Transesophageal Echocardiography of Congenital Heart Diseases Poonam Malhotra Kapoor, Sarvesh Pal Singh
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1TRANSESOPHAGEAL ECHOCARDIOGRAPHY OF CONGENITAL HEART DISEASES2
3TRANSESOPHAGEAL ECHOCARDIOGRAPHY OF CONGENITAL HEART DISEASES
Editors Poonam Malhotra Kapoor MD DNB MNAMS FIACTA FTEE FISCU Professor Department of Cardiac Anesthesia Cardio-Neuro Center (CNC) All India Institute of Medical Sciences, New Delhi, India Secretary Society of Cardiac Anesthesia Delhi and NCR Branch Coordinator Indian Association of Cardiovascular Thoracic Anesthesiologists (IACTA) Education and Research Cell Co-editor Annals of Cardiac Anesthesia Sarvesh Pal Singh MD DM FIACTA FTEE Senior Resident Department of Cardiac Anesthesia Cardio-Neuro Center (CNC) All India Institute of Medical Sciences New Delhi, India Forewords MC Misra, Navin C Nanda, Balram Airan Usha Kiran, Yatin Mehta
4
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Transesophageal Echocardiography of Congenital Heart Diseases
First Edition: 2014
9789351522195
Printed at
5Dedicated to
My father and family
Dr KK Malhotra
(4.7.1929–4.1.2011)
My father is a never-ending song in my heart—of comfort, happiness and well-being. I may sometimes forget the words but I always remember the tune.
My mentor, guide and inspiration in life
An extraordinary physician and human being with boundless affection, witty, hardworking and godly qualities who three years after he's gone, still inspires me to read and write. He is my bridge and good luck charm.
—Poonam Malhotra Kapoor
Dedicated to
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7Contributors
Foreword
A precise and complete diagnosis of congenital heart disease has always been a very challenging problem. Cardiac catheterization had to be resorted to it in all cases prior to surgery especially in congenital heart disease. The access to echo-Doppler has enabled the echocardiographer to deliberate the pathoanatomy and pathophysiology of congenital heart disease with great ease and perfection, and a major chunk of this population is now submitted directly to surgery. The availability of perioperative transesophageal echocardiography (TEE) has paved the way for evaluation of all cases in a tertiary center like All India Institute of Medical Sciences (AIIMS), New Delhi, India, enabling good surgical outcomes in complex pediatric patients undergoing corrective cardiac surgery.
The intraoperative echocardiography and echocardiography during catheter interventions have also proved very gratifying. The key to success in congenital heart disease is to proceed in a much planned systemic way. Transesophageal Echocardiography of Congenital Heart Diseases by Dr Poonam Malhotra Kapoor and Dr Sarvesh Pal Singh is so elegantly edited and illustrated that it will automatically pave the way for a correct and complete diagnosis of congenital heart disease. I am confident that the contents of the book are original and the editors have exercised extreme caution while reproducing text, pictures and diagrams.
The book will continue to vibrate you from beginning-to-end and going through the book is a pleasure. The reading shows that the editors of the book are unmatched in their pediatric perioperative TEE skills and have excelled in their fields.
I am sure that the book will find a permanent place on the desk of all echocardiographers interested in congenital heart diseases. I compliment and congratulate Dr Poonam Malhotra Kapoor and her team for this wonderful endeavor, and wish the book and all of them a great success.
MC Misra
Director
All India Institute of Medical Sciences
New Delhi, India
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11Foreword
Traditionally, transesophageal echocardiography (TEE) provides a very clear picture in most cardiac congenital diseases, for diagnosing various pathologies and is a rapid diagnostic screening tool, though not universally available, because of its cost.
This book tries to present a very easy-to-use practical approach to TEE in complex and simple congenital heart diseases, which is not an easy subject in itself.
We are well aware, that three-dimensional (3D) TEE is now a potent visual medium which can be used by the novice or experienced echocardiographer and beautifully complements the traditional 2D and 3D imaging and it also permits visualization of any cardiac structure of interest from multiple perspectives.
Transesophageal Echocardiography of Congenital Heart Diseases represents a unique work, the only textbook of its kind that focuses specifically upon the applications of TEE in congenital heart disease (CHD). In each chapter, the contributors—highly regarded specialists and leaders in the field—provide practical and instructive information on many different aspects of CHD evaluation by TEE. The textbook is extensively supplemented with figures/illustrations and all from All India Institute of Medical Sciences (AIIMS), New Delhi, India. This reference will prove an invaluable resource for those who use TEE in the care of both children and adults with CHD, whether they be cardiologists, surgeons, anesthesiologists, intensivists, sonographers, or trainees wishing to obtain basic knowledge or advance their understanding of the field.
The details of each lesion on TEE are very beautifully illustrated with tables, figures which are self-explanatory.
The textbook will rekindle everyone's interest in the operating room especially amongst postgraduates, dealing with the subject to this powerful tool TEE.
The wealth of information provided in the book is truly awesome. Every clinician who sees patients with congenital lesions of the heart would want a copy of the book, close at hand. I wish the editors all success in their academic endeavor. It is with pleasure that I write a foreword to the book.
Navin C Nanda
Professor
Department of Medicine and Cardiovascular Disease
Director
Heart Station/Echocardiography Laboratories
University of Alabama
Birmingham, Alabama, USA
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13Foreword
Transesophageal Echocardiography of Congenital Heart Diseases is an important and admirable book. It is thorough, lucid and extremely practical, and is a manual of all echocardiographers need to know about their proper role in the operative room and the intensive care unit (ICU), postoperative about the adequacy of surgery.
This is an excellent addition to the library of books on TEE. It is concise yet thorough, well-written with excellent illustrations, and tables that enhance the reading, and provides an outstanding review of the subject. I would highly recommend this to all cardiothoracic anesthesiologists/surgeons, especially fellows in training of the subject and taking examinations.
It is not only a practical guide to best practice in TEE of CHD, but also sets out the procedure which apply to reach the diagnosis of disease and clinical negligence cases. The text is expressed in clear and accessible terms, and also offers useful practical guidance on many of the difficult issues that arise in obtaining good views of this subject.
All-in-all, the Transesophageal Echocardiography in Congenital Heart Diseases, is a very important entry into what I would consider the “examination preparation” category of echocardiography textbooks for fellows and students in the subject. The chapters are well-illustrated, and most have an extensive number of topics that they may need to review in greater depth. With expert contributors and sound editing, the book would be a valuable addition to the library of anesthesiologists, surgeons and cardiologists interested in a text covering the breadth of topics related to transesophageal echocardiography in congenital heart disease.
The eyes do not see what the mind does not know is very true about TEE in congenital heart disease. As a result, a simple atrial septal defect (ASD) may be missed. There is a great need for a book of this type and editors' present work goes a long way in fulfilling this need.
I wish the editors all success in their venture.
Balram Airan
Professor and Head
Department of Cardiothoracic and Vascular Surgery (CTVS)
Chief
Cardiothoracic Center
All India Institute of Medical Sciences
New Delhi, India
14
15Foreword
It has been my experience that transesophageal echocardiography (TEE) is highly essential tool for intraoperative monitoring and guiding surgical procedures. Advancement in non-invasive and invasive perioperative monitorings has grown by leaps and bounds in last two decades. Transesophageal echocardiography though invasive but evidence narrates almost negligible complications and is as safe as noninvasive technology in expert hands.
Any technology will be useful, if proper training skills are developed to make maximum use. Experience is substantiated by a nationwise survey and conducting various transesophageal echocardiography workshops and hand-on training programs. Faculty and resident doctors involved in cardiac anesthesia have shown a lot of interest in learning their skills.
Transesophageal Echocardiography of Congenital Heart Diseases is a practical guidance for those doctors who want to get benefit of advanced perioperative monitoring and are thoroughly involved in pediatric care.
Hoping that, this book will be highly useful for Cardiac Anesthesia Residency Training Program and for those, anesthesiologists involved in subspecialties like neurosurgery, orthopedic surgery especially those who are managing the patients with the higher risk of thromboembolic phenomenon.
May I thank the editors and Department of Cardiac Anesthesia as well as Department of Cardiothoracic Vascular Surgery of All India Institute of Medical Sciences (AIIMS), New Delhi, India, their staff and technical officers for consistent efforts in bringing out the book with illustrations from patients who underwent successful surgery in cardiothoracic center at AIIMS.
Usha Kiran
Professor and Head
Department of Cardiac Anesthesia
Cardio-Neuro Center (CNC)
All India Institute of Medical Sciences
New Delhi, India
16
17Foreword
Transesophageal Echocardiography of Congenital Heart Diseases by Professor Poonam Malhotra Kapoor is another landmark book in a series of books from her. Each book gets better than the previous and all within a year!
It is a commendable effort, timely and highly recommended. This is a book for a quick read or for refreshing ones memory prior to a viva or examination! It is particularly useful for MD, DM, FIACTA or FNB examination going candidates for a quick revision prior to a presentation or examination or for a senior cardiac anesthesiologist like me who mostly does adult anesthesia and does not have time for a detailed time consuming reading! It has twenty-five chapters each with a few salient features of that particular pathology with pre- and postoperative TEE images of very good quality along with brief description of the ECGs and X-ray chest views for the same pathology as TEE.
It is a unique, easily readable book with just the right amount of information in right doses. M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, has done a very good job as usual, and printing and image quality is excellent.
I would strongly recommend the book for everyone dealing with pediatric-cardiac patients, surgeons, anesthesiologists, cardiologists and intensivists.
Yatin Mehta
Chairman
Medanta Institute of Critical Care and Anesthesiology
Medanta—The Medicity
Gurgaon, Haryana, India
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19Preface
The purpose of Transesophageal Echocardiography of Congenital Heart Diseases is to provide the definitive advanced reference text on the diagnostic utility of echocardiography in clinical practice. Put simply, the book reflects our role as clinicians caring for patients with congenital heart disease. The clinical information in the book will be of value to all cardiovascular specialists, anesthetists and surgeons not just those focused on cardiovascular imaging. The book will also be of interest to cardiology fellows, cardiovascular anesthesiologists, and other healthcare providers using echocardiographic approaches in the clinical setting, including interventional cardiologists, electrophysiologists, emergency medicine physicians, and internists with an active interest in cardiovascular disease with congenital heart diseases and titling in the lacunae have done along with Dr Poonam Malhotra Kapoor, Dr Sarvesh Pal Singh for the text, and Dr Jitin Narula for editing.
We have many people to thank for their efforts in producing the book. First, the contributors have done a superb job of producing authoritative chapters that synthesize vast amounts of scientific and clinical data to create state-of-the-art descriptions of medical disorders. In today's information rich, rapidly evolving environment, they have ensured that this information is current. Helpful suggestions and critical inputs have been provided by a number of colleagues; particularly notable was the advice and encouragement of Dr Usha Kiran. We are most grateful to all our colleagues in each of our chapters who have kept track of the operating rooms and helped us complete it directly or indirectly.
Why is this book necessary? Today echo facility is available in most operating rooms doing pediatric-cardiac surgery. Further, echo is reported by technicians and clinicians who are otherwise good but have less exposure to echo in congenital heart disease.
The book will also appeal to all examinees wanting to know about the echo which is simple, safe, cost-effective, and the excellent noninvasive diagnostic tool that is easily available. We hope readers will be richly benefited by the book and do well in all examinations, such as DNB, DM, FIACTA, and perioperative TEE examinations.
Thank you all and happy reading.
Poonam Malhotra Kapoor
Sarvesh Pal Singh
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21Acknowledgments
At the outset we would like to thank the God Almighty for enabling us to put this book to print. It has been a proud privilege to work at All India Institute of Medical Sciences (AIIMS), New Delhi, India, for all these years. We would like to thank the whole staff of Cardiothoracic Center at AIIMS for the exceptional work, they have been doing for years. We thank Professor Balram Airan, Chief, Cardiothoracic Center for his exceptional leading capacity and unrelenting support. We extend our gratitude to Professor Usha Kiran, Head, Department of Cardiac Anesthesia and Professor Sandeep Chauhan for their constant encouragement and supervision and expert suggestions at all time. Our special thanks to the Faculty, Department of Cardiac Anesthesia and to Dr Sachin Talwar for his invaluable inputs regarding the aspects of different complex surgeries.
Thanks to Professor MC Mishra, The Director, AIIMS, for his amiable, communicative and for AIIMS in having a ‘doer’ director personality and one who is inspirational, encouraging and has unbridled enthusiasm, to go ahead and get things done. He is a true leader and we are lucky at AIIMS to be having him direct us, we thank him, and Dr Navin C Nanda, Professor Balram Airan and Professor Usha Kiran whole-heartedly for writing forewords in the book and encouraging us with expert suggestions.
Our heartfelt gratitude to Dr Yatin Mehta for his untiring effort and support for SCA—Delhi and NCR and his motivation for this book. A leader like him has made us put in all efforts in building up a strong academics society within 5 years time. He is an encouraging and inspirational senior. He is a true maestro and stalwart.
Our office team Mr Sandeep, Mr Manoj Mishra, Mr Pradeep, Mr Sachin Balyan, and Miss Poonam are to be especially thanked for their data and reference input and typing and preparation of the book in such a short time. We could not work without them!
We express our sincere gratitude to all contributors of the individual chapters, faculty and senior residents at Department of Cardiac Anesthesia, Cardio-Neuro Center (CNC), AIIMS. Without their hard work and dedication, this textbook could not have been completed.
We are heartily thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Mr Tarun Duneja (Director-Publishing), Mr Sunil Kumar Dogra (Production Executive), Mr Neelambar Pant (Production Coordinator), Mr Chandra Dutt (Typesetter), Mr Gurnam Singh (Senior Proofreader), Mr Binay Kumar (Proofreader) Mr Manoj Pahuja (Graphic Designer-Head) of M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India, and also like to acknowledge the professionalism and talent of Shri Jitendar P Vij and his publishing team for a speedy and professional academic venture for the fourth time, within a year. Thanks to their editorial efforts to improve the book overall.
Special thanks to DSS, CAE viamedix team of Mr Kandhari, Mr Praveen and Mr Manish Bansal for their “simulation” inputs in the chapter of “TEE views”. A heartfelt thank also goes to Dr Varun Kapoor, for always looking at the bright side of life, Mr Pranav Kapoor, for making us realize what is really important in life and our family members who are our moral and emotional supporters at all adverse moments, we thank Almighty for his utmost blessings on us, AIIMS and SCA—Delhi and NCR. Thank you God for everything.
Poonam Malhotra Kapoor
Sarvesh Pal Singh
22Abbreviations A :
Anterior
Ao :
Aorta
ASD :
Atrial Septal Defect
ASO :
Anti-Streptolysin O
ATL :
Anterior Tricuspid Leaflet
AV :
Atrioventricular
AVSD :
Atrioventricular Septal Defect
CCTGA :
Congenitally Corrected Transposition of the Great Arteries
CHF :
Congestive Heart Failure
CVP :
Central Venous Pressure
DORV :
Double-Outlet Right Ventricle
ECG :
Electrocardiogram
ESM :
Ejection Systolic Murmur
ECHO :
Echocardiogram
IAS :
Interatrial Septum
IVC :
Inferior Vena Cava
IVS :
Interventricular Septum
LA :
Left Atrium
LAA :
Left Atrial Appendage
LAX view :
Long-axis View
LPA :
Left Pulmonary Artery
LSPV :
Left Superior Pulmonary Vein
LSVC :
Left Superior Vena Cava
LV :
Left Ventricular
LVOT :
Left Ventricular Outflow Tract
ME :
Midesophageal
MPA :
Main Pulmonary Artery
MPAP :
Mean Pulmonary Artery Pressure
MV :
Mitral Valve
P :
Posterior Leaflet of the Tricuspid Valve
PA dilatation :
Pulmonary Artery Dilatation
PAD :
Peripheral Artery Disease
PAH :
Pulmonary Arterial Hypertension
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PAP :
Pulmonary Artery Pressure
PAV :
Partial Atrioventricular/Posteroanterior View
PBS :
Pulmonary Branch Stenosis
PDA :
Patent Ductus Arteriosus
PEDP :
Pulmonary Artery End-diastolic Pressure
Pre-CPB :
Pre-cardiopulmonary Bypass
PS :
Progressive Supranuclear
PV :
Pulmonary Valve
PVR :
Pulmonary Vascular Resistance
PW Doppler :
Pulsed Wave (PW) Doppler
RA :
Right Atrium
RPA :
Right Pulmonary Artery
RUPV :
Right Upper Pulmonary Vein
RV :
Right Ventricle
RVH :
Right Ventricular Hypertrophy
RVOT :
Right Ventricular Outflow Tract
RVSP :
Right Ventricular Systolic Pressure
S :
Septal Leaflet of the Tricuspid Valve
SAX view :
Short-axis View
SPAP :
Systolic Pulmonary Artery Pressure
STL :
Septal Tricuspid Leaflet
SVA :
Systemic Venous Atrium
SVC :
Superior Vena Cava
SVR :
Systemic Vascular Resistance
TAPSE :
Tricuspid Annular Plane Systolic Excursion
TGA :
Transposition of the Great Arteries
TOF :
Tetralogy of Fallot
TEE :
Transesophageal Echocardiography
TTE :
Transthoracic Echocardiography
TRV :
Tricuspid Regurgitation Jet Velocity
TV :
Tricuspid Valve
VSD :
Ventricular Septal Defect
XC :
Cor Triatriatum Chamber