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Intraoperative Transthoracic Echocardiography for a Neonate Using an Adult Multiplane Transesophageal Echocardiography Probe

Miura, Daisuke MD*; Yamada, Yasutaka MD*; Nakao, Misaki MD*; Sakaguchi, Yoshiro MD; Mizuno, Keiichiro MD

doi: 10.1213/XAA.0000000000000972
Echo Rounds

From the *Department of Anesthesiology, Saga University Medical Hospital, Saga, Japan

Department of Anesthesiology, School of Medicine, Saga University, Saga, Japan

Department of Anesthesia, Fukuoka Children’s Hospital, Fukuoka, Japan.

Accepted for publication December 18, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Daisuke Miura, MD, Department of Anesthesiology, Saga University Medical Hospital, Saga, Japan. Address e-mail to

An 8-day-old male neonate with a ventricular septal defect and trisomy 21, weighing 2273 g, was diagnosed with congenital hydronephrosis due to urethral stricture. He was scheduled for bladder dermostomy.

On preoperative echocardiogram, left ventricular ejection fraction was 87%, but the left atrium and ventricle were enlarged. Left-to-right shunt signal and perimembranous inlet type ventricular septal defect with 4.5 × 5.0 mm orifice size were seen.

After general anesthesia induction, we planned to evaluate his cardiac function and heart size via an adult multiplane transesophageal echocardiography (TEE) probe (6VT-D used with the Vivid E9 system; GE Healthcare; Amersham, Buckinghamshire, England) placed on the epigastrium for fluid management. The narrow intercostal space made obtaining adequate images at the transthoracic wall difficult. Ultrasound examination of the epigastrium (TEE probe 60-mm depth, approximately 0° sector scan, and maximum frequency 6 MHz to optimize resolution) was performed using acoustic gel. We observed the left ventricular short-axis image from the epigastrium by slightly rotating the TEE probe shaft from the sagittal to coronal plane. The echo probe was placed on the epigastrium with the probe slightly toward the head. By rotating the omniplane angle, we could observe the target structure in detail. The epigastrium equals a subcostal window in focused cardiac ultrasound. The echo probe was not left on continuously and only applied when needed.

The entire heart could be visualized up to approximately 60-mm depth; the ventricular septal defect and shunt flow were also clearly observed (Figure 1; Supplemental Digital Content, Video 1, The exact defect position was confirmed using 3-dimensional echocardiography (Figure 2). The cardiac cavity size and ventricular septal defect shunt were examined several times to confirm no major change during surgery. Based on these findings, he was treated with only maintenance fluid infusion at a rate of 4 mL/kg/h.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

A written consent was obtained from the patient’s parents for publication of this case.

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Intraoperative TEE is widely used for cardiac function monitoring during surgery. It is useful for assessing heart function, detecting excess or deficient circulating blood volume, and determining the effect of catecholamine use during surgery. TEE probes for newborns are not always available; the one used for low-birth-weight newborns may be limited to single planes that can visualize only a single section. In addition, the incidence of complications associated with TEE probe insertion is high, 2.2%–5.5%.1–3 Airway obstruction and circulatory changes can occur in infants weighing <4 kg, even when a TEE probe designed for infants is used.2

Previous reports indicate that using intraoperative transthoracic echocardiography provides quick diagnostic information, enabling appropriate treatment.4 In this case, we present the off-label use of an adult multiplane TEE probe on the body surface of a neonate during noncardiac surgery for cardiac function monitoring. This report is the first to describe the intraoperative monitoring of cardiac function using a TEE probe for surface ultrasound. By performing cardiac echocardiography monitoring from the body surface, TEE-associated complications were avoided. When performing transthoracic echocardiography using a general sector echo probe, a probe that is held upright on the body surface is essential. To visualize the heart from the epigastrium, the transthoracic echocardiography probe needs to be placed in a position that may interfere with surgical procedures. However, adult multiplane TEE probe on the body surface allows us to manipulate the probe without disturbing surgical procedures (Figure 3). Teng et al5 and Stevenson et al6 reported that when performing central venous catheter insertion from the internal jugular vein in the absence of vascular probes, it is possible to obtain the same image with the TEE probe that is placed on the neck surface.5,6 These reports support the utility of TEE probe usage in this case.

Figure 3.

Figure 3.

This method may also be applicable to patients with contraindications to TEE, such as esophageal tumors or varices, and cases where appropriate pediatric TEE probes are unavailable. However, this method has a limitation. Because the parasternal and apical windows rely on imaging via small intercostal spaces, it was difficult to visualize the entire heart from these positions. Conversely, the acoustic window of the epigastrium had a high degree of freedom for TEE probe manipulation and it was easy to visualize the heart during surgery; the probe was placed on the epigastrium for observation during surgery. Generally, transthoracic echocardiography is more susceptible to ultrasonic transparency and attenuation than TEE. Therefore, with this method, it may be difficult to visualize images equivalent to TEE in patients with a large body size. Although there is a danger of thermal damage due to continuous use of the echo probe for a long time, in this case, the probe was not fixed, and the use was intermittent and for short durations. Therefore, it is considered that there was no skin disorder caused by heat.

In conclusion, intraoperative transthoracic cardiac function monitoring using adult TEE probes during neonatal noncardiac surgery is a useful method.

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Name: Daisuke Miura, MD.

Contribution: This author helped treat the patient and write the manuscript.

Name: Yasutaka Yamada, MD.

Contribution: This author helped treat the patient and write the manuscript.

Name: Misaki Nakao, MD.

Contribution: This author helped treat the patient and write the manuscript.

Name: Yoshiro Sakaguchi, MD.

Contribution: This author helped conduct the study and write the manuscript.

Name: Keiichiro Mizuno, MD.

Contribution: This author helped conduct the study and write the manuscript.

This manuscript was handled by: Kent H. Rehfeldt, MD.

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1. Stayer SA, Bent ST, Andropoulos DA. Proper probe positioning for infants with compromised ventilation from transesophageal echocardiography. Anesth Analg. 2001;92:1076–1077.
2. Stevenson JG. Incidence of complications in pediatric transesophageal echocardiography: experience in 1650 cases. J Am Soc Echocardiogr. 1999;12:527–532.
3. Yumoto M, Katsuya H. Transesophageal echocardiography for cardiac surgery in children. J Cardiothorac Vasc Anesth. 2002;16:587–591.
4. Hori K, Matsuura T, Mori T, Nishikawa K. Usefulness and growing need for intraoperative transthoracic echocardiography: a case series. BMC Anesthesiol. 2015;15:90.
5. Teng Y, Ou M, Yu H. Feasibility of the use of transesophageal echocardiography as a surface probe for puncturing and catheterization of the internal jugular vein: a randomized controlled pilot study. J Cardiothorac Vasc Anesth. 2018;32:363–369.
6. Stevenson J, Ural N, LeVan P, Mukherji J. Use of a transesophageal echocardiographic probe as a surface probe for evaluating the size, position, and patency of the internal jugular veins. J Cardiothorac Vasc Anesth. 2010;24:119–120.

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