title: Utility of a standardized postcardiopulmonary bypass epicardial echocardiography protocol for stage I Norwood palliation.
abstract: OBJECTIVE
  Stage 1 Norwood palliation is one of the highest risk procedures in congenital cardiac surgery. Patients with superior technical performance scores have more favorable outcomes. Intraoperative epicardial echocardiography may allow the surgeon to address residual lesions prior to leaving the operating room, resulting in improved technical performance. The ability of intraoperative epicardial echocardiography to visualize the relevant anatomy and its association with outcomes is not known.
  
  
  METHODS
  A standardized intraoperative epicardial echocardiography protocol was developed and performed at the conclusion of Stage 1 Norwood palliation. Data pertaining to visualization of relevant anatomy, and comparison of intraoperative echocardiogram findings with other postoperative investigations was performed. Clinical outcomes, including technical performance, were collected. A historical cohort who received either no echocardiogram or a nonstandardized examination was used as a comparison group.
  
  
  RESULTS
  Thirty on-protocol and 30 preprotocol patients, 22 of whom had a nonstandardized intraoperative epicardial echocardiogram, were studied. Compared with preprotocol, visualization of the relevant anatomy was significantly increased for the Damus-Kaye-Stansel anastomosis (93% vs. 68% P = .03) and branch pulmonary arteries (70% vs. 36%, P = .02). One residual lesion requiring immediate operative reintervention was diagnosed in the preprotocol group. There were 5 patients in each cohort with residual lesions during the postoperative hospitalization that were not appreciated on the intraoperative echocardiogram. Technical performance, rates of reintervention and clinical outcomes were not significantly different between the two groups.
  
  
  CONCLUSIONS
  Intraoperative epicardial echocardiography is technically feasible and increases visualization of the relevant anatomy. Larger investigations may be warranted to determine if there is clinical benefit to such an approach.
authors.affiliation: Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.|Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Kenan W D
authors.identifier: http://orcid.org/0000-0003-0016-9036
authors.initials: KWD
authors.lastname: Stern
authors.affiliation: Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.|Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Kimberlee
authors.initials: K
authors.lastname: Gauvreau
authors.affiliation: Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.|Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Sitaram
authors.initials: S
authors.lastname: Emani
authors.affiliation: Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.|Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Tal
authors.initials: T
authors.lastname: Geva
mesh_terms: D002315:Cardiopulmonary Bypass / Q000379:methods*; D004452:Echocardiography / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D007231:Infant, Newborn; D007432:Intraoperative Period; D008297:Male; D058327:Norwood Procedures / Q000379:methods*; D010166:Palliative Care / Q000379:methods*; D010496:Pericardium / Q000000981:diagnostic imaging*; D015203:Reproducibility of Results
keywords: Epicardial echocardiography; intraoperative echocardiography; protocol; stage I Norwood procedure