Two-dimensional echocardiographic and color Doppler measurements of atrial septal defect, and comparison with the balloon-stretched diameter

Assessment of atrial septal defects using 3-dimensional transthoracic echocardiography prior to percutaneous device closure: first report from Bangladesh

BACKGROUND

Secundum atrial septal defect (ASD) is treated following trans-catheter closure in alternative to surgical treatment. Per-intervention selection of device size with balloon occlusive diameter (BOD) often cause tearing or enlarging, causing arrhythmias and hypotension. We assessed the suitability of percutaneous device closure for ASD using 3-dimensional transthoracic echocardiography (3DTTE).

OBJECTIVES

This study was conducted to investigate if 3DTTE could be an alternative of balloon sizing for selection of device size in atrial septal defect device closure.

DESIGN

It was a cross-sectional comparative study.

METHODS

This study was conducted at the department of Pediatric Cardiology, Bangabandhu Sheikh Mujib Medical University for a period of 2 years. Thirty-three purposively selected secundum ASD patients suitable for device closure were included in the study. Ethical permission was taken from the Institutional Review Board and written consent was taken from each patient's guardian. In this study, 3DTTE derived ASD diameter and BOD were compared with that of deployed device size using correlation analysis.

RESULTS

Out of 33 patients, 63.6% were female and 36.4% were males had a mean age of 18.07 ± 14.58 years (range 2-55 years). Mean diameter of ASD measured by 2-dimensional (2D) and 3-dimensional (3D) echocardiography were 17.09 ± 6.08 mm and 21.30 ± 6.56 mm, respectively, yielding a significant difference (p < 0.001). 3D echocardiography derived ASDs diameter were highly correlated with device size than BOD and 2D echocardiography derived diameter (2D echocardiography: r = 0.796, p = <0.001, 3D echocardiography: r = 0.960, p = <0.001, BOD: r = 0.840, p = <0.001).

CONCLUSION

3DTTE can accurately measure ASD diameter and can be used as an alternate, effective, and safe method to select device size.

ASD device closure in pediatrics: 3-Dimensional transthoracic echocardiography perspective

OBJECTIVE

Real-time three-dimensional echocardiography, using both reconstruction methods and RT3D, has been used as an extra helping tool in several forms of congenital heart diseases. Our aim was to understand the relation of the ASD device to all surrounding structures by 3-dimensional echocardiography (3D).

METHODS

This prospective study included 37 patients diagnosed as ASD secundum by transthoracic (TTE) and transesophageal echocardiography (TEE) referred for transcatheter closure from October 2013 to July 2016. Follow-up for 1 year using 2D and 3D-echocardiography was performed to assess the relations of the device to the surrounding structures.

RESULTS

Transcatheter ASD closure and echocardiographic examinations were successfully performed for all patients. By 3D echocardiography, 16 patients (43.24%) had their ASD device close to the aortico-mitral continuity plane without apparent regurgitation, while the rest of our patients (56.75%) the devices were away from this plane. The following variables were significantly different between the two groups; body surface area, atrioventricular rim (AV), device size, left disc size and ratio of left disc to interatrial septum. A cut-off AV rim length not less than 8 mm was found optimal to avoid device encroachment on the sensitive surrounding structures. New Formula was constructed to aid in device choice.

CONCLUSION

Use of 3D before and after ASD closure is of value to determine the device relation to the surrounding structures. AV rim by TEE is an important rim to avoid eventual encroachment on the mitral valve and aorta.

Transthoracic echocardiography is a safe alternative for assessment and guidance of transcatheter closure of secundum atrial septal defect in children

BACKGROUND

2D-transesophageal echocardiography (TEE) is routinely performed to guide percutaneous ASD closure in children. We aimed to assess whether two-dimensional (2D)-transthoracic echocardiography (TTE) is a safe alternative for assessment and guidance of atrial septal defect (ASD) closure in unselected children.

METHODS

We performed a retrospective single-center study including 389 consecutive children aged less than 15-year-old who underwent percutaneous ASD closure under 2D-TEE (1998-2005, n=133) or 2D-TTE (2005-2014, n=256). A balloon calibration was performed in all cases for the Amplatz Septal Occluder choice.

RESULTS

ASDs were larger and rims deficiencies were more frequent in the TTE-guided group. The procedure was successful in 376 patients [96.7%; 95% confidence interval (CI), 94.4-98.2%]. The success rate tended to be higher in the TTE- versus TEE-guided group (98.0% versus 94.0%, P=0.069). Device migration occurred in 4 patients (1.0%; 95% CI: 0.3-1.6%), all after TEE-guided procedure (P=0.013). Early major adverse events were observed in 5 patients (1.3%; 95% CI: 0.4-3.0%), all in the TEE group (P=0.004). Fluroroscopic time and irradiation dose were not different among the 2 groups (P=0.450 and P=0.130 respectively). After a median follow-up of 7 years (range, 1-16 years), no adverse events was reported. One (0.3%, 95% CI: 0-1.4%) 12-year-old patient developed atrial fibrillation 5 years after the procedure. Pregnancies were uneventful in 72 cases.

CONCLUSIONS

When a balloon sizing is performed, 2D-TTE imaging is as efficient as 2D-TEE to guide percutaneous ASD closure in children. The procedure can safely be done in spontaneously breathing children under TTE guidance alone in experienced centers.

Accuracy of Transthoracic Echocardiography in Assessing Retro-aortic Rim prior to Device Closure of Atrial Septal Defects

OBJECTIVE

Deficient retro-aortic rim has been identified as a risk factor for device erosion following trans-catheter closure of atrial septal defects (ASDs). Transthoracic echocardiography (TTE) is the primary screening method for subjects for possible device closure of ASD, but its reliability in measuring retro-aortic rim size has not been assessed previously.

DESIGN

A single-institution cross-sectional analysis of children and adults referred for trans-catheter device closure of single ostium secundum ASD from January 1, 2005 to April 1, 2012 with reviewable TTE and trans-esophageal echocardiogram images was performed. Inter-rater reliability of measurements was tested in a 24% sample. Accuracy of TTE measurement of retro-aortic rim was assessed using a Bland-Altman plot with trans-esophageal echocardiogram measurement as the gold standard. Test characteristics of TTE detection of deficient retro-aortic rim were calculated. Risk factors for misclassification of deficient retro-aortic rim were assessed using receiver operator characteristic curves. Risk factors for measurement error were assessed through multivariate linear regression.

RESULTS

In total, 163 subjects of median age 5 years (range: 0.3-46 years) were included. Trans-thoracic echocardiography had 90% sensitivity, 84% specificity, 90% positive predictive value, and 83% negative predictive value to detect deficient retro-aortic rim. Bland-Altman plot demonstrated no fixed bias (P = .23), but errors in measurement increased on average as the aortic rim increased in size (P < .001). Prespecified patient level risk factors did not affect receiver operator characteristic curve area under the curve, nor were any patient-level risk factors independently associated with increased measurement error on TTE.

CONCLUSIONS

TTE is a sensitive and specific screening test for deficient retro-aortic rim across a range of patient ages and sizes.

Influence of PFO Anatomy on Successful Transcatheter Closure

Patent foramen ovale (PFO) is considered a risk factor for serious clinical syndromes, the most important of which is cryptogenic stroke in the setting of paradoxic embolism. The safety and feasibility of transcatheter PFO closure have been addressed in several studies; this procedure is performed worldwide with excellent results. Variations in the atrial septal configuration and PFO are frequent and have an impact on the technical aspects and success in transcatheter PFO closure. To minimize the rate of complications of percutaneous closure of PFO, patients must be carefully selected on the basis of morphology and location of the interatrial defect.

Trans-catheter closure of atrial septal defect: Balloon sizing or no Balloon sizing - single centre experience

BACKGROUND

Selecting the device size using a sizing balloon could oversize the ostium secundum atrial septal defect (OSASD) with floppy margins and at times may lead to complications. Identifying the firm margins using trans-esophageal echocardiography (TEE) and selecting appropriate-sized device optimizes ASD device closure. This retrospective study was undertaken to document the safety and feasibility of device closure without balloon sizing the defect.

METHODS

Sixty-one consecutive patients who underwent trans-catheter closure of OSASD guided by balloon sizing of the defect and intra procedural fluoroscopy (group I) and 67 consecutive patients in whom TEE was used for defect sizing and as intraprocedural imaging during device deployment (group II) were compared. The procedural success rate, device characteristics, and complications were compared between the two groups.

RESULTS

The procedure was successful in 79.7 % patients. The success rate in group II (60 of 67, 89.6%) was significantly higher than in group I (41 of 61, 67.2 %) (P = 0.002). Mean upsizing of ASD device was significantly lower in group II (P < 0.001). TEE also provided better success rate with smaller device in subjects with large ASD (>25 mm) and in those who were younger than 14 years of age. There were four cases of device embolization (two in each group); of which one died in group II despite successful surgical retrieval.

CONCLUSION

Balloon sizing may not be essential for successful ASD device closure. TEE-guided sizing of ASD and device deployment provides better success rate with relatively smaller sized device.

Sizing of atrial septal defects by intracardiac echocardiography for device closures

BACKGROUND

Transcatheter closure of a secundum atrial septal defect (ASD) has become an effective method for surgical treatment. In this study, we evaluated the feasibility and accuracy of intracardiac echocardiography (ICE) for sizing ASDs compared with conventional methods.

METHODS

Between January 2004 and December 2006, 270 patients underwent transcatheter closure of secundum ASD by using septal occluders. For 142 patients, the procedure was guided by transesophageal echocardiography (TEE), and for 128 patients by ICE. We compared the maximal diameters of the ASDs obtained during angiocardiography, transthoracic echocardiography (TTE), ICE, and TEE with balloon-stretched sizes ascertained by using a sizing plate.

RESULTS

ASD diameters measured with the sizing plate were significantly correlated with those measured with ICE (r = 0.963), TEE (r = 0.912), angiography (r = 0.88), and TTE (r = 0.85). The predicted stretched diameter of the ASDs, i.e. (nonstretched diameter measured with ICE x 1.07) + 3.23 mm, agreed well with that measured by using a sizing plate (Ri = 0.974).

CONCLUSION

ASD diameters measured with ICE correlated with sizing-plate measurements better than those determined with TEE, angiography or TTE.

Impact of intracardiac echocardiography on radiation exposure during adult congenital heart disease catheter-based interventions

BACKGROUND

Intracardiac echocardiography (ICE) is a widespread approach in many cardiovascular procedures in which it has the potential to reduce the fluoroscopy time and patients radiation exposure. We sought to assess the patient radiation exposure during transcatheter closure of interatrial communications with and without ICE-guidance.

METHODS

In a prospective consecutive series of 25 consecutive patients who underwent transcatheter closure of interatrial communications between May and October 2005 with (15 patients) and without (10 patients) ICE-guidance in a single secondary care referral centre, we measured the dose-area product (DAP), the fluoroscopy dose-area product (FDAP), the total dose-area product (TDAP), and the mean procedural time.

RESULTS

In patients underwent ICE-guided transcatheter closure procedure the mean fluoroscopy time, the mean DAP, mean FDAP, and mean TDAP resulted significantly lower than in control patients: 2.0 +/- 0.21 (range 1.6-2.2) versus 5.05 +/- 0.54 (range 4.2-5.8) minutes (P < 0.001) , 13.72 +/- 9.03 (range 11.36-14.63) versus 21.95 +/- 6.93 (range 20.90-23.93) Gycm2 (P < 0.001), 8.25 +/- 1.22 (range 6.60-9.50) versus 20.15 +/- 8.83 (range 18.90-20.93) Gycm2 (P < 0.001), and 29.33 +/- 1.51(range 27.16-31.00) versus 32.61 +/- 2.53 (range 29.20-35.55) Gycm2 (P < 0.01). On the contrary, the mean procedural time, was significantly higher in ICE-guided transcatheter closure patients: 30.2 +/- 2.45 (range 23-40) versus 24.5 +/- 2.45 (range 24-31) minutes (P = 0.03).

CONCLUSION

The radiation exposure during ICE-guided transcatheter closure of interatrial communications in this group of patients was quite lower than that reported in literature for such procedures and compared favourably with radiation exposure of patients in whom the intervention was performed without ICE guidance.

Assessment of atrial septal defect size with 3D-transesophageal echocardiography: comparison with balloon method

BACKGROUND

Transcatheter closure of atrial septal defect (ASD) is an alternative approach to surgery in selected patients. Balloon stretched diameter (BSD) is considered as the standard way of measuring ASD size. Three-dimensional transesophageal echocardiography (3D-TEE) provides views of the ASD allowing its measurement and identifying its spatial relation with neighboring structures. Our aim was to compare the BSD and 3D-TEE methods to measure the ASD size before transcatheter closure.

METHODS AND RESULTS

Seventy-six consecutive patients were enrolled for ASD device closure. Three-dimensional transesophageal echocardiography and balloon sizing were adequately performed in 70 patients before the defect closure. The mean maximal diameter measured by 3D-TEE was 20 +/- 15 mm (range 10-28) while the mean BSD was 22 +/- 4.8 mm (range 9-31). When comparing the 3D-TEE and transcatheter measurements, there was a good correlation between the two methods (y = 3.15 + 0.77x; r = 0.8). The defect as viewed by 3D-TEE was unique in 54 patients and multiple in 16 patients. In patients with a single defect, the correlation between the two methods was high (y = 1.74 + 0.84x; r = 0.85) while patients with multiple ASDs, the correlation was poor (y = 12.4 + 0.4x; r = 0.45). Transcatheter closure was performed successfully in 86%. The mean size of the Amplatzer device was 23 +/- 4.8 mm (range 4-32). The reference to choose the size of the device was the BSD in single defects and the 3D-TEE maximal diameter in multiple defects.

CONCLUSION

Three-dimensional transesophageal echocardiography and transcatheter methods are two complementary techniques for the success of transcatheter ASDs closure.

On-line intracardiac echocardiography alone for Amplatzer Septal Occluder selection and device deployment in adult patients with atrial septal defect

BACKGROUND

During the last few years, several different devices have been proposed for atrial septal defect (ASD) percutaneous closure. For the Amplatzer Septal Occluder (ASO) device, accurate balloon sizing is considered of paramount importance because the prosthesis waist has to be exactly adjusted to the defect diameter (+/-1 mm). In this study, we aimed to demonstrate the possibility of marked misinterpreting of the actual defect size using the balloon technique in patients with secundum ASD and to evaluate the accuracy of intracardiac echocardiography (ICE) measurements as a new method for selecting the size of ASO device.

METHODS

Between February 1999 and December 2000, 166 consecutive adult patients underwent percutaneous transvenous secundum ASD occlusion using the ASO device. In 124 patients (control group), ASD were closed by conventional methods. In 13 patients (pilot group), balloon pulling technique was used in size selection, whereas ICE was used on-line to monitor device placement and off-line to assess its possibilities for accurate quantitative measurements and qualitative evaluation. In 31 patients (study group), ICE was used as the sole imaging tool both for guiding device selection and monitoring the procedure. All patients underwent complete transthoracic echocardiographic study before discharge and during follow-up visits at 3 and 12 months.

RESULTS

Successful device implantation was accomplished in 163 of the 166 patients (98.2%). Short-term follow-up results were available in all eligible patients at least 3 months. Complete occlusion was demonstrated in 91.4% and 92.2% of patients in the control and pilot groups, respectively, increasing to 97.3% in the study group (p<0.01 vs. both control and pilot groups). There were no significant differences in mean ASO diameters in the control and pilot groups (20+/-7.7 and 22+/-5.4 mm, respectively), whereas the mean size of the devices used in the study group was significantly larger (27.4+/-6.2 mm, p<0.01 vs. both control and pilot groups). In the pilot group, the underestimation effect of the balloon strategy was evident, with a mean 12.3% larger diameter required on ICE measurements. Moreover, a misalignment between the ASO and the atrial septum was seen on ICE in 9 of 13 patients of the pilot group, whereas good apposition of the ASO on the septum secundum was seen in all patients of the study group.

CONCLUSION

ICE is a safe and effective method for selecting ASO size and continuous monitoring of the procedure. In contrast to the previously reported implantation procedure (device-to-defect ratio 1:1), a device 10-20% larger than invasively measured stretched defect diameter should be chosen and implanted on the basis of the ICE data.

Transthoracic three-dimensional echocardiography prior to closure of atrial septal defects in children

AIMS

Our aims were to use transthoracic three-dimensional echocardiography to assess the morphology of atrial septal defects in children prior to closure, and to compare the three-dimensional echocardiographic data with transcatheter and surgical findings.

METHODS AND RESULTS

We used transthoracic three-dimensional echocardiography in 62 consecutive patients, aged from 2 to 18 years, with atrial septal defects, measuring the maximal diameter and the extent of the rims. Subsequent to the study, we referred 42 patients for transcatheter closure, the rims being measured at greater than 4 mm. We found a good correlation between the maximal diameter of the defect as measured at transthoracic three-dimensional echocardiography and using a balloon (y = 3.45 - 0.73x; r = 0.78; p < 0.0001), the mean difference between the measurements being 2.4 +/- 2.8 mm. Successful closure with the Amplatzer septal occluder, having a mean size of 22 +/- 4 mm, was achieved in 95% of the patients. Of the original cohort, 20 patients were referred for surgical closure. In these patients, the inferior rim had been deemed insufficient in 5, the postero-superior rim in 6, and the postero-inferior rim in 9. Complete agreement was found when the deficiency of the rim as judged using transthoracic three-dimensional echocardiography was compared with intraoperative findings. The correlation between measurements of the deficiency of the rim achieved by transthoracic three-dimensional echocardiography and at surgery was excellent (y = 0.2 + 0.98x; r = 0.93; p < 0.0001), the mean difference between the measurements being no more than 0.6 +/- 0.4 mm.

CONCLUSIONS

Transthoracic three-dimensional echocardiography proved accurate in measuring the maximal diameter and rims of atrial septal defects within the oval fossa. This non-invasive method will be valuable in selecting children for transcatheter or surgical closure of such defects.

Intracardiac ultrasound assessment of atrial septal defect: comparison with transthoracic echocardiographic, angiocardiographic, and balloon-sizing measurements

PURPOSE

Accurate evaluation of the size, location and adjacent structure of an atrial septal defect (ASD) is very important in the selection of patients for further management. We directly compared the utility of transthoracic echocardiography, angiocardiography, balloon sizing, and intracardiac ultrasound (ICUS) in the detection of ASD.

METHODS

Twenty-one children underwent an ICUS study of ASD after routine clinical and laboratory studies. All patients had received transthoracic echocardiography (TTE), cardiac catheterization, cineangiography, and balloon sizing before the ICUS to evaluate the ASD.

RESULTS

There was a significant correlation between the ICUS-derived ASD diameter and the other methods (p < 0.001). The balloon-sizing diameter was estimated by the equation: TTE diameter x 1.09 + 3.9 mm. There was a good correlation between the predicted and measured balloon-sizing diameter (r = 0.963; p < 0.001).

CONCLUSION

It is worthwhile spending a few minutes to perform ICUS during cardiac catheterization since it will provide more detailed information on and high resolution images of atrial septal morphology, especially for patients undergoing transcatheter closure by device.

Experience in one centre using the buttoned device for occlusion of atrial septal defect: comparison with the Amplatzer septal occluder

We report our experience using the buttoned device to close defects within the oval fossa and probe-patent oval foramens, comparing the findings with those obtained with the Amplatzer septal occluder. From 1992 to 1997, we used the buttoned device to close defects in 73 consecutive patients, 64 with defects in the oval fossa and nine with patent foramens. We compared this experience with a further series of 62 patients seen from 1997 to 1999 in whom the Amplatzer septal occluder was used. Successful implantation was achieved in three-quarters of those with septal defects in whom the buttoned device was used, in all of those in whom the buttoned device was used for patent foramens, and in nine-tenths of those in whom closure was attempted using the Amplatzer occluder. Immediate surgery was needed in 3 patients in whom a buttoned device was used, one because of embolization and two with residual shunts and a straddling device. Similar immediate surgery was needed to retrieve one embolized Amplatzer occluder. During follow-up, surgery was needed in a further 7 patients, all having had insertion of a buttoned device, because of atrial perforation in one and a significant residual shunt in the remainder. At late follow-up, the rate of complete occlusion was 69% in the patients in whom the buttoned device was used to close a septal defect, 100% when the buttoned device was used for patent foramens, and 95% in those treated with the Amplatzer occluder. Our experience shows that the Amplatzer occluder produced a significantly higher rate of occlusion for larger defects, and with a shorter fluoroscopy time than the buttoned device. The Amplatzer septal occluder, therefore, is our preferred device for closure of defects within the oval fossa.

The role of echocardiography in transcatheter closure of atrial septal defects

Closure of so-called "secundum" atrial septal defects with a device inserted on a catheter necessitates precise delineation of their morphology. Echocardiography is the diagnostic method of choice to demonstrate this morphology, and to differentiate such defects located within the oval fossa from the other variants producing an interatrial communication. Precordial echocardiography usually allows selection of cases likely to be suitable for closure in this fashion. This selection is based on the localisation and the size of the deficiency in the oval fossa, the length of the interatrial septum, and the adequacy of the infolded rims surrounding the defect. Suitability for closure is reevaluated by transesophageal echocardiography, either as a separate investigation or at the start of the interventional catheterisation. This investigation requires a multiplane transesophageal echocardiographic probe, since only oblique planes will demonstrate the entrance of the systemic and pulmonary veins and their relationship to the defect. Transesophageal echocardiography serves as an important monitoring tool during the interventional procedure. As such, it is a necessary adjunct to fluoroscopy. The stretched diameter of the defect measured with a balloon is the main determinant of the choice of the type and size of the device. This diameter can be measured fluoroscopically, as well as on echo. Colorflow mapping serves to rule out residual shunting during the occlusion of the defect with the balloon. During deployment of the device, constant echocardiographic visualisation of the device and its position relative to the atrial septum facilitates proper placement. Such constant visualisation can only be provided by repeated quick acquisitions of multiple planes. Once the device is released, the investigator should continue to record the position of the device, and assess the potential for residual shunting. Most of the devices show some subtle change in position during the first 20 minutes after implantation.

Surgical validation and implications for transcatheter closure of quantitative echocardiographic evaluation of atrial septal defect

Accurate evaluation of secundum atrial septal defect (ASD) is important for the success of transcatheter closure. The purpose of this study was (1) to describe a quantitative evaluation by transthoracic (TTE) and transesophageal (TEE) echocardiography of the various morphologic features of ASD that might be important for patient selection for transcatheter closure, and (2) to assess the reliability of these 2 methods by surgical findings. Preoperative TTE and TEE were used to evaluate the ASD of 27 children undergoing surgical closure. Measurements included the diameters of ASD and the atrial septal lengths in the transverse and longitudinal axis, and the width of the superior, inferior, anteroinferior, and posterior septal margins. The shape and location of the ASD and the adequacy of the septal margins for anchoring occluding devices were determined. Echocardiographic data were compared with corresponding surgical measurements. No significant difference occurred in the means of all the parameters measured with the 3 methods, except for the transverse ASD diameter (p <0.05). Good agreement occurred between TTE and TEE and surgical data, except for the transverse ASD diameter, transverse atrial septal length, and the posterior septal margin on TTE. Intraclass correlations between TTE and TEE and surgical measurements of all parameters were good, except for the transverse ASD diameter. The accuracy in determining shape and location of the ASD by TTE and TEE were 100%, whereas that for determining the adequacy of septal margins was 98% and 97%, respectively. In conclusion, TTE and TEE are reliable methods for quantitative evaluation of ASD.

Stretched minimal diameter of the ductus and coil occlusion

BACKGROUND

Stretching of the ductus was supposed to determine the size mismatch of the coil with the ductus in coil occlusion that results in residual leak or migration.

METHODS

We measured the minimal diameter (D) and the stretched minimal diameter (S) of the ductus in 12 patients with patent ductus arteriosus (PDA). The stretch index (SI) was calculated as S divided by D. We calculated ratios of the loop diameter of the first implanted coil to D (C1/D) and S (C1/S) and those of the sum of all the loop diameters of all implanted coils for complete closure to D (total C/D) and to S (total C/S).

RESULTS

Stretched minimal diameter divided by D was 1.8 +/- 0.3. Ratios of the loop diameter of the first implanted coil to D (C1/D), and S (C1/S) were 3.7 +/- 1.8 and 2.1 +/- 0.9, respectively. Ratios of the sum of all the loop diameters of all coils to D (total C/D) and S (total C/S) were 5.2 +/- 1.6 and 2.9 +/- 0.9, respectively. Standard deviations of C1/S and total C/S are significantly smaller than those of C1/D and total C/D, respectively.

CONCLUSIONS

The narrowest segment of the ductus could be stretched to twice the size of the minimal diameter. The stretched minimal diameter may be a more reliable parameter to select the loop diameter of coils than the angiographic minimal diameter.

Volume-rendered, three-dimensional echocardiographic determination of the size, shape, and position of atrial septal defects: validation in an in vitro model

Accurate evaluation of atrial septal defect (ASD) size and shape is very important for the selection of patients for transcatheter occlusion. The ability of volume-rendered, three-dimensional echocardiography (3DE) in displaying ASDs in a dynamic mode has been demonstrated; however, its accuracy in sizing ASDs is unknown. To assess this, we performed 3DE of 10 explanted pig hearts in which ASDs of various locations, sizes, and shapes had been experimentally created. From en face 3DE views of the atrial septum containing the defects, major and minor diameters of the defect were measured by a blinded observer, and these data were compared to direct anatomic measurements. The correlations between 3DE and anatomy for the major and minor ASD diameters were y = 0.83x + 3.4 (r = 0.97, p < 0.0001) and y = 0.92x + 1.3 (r = 0.92, p < 0.0001) respectively. The correlation between the measures for major and minor axis ratio was y = 1.06 x - 0.052, r = 0.91, p < 0.0002. Good agreement between both methods of measurements was demonstrated for all measurements. In addition, 3DE portrayed the location and shape of the defects accurately. Thus 3DE provides excellent visualization of ASD and is able to accurately define the size of the defects. These qualitative and quantitative capabilities enhance the clinical potential of this technique in the appraisal of ASDs for decisions regarding application of closure devices.

Echocardiographic predictors of success of catheter closure of atrial septal defect with the buttoned device

Transcatheter occlusion of ostium secundum atrial septal defects (ASD) with the buttoned device has been shown to be feasible, effective, and safe. The final decision to implant the device is largely based on the balloon sizing of the ASD during cardiac catheterization. Only subjective criteria of ASD size and the septal rims on echocardiography have been used before catheterization, balloon sizing, and transcatheter occlusion. The purpose of this study was to determine whether objective echo criteria could be developed to predict successful occlusion of the ASD. During a 46-month period ending August 1992, 29 children with secundum ASD were evaluated for transcatheter occlusion. The device was successfully implanted in 15 (group A); in the remaining 14 children, this procedure could not be performed (group B). Preocclusion echos were analyzed by independent investigators who had no knowledge of outcome of the procedure. Echo parameters studied included size of ASD, length of atrial septum (LAS), and size of the superior and inferior rims in precordial and subcostal views and maximum jet width by color flow mapping. From these measurements several ratios were derived, and the data were compared. A smaller (p < 0.05) ASD was present in the group of patients with successful implantation of the device; LAS was similar (p > 0.1) in both groups. A lower (p < 0.05) ratio of ASD to LAS and a higher (p < 0.05) ratio of the superior and inferior septal rims to ASD were associated with the group of patients with successful implantation of the device.(ABSTRACT TRUNCATED AT 250 WORDS)