Improving Cardiac Anesthesiology for the Youngest Patients

Anesthesiologists in the Texas Center for Pediatric and Congenital Heart Disease enter a multi-site clinical trial to determine best care practices for patients undergoing congenital heart surgery

Reviewed by Erin Gottlieb, MD, MHCM

Written by Lauren Schneider

A small infant swaddled in a white blanket is laying on an exam table as a doctor holds a stethoscope to its chest.

UT Health anesthesiologists have joined a clinical trial comparing two methods of inserting breathing tubes for surgeries to treat cardiac conditions and anomalies in infants.

Formally known as the Nasotracheal Intubation with Video Laryngoscopy versus Direct Laryngoscopy in Infants (NasoVISI) trial, the study was initiated by the Children’s Hospital of Philadelphia (CHOP) and has expanded to seven other pediatric cardiac centers including the Texas Center for Pediatric and Congenital Heart Disease, a clinical partnership between Dell Children’s Medical Center and UT Health Austin.

“Our team is excited to be doing important research that could potentially change clinical practice,” says Erin Gottlieb, MD, the chief of Pediatric Cardiac Anesthesiology at the Texas Center for Pediatric and Congenital Heart Disease.

Facilitating surgery for congenital heart conditions

The NasoVISI trial aims to improve anesthetic care for infants who must undergo surgery or cardiac catheterization in the first year or even the first week of life due to congenital anomalies such as the following:

  • Atrial or ventricular septal defects: Defects in the walls dividing the top or bottom two chambers of the heart, respectively
  • Tetralogy of Fallot: A structural defect that affects blood flow between the heart and the lungs, resulting in a blue skin tint (cyanosis) from the oxygen-poor blood circulating throughout the body
  • Transposition of the great arteries: A defect in which the two major arteries that carry blood out of the heart are in each other’s position
  • Hypoplastic left heart syndrome: A condition in which the left side of the heart is not fully formed at the time of birth
  • Truncus arteriosus: A defect in which a single arterial structure arises from the left ventricle that supplies both the body and the lungs

According to Dr. Gottlieb, all heart surgeries involve the placement of a breathing tube to provide patients with anesthetic gases and oxygen and to breathe for them during the procedure. At the Texas Center for Pediatric and Congenital Heart Disease, this is accomplished with a nasotracheal tube that is inserted through the nose into the trachea (windpipe).

The process of nasotracheal intubation requires the practitioner to visualize the larynx (vocal cords). This has traditionally been accomplished through direct laryngoscopy, meaning anesthesia providers rely on their eyes to visualize the larynx. The present study will compare direct laryngoscopy to a newer method called video laryngoscopy. In this technique, a video camera on the blade of the laryngoscope enables anesthesiologists and other practitioners to view the larynx on an enlarged screen.

“Nasotracheal intubation takes a lot of skill, and difficulties in placing the breathing tube may cause hemodynamic (blood flow) or respiratory instability,” explains Dr. Gottlieb. She lists bradycardia (abnormally slow heart rate) and desaturation (low blood oxygen levels) as two potential complications of difficult intubation. “We want to know which method is the fastest and which one is associated with the least amount of hemodynamic or respiratory compromise.”

Advancing the field of pediatric cardiac anesthesiology

The NasoVISI project builds on an earlier clinical trial by the CHOP team called Videolaryngoscopy in Small Infants (VISI) that compared direct and video laryngoscopy in orotracheal intubation, in which the breathing tube is inserted into the mouth rather than the nose. In the VISI trial, clinicians were more likely to successfully intubate patients on the first attempt when using video rather than direct laryngoscopy. With the NasoVISI trial, researchers will evaluate whether the advantages of video laryngoscopy extend to nasotracheal intubation.

Dr. Gottlieb describes the sense of excitement she felt when CHOP cardiac anesthesiologist Susan Nicholson, MD contacted her inviting the Texas Center for Pediatric and Congenital Heart Disease to participate in the NasoVISI project. “She’s one of my mentors and a person I’ve looked up to in my career.”

She adds that the project demonstrates her team’s place at the forefront of their medical discipline. “We want to be among the leaders in the field of pediatric cardiac anesthesiology, and you do that by doing research like this that advances the field.”

About the Partnership Between UT Health Austin and Dell Children’s Medical Center

The collaboration between UT Health Austin and Dell Children’s Medical Center brings together medical professionals, medical school learners, and researchers who are all part of the integrated mission of transforming healthcare delivery and redesigning the academic health environment to better serve society. This collaboration allows highly specialized providers who are at the forefront of the latest research, diagnostic, and technological developments to build an integrated system of care that is a collaborative resource for clinicians and their patients.