287CHAPTER 29 Echocardiographic Imaging Balloon Atrial Septostomy Patients with transposition of the great arteries are dependent on adequate mixing between the pulmonary and systemic circula tions pr[.]
287 X X CHAPTER 29 Echocardiographic Imaging RA RA X LA A • Fig 29.30 An X umbilical venous catheter (arrow) is seen crossing the patent foramen ovale and into the left atrium (LA) RA, Right atrium Balloon Atrial Septostomy Patients with transposition of the great arteries are dependent on adequate mixing between the pulmonary and systemic circulations prior to surgical repair Typically, a patent ductus arteriosus alone will not result in adequate mixing; thus, patients with an intact ventricular septum often require enlargement of their atrial communication Balloon atrial septostomy is performed by passing a balloon catheter across the atrial septum, inflating the balloon, and rapidly pulling it back into the right atrium to create a tear in the atrial septum (Fig 29.31) The procedure is traditionally performed in the cardiac catheterization laboratory where fluoroscopy, with or without echocardiography, can help guide catheter advancement into the left atrium However, the procedure can also be performed at bedside solely under echocardiographic guidance.102 Bedside balloon atrial septostomy avoids transporting a medically fragile newborn but limits availability of equipment during the procedure Regardless of the location of the procedure, when the umbilical vein is selected as the catheter insertion route, echocardiography can help guide the catheter through the ductus venosus into the inferior vena cava Extracorporeal Membrane Oxygenation and Ventricular Assist Devices Extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) are frequently used to support children with advanced cardiopulmonary or cardiac failure ECMO can be used for emergent resuscitation (extracorporeal membrane oxygenation cardiopulmonary resuscitation [E-CPR]) or for short-term circulatory support When longer-term support is needed, VADs can be used in children with cardiomyopathies or congenital heart disease as a bridge to transplantation or as a destination therapy.103,104 Echocardiography has a role in candidate selection for mechanical support and as a noninvasive modality for guiding appropriate cannula position, measuring effectiveness of mechanical support, monitoring for changes in ventricular and valve function, and assessing for complications.105 In children, transthoracic echocardiography usually provides adequate imaging, but TEE may be necessary if transthoracic imaging is inadequate A PFO or atrial septal defect can increase risk for hypoxia and X LA B • Fig 29.31 Echocardiographic guidance of a balloon atrial septostomy (A) The catheter extends across the patent foramen ovale into the left atrium (LA) and the balloon (X) is inflated (B) The inflated catheter has been pulled across the atrial septum, leaving a larger atrial septa defect RA, Right atrium paradoxical emboli with mechanical support; thus, intraatrial communications are typically closed prior to placement of a VAD.106 Significant aortic valve regurgitation can result in circular flow through the VAD rather than augmentation of systemic blood flow; thus, the aortic valve may be repaired or oversewn at the time of VAD implantation.106 Echocardiographic imaging of a patient on mechanical cardiac support focuses on assessment of cannula placement, wall motion, chamber size, valve function, estimation of pressure gradients, and surveillance for effusions and thrombi Imaging of the cannula should ensure that it is properly positioned, free from the cardiac wall and valves, and free of thrombi related to the device (Fig 29.32) Documentation of ECMO/VAD flows during various stages of the echocardiogram is essential for accurate interpretation of the findings Inotropic support affects assessment of ventricular function and must also be taken into consideration A goal of VAD support is to unload the left ventricle; thus, effective VAD support should lead to decreased LV dimensions Therefore, distention of cardiac chambers could signal inadequate mechanical support Presence of significant mitral regurgitation also can be a sign of inadequate LV decompression With pulsatile VADs, the device’s ejection is not synchronized to the intrinsic heartbeat Therefore, maximal dimensions may not correlate to 288 S E C T I O N I V Pediatric Critical Care: Cardiovascular • Fig 29.32 The opening of the left ventricular assist device cannula is the echobright structure seen in the center of the image In this patient, the cannula appears to be free from obstruction from thrombi or adjacent cardiac structures the ECG tracing, which can complicate accurate assessment of function The VAD driveline positioned in the apex may cause shadows that prohibit adequate visualization of apical walls for accurate measurement of EF Patients with left heart failure can develop elevated pulmonary artery pressure secondary to a backing up of pressure With adequate left ventricular assist device (LVAD) support, the decrease in LV filling pressure should lead to a decrease in pulmonary artery pressure As pulmonary artery pressures improve, corresponding changes should be noted in the RV size and function as well as tricuspid regurgitation velocities As described earlier, estimation of right ventricular function in children is difficult In patients on LVADs, right ventricular cardiac output can be calculated from the continuity equation using the RV outflow tract diameter and time-velocity integral However, there are significant limitations to this calculation based on assumptions used In patients with a pulsatile VAD, the aortic valve is expected to have intermittent opening during LV systole, with opening dependent on variable loading conditions With continuous-flow VADs, the aortic valve may or may not open depending on the left ventricle’s ability to generate sufficient force to overcome constant afterload from the pump flow Complete aortic valve closure is associated with risk of thrombosis; thus, the valve is not routinely oversewn unless there is significant (moderate or greater) aortic valve insufficiency Accurate assessment of aortic insufficiency can be difficult in a low-output state A detailed assessment prior to VAD placement is essential, as significant aortic insufficiency can create a circular loop of flow through the device Serial echocardiography plays an important role in cannula assessment to ensure that there is no cannula obstruction due to displacement or development of thrombus There are no normal values for mechanical assist device cannula Doppler flow velocities in children.107 The pericardial space should also be assessed in any child on mechanical assist device support, as patients may develop significant pericardial effusions or hematomas These may be asymptomatic during full support, but the presence of effusion or hematoma may significantly impact the patient’s ability to wean from support The decision to wean ECMO or VAD support is made through a combination of clinical and echocardiographic assessments while gradually lowering and then eventually stopping support During weaning trials, the arterial pressure, systemic saturation, and mixed venous saturations are closely monitored Echocardiography during low flow or cross-clamp trials allows for careful evaluation of right and left ventricular size, ventricular contractility, valve function, and estimations of pulmonary artery pressure This information should be interpreted in the context of the amount of flow support at each stage of weaning.105,107 Key References Abman SH, Hansmann G, Archer SL, et al Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society Circulation 2015;132(21):2037-2099 Dragulescu A, Mertens L, Friedberg MK Interpretation of left ventricular diastolic dysfunction in children with cardiomyopathy by echocardiography: problems and limitations Circ Cardiovasc Imaging 2013;6(2):254-261 Kirkpatrick JN, Grimm R, Johri AM, et al Recommendations for Echocardiography Laboratories Participating in Cardiac Point of Care Cardiac Ultrasound (POCUS) and Critical Care Echocardiography Training: Report from the American Society of Echocardiography J Am Soc Echocardiogr 2020;33(4):409-422.e404 Lopez L, Colan SD, Frommelt PC, et al Recommendations for quantification methods during the performance of a pediatric echocardiogram: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council J Am Soc Echocardiogr 2010;23(5):465-495 Snider AR SG, Ritter SB Echocardiography in Pediatric Heart Disease 2nd ed St Louis Mosby; 1997 The full reference list for this chapter is available at ExpertConsult.com e1 References Parthiban A, Levine JC, Nathan M, et al Implementation of a quality improvement bundle improves echocardiographic imaging after congenital heart surgery in children J Am Soc Echocardiogr 2016;29(12): 1163-1170.e1163 Barker PC, Ensing G, Ludomirsky A, 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Estep JD, Agler DA, et al Echocardiography in the management of patients with left ventricular assist devices: recommendations from the American Society of Echocardiography J Am Soc Echocardiogr 2015;28(8):853-909 106 Feldman D, Pamboukian SV, Teuteberg JJ, et al The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary J Heart Lung Transplant 2013;32(2):157-187 107 Sachdeva R, Frazier EA, Jaquiss RD, Imamura M, Swearingen CJ, Vyas HV Echocardiographic evaluation of ventricular assist devices in pediatric patients J Am Soc Echocardiogr 2013;26(1):41-49 ... Disease 2nd ed St Louis Mosby; 1997 The full reference list for this chapter is available at ExpertConsult.com e1 References Parthiban A, Levine JC, Nathan M, et al Implementation of a quality... outflow tract diameter and time-velocity integral However, there are significant limitations to this calculation based on assumptions used In patients with a pulsatile VAD, the aortic valve is... ventricular size, ventricular contractility, valve function, and estimations of pulmonary artery pressure This information should be interpreted in the context of the amount of flow support at each stage