Diagnostic accuracy and role of intraoperative biplane transesophageal echocardiography in pediatric patients with left ventricle outflow tract lesions

OBJECTIVES: To define the lesion-specific role of biplane transesophageal echocardiography in children with left ventricular outflow tract obstructive lesions, the diagnostic accuracy of transthoracic and transesophageal images were compared, and the impact of transesophageal echocardiography on perioperative management was evaluated.

BACKGROUND: The reported high postoperative recurrence of left ventricular outflow tract obstructive lesion can be due to its incomplete surgical relief. A full preoperative definition of the lesions would aid in better surgical outcome. The complexity and spectrum of such lesions provide opportunity to evaluate the role of a recently available biplane transesophageal pediatric probe in its diagnosis and surgical management.

METHODS: In 16 consecutive patients (11 male patients) with left ventricular outflow tract obstructive lesions and with a mean age of 7.9 +/- 5.7 years (range 0.25 to 20.0 years) and a mean weight of 29 +/- 19 kg (range 4 to 66 kg), the morphologic and hemodynamic findings of standard preoperative transthoracic and intraoperative biplane transesophageal echocardiography were compared with surgical and cardiac catheterization findings (in seven patients) for the diagnostic accuracy and impact on the surgical management of the lesions.

RESULTS: Based on the levels of agreement, transesophageal echocardiography demonstrated higher diagnostic sensitivity (chi-squared analysis = 13.4 < 0.001) to the presence and extent of associated lesions (septal hypertrophy, multiple fibromuscular insertions, involvement of aortic and mitral valves not revealed by transthoracic imaging) and trend toward higher sensitivity (Fisher's exact p = 0.17) to primary morphologic diagnoses (abnormal chordal attachments, prolapsed aortic cusp, and tunnel-like outflow tract obstructive lesions missed by transthoracic imaging). As a result of these factors, intraoperative transesophageal imaging changed the surgical plan in 25% of the patients and modified it in an additional 25% of the patients.

CONCLUSIONS: Transesophageal echocardiography can be a reliable diagnostic tool and has an important role in the surgical management of left ventricular outflow tract lesions in children.