In Reply: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion

To the Editor: We thank the authors for their letter1 and comments regarding our paper that presented the technique and initial experience using transesophageal echo (TEE) to guide insertion of the atrial catheter during a ventriculoatrial (VA) shunt insertion.2 We agree with the authors1 that there is a “lack of consensus about the optimal position of the [VA shunt distal] catheter tip.” The authors also indicate that the “lower third of the superior vena cava (SVC) is generally considered an acceptable target position.” The latter statement unfortunately lacks adequate support from the available literature and somewhat contradicts their first statement. Our study2 documented the feasibility of distal catheter placement at a very specific location and identified a need to ultimately define an optimal distal catheter position within the SVC or atrium. The report by Della Pepa et al3 describes the experience with “echocardiography (EKG)-guided VA shunt insertion” in 5 patients with good results and verified catheter placement with chest radiography. However, chest radiography is an indirect method, which only verified placement within the “correct range” corresponding to the lower third of the SVC and cannot be as precise as is possible with TEE. But what is not known is whether the potential differences regarding the location of the catheter tip in these 2 studies have any relationship with shunt function or risk of shunt failure. The authors expressed concern that the described TEE technique “may somehow [be] burdensome.” We respectfully disagree. As we have indicated, TEE is very much available at modern surgical centers. TEE is commonly used in the hospital setting and, for example, intraoperatively for cardiac surgery, and adopting TEE in the neurosurgical operating room is not unreasonable.4 Lastly, in examining the risks associated with TEE, Hilberath et al5 summarized that “in comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma.”5 It is important to note that this extensive review5 of TEE literature prior to 2010 also reinforces that the actual risk of complications with intraoperative use of TEE is very low. This is further supported by guidelines reported by Porter et al4 in 2015. The use of TEE is accepted as an adjunct for many intraoperative procedures and the risk associated with the use of TEE as a precise method for VA shunt distal catheter positioning is low. We would consider that the primary goals for further investigations should focus on achieving a combination of effective shunt function (ie, treatment of hydrocephalus), a low risk of shunt failure, and a low risk of treatment-associated complications. As part of this, we would advocate for additional research comparing different techniques for VA shunt distal catheter insertion. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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