Feasibility of clinical hypnosis for transesophageal echocardiography in children and adolescents

Indications for TEE in paediatric cardiology (adapted from Pediatric Council of the American Society of Echocardiography).²⁶

Diagnosis

• Patient with suspected CHD and non-diagnostic TTE

• Presence of PFO and direction of shunting as possible aetiology for stroke

• PFO evaluation with agitated saline contrast to determine possible right-to-left shunt, prior to transvenous pacemaker insertion

• Evaluation of intra or extra-cardiac baffles following the Fontan, Senning, or Mustard procedure

• Aortic dissection (Marfan syndrome)

• Intra-cardiac evaluation for vegetation or suspected abscess

• Pericardial effusion or cardiac function evaluation and monitoring postoperative patient with open sternum or poor acoustic windows

• Evaluation for intra-cardiac thrombus prior to cardioversion for atrial flutter/fibrillation

• Evaluating status of prosthetic valve

Perioperative indications

• Immediate preoperative definition of cardiac anatomy and function

• Postoperative surgical results and function

Intraoperative TEE-guided procedures^a

• Guidance for placement of ASD or VSD occlusion device

• Guidance for blade or balloon atrial septostomy

• Catheter tip placement for valve perforation and dilation in catheterisation laboratory

• Guidance during radiofrequency ablation procedure

• Results of minimally invasive surgical incision or video-assisted cardiac procedure

ASD: atrial septal defect; CHD: congenital heart disease; PFO: patent foramen ovale; TTE: transthoracic echocardiography; VSD: ventricular septal defect.

^a

Procedure always performed inside the operating room or catheterisation laboratory.

Table 1.

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Indications for TEE in paediatric cardiology (adapted from Pediatric Council of the American Society of Echocardiography).²⁶

Diagnosis

• Patient with suspected CHD and non-diagnostic TTE

• Presence of PFO and direction of shunting as possible aetiology for stroke

• PFO evaluation with agitated saline contrast to determine possible right-to-left shunt, prior to transvenous pacemaker insertion

• Evaluation of intra or extra-cardiac baffles following the Fontan, Senning, or Mustard procedure

• Aortic dissection (Marfan syndrome)

• Intra-cardiac evaluation for vegetation or suspected abscess

• Pericardial effusion or cardiac function evaluation and monitoring postoperative patient with open sternum or poor acoustic windows

• Evaluation for intra-cardiac thrombus prior to cardioversion for atrial flutter/fibrillation

• Evaluating status of prosthetic valve

Perioperative indications

• Immediate preoperative definition of cardiac anatomy and function

• Postoperative surgical results and function

Intraoperative TEE-guided procedures^a

• Guidance for placement of ASD or VSD occlusion device

• Guidance for blade or balloon atrial septostomy

• Catheter tip placement for valve perforation and dilation in catheterisation laboratory

• Guidance during radiofrequency ablation procedure

• Results of minimally invasive surgical incision or video-assisted cardiac procedure

ASD: atrial septal defect; CHD: congenital heart disease; PFO: patent foramen ovale; TTE: transthoracic echocardiography; VSD: ventricular septal defect.

^a

Procedure always performed inside the operating room or catheterisation laboratory.

Children were hospitalised in the morning, after 8 hours of fasting, in the outpatient paediatric unit. After a physical examination and the verification of contraindications by a paediatric cardiologist, a paediatric nurse placed a peripheral venous catheter, usually on the right hand or forearm. Then the child was placed in a dedicated specialised procedure room with monitoring and support personnel (e.g. a medical assistant), as recommended.²⁸ Two experienced senior paediatric cardiologists performed the TEE examinations.

The equipment used was the Epiq 7 ultrasound system (Philips Healthcare, Amsterdam, The Netherlands) and the paediatric S7-3t sector array transducer (broadband technology; 48 elements; 7–3 MHz frequency range; 7.25 mm aperture; 90° field of view; physical dimensions: tip 10.7 × 8 × 27 mm, shaft 7.4 mm diameter and 70 cm length). Pre-TEE oropharyngeal anaesthesia was performed with application on the probe of 3 ml of 2% lidocaine gel. We used a disposable latex-free bite block, providing a safe passage through the child’s mouth during TEE, and protecting their teeth as well as the probe.

After TEE examination, the child was watched for 2 hours in the outpatient unit and discharged after a physical examination by the paediatric cardiologist.

Clinical hypnosis session

Clinical hypnosis is a procedure during which a qualified health professional (e.g. the ‘hypnotherapist’) gives carefully worded instructions to bring the patient to a state of deep relaxation. The hypnotic state corresponds to a state close to ‘falling asleep’ with a patient presenting with a modified state of consciousness, a logic close to dream and a modification of the perception of time and space. In this hypnotic state, the patient is aware of everything that is going on, but at the same time becomes increasingly absorbed in using his or her imagination as directed by the hypnotherapist. Hypnotherapists use clinical hypnosis in three main ways, depending on the patient’s adherence: they encourage the use of the patient’s imagination, they give direct suggestions for therapeutic change, and/or they conduct subconscious exploration to promote understanding and insight about the roots of any problem.²⁹

In this study, two technicians in paediatric radiology trained in clinical hypnosis (e.g. ‘the hypnotherapists’) performed the hypnosis sessions. They were trained in the French Institute of Hypnotherapy (IFH), with 2 days of initiation followed by 7 days of professional training. Then they first practised clinical hypnosis on real patients under the supervision of an experienced hypnotherapist working in our hospital. The price of this training was €1000, fully supported by our institution. One of the two hypnotherapists had previously performed 10 clinical hypnosis sessions for children undergoing ultrasound-guided biopsies. The other hypnotherapist had just completed her training and had only performed sessions under supervision. Therefore, she started her first sessions alone for the TEE examinations.

First, the hypnotherapists had a preliminary interview with the child and his or her parents to explain the procedure of clinical hypnosis, verify the absence of contraindications for hypnotherapy, and gather information about the child’s life in order to prepare the theme and speech of the session. They were particularly interested in finding the sources of pleasure for the child in his or her daily life.

Then the child was placed in the TEE procedure room, lying on the examination table in the left lateral decubitus position, the head in semi-flexion, with ECG, blood pressure and pulse oximeter monitoring (Figure 1). The parents and the other healthcare professionals left the child alone with the hypnotherapist in a quiet room with dim light.

Figure 1.

Transesophageal echocardiography (TEE) examination under clinical hypnosis on a 13-year-old boy with a complex atrial septal defect

The child is installed in the fully equipped TEE procedure room (monitoring, venous catheter, ultrasound, probe, quiet room, dim light). The healthcare members (e.g. two paediatric cardiologists and one medical assistant) are on the left, and the hypnotherapist is on the right. The paediatric cardiologist holding the TEE probe waves at the medical assistant to coordinate the Valsalva manoeuvre with the hypnotherapist.

The session of clinical hypnosis was organised into the following steps:³⁰

Assessment of hypnotic ability and hypnotic induction: authorisation to contact the unconscious.
Dissociation from the environment: breakdown in the unity of consciousness and the cohesion of perceptions.
Set up of a safe place: imaginary place providing important feeling of internal security and protection, and representing a place of resource or relaxation.
Termination of hypnosis, psychodynamic reprocessing of emotional factors and post-hypnotic suggestions.
Discussion and collection of experience with the child.

The hypnotherapist started the session, using a soft voice tone, with simple words, short sentences and repetitions. The hypnotherapist’s attitude and speech had to be calm, reassuring and positive. The theme of the speech was adapted to the age and interests of the child.

Once the child had achieved the hypnotic state, the hypnotherapist had the three other healthcare members (e.g. two paediatric cardiologists and one specialist nurse) quietly enter the room to perform the TEE examination. All four healthcare members minutely knew the detailed TEE procedure and communicated together by signs in order to remain silent and not interrupt the hypnotherapist’s speech dedicated to the child. The scenario of that speech accompanied each step of the TEE examination. For instance, when the probe was about to be introduced, the hypnotherapist could say: ‘you are thirsty, you open your mouth widely and take this tasty glass of fresh fruit juice’. Similarly, the hypnotherapist’s speech facilitated the coordination of contrast injection with the release of the Valsalva manoeuvre. Once TEE was over, the three healthcare professionals quietly left the room and the results of the examination were given to the parents. The hypnotherapist remained with the child in the room and started to bring the child back from the hypnotic state. To get out of the trance, the hypnotherapist gently takes the patient out of his ‘safe place’ by gradually making him aware of the world that really surrounds him by making him listen to the noises, imagine a familiar smell, feel his body.

After the session, and before the patient’s discharge, the hypnotherapist checked for adverse effects related to clinical hypnosis (fatigue, anxiety, confusion, fainting, dizziness, nausea, stupor, resurrection of memories of previous trauma and seizures).³¹ Delayed adverse effects were sought during follow-up visits.

Ethics

The study was conducted in compliance with the good clinical practices protocol and Declaration of Helsinki principles. It belongs to a large multicentre European research programme led by our team on quality of life in children with CHD, and was approved by the South Mediterranean IV Ethics Committee (2009-A00423-54). Informed consent was obtained from all parents or legal guardians. All children were explained the TEE procedure by their paediatric cardiologist and the hypnosis session by the hypnotherapist before they gave their oral consent.

Statistics

Quantitative variables were described with means and standard deviation or median and range, and qualitative variables were described with frequencies. Data were entered, double-checked by two investigators (PA and AG) and analysed in Excel (Microsoft, version 14.7.7).

Results

Over the 24-month study period, 17 children required a TEE examination in their follow-up, apart from those requiring TEE inside the operating room or the catheterisation laboratory. All children eligible for the study and their parents or legal guardians chose to undergo TEE under clinical hypnosis, except for one child. This 11-year-old girl with a large atrial septal defect (ASD) and suspected deficient rims was very anxious about experiencing hypnosis. She had seen a comedy stage hypnotist on television and refused to experience clinical hypnosis. She finally underwent TEE under general anaesthesia before surgical ASD closure.

Finally, 16 children aged 11–18 years (seven girls, mean age 14.1±2.5 years) underwent TEE examination under clinical hypnosis, without requiring any sedative drug therapy. Indications for the TEE procedure in these patients complied with the international guidelines: immediate preoperative evaluation for eight children with complex interatrial shunts, incomplete diagnosis of congenital valvular diseases with TTE for seven children, and postoperative complication for one child with a complex CHD (Table 2).

Table 2.

Population

Patients	Age (years)	Gender	Height (cm)	Weight (kg)	Clinical hypnosis success	TEE success	CHD	Indications for TEE	Results
Patient 1	16	Male	170	53	Yes	Yes	ASD	Suspicion of deficient rims	Indication for ASD percutaneous closure
Patient 2	16	Male	178	53	Yes	Yes	ASD	RV dilatation and ventricular premature beats: suspicion of ASD	No ASD
Patient 3	11	Female	ND	51	Yes	Yes	Aortic valvular disease	Atypical fainting and discordance between TTE and TEE performed in adult cardiology unit	Moderate aortic stenosis
Patient 4	12	Female	163	41	Yes	No	ASD	Suspicion of deficient rims	TEE not performed but full diagnosis with TTE: indication for ASD percutaneous closure
Patient 5	14	Male	170	98	Yes	Yes	Aortic valvular disease	Poor echogenicity, overweight	Moderate aortic regurgitation, surgery not indicated
Patient 6	14	Female	160	55	Yes	Yes	ASD	Possible multiple ASD	Confirmation of multiple ASD, indication for surgical ASD closure
Patient 7	11	Female	132	32	Yes	Yes	ASD	Pulmonary venous return abnormal and possible ASD	Confirmation of ASD sinus venosus
Patient 8	13	Male	135	25	Yes	Yes	Mitral valvular disease	Haemolytic anaemia following mitral annuloplasty	Severe mitral insufficiency
Patient 9	17	Male	177	56	Yes	Yes	Aortic valvular disease	Atypical aortic insufficiency, possible aorto-left ventricular tunnel	No aorto-left ventricular tunnel, mild aortic valvular regurgitation
Patient 10	16	Male	174	51	Yes	Yes	ASD	Suspicion of deficient rims	Confirmation of deficient rims, indication for surgical ASD closure.
Patient 11	14	Female	159	42	Yes	Yes	Double outlet right ventricle	Redux complex CHD surgery, heart failure	Significant residual VSD, right heart severe dysfunction
Patient 12	12	Male	171	60	Yes	Yes	ASD	Right ventricular dilatation, no shunt on TTE and normal cardiac MRI: suspicion of ASD	Patent foramen ovale
Patient 13	11	Female	154	44	Yes	Yes	Aortic valvular disease	Mild aortic insufficiency and sub aortic membrane: morphological analysis of aortic valve	Normal aortic valve, surgery not indicated
Patient 14	18	Male	181	89	Yes	Yes	Aortic valvular disease	Preoperative assessment	Severe valvular disease, indication for surgery
Patient 15	13	Male	156	46	Yes	Yes	Aortic valvular disease	Preoperative assessment	Severe valvular disease, indication for surgery
Patient 16	18	Female	170	111	No	Yes	ASD	Suspicion of deficient rims, obesity	Indication for percutaneous ASD closure

Patients	Age (years)	Gender	Height (cm)	Weight (kg)	Clinical hypnosis success	TEE success	CHD	Indications for TEE	Results
Patient 1	16	Male	170	53	Yes	Yes	ASD	Suspicion of deficient rims	Indication for ASD percutaneous closure
Patient 2	16	Male	178	53	Yes	Yes	ASD	RV dilatation and ventricular premature beats: suspicion of ASD	No ASD
Patient 3	11	Female	ND	51	Yes	Yes	Aortic valvular disease	Atypical fainting and discordance between TTE and TEE performed in adult cardiology unit	Moderate aortic stenosis
Patient 4	12	Female	163	41	Yes	No	ASD	Suspicion of deficient rims	TEE not performed but full diagnosis with TTE: indication for ASD percutaneous closure
Patient 5	14	Male	170	98	Yes	Yes	Aortic valvular disease	Poor echogenicity, overweight	Moderate aortic regurgitation, surgery not indicated
Patient 6	14	Female	160	55	Yes	Yes	ASD	Possible multiple ASD	Confirmation of multiple ASD, indication for surgical ASD closure
Patient 7	11	Female	132	32	Yes	Yes	ASD	Pulmonary venous return abnormal and possible ASD	Confirmation of ASD sinus venosus
Patient 8	13	Male	135	25	Yes	Yes	Mitral valvular disease	Haemolytic anaemia following mitral annuloplasty	Severe mitral insufficiency
Patient 9	17	Male	177	56	Yes	Yes	Aortic valvular disease	Atypical aortic insufficiency, possible aorto-left ventricular tunnel	No aorto-left ventricular tunnel, mild aortic valvular regurgitation
Patient 10	16	Male	174	51	Yes	Yes	ASD	Suspicion of deficient rims	Confirmation of deficient rims, indication for surgical ASD closure.
Patient 11	14	Female	159	42	Yes	Yes	Double outlet right ventricle	Redux complex CHD surgery, heart failure	Significant residual VSD, right heart severe dysfunction
Patient 12	12	Male	171	60	Yes	Yes	ASD	Right ventricular dilatation, no shunt on TTE and normal cardiac MRI: suspicion of ASD	Patent foramen ovale
Patient 13	11	Female	154	44	Yes	Yes	Aortic valvular disease	Mild aortic insufficiency and sub aortic membrane: morphological analysis of aortic valve	Normal aortic valve, surgery not indicated
Patient 14	18	Male	181	89	Yes	Yes	Aortic valvular disease	Preoperative assessment	Severe valvular disease, indication for surgery
Patient 15	13	Male	156	46	Yes	Yes	Aortic valvular disease	Preoperative assessment	Severe valvular disease, indication for surgery
Patient 16	18	Female	170	111	No	Yes	ASD	Suspicion of deficient rims, obesity	Indication for percutaneous ASD closure

ASD: atrial septal defect; CHD: congenital heart diseases; MRI: magnetic resonance imaging; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography; VSD: ventricular septal defect.

Table 2.

Population

Patients	Age (years)	Gender	Height (cm)	Weight (kg)	Clinical hypnosis success	TEE success	CHD	Indications for TEE	Results
Patient 1	16	Male	170	53	Yes	Yes	ASD	Suspicion of deficient rims	Indication for ASD percutaneous closure
Patient 2	16	Male	178	53	Yes	Yes	ASD	RV dilatation and ventricular premature beats: suspicion of ASD	No ASD
Patient 3	11	Female	ND	51	Yes	Yes	Aortic valvular disease	Atypical fainting and discordance between TTE and TEE performed in adult cardiology unit	Moderate aortic stenosis
Patient 4	12	Female	163	41	Yes	No	ASD	Suspicion of deficient rims	TEE not performed but full diagnosis with TTE: indication for ASD percutaneous closure
Patient 5	14	Male	170	98	Yes	Yes	Aortic valvular disease	Poor echogenicity, overweight	Moderate aortic regurgitation, surgery not indicated
Patient 6	14	Female	160	55	Yes	Yes	ASD	Possible multiple ASD	Confirmation of multiple ASD, indication for surgical ASD closure
Patient 7	11	Female	132	32	Yes	Yes	ASD	Pulmonary venous return abnormal and possible ASD	Confirmation of ASD sinus venosus
Patient 8	13	Male	135	25	Yes	Yes	Mitral valvular disease	Haemolytic anaemia following mitral annuloplasty	Severe mitral insufficiency
Patient 9	17	Male	177	56	Yes	Yes	Aortic valvular disease	Atypical aortic insufficiency, possible aorto-left ventricular tunnel	No aorto-left ventricular tunnel, mild aortic valvular regurgitation
Patient 10	16	Male	174	51	Yes	Yes	ASD	Suspicion of deficient rims	Confirmation of deficient rims, indication for surgical ASD closure.
Patient 11	14	Female	159	42	Yes	Yes	Double outlet right ventricle	Redux complex CHD surgery, heart failure	Significant residual VSD, right heart severe dysfunction
Patient 12	12	Male	171	60	Yes	Yes	ASD	Right ventricular dilatation, no shunt on TTE and normal cardiac MRI: suspicion of ASD	Patent foramen ovale
Patient 13	11	Female	154	44	Yes	Yes	Aortic valvular disease	Mild aortic insufficiency and sub aortic membrane: morphological analysis of aortic valve	Normal aortic valve, surgery not indicated
Patient 14	18	Male	181	89	Yes	Yes	Aortic valvular disease	Preoperative assessment	Severe valvular disease, indication for surgery
Patient 15	13	Male	156	46	Yes	Yes	Aortic valvular disease	Preoperative assessment	Severe valvular disease, indication for surgery
Patient 16	18	Female	170	111	No	Yes	ASD	Suspicion of deficient rims, obesity	Indication for percutaneous ASD closure

Patients	Age (years)	Gender	Height (cm)	Weight (kg)	Clinical hypnosis success	TEE success	CHD	Indications for TEE	Results
Patient 1	16	Male	170	53	Yes	Yes	ASD	Suspicion of deficient rims	Indication for ASD percutaneous closure
Patient 2	16	Male	178	53	Yes	Yes	ASD	RV dilatation and ventricular premature beats: suspicion of ASD	No ASD
Patient 3	11	Female	ND	51	Yes	Yes	Aortic valvular disease	Atypical fainting and discordance between TTE and TEE performed in adult cardiology unit	Moderate aortic stenosis
Patient 4	12	Female	163	41	Yes	No	ASD	Suspicion of deficient rims	TEE not performed but full diagnosis with TTE: indication for ASD percutaneous closure
Patient 5	14	Male	170	98	Yes	Yes	Aortic valvular disease	Poor echogenicity, overweight	Moderate aortic regurgitation, surgery not indicated
Patient 6	14	Female	160	55	Yes	Yes	ASD	Possible multiple ASD	Confirmation of multiple ASD, indication for surgical ASD closure
Patient 7	11	Female	132	32	Yes	Yes	ASD	Pulmonary venous return abnormal and possible ASD	Confirmation of ASD sinus venosus
Patient 8	13	Male	135	25	Yes	Yes	Mitral valvular disease	Haemolytic anaemia following mitral annuloplasty	Severe mitral insufficiency
Patient 9	17	Male	177	56	Yes	Yes	Aortic valvular disease	Atypical aortic insufficiency, possible aorto-left ventricular tunnel	No aorto-left ventricular tunnel, mild aortic valvular regurgitation
Patient 10	16	Male	174	51	Yes	Yes	ASD	Suspicion of deficient rims	Confirmation of deficient rims, indication for surgical ASD closure.
Patient 11	14	Female	159	42	Yes	Yes	Double outlet right ventricle	Redux complex CHD surgery, heart failure	Significant residual VSD, right heart severe dysfunction
Patient 12	12	Male	171	60	Yes	Yes	ASD	Right ventricular dilatation, no shunt on TTE and normal cardiac MRI: suspicion of ASD	Patent foramen ovale
Patient 13	11	Female	154	44	Yes	Yes	Aortic valvular disease	Mild aortic insufficiency and sub aortic membrane: morphological analysis of aortic valve	Normal aortic valve, surgery not indicated
Patient 14	18	Male	181	89	Yes	Yes	Aortic valvular disease	Preoperative assessment	Severe valvular disease, indication for surgery
Patient 15	13	Male	156	46	Yes	Yes	Aortic valvular disease	Preoperative assessment	Severe valvular disease, indication for surgery
Patient 16	18	Female	170	111	No	Yes	ASD	Suspicion of deficient rims, obesity	Indication for percutaneous ASD closure

ASD: atrial septal defect; CHD: congenital heart diseases; MRI: magnetic resonance imaging; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography; VSD: ventricular septal defect.

The hypnotic state was achieved for 15 out of the 16 participating children (94%). For one anxious 18-year-old child, the hypnotic state could not be fully achieved but the good tolerance of the child allowed the TEE examination to be performed without any sedation with midazolam. Of note, this child presented with an ASD with severe obesity associated with Prader–Willi syndrome.

The TEE examination could be completely achieved with a full diagnosis for 15 out of 16 children (94%). In one case, a 12-year-old girl achieved the state of clinical hypnosis, but presented with a panic attack while being hypnotised. This episode consisted mainly of tears, a fear of return to consciousness and panic associated with the feeling of letting go. The hypnotherapist placed the patient in a deeper state of trance. We decided that this condition was not compatible with the examination and did not introduce the TEE probe. Afterwards, this child had no memory of this episode and recovered completely.

In all cases, TEE examination under clinical hypnosis provided a complete diagnosis and made it possible to adapt the therapeutic management adequately. The median overall clinical hypnosis session duration was 40 minutes (range of 30–60 minutes), equally divided into 20 minutes (range of 15–30 minutes) between hypnosis induction and TEE probe insertion and 20 minutes (range of 15–30) between TEE probe insertion and hypnotic state termination. The median TEE procedure duration (e.g. time between insertion and removal of the probe) was 7 minutes (range of 5–12 minutes), which is similar to TEE under general anaesthesia or sedation with midazolam in our institution.

After the 2-hour clinical monitoring in the outpatient unit, all children had a normal physical examination by the paediatric cardiologist and the hypnotherapist reported no adverse effects, therefore all children were discharged from hospital. No immediate or delayed adverse effects were reported after a mean follow-up of 15±8 months since the TEE procedure under clinical hypnosis.

Discussion

Our data suggest that clinical hypnosis represents an interesting method to perform TEE examination in children and adolescents with CHD, for indications outside the operating room and the catheterisation laboratory. With a high rate of successful procedures, and nearly no adverse events, it appears to be a simple and safe tool in clinical practice. To our knowledge, this is the first study reporting the feasibility and safety of clinical hypnosis for TEE examination in a paediatric population.

The additional 40 minutes needed for the hypnosis procedure did not affect the practicality of performing TEEs in our paediatric cardiology department, as most procedures were usually performed under general anaesthesia. In practice, we used to perform two TEEs per paediatric anaesthesia session, which happened to be the same thing with hypnosis. In terms of financial aspects, the cost for TEE under general anaesthesia is €1334, while the cost for TEE under hypnosis is €670 (social security tariffs for hospital stays).

Thanks to diagnostic and surgical advances over past decades, there is a new and increasing population of adolescents and young adults with complex congenital cardiac anomalies, and diagnostic problems are often different from those in childhood, relating to the residual lesions of previous surgery.¹⁷ TTE is the first-line examination used in CHD but it might be incomplete in adolescents with CHD because of a larger body mass index, chest deformities and poor acoustic windows. Nevertheless, specific diagnosis is needed in several situations to adapt the therapeutic management. According to the task force of the Pediatric Council of the American Society of Echocardiography, TEE is indicated in inconclusive TTE for suspected or confirmed CHD, if endocarditis is suspected or to exclude intracardiac thrombi.²⁶

In paediatrics, hypnosis has been studied in minor surgery, medical procedures or pain management with encouraging results,^{2, 10, 32, 33} but has been rarely described in paediatric cardiology. Interestingly, hypnosis has been used to avoid general anaesthesia in a child with severe pulmonary arterial hypertension.³⁴ Usually, children are easier to hypnotise than adults. They are less burdened with cognitive stereotypes than adults, and their boundaries between imagination and reality are less important. For instance, children respond better than adults to clinical hypnosis in both acute and chronic pain management.³¹

The use of clinical hypnosis for TEE examination in children had never been reported, to our knowledge. Yet, young patients appear to be more apprehensive and less cooperative than older patients, and the procedure duration is often longer than in patients with acquired heart disease.^{25, 35} Moreover, most of the young patients with CHD have had multiple invasive or surgical interventions in their past, which may contribute to anxiety, pain and psychological stress for both the child and the family.³⁶

In our study, hypnosis seems to improve successful insertion and tolerance of the probe by minimising anticipatory anxiety for the child’s own benefit. Only one patient failed to be fully hypnotised. He had Prader–Willi syndrome, which is often associated with behaviour disorder, psychiatric issues and anxiety. In particular, this patient was anxious but did not refuse the procedure. Anxiety classically alters the ability to let go. However, despite an incomplete hypnotic state, we were able to perform a complete TEE examination in this patient without any sedation. Moreover, only one patient presented with an adverse effect during the hypnosis session (e.g. a panic attack), which is likely to be lower than the overall adverse event rate for TEE procedures in children.²⁶ Adverse effects of clinical hypnosis are mostly short term (fatigue, anxiety, confusion, fainting, dizziness, nausea), but can include such serious reactions as stupor, chronic psychological problems, spontaneous dissociative episodes, resurrection of memories of previous trauma and seizures.³¹ Medical trauma is not uncommon for CHD survivors,³⁷ and we feared that the panic attack presented by our patient could have been an example of memories of medical trauma that were ‘resurrected’. Fortunately, the patient was simply in a desire to prolong the hypnotic state.

Therefore, screening for vulnerable individuals is recommended before beginning treatment. Indeed, two notions are essential to take into account: suggestion (suggestibility) and modified state of consciousness (dissociation). Anyone can be hypnotisable, but the level of suggestibility would vary according to age: higher in early childhood, decreasing in adulthood (between 17 and 40 years) and increasing in old age. Personality is also an important parameter in variations of suggestibility to hypnosis; some subjects would be more sensitive, receptive and others less likely to respond to hypnotic suggestion.¹⁰ In paediatrics, hypnosis can only be implemented in children when the child can access the symbolisation (3–4 years old) and thus be able to imagine and modify the way he or she perceives reality. Finally, the process of hypnosis requires training and supervised practice.

The high rate of successful TEE procedures under clinical hypnosis, added to the strong adherence of children and their families to this study, needs to be highlighted. If this procedure is disseminated more widely and confirms those preliminary results, it is possible that paediatric TEE examinations that would not have been performed because of the need for anaesthesia, will be possible thanks to clinical hypnosis.

Study limitation

This was a single-centre non-randomised study with a small sample size, including mostly patients with ASDs and valvular disease. Other populations of congenital cardiac patients should be included in future studies. Moreover, we share the idea that mind–body therapies need to increase their level of evidence, and should benefit from randomised controlled trials, even in paediatrics.³⁸ However, in this study, all children and families but one refused TEE under anaesthesia, in favour of hypnosis. A larger sample size is needed further to discern adverse event rates and compare them to what has been shown for anaesthesia during TEE.

Another limitation of this study is that intervention efficacy has not been examined in younger children. However, TEE is less used in younger aged patients as acoustic transthoracic windows are good and much of the time are sufficient for the clinical setting.

Conclusion

This study suggested, from a small non-randomised cohort, that clinical hypnosis was feasible for TEE in children and adolescents, and might be a good alternative to general anaesthesia or sedation. Moreover, hospital costs could potentially be halved with such a procedure. However, good preparation of the child should be anticipated prior to the examination, including trial sessions under hypnosis, if necessary. Further prospective studies could shed additional light on the benefits of clinical hypnosis in paediatric cardiology, including younger patients.

Conflicts of interest

The authors declare that there is no conflict of interest.

Funding

Montpellier University paediatric and congenital cardiology clinical research funds supported this study.

Implications for practice

Transesophageal echocardiography in children is usually performed under anaesthesia.
Clinical hypnosis is safe and efficient in children for pain and anxiety.
Clinical hypnosis needs to be evaluated in paediatric cardiology.
Paediatric transeophageal echocardiography under clinical hypnosis is feasible and safe.

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