Left ventricular outflow tract obstruction: an indication for intraoperative transesophageal echocardiography

Transesophageal echocardiography (TEE) provides detailed anatomic imaging of both discrete and complex forms of left ventricular outflow tract (LVOT) obstruction, and Doppler techniques provide additional information regarding the site, mechanism, and severity of the obstruction. Because the transaortic surgical approach to LVOT obstruction often provides limited direct visualization during surgery, we sought to evaluate the utility of intraoperative TEE during surgery for LVOT obstruction. We tested the hypotheses that intraoperative TEE would (1) be useful in defining the level and nature of LVOT obstruction, (2) serve to direct the surgical approach, (3) define the adequacy of relief of LVOT obstruction, and (4) detect surgical complications. Study population consisted of a consecutive series of 27 infants and children undergoing surgery for LVOT obstruction. Patient age ranged from 0.5 to 17.9 years, and weight from 5.4 to 71.2 kg. In 14 patients LVOT obstruction resulted from a discrete membrane, whereas 13 had complex forms of LVOT obstruction. Fully anesthetized and monitored patients were examined with 5 MHz TEE probes appropriate to the size of the patient. In the 14 patients with discrete LVOT obstruction, discrete membranes were identified by TEE in all; gradients ranged from 36 to 75 mm Hg. In 13 of 14 patients, postbypass TEE demonstrated removal of the membrane and excellent relief of gradients. In one of these patients, TEE demonstrated a small ventricular septal defect acquired during resection; the patient was returned to bypass for closure. In one patient, return to bypass for further resection of LVOT obstruction was prompted by TEE demonstration of a high residual gradient. In the 13 patients with complex LVOT obstruction, TEE demonstrated the complexity of LVOT obstruction in all. Gradients ranged from 4 to 95 mm Hg. Although this information was used in surgical planning, five patients had high residual gradients after bypass and underwent further resection. An additional two were returned to bypass for mitral valve replacement. Overall, 8 of 27 patients (29.6%) were returned to bypass based on TEE demonstration of residual anatomic or hemodynamic abnormalities. This occurred significantly more frequently in complex LVOT obstruction than in discrete LVOT obstruction (p = 0.045). We conclude that intraoperative TEE has substantial utility in the demonstration of site, mechanism, and severity of LVOT obstruction and for surgery designed to relieve LVOT obstruction. We believe that TEE should be an integral part of surgical management of LVOT obstruction.