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ECHO ASSESSMENT OF ASD FOR DEVICE CLOSURE
DR SASINTHARSR, CARDIOLOGY
JIPMER
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VARIOUS ECHO MODALITIES
• TTE• TEE• 3D ECHO• ICE
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WHEN TO SUSPECT IN 2D ECHO
•RIGHT VENTRICULAR DILATIONABNORMAL MOTION OF IVS- brisk anterior movement in early systole or flattened movement throughout systole•? IAS DROP OUT IN APICAL 4C VIEW•RELATIVE ATRIAL INDEX
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2D ECHO
RA RV VOLUME OVERLOAD
SEPTAL FLATTENING IN DIASTOLE
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The Relative Atrial Index (RAI)—A Novel, Simple, Reliable, and Robust Transthoracic Echocardiographic Indicator of Atrial Defects
Cutoff value of >0.92 predicted patients with ASDs v/s matched controls with 99.1% sensitivity and 90.5% specificity
Natalie A Kelly -Journal of the American Society of EchocardiographyVolume 23, Issue 3 , Pages 275-281, March 2010
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SUB COSTAL 4C VIEW• Keeps the atrial septum perpendicular to the ultrasound beam• Distinguishes OS , OP & SV ASDs• SV ASD are consistently visualised in the SUBCOSTAL 4C VIEW• Anomalous drainage of pulmonary veins • Atrial septal aneurysm• Viewed with breath held in inspiration- index marker in 3o` clock
position
SUB COSTAL SHORT AXIS
• Index marker at 12o`clock position and sweeping the transducer from midline to Rt side of patient
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SUBCOSTAL 4C VIEW
SUB COSTAL SHORT AXIS VIEWALSO SHOWS IVC DRAINING TO RA AND EUSTACHIAN VALVE
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Other TTE -views for ASD
• PSAX-IAS separates Rt &Lt atrium and runs posteriorly from NCC of aortic valve. Not seen in entirety as a result of drop out artefact
• APICAL 4C- Posterior aspect of Interatrial septum is clearly delineated in this view but drop out artefact is seen in region of fossa ovalis.
• Pulmonary venous drainage- 3 veins draining to LA• APICAL 5C VIEW- Anterior aspect of interatrial
septum
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PSAX VIEW IAS AGAINST NCC OF AORTA
APICAL 4C VIEW SHOWING THE IAS AND 3 VEINS DRAINING TO LA, RT LOWER PULMONARY VEIN IS USUALLY NOT SEEN
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ANOMALOUS PULMONARY VEIN
• Can be associated with ASD or can occur as an isolated anomaly• 95% of SV ASD a/w RUPV-SVC • RUPV-SVC; LUPV- innominate vein ;
RLPV- IVC• Isolated LLPV – extremely rare
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`Crab view` showing absent Rt upper and Rt lower pulmonary vein
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En face view in 2D
• First the apical 4c view was taken. The image index marker was at approximately kept at 1 o'clock. Keeping the atrial septum and ASD in the region of interest, the transducer was rotated counterclockwise approximately 45° to 60°
Xinseng et al Journal of the American Society of Echocardiography Volume 23, Issue 7 , Pages 714-721, July 2010
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A-4c view & B-En face view
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Morphological variations1.MC- Deficient aortic rim (42.1%)
2.Central defects (24.2%) 3.Deficient Inferoposterior rim (12.1%)
4.Perforated aneurysm of the septum (7.9%) 5.Multiple defects (7.3%)
6.Combined deficiency of mitral and aortic rims (4.1%), 7.Deficient SVC rim (1%),
8.Deficient coronary sinus rim (1%).
Podnar T, Martanovic P, Gavora P,Masura J. Morphological variations of secundum-type atrial septal defects: feasibility for percutaneous closure using Amplatzer septal occluders. Catheter Cardiovasc Interv 2001;53:386 –91.
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ATRIAL SEPTAL ANEURYSM
CRITERIA
A-PROTRUSION OF ANEURYSM ATLEAST15MM OF PLANE OF IAS OR IAS SHOWING15MM OF PHASIC EXCURSION DURINGCARDIORESPIRATORY CYCLEB- BASE WIDTH≥ 15MM
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TRANSVERSE PLANE VIEWS VERTICAL PLANE SWEEP
TEE
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Centrally located ASD imaged at 0°
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ASD with deficient Aortic margin
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Large ASD with deficient posterior and Aortic margins
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Multiple ASDs; larger anterior defect (block arrow) and a smaller posterior defect
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RIMS OF ASD
Aortic - Superoanterior Atrioventricular (AV) valve -mitral or inferoanterior Superior Vena Caval SVC – Superoposterior Inferior venacaval (IVC or Inferoposterior) Posterior (from the posterior free wall of the atria).
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IVC AND SVC RIMS
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OTHER RIMS
TEE
TTE
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Measurement of the ASD rims
• Atleast 5 mm• IVC rim-most important
Schematic representation of the locations of the ASD rims
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TEE 4-chamber view depicting an adequate posterior rim for percutaneous closure of
20 mm.
Transesophageal 4-chamber view: The AV rim measures 9.5 mm, which is
adequate for PCT
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TEE upper-esophageal 4-chamber view with rightward (clockwise) rotation of the probe revealing an adequate RUPV rim of 15 mm . Beside, Doppler color image shows in red the inflow of the RUPV (white arrow). Note the correct ECG timing of the measure at the end of the ventricular systole while the atrio-ventricular valves are still closed.
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Mid-esophageal short axis view of the aortic rim at 56 degrees with an adequate aortic rim (11 mm) for percutaneous closure
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• Absent aortic rim makes the procedure more challenging but does not, preclude device closure of the defect
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Mid-esophageal bi-caval view at 97 degrees, an adequate SVC rim is noted,
measuring 13 mm .
Mid-esophageal bi-caval view at 97 degrees with an adequate IVC rim
of 10 mm
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Special tee views for Inferoposterior rims
No Infero posterior rim with probe in normal position
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Catheter Closure of Atrial Septal Defects With Deficient IVC Rim Under TEE GuidanceK.S. Remadevi, MD, FNB, Edwin Francis, DM, and Raman Krishna Kumar, DM, FACC . Catheterization and Cardiovascular Interventions (2008)
Retroflexed probe in the stomach and bought towards the esophagus and viewedIn the 70-90o view
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3D ECHO
• Matrix transducers – pyramid shaped volumes• Full volume 3D dataset in 4-7 cardiac cycles• Ideal window is the mid esophageal basal long
axis (bicaval view)• Subcostal 4c view- enface septum• Low parasternal 4c view case of suboptimal
windows• 3D tee overcomes 3D TTE if suboptimal windows
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• Real-time 3D imaging demonstrates the changing shape of the ASD during a cardiac cycle, with maximum size in diastole
• As we take the Bicaval view structures – we first remove the right atrial free wall .
• Images are taken with suspended respiration and ECG gating with optimal gain settings
• Low gain – drop outs and high gain – blurring of structural details
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Gain settingsFor Best view
Cropping toGet the IAS
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TUPLE (TILT UP & LEFT)-ENFACE VIEW OF IAS FROM LT ATRIAL PERSPECTIVE
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RIMS OF ASD
ASD IN VARIOUS PHASES OF CARDIAC CYCLE
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ATRIAL SEPTUM ANEURYSM WITH ASD
MULTIPLE ASDs
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DEFECT NEAR THE IVC
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3D echo- En face 3D reconstruction of a secundum ASD with a relatively deficient
IVC and posterior rim
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multiple ASDs with the thin atrial septum (*) separating the 2 defects
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The correlations between the ASD maximal diameter by RT-3DE and operation or balloon sizing were excellent (r > 0.95). All surrounding rims of the atrial septum could be assessed on 3D reconstruction; except for the aortic rim, a
cross-sectional reconstruction was created mimicking the transesophageal echocardiographic cross section (r > 0.92)
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• Maximal criteria for transcatheter closure with ASO device are
(1) ASD secundum with a maximum TEE diameter of 34 mm (2) rims, except the anterosuperior rim, of at least 5 mm, and (3) the dimensions of the total length of the atrial septum were not smaller than the left atrial disk of the chosen device
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Measurement of ASD size
• Maximal ASD diameter must be measured at the end of ventricular systole
• Atleast two orthogonal views
• SBP = Max in TEE + 4 to 6mm
Mid-esophageal 4-chamber view at 0 degree depicting an ostium secundum ASD with a maximal transverse diameter of 18 mm .
Mid-esophageal bi-caval view at 97 degrees showing an ASD with a maximal longitudinal diameter of 14 mm
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• Max size of device used -44 mm• Device embolisation in 3/169 patients • 2- deficient posterior rim and large size (38
mm, 35 mm) were the reasons for instability, • In the third patient, the complete absence of
aortic rim with malaligned septum made the procedure difficult
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CONCLUSION
• Proper case selection• It is important to have inferior and posterior
rims• An anterior rim is not as important as the
device will grasp the aorta• A superior rim is less important as the device
will grasp the SVC orifice