Hx
-First started in adults in 1970s
-1980s used in adults w CHD
-1990- first pediatric TEE probe, w biplane made thereafter --> can interrogate outflow tracts bc can see heart in vertical/longitudinal axis too in addition to horizontal axis
-mid 1990s- multiplane ped probe available
Indications in CHD pts
-Ayres JASE 2005 paper
-mainly periop check, and also dx thrombi, etc....
-closure of ASD, VSD, etc
Pre-op exam
-baseline, confirm the dx, ID new/diff pathology, exclude additional defects, help plan surgery/anesthesia
-Post-op exam
-assess repair, ID problems w wean fr CPB, help influence postop mgt...
Pedi TEE Practices
-used in most cases at TCH, other settings only in some patients or only if a specific problem is present...
-Probe/scan
-some place probe before, and some after CPB started
-some leave probe in until the very end of the case (at risk of xx related to prolonged probe insertion...)
-some do a focused exam, some do a complete exam
-usually a peds cardiologist doing it in US, but in Eu it is usually anesthesia
-Probe selection - recs for wt:
-Pedi Micro (2.5kg or greater pt wt)
-Pedi Mini (3.5 kg or greater, some used at 3kg))
-Adult 2D (25kg or greater; some ppl use 20kg)
-Adult 3D (note square at tip, not circle... help ID which is 3D) (30kg or greater)
-c/s premie, 22q11del, abNl craniofacial anatomy as risk for TEE entry, so use smaller probe...
-Down's has harder anatomy to insert TEE, ?why...
Contraindications
-Ayres JASE 2005 guidelines
-Absolute: TEF, esoph obstruction/stricture, perferated hollow viscus, poor airway ctrl, severe resp dp, uncooperative unsedated pt
-Relative: h/o esoph surg, esoph varices/divertic (? if really count), vasc rings, arch anomaly, gastric/esoph bleeding, oropharyngeal pathology, severe coagulopathy, cervicap spin injury/xx
-?how long G tube/fund is it ok to do TEE
-?TAPVR is c/i xx bc probe compresses on confluence
-?anticoag pt - ?pt on mech circ support
-?Downs etc - they have high vagal tone, so not uncommon to get brady, even sinus arrest, espec if pt had sx w the laryngoscopy
Complications
-...
-at time of incision, don't have it in stomach, espec flexed, bc surgeon has mistaken it for xyphoid--> cut thru the stomach!
-esoph perf..
-bleeding, mucosal erosions - can be very high per one study...
-if flex and pull back probe w/o unflexing it, --> buckle the esophagus, --> hard to get probe out, need to advance it to stomach, straighten it out, and then ok to pull back...
Wanda's approach to Probe Selection
-Indication? --> ok
-Contraindication? --> if yes, c/s epicardial or no imaging
-Wt >15-20kg--> adult multi, unless 15-20 then pedi mini
- >3kg then pedi mini, other c/s micro if really needed, or just a pedi biplane, otherwise c/s epicardial or ICE probe (limited)
Location of TEE WIndows
-UE - upper Esoph
-ME- middle Esoph
-LE- lower Esoph
-Transgastric - at level of diaphragm
- Deep Transgastric- in stomach, looking straight up...
-always ensure probe is UNLOCKED when moving probe up and down...
-See JASE 2013 comprehensive PTE standard views...
...