Characterization of Atrial Septal Defect Assessed by Real-time 3-Dimensional Echocardiography

Intracardiac Echocardiogram: Feasibility, Efficacy, and Safety for Guidance of Transcatheter Multiple Atrial Septal Defects Closure

We aimed to determine the feasibility, efficacy, success, and safety of intracardiac echocardiography (ICE) in transcatheter multiple atrial septal defect (ASD) closure. Of 185 patients with multiple ASDs who underwent transcatheter closure, 140 (76%) patients who weighed <30kg with a narrow distance between defects or in whom single device closure was anticipated were guided by ICE and 45 patients were guided by three-dimensional (3D) transesophageal echocardiography (TEE) with or without ICE. Patients in the ICE group were relatively younger and weighed less than those in the 3D TEE group (p < 0.0001). The ratio of the distance between defects >7 mm was high, and more cases required ≥2 devices in the 3D TEE group than those in the ICE group (p < 0.0001). All patients in the 3D TEE group and seven patients (5%) in the ICE group were operated on under general anesthesia (p < 0.0001). The fluoroscopic time was shorter in the ICE group (13.98 ± 6.24 min vs. 24.86 ± 16.47 min, p = 0.0005). No difference in the complete closure rate and complications was observed. ICE-guided transcatheter and 3D TEE were feasible, safe, and effective in successful multiple ASD device closures, especially for young children and patients at high risk under general anesthesia.

Assessment of atrial septal defect using 2D or real-time 3D transesophageal echocardiography and outcomes following transcatheter closure

Background

The assessment of interatrial septum (IAS) requires a standardized, systematic approach, including two-dimensional transthoracic echocardiography (2D TTE), 2D transesophageal echocardiography (2D TEE), and three-dimensional (3D) TEE. Although 2D TEE has been widely used for the preoperative assessment of atrial septal defect (ASD), its ability to provide reliable information is often limited due to the structural characteristics of IAS. The introduction of 3D TEE provides a unique "en face" view of IAS, which allows the visualization and accurate measurements of diameters, area, and rims of ASD. Hence, appropriate ASD imaging information is particularly important in successful transcatheter closure.

Methods

In this retrospective study, 2D TTE/TEE, and 3D TEE were performed before ASD closure, with 2D minimal and maximal diameters, areas, and residual rims being recorded. Adequate 3D TEE imaging data sets were collected and then analyzed. ASD related parameters were compared using different echocardiography. Patients who underwent ASD closure completed a clinical follow-up.

Results

The mean defect maximal diameter and aperture area by 3D TEE was significantly larger than that of the corresponding 2D TEE (P<0.05). There was no statistical difference in the minimal and maximal diameter or area by TEE for circular-shaped ASDs. For oval ASDs, mean minimal diameter on 2D TEE was larger than that on 3D TEE. The mean maximal diameter measured using 2D TEE was smaller than the 3D TEE measurement (16.0±7.1 vs. 19.8±8.6; P<0.05). For complex-shaped defects, there were statistical differences in minimal and maximal diameter between TEEs. Furthermore, 2D and 3D TEE had a longer superior vena cava (SVC) residual rim than did 2D TTE (P<0.05). The 3D TEE residual rims of the inferior vena cava (IVC) was significantly larger than the corresponding 2D TEE. There was a very strong correlation between the residual rim measurements using 3D and 2D TEE. However, the limits of agreement between 2D and real-time 3D TEE measurements were more apparent in the IVC rim group than in the other groups.

Conclusions

Our study confirms the value of 3D TEE in assessing ASD shape and size reported by previous studies, and is also the first to accurately and systematically characterize ASD residual rim in complex ASDs.

Visual interaction networks: A novel bio-inspired computational model for image classification

Inspired by biological mechanisms and structures in neuroscience, many biologically inspired visual computational models have been presented to provide new solutions for visual recognition task. For example, convolutional neural network (CNN) was proposed according to the hierarchical structure of biological vision, which could achieve superior performance in large-scale image classification. In this paper, we propose a new framework called visual interaction networks (VIN-Net), which is inspired by visual interaction mechanisms. More specifically, self-interaction, mutual-interaction, multi-interaction, and adaptive interaction are proposed in VIN-Net, forming the first interactive completeness of the visual interaction model. To further enhance the representation ability of visual features, the adaptive adjustment mechanism is integrated into the VIN-Net model. Finally, our model is evaluated on three benchmark datasets and two self-built textile defect datasets. The experimental results demonstrate that the proposed model exhibits its efficiency on visual classification tasks. Furthermore, a textile industrial application shows that the proposed architecture outperforms the state-of-the-art approaches in classification performance.

Atrial septal defect closure in a midget toy poodle

Background

Atrial septal defect (ASD) is a rare congenital cardiac disease, and there have been no reports about the treatment of ASD in midget breed dogs.

Case Description

A 7-month-old female toy poodle weighing 1.4 kg presented with cardiac enlargement. Echocardiography revealed a secundum-type ASD, right ventricular and atrial enlargement, and pulmonary hypertension. Blood flow through the ASD exhibited left-to-right shunting. The dog underwent ASD closure through a hybrid approach, in conjunction with catheter techniques and thoracotomy. Ten months after treatment, cardiac enlargement and pulmonary hypertension were improved.

Conclusion

Even in midget dog breeds, ASD can be corrected through a hybrid approach.

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.

Atrial septal defects

Atrial septal defects are the third most common type of congenital heart disease. Included in this group of malformations are several types of atrial communications that allow shunting of blood between the systemic and the pulmonary circulations. Most children with isolated atrial septal defects are free of symptoms, but the rates of exercise intolerance, atrial tachyarrhythmias, right ventricular dysfunction, and pulmonary hypertension increase with advancing age and life expectancy is reduced in adults with untreated defects. The risk of development of pulmonary vascular disease, a potentially lethal complication, is higher in female patients and in older adults with untreated defects. Surgical closure is safe and effective and when done before age 25 years is associated with normal life expectancy. Transcatheter closure offers a less invasive alternative for patients with a secundum defect who fulfil anatomical and size criteria. In this Seminar we review the causes, anatomy, pathophysiology, treatment, and outcomes of atrial septal defects in children and adult patients in whom this defect is the primary cardiac anomaly.

Characterization of atrial septal defect by simultaneous multiplane two-dimensional echocardiography

AIMS

The aim of this study was to assess the value of two-dimensional (2D) transthoracic simultaneous multiplane imaging (SMPI) in the evaluation of suitability for percutaneous atrial septal secundum defect (ASD) closure compared with the golden standard 2D transoesophageal echocardiography (TEE).

METHODS AND RESULTS

Twenty-nine patients with an ASD underwent both SMPI and TEE. Ten patients (34%) were male (age 41 ± 18 years, range 20-74). SMPI assessment of ASD size and rims included xPlane and I-rotate modes. Rims were defined as suitable for ASD percutaneous closure using a cut-off value of 5 mm. There were no significant differences between SMPI in xPlane mode and TEE regarding the sizes of the anterior-posterior dimension (13.7 ± 4.5 vs. 14.5 ± 5.2 mm) and superior-inferior dimension (13.5 ± 3.9 vs. 14.1 ± 5.0 mm, respectively). Agreement for the aortic, atrioventricular, inferior, right upper pulmonary vein, and superior rims was 100, 100, 100, 96, and 96%, respectively.

CONCLUSION

The SMPI technique can reliably assess the dimensions and rim size of a secundum ASD for pre-interventional selection when compared with TEE and has thus the potential to replace TEE.

Application of the defect area in transcatheter closure of atrial septal defect

OBJECTIVES

It was our aim to evaluate whether the defect area plays a crucial role in successful device closure of atrial septal defects (ASDs).

METHODS

The long and short diameters of the defect were measured on en-face images. The defect area was then measured by planimetry. The device size compared to the defect length and defect area was analyzed in each group.

RESULTS

There were 22 patients in the circular group and 45 patients in the noncircular group. The defect area did not differ between the groups (201.6 ± 107.1 vs. 245.6 ± 127.6 mm(2)). Although the length between the device size and the long diameter differed between the groups (3.4 ± 2.0 vs. 0.8 ± 3.7 mm; p = 0.003), there was no difference in the ratio of the device area compared to the defect area, which was constant even in the noncircular defect (1.73 ± 0.41 vs. 1.72 ± 0.53 mm(2); p = 0.947). The device size was positively correlated with the defect area (p < 0.01).

CONCLUSION

The defect area measured by planimetry on en-face images might be useful in selecting the device size for transcatheter closure of ASDs.

Balloon occlusive diameter of non-circular atrial septal defects in transcatheter closure with amplatzer septal occluder

Background and Objectives

The aim of this study was to investigate the balloon occlusive diameter (BOD) of non-circular defects in the transcatheter closure of atrial septal defect (ASD).

Subjects and Methods

A total of 67 patients who had undergone transcatheter closure of an ASD were reviewed retrospectively. A non-circular defect was defined as the ratio of the short diameter to the long diameter of the defect on the en-face image less than 0.75. The BOD was compared with the long diameter of the defect and then compared between the two groups.

Results

There were 22 patients with circular defects and 45 patients with non-circular defects. The difference in BOD measuring from the long diameter of the defect was quite different between the two groups and significantly smaller in non-circular morphology (0.1±4.0 vs. 2.3±2.1, p=0.006). The difference in BOD measurement from the long diameter of ASD showed a positive correlation with the ratio of the short diameter to the long diameter of ASD (b/a) (r²=0.102, p=0.008). In the non-circular morphology of ASD, the difference in BOD measured from the long diameter had a significant negative correlation with the long diameter of ASD (r²=0.230, p=0.001), whereas in circular ASD, no significant correlation was found between the difference in BOD and the long diameter of ASD (p=0.201).

Conclusion

The BOD compared with the long diameter measured from three-dimensional transesophageal echocardiography was smaller in non-circular ASD than in circular ASD. This difference was much smaller in non-circular ASD with a large long diameter.

[Current value of 3D echocardiography in international guidelines]

Real-time 3D echocardiography is one of the most important developments in the field of non-invasive cardiac imaging within the last years. To investigate whether this new technology can be considered as a standard method the current guidelines and recommendations were reviewed. In the field of left ventricular function assessment, evaluation of mitral valve pathologies and peri-interventional monitoring of percutaneous valve repair procedures 3D echocardiography plays a major role. For other clinical applications, such as right heart assessment, congenital heart disease and stress echocardiography, a high potential is seen but evidence is currently too weak for general recommendations. However, in the near future no echo laboratory will be working without 3D modalities.

Advanced echocardiographic techniques

Echocardiography has advanced significantly since its first clinical use. The move towards more accurate imaging and quantification has driven this advancement. In this review, we will briefly focus on three distinct but important recent advances, three‐dimensional (3D) echocardiography, contrast echocardiography and myocardial tissue imaging. The basic principles of these techniques will be discussed as well as current and future clinical applications.

Transthoracic echocardiography in children and young adults with congenital heart disease

Transthoracic echocardiography (TTE) is the first-line tool for diagnosis and followup of pediatric and young adult patients with congenital heart disease (CHD). Appropriate use of TTE can reduce the need for more invasive modalities, such as cardiac catheterization and cardiac magnetic resonance imaging. New echocardiographic techniques have emerged more recently: tissue Doppler imaging, tissue tracking (strain and strain rate), vector velocity imaging (VVI), myocardial performance index, myocardial acceleration during isovolumic acceleration (IVA), the ratio of systolic to diastolic duration (S/D ratio), and two dimensional measurements of systolic right ventricular (RV) function (e.g., tricuspid annular plane systolic excursion, TAPSE). These may become valuable indicators of ventricular performance, compliance, and disease progression. In addition, three-dimensional (3D) echocardiography when performed for the assessment of valvular function, device position, and ventricular volumes is being integrated into routine clinical care. In this paper, the potential use and limitations of these new echocardiographic techniques in patients with CHD are discussed. A particular focus is on the echocardiographic assessment of right ventricular (RV) function in conditions associated with increased right ventricular volume (e.g., pulmonary regurgitation after tetralogy of Fallot repair) or pressure (e.g., pulmonary hypertension) in children and young adults.

Subcostal real-time three-dimensional echocardiography of interatrial communications: reconstruction of an oval fossa defect, a superior sinus venosus defect with partially anomalous pulmonary venous drainage, an infero-posterior oval fossa defect, and a coronary sinus defect

Real-time three-dimensional echocardiography can surpass simple cross-sectional echocardiography in providing precise details of cardiac lesions. For the purpose of optimising treatment, we describe our findings with real-time three-dimensional echocardiography when interrogating different types of communications permitting interatrial shunting. A three-dimensional reconstruction of defects within the oval fossa enabled reliable identification of location, size, and integrity of surrounding rims. In the superior sinus venosus defect associated with partially anomalous pulmonary venous drainage, three-dimensional reconstruction helped to provide a better understanding of the relationship between the interatrial communication, the orifice of the superior caval vein, and the connections of the right upper pulmonary vein. In the defect opening infero-posteriorly within the oval fossa, three-dimensional reconstruction helped to avoid the risk of potentially inappropriate closure of the defect by suturing the hyperplastic Eustachian valve to the atrial wall, which could have diverted the inferior caval venous return into the left atrium, or obstructed the caval venous orifice. In the coronary sinus defect, three-dimensional echocardiography provided a 'face to face' view of the entire coronary sinus roof, showing a circular defect communicating with the cavity of the left atrium. Acquisition of the full-volume data sets took less than 2 minutes for the patients having defects within the oval fossa, and no more than 3 minutes for the patients with the sinus venosus and coronary sinus defects. Post-processing for the defects in the oval fossa took from 5 to 8 minutes, and from 12 to 16 minutes for the more complicated defects.

CONCLUSION

Cross-sectional two-dimensional echocardiography can establish correct diagnosis in all types of atrial communications; however, real-time three-dimensional reconstruction provides additional value to the surgeon and interventionist for better understanding of spatial intracardiac morphology.

Usefulness of the right parasternal approach to evaluate the morphology of atrial septal defect for transcatheter closure using two-dimensional and three-dimensional transthoracic echocardiography

BACKGROUND

The aim of this study was to demonstrate the feasibility and usefulness of addition of the right parasternal approach to the conventional left parasternal and apical approaches using two-dimensional (2D) and three-dimensional (3D) transthoracic echocardiography (TTE) for morphologic evaluation in cases of transcatheter closure of atrial septal defects (ASDs).

METHODS

In 112 consecutive patients with ASDs, the morphology of the defects was evaluated for transcatheter closure in the right parasternal view in addition to the conventional left views using 2D and 3D TTE. Measurements of the maximal ASD diameter and detection of deficient rim obtained on 2D TTE were compared with those obtained by 2D transesophageal echocardiography. The shapes and locations of ASDs visualized by 3D TTE were compared with those visualized by 3D transesophageal echocardiography.

RESULTS

In 88 patients (80.0%), optimal images from the right parasternal approach for morphologic evaluation of ASDs were obtained. Although there was a significant difference in maximal ASD diameter obtained only in the conventional left approach compared with transesophageal echocardiographic measurements (P < .05), when the right parasternal approach was applied, a significant difference was not found (P = .18), and the diagnostic concordance of the rim deficiency was improved from 85.2% to 90.9%. Three-dimensional TTE from the right parasternal approach improved visualization of the shape and location of ASDs from 65.5% to 74.5%.

CONCLUSIONS

Additional use of the right parasternal approach enables detailed morphologic evaluation for transcatheter closure of ASDs. In patients with suboptimal images on 3D TTE in the left conventional approach, additional 3D TTE in the right parasternal approach can improve the feasibility of obtaining optimal 3D images to evaluate the shapes and locations of ASDs.

Non-Invasive Imaging for Congenital Heart Disease: Recent Innovations in Transthoracic Echocardiography

Transthoracic echocardiography (TTE) is an important tool for diagnosis and follow-up of patients with congenital heart disease (CHD). Appropriate use of TTE can reduce the need for more invasive and complex modalities, such as cardiac catheterization and cardiac magnetic resonance imaging. New echocardiographic techniques have emerged for the assessment of ventricular systolic and diastolic function: Tissue Doppler imaging, tissue tracking, strain and strain rate imaging, vector velocity imaging (VVI), myocardial performance index, myocardial acceleration during isovolumic contraction (IVA), the ratio of systolic to diastolic duration (S/D ratio), and other measurements of systolic right ventricular (RV) function like tricuspid annular plane systolic excursion (TAPSE). These modalities may become valuable indicators of ventricular performance, compliance and disease progression, with the caveat of preload-dependency of the variables measured. In addition, three-dimensional (3D) echocardiography for the assessment of cardiac anatomy, valvular function, device position, ventricular volumes and ejection fraction is integrated into routine clinical care. In this review, we discuss the potential use and limitations of these new echocardiographic techniques in patients with CHD. A particular focus is on the echocardiographic assessment of right ventricular (RV) function by means of tissue Doppler imaging, tissue tracking, and three-dimensional imaging, in conditions associated with increased right ventricular volume or pressure load.

Real time three-dimensional transesophageal echocardiographic evaluation of a sinus venosus atrial septal defect

We present a case of a 65-year-old man who presented with atrial flutter and dilation of right heart was noted on transthoracic echocardiography. Transesophageal echocardiography revealed a large sinus venosus atrial septal defect close to superior vena cava and anomalous connection of right superior pulmonary vein. Additionally, real time three-dimensional transesophageal echocardiography provided superior spatial details and demonstrated the size, location of the defect and its spatial relationship to the surrounding structures. Patient underwent successful surgical repair.

What is new in pediatric cardiac imaging?

Cardiac imaging has had significant influence on the science and practice of pediatric cardiology. Especially the development and improvements made in non-invasive imaging techniques, like echocardiography and cardiac magnetic resonance imaging (MRI), have been extremely important. Technical advancements in the field of medical imaging are quickly being made. This review will focus on some of the important evolutions in pediatric cardiac imaging. Techniques such as intracardiac echocardiography, 3D echocardiography, and tissue Doppler imaging are relatively new echocardiographic techniques, which further optimize the anatomical and functional aspects of congenital heart disease. Also, the current standing of cardiac MRI and cardiac computerized tomography will be discussed. Finally, the recent European efforts to organize training and accreditation in pediatric echocardiography are highlighted.

Real-time 3-dimensional echocardiography – can there be one more dimension?

A kardiológiai betegek ellátásában a noninvazív vizsgáló módszereknek alapvető jelentőségük van. Elméletileg a szív akkor vizsgálható tökéletesen, ha természetének megfelelően három dimenzióban rögzítjük a szívciklus szerint. A második generációs, immár real-time (vagyis valós idejű) háromdimenziós echokardiográfok elméletileg optimális lehetőséget nyújtanak a cardialis struktúrák háromdimenziós elemzésére. Real-time 3-dimenziós echokardiográfia során pontosan mérhetők a kamrai és pitvari térfogatok, valamint a kamrai izomtömeg. A billentyűk és a congenitalis abnormalitások ‘en-face’ vizsgálhatók. Használhatóságát terheléses protokollok alkalmazása mellett igazolták. A jelen összefoglaló közlemény célja a módszer bemutatása, lehetséges előnyeinek tisztázása a jelenleg még fennálló technológiai korlátok bemutatásával együtt.

Blood Flow Imaging?A New Angle-Independent Ultrasound Modality for the Visualization of Flow in Atrial Septal Defects in Children

BACKGROUND

Color Doppler imaging (CDI) is the most applied method for evaluation of flow in atrial septal defects (ASD). A new real time ultrasound flow imaging modality called blood flow imaging (BFI) is able to visualize the blood flow in any direction of the image and is not limited by velocity aliasing. The method thereby overcomes the two limitations most often encountered in CDI. In this study we compared BFI with CDI for the visualization of interatrial blood flow in children.

METHODS

We studied ASD flow in 13 children using both CDI and BFI in the same examination. CDI and BFI cineloops were prepared off-line and both optimal and suboptimal (increased color artifacts) images were presented in random order to four observers. They were asked to range from 0-100 on a visual analogue scale how certain they were of interatrial blood flow. The CDI and BFI ratings were compared using the exact Wilcoxon signed rank test for paired samples.

RESULTS

All ASDs visualized with CDI were confirmed using BFI. Two of the observers ranked BFI as being significantly better than CDI when the images were optimized. When the images were suboptimal three of the observers rated BFI as being significantly better.

CONCLUSIONS

This pilot study indicates that BFI improves the visualization of interatrial blood flow in children. To include BFI in the ordinary echocardiography examination is easy and not time consuming. The method may prove to be a useful supplement to CDI in ASD imaging.