most overriding of which was the risk of the procedure to the children. We had observed that in sedated patients, the cardiologist was so preoccupied with the quest for echo information that it was very difficult to adequately supervise the clinical monitoring of the patient. For this reason we required that an anesthesiologist intubate the airway and often even pass the endoscope, and to manage the patient so that we could devote our undivided attention to the cardiac examination.

Today, that concern is even greater as we are now working in the operating room. In this setting we are required to do highly detailed 2D and Doppler examinations, often with complex and surgically modified anatomy, and many times with the added pressure of a clinically unstable patient immediately following bypass. We share space with the busy anesthesiologist who is engrossed in skillfully managing the rapidly changing hemodynamics and rhythm problems of the child. We discuss the specific surgical difficulties the surgeon may have encountered, and try to interrogate every aspect of the heart, so that if return to bypass has to occur it is with full information. Thus, all deficiencies can be addressed at once.

I find it perplexing that an anesthesiologist working alone would choose to try to perform such a detailed congenital echo exam at the peak of his own activity, as I for one certainly would not have the necessary time or hands to attempt to manage the anesthesia care of the child at this juncture even if I were trained in anesthesia.

It has been proposed that, if in the future, guidelines for the performance of pediatric TEE are discussed, the Joint SCA/ASE Task Force on Perioperative Echocardiography participate. Although the task force is comprised of exemplary anesthesiologists and cardiologists, they are not practicing full time pediatric cardiologists or pediatric anesthesiologists. I have proposed to Tom Kimball, the chairman of the Council on Pediatric Echocardiography of ASE , and I will also propose to the president of the Society of Pediatric Echocardiography (SOPE), that if further changes in the guidelines are deemed necessary, we create a pediatric task force with SCA to address the many unique issues we face with intraoperative echo in congenital heart surgery. Needless to say, I would be pleased to participate in future discussions of this subject in any such forum.

Derek A. Fyfe, M.D.

Emory University

Atlanta, GA