Transoesophageal echocardiography following ventricular septal defect repair: A retrospective case series on the upcoming role of right ventricular–pulmonary arterial uncoupling

Abstract

The role of right ventricular (RV)–pulmonary arterial (PA) coupling is being increasingly recognized, with the ratio of tricuspid annular plane systolic excursion (TAPSE) to PA systolic pressure (PASP) emerging as a useful non-invasive metric in this regard. However, the perioperative assessment in congenital cardiac surgery remains underexplored. Thus, we retrospectively mapped the course of 10 pediatric patients following surgical ventricular septal defect (VSD) repair, whose post-cardiopulmonary bypass (CPB) TAPSE/PASP values were below 0.55 mm/mmHg on the intraoperative transesophageal echocardiographic (TEE) data. Employing the lower recommended threshold value of TAPSE/PASP <0.31 mm/mmHg to label RV-PA uncoupling on TEE, six out of our 10 included patients were classified in the former category on post-CPB evaluation. With four out of these six patients manifesting intraoperative pulmonary hypertensive (PH) crisis, five landed in postoperative low cardiac output syndrome. Herein, the requirement for inodilator therapy resulted in higher vasoactive-inotropic scores. Acute kidney injury followed in a couple of these patients. Further, the mean duration of postoperative mechanical ventilation turned out to be 2.5 times higher in the patients with RV-PA uncoupling when compared to the others. We retrospectively observed poor outcomes with post-CPB TAPSE/PASP <0.31 mm/mmHg, in a clinical setting of VSD repair, mandating future prospective studies on the subject.