Effect of Atrial Septal Defect Shape Evaluated Using Three-Dimensional Transesophageal Echocardiography on Size Measurements for Percutaneous Closure

Echocardiography-guided percutaneous closure of oval-shaped secundum atrial septal defects

BACKGROUND

An atrial septal defect (ASD) is considered oval-shaped when its shortest diameter is less than 75% of the longest diameter. Research on percutaneous closure of oval-shaped ASDs is limited, with no known reports of non-fluoroscopic closure for this population.

OBJECTIVE

To assess the effectiveness of non-fluoroscopic percutaneous closure for oval-shaped ASDs.

METHODS

This single-center retrospective study evaluates patients undergoing non-fluoroscopic percutaneous closure of oval-shaped ASDs, defined by the shortest to longest diameter ratio < 0.75, a circular index of 1.33, or ultrasound visualization of an oval shape. Device size was chosen to be 0-4 mm larger than the defect's longest diameter, based on transthoracic and transesophageal ultrasound measurements.

RESULTS

We identified 78 patients (33.3% children, 20.5% males) with a mean age of 27.4 ± 16.3 years and a mean weight of 46.8 ± 19.8 kg. The mean longest diameter and mean shortest diameter of ASDs were 23.3 ± 6.8 mm and 15.8 ± 5 mm, respectively. The mean ratio of the shortest to longest diameter was 0.7 ± 0.1. Percutaneous closure was not attempted in 7/78 (9%) patients. Three out of 71 (4.2%) procedures were fluoroscopy-guided upfront due to technical difficulties, and 5/71 (7%) were converted to fluoroscopy-guided closure. Overall procedural success rate was 98.6% (70/71) including 63/71 (88.7%) performed with zero fluoroscopy. Mean device size was 26.5 ± 7.1 mm. Mean procedural time was 45.3 ± 22.6 min. Eleven intraprocedural complications occurred including 6 arrhythmias, 3 pericardial effusions, and 2 device dislodgements.

CONCLUSION

Transcatheter closure of oval-shaped ASD is safe and feasible. Echocardiography is adequate for adequate operative guidance.

Perioperative Assessment and Clinical Outcomes of Percutaneous Atrial Septal Defect Closure with Three-Dimensional Transesophageal Echocardiography

BACKGROUND/OBJECTIVES

To close the atrial septal defect (ASD) with the transcatheter method, correctly defining the defect and selecting the appropriate closure device size are the most critical steps for the procedure's success. Although ASD can be successfully closed under the guidance of three-dimensional (3D) transesophageal echocardiography (TEE) and two-dimensional (2D) TEE, measurement comparisons between different types of defects are still needed.

METHODS

Our study was designed retrospectively. Sixty-one patients who underwent transcatheter ASD closure with 2D TEE and 3D TEE between 2020 and 2024 were included. The patients were divided into three groups according to the defect shape: circular, oval, and complex; and the measurement results, perioperative process, and clinical outcomes were compared in each group.

RESULTS

The average age of the patients was 35.05 ± 13.87 years, and 41 (67.2%) were women. The average follow-up period of the patients was 15.3 ± 9.18 months. No statistical significance was observed in the comparison of measurements obtained with 3D TEE and 2D TEE in the circular and oval defect groups. The differences between the minimum defect diameters of complex defects measured by 2D TEE and 3D TEE (p: 0.037), IVC rims (p < 0.001), aortic rims (p: 0.012), and the differences between implanted device dimensions and the maximum defect diameters measured by both methods were compared; statistical significance was observed (p: 0.025).

CONCLUSIONS

In circular and non-complex oval defects, it has been observed that the size of the closure device selected with 2D TEE or 3D TEE is optimal, and the procedure is practical and feasible. While the closure of complex ASDs with 3D TEE provides reliable and optimal results, using only 2D TEE in complex ASDs may lead to selecting a smaller-sized device.

Can Artificial Intelligence Revolutionize the Diagnosis and Management of the Atrial Septal Defect in Children?

Atrial septal defects (ASDs) present a significant healthcare challenge, demanding accurate and timely diagnosis and precise management to ensure optimal patient outcomes. Artificial intelligence (AI) applications in healthcare are rapidly evolving, offering promise for enhanced medical decision-making and patient care. In the context of cardiology, the integration of AI promises to provide more efficient and accurate diagnosis and personalized treatment strategies for ASD patients. In interventional cardiology, sometimes the lack of precise measurement of the cardiac rims evaluated by transthoracic echocardiography combined with the floppy aspect of the rims can mislead and result in complications. AI software can be created to generate responses for difficult tasks, like which device is the most suitable for different shapes and dimensions to prevent embolization or erosion. This paper reviews the current state of AI in healthcare and its applications in cardiology, emphasizing the specific opportunities and challenges in applying AI to ASD diagnosis and management. By exploring the capabilities and limitations of AI in ASD diagnosis and management. This paper highlights the evolution of medical practice towards a more AI-augmented future, demonstrating the capacity of AI to unlock new possibilities for healthcare professionals and patients alike.

Utility of 3D Echocardiography for Device Sizing During Transcatheter ASD Closure: A Comparative Study

BACKGROUND

Two-dimensional (2D) transesophageal echocardiography (TEE) is commonly used for assessing patients undergoing transcatheter atrial septal defect (ASD) device closure. 3D TEE, albeit providing high resolution en-face images of ASD, is used in only a fraction of cases. We aimed to perform a comparative analysis between 3D and 2D TEE assessment for ASD device planning.

METHODS

This was a prospective, observational study conducted over a period of one year. Patients deemed suitable for device closure underwent 2D and 3D TEE at baseline. Defect characteristics, assessed separately in both modalities, were compared. Using regression analysis, we aimed to derive an equation for predicting device size using 3D TEE parameters.

RESULTS

Thirty patients were included in the study, majority being females (83%). The mean age of the study population was 40.5 ± 12.05 years. Chest pain, dyspnea and palpitations were the common presenting complaints. All patients had suitable rims on 2D TEE. A good agreement was noted between 2D and 3D TEE for measured ASD diameters. 3D TEE showed that majority of defects were circular in shape (60%). The final device size used had high degree of correlation with 3D defect area and circumference. An equation was devised to predict device size using 3D defect area and circumference. The mean device size obtained from the equation was similar to the actual device size used in the study population (p = 0.31).

CONCLUSIONS

Device sizing based on 3D TEE parameters alone is equally effective for transcatheter ASD closure as compared to 2D TEE.

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.

Limitations of Percutaneous Closure of a Complex Secundum Atrial Septal Defect

•

Percutaneous closure of ASDs can be limited by size or shape of the defect.

•

A 3D evaluation of ASDs is essential for proper sizing and procedural planning.

•

Balloon sizing may help for large or irregularly shaped ASDs.

Role of Echocardiography in the Diagnosis and Interventional Management of Atrial Septal Defects

This review centers on the usefulness of echo-Doppler studies in the diagnosis of ostium secundum atrial septal defects (ASDs) and in their management, both in children and adults. Transthoracic echocardiography can easily identify the secundum ASDs and also differentiate secundum ASDs from other kinds of ASDs, such as ostium primum ASD, sinus venosus ASD and coronary sinus ASD, as well as patent foramen ovale. Preliminary selection of patients for device occlusion can be made by transthoracic echocardiograms while final selection is based on transesophageal (TEE) or intracardiac (ICE) echocardiographic studies with optional balloon sizing of ASDs. TEE and ICE are extremely valuable in guiding device implantation and in evaluating the position of the device following its implantation. Echo-Doppler evaluation during follow-up is also useful in documenting improvements in ventricular size and function, in assessing the device position, in detecting residual shunts, and in identifying rare device-related complications. Examples of echo images under each section are presented. The reasons why echo-Doppler is very valuable in diagnosing and managing ASDs are extensively discussed.

Role of MDCT in evaluating prothesis size prior to percutaneous transcatheter closure of ostium secundum atrial septal defect

To investigate the feasibility and accuracy of cardiac multidetector computed tomography (MDCT) prosthesis sizing prior to ostium secundum atrial septal defect (ASD) percutaneous closure. Seventy consecutive patients were included in this retrospective bicentric study between May 2012 and June 2018. All underwent cardiac MDCT (primarily performed to rule out abnormal venous pulmonary return and coronary anomaly) and transesophageal echocardiography (TEE) before transcatheter closure: dimensions of the defect and peripheral rims were measured. Measurements of the defect obtained at TEE and MDCT were compared to prosthesis size. Our primary objective was the comparison of ASD maximal diameter obtained at MDCT (CT-Dmax) to prosthesis size. Intraclass correlation coefficient (ICC), Bland Altman plots and linear regression were calculated. Intra- and inter-observer agreements were calculated for MDCT defect measurements. Forty-three patients were finally included for defect measurements: 17 patients did not undergo transcatheter closure, and 10 had incomplete data. For CT-Dmax, ICC was 0.88 (CI 95% = [0.78-0.93]; p = 0.06); mean difference was - 0.8 ± 5.7 mm; regression linear equation was 0.9 × + 3.2 (p < 0.001). For maximal diameter at TEE versus prosthesis size, ICC was 0.46 (CI 95% = [0.21-0.61]; p = 0.003); mean difference was-6.0 ± 8.2 mm; regression linear equation was 0.91 × + 7.6 (p < 0.001). Intra- and inter-observer agreement for CT-Dmax were 0.97 (CI 95% = [0.95-0.98]) and 0.86 (CI 95% = [0.73-0.93]) respectively. MDCT is a reliable tool for sizing the defect of ostium secundum ASD, making it a complement or even an alternative to pre-procedural TEE.

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.

Catheter-based closure of a large atrial septal defect with inferior rim deficiency using pulmonary vein slide-out assisted implantation technique: a case report

Background

Transcatheter approach for large and complex atrial septal defects may represent a therapeutic challenge, particularly when the postero-inferior rim is deficient and floppy.

Case summary

Here, we describe a successful catheter-based closure of a large (>30 mm) secundum atrial septal defect associated with postero-inferior rim deficiency in a 35-year-old female with congestive heart failure using pulmonary vein slide-out assisted implantation technique.

Discussion

Inferior–posterior rim deficiency is a well-known risk factor for device instability or embolization. Transcatheter closure may represent a safe and effective alternative to the traditional surgical approach provided that modified implantation techniques are employed.

Appropriate device selection for transcatheter atrial septal defect closure using three-dimensional transesophageal echocardiography

Detail morphological evaluation for ASD is essential to achieve successful transcatheter closure. Three-dimensional transesophageal echocardiography (3D-TEE) is emerging, but few studies have comprehensively verified the usefulness of 3D-TEE. We divided 329 patients who underwent transcatheter ASD closure at our university hospital into 157 in the Conventional group evaluated with 2-dimensional transesophageal echocardiography and balloon sizing (BS), and 172 in the 3D-TEE group evaluated with 3D-TEE additionally. We assessed usefulness of 3D-TEE and consider appropriate device selection procedure. Overall, the percentage with re-sizing of device tended to be lower in the 3D-TEE group than in the Conventional group (10.1% vs 6.0%, p = 0.187). Among preprocedural modalities, the device size was mainly decided based on the BS diameter. A logistic regression analysis demonstrated that large atrial septum aneurysms (ASA) were associated with a ≥ 2 mm discrepancy of the BS diameter from the preprocedural 3D-TEE diameter (p < 0.05). Compared to the Amplatzer Septal Occluder, the differences in device size and the preprocedural ASD measurement were greater when using the Occlutech Figulla Flex II Occluder (FFII). Particularly, among the patients implanted with FFIIs, the discrepancies of the device size from the 3D-TEE measurement were greater in patients with large ASA than those with small ASA. Preprocedural 3D-TEE is useful to select the appropriate device size. Particularly, it is necessary to select a much larger device than that derived from the preprocedural 3D-TEE measurement when using FFII in patients with a septal aneurysm.

Long-Term Follow-Up of Transthoracic Echocardiography-Guided Transcatheter Closure of Large Atrial Septal Defects (≥ 30 mm) Using the SHSMA Occluder

Transcatheter closure of large atrial septal defects (ASDs) remains controversial. The aim of this study was to evaluate the feasibility and safety of transthoracic echocardiography (TTE)-guided transcatheter closure of large ASDs. Patients with large secundum ASDs (≥ 30 mm) who underwent device closure were retrospectively reviewed. TTE was performed to guide ASD occluder positioning and assess the immediate and long-term outcomes. A total of 60 patients (median age 43.5 years, range 15-78 years) were enrolled in the study. The median ASD size was 35 mm (range 30-42 mm). Mild to moderate pulmonary hypertension was observed in 36 patients (60%). Thirty-one patients (51.7%) had one short rim, and 18 patients (30.0%) had two deficient rims. Placement of the device was successful in 57 patients (95%), and the median device size was 42 mm (range 40-50 mm). Dislodgement of the device occurred in three patients with two deficient rims: a larger device was redeployed in one case, and two patients required surgical repair. During a median follow-up of 37 months (range 6-83 months), no residual shunts, erosion, or embolization were noted, and pulmonary hypertension resolved in 75% of the patients. Thus t vast majority (95%) of large ASDs can be successfully closed percutaneously using the Chinese-made Shanghai Shape Memory Alloy (SHSMA) occluder under TTE guidance. Long-term follow-up showed that transcatheter closure could become a safe and effective alternative to surgery in select large ASDs.

A novel three-dimensional echocardiographic method for device size selection in patients undergoing ASD trans-catheter closure

Background

Proper device size selection is a crucial step for successful ASD device closure. The current gold standard for device size selection is balloon sizing. Balloon sizing can be tedious, time consuming and increase fluoroscopy and procedure times as well as risk of complications. We aimed to establish a simple and accurate method for device size selection using three-dimensional echocardiographic interrogation of the ASD.This is a prospective observational study conducted over a period of 12 months. All patients underwent 2D TTE, three-dimensional echocardiographic assessment of the IAS and transesophageal echocardiogram. Comparison between echocardiographic variables was done using independent sample t test. Linear correlation was established between three dimensional echocardiographic variables and respective variables of device size and 2D TTE and TEE measurements.

Results

The study included 50 patients who underwent successful ASD device closure with properly sized device. There was no significant difference between 3D ASD maximum diameter and all diameters measured by TTE and TEE. There was a strong positive correlation between device size used for closure and both 3D measured ASD area (r = 0.907, P<0.0001) and 3D measured ASD circumference (r = 0.917, P<0.0001). Two regression equations were generated to determine proper device size where Device size = 10.8 + [3.95 x 3D ASD area] and Device size = [3.85 x 3D ASD circumference] -1.02

Conclusion

Three-dimensional echocardiogram can provide a simple and accurate method for device size selection in patients undergoing ASD device closure using either 3D derived ASD area or ASD circumference

Atrial Septal Defect Size and Rims on Transesophageal Echocardiogram

Background and aims:Rims and size of atrial septal defect (ASD) are crucial for the success of transcatheter ASD closure. The maximal diameter and dimensions of various rims of the ASD are essential for sizing and optimal placement of the device. We aimed to study the size and rims of ASD in our patients. Methods:This was a prospective study that was done at Shahid Gangalal National Heart Centre. All patients aged over 18 and referred to a unit IV in the Department of Cardiology for ASD device closure were included in the study. The study duration was six months, from April to September 2018. The size and rims of ASD were evaluated by transesophageal echocardiogram. Results:During the study, 173 patients underwent transesophageal echocardiogram. Most of them [122 (70.1%)] were women. Age ranged from 18 to 68 (mean, 35 years). The most common symptom was shortness of breath. Twenty-one (12.1%) patients were incidentally detected with ASDs. Sinus rhythm with right bundle branch block was present in 148 (85.5%) subjects. Right atrium and right ventricle were dilated in 162 (93.6%) patients. One patient had dextrocardia with situs inversus. More than half of all patients (54.9%) had mild tricuspid regurgitation. Mean tricuspid regurgitation pressure gradient was 39.5±16.8 mm Hg. More than one ASD was present in 11 (6.3%) patients. ASD size ranged from 2 mm to 43 mm in 4-chamber view, 2 mm to 44 mm in short axis view, and 2 mm to 47 mm in bicaval view. The mean ASD size was 18.6±7.7 mm in 4-chamber view, 19.6±8.5 mm in short axis view, and 18.7±8.0 mm in bicaval view. In only 11 (6.4%) patients, all rims were present and not floppy, while in other 11 (6.4%) subjects all rims were present, but floppy. With the exception of aortic rim, all other rims were present and good in 55 (33.9%) patients, while in 45 (27.7%) patients, other rims were present but floppy. Conclusion:Many ASD have absent, inadequate and floppy rims.

Transesophageal echocardiography and fluoroscopy for percutaneous closure of atrial septal defects: A comparative study

The aim of the study was to compare transesophageal echocardiography (TEE) and fluoroscopy for percutaneous atrial septal defect (ASD) closure.This was a retrospective analysis of children who underwent percutaneous ASD closure. The procedure was guided by TEE without fluoroscopy in 130 patients (TEE group) and by fluoroscopy in 163 patients (fluoroscopy group). Baseline demographic/clinical characteristics were recorded. Patients were followed until hospital discharge. Outcomes were procedure duration, peri/postoperative complications, hospital stay, and costs.The TEE and fluoroscopy groups showed no significant differences in age (71.7 ± 40.7 vs 62.5 ± 38.8 months), male/female ratio (54/76 vs 66/97), weight (22.0 ± 12.0 vs 20.1 ± 9.0 kg), ASD diameter (9.9 ± 4.2 vs 9.3 ± 3.9 cm), distances to the superior vena cava (13.4 ± 4.6 vs 13.3 ± 4.2 cm), inferior vena cava (13.4 ± 4.3 vs 13.9 ± 4.1 cm) and atrial septal roof (12.1 ± 4.0 vs 12.3 ± 3.2 cm), or atrial septal size (38.2 ± 6.2 vs 39.4 ± 26.6 cm); distance to the mitral valve was greater in the TEE group (13.2 ± 4.4 vs 11.3 ± 3.9 cm; P < .001). The TEE and fluoroscopy groups showed no significant differences in occlusion device size (14.3 ± 4.6 vs 13.8 ± 4.0 cm) or sheath size (8.7 ± 1.8 vs 8.7 ± 0.9 cm), but procedure duration was shorter in the TEE group (21.5 ± 14.6 vs 28.6 ± 10.9 minutes; P < .001). Postoperative fever (>38°C) occurred less frequently in the TEE group than in the fluoroscopy group (0.8% vs 9.2%; P < .001); there were no significant differences for the other complications. No patient had postoperative residual shunt, occlusion device shedding/displacement, or pericardial effusion. The TEE group had longer hospital stay (3.2 ± 0.6 vs 2.9 ± 0.6 days; P < .001) and higher procedure cost (29,687 ± 4218 vs 28,530 ± 1668 CNY (China Yuan); P = .002) than the fluoroscopy group.TEE-guided percutaneous ASD closure can be used as an alternative to fluoroscopy-guided procedures and avoids the use of radiation or contrast agents.

Atrial septal defect closure: indications and contra-indications

Transcatheter closure has become an accepted alternative to surgical repair for ostium secundum atrial septal defects (ASD). However, large ASDs (>38 mm) and defects with deficient rims are usually not offered transcatheter closure but are referred for surgical closure. Transcatheter closure also remains controversial for other complicated ASDs with comorbidities, additional cardiac features and in small children. This article not only provides a comprehensive, up-to-date description of the current indications and contra-indications for ASD device closure, but also further explores the current limits for transcatheter closure in controversial cases. With the devices and technology currently available, several cohort studies have reported successful percutaneous closure in the above-mentioned complex cases. However the feasibility and safety of transcatheter technique needs to be confirmed through larger studies and longer follow-up.

Efficacy of 3D transoesophageal echocardiography for transcatheter device closure of atrial septal defect without balloon sizing

Aims

Using balloon sizing to determine device size may cause complications and increase procedure time in performing transcatheter closure of atrial septal defect (ASD). We aimed to validate the clinical utility of a formula using measurements from 3D transoesophageal echocardiography (TOE) images in performing the procedure without balloon sizing.

Methods and results

We enrolled 248 consecutive patients with ASD in a prospective registry. In the first tier (n = 53), we determined the device size before the procedure using our formula and performed balloon sizing during the procedure to verify our decision. In the second tier (n = 195), the procedure was performed without balloon sizing. In the first tier, the estimated device size correlated well with the device size finally implanted (R = 0.961, P < 0.001; bias, 0.38 ± 1.5 mm, P < 0.001) and with the stretched balloon diameter (R = 0.929, P < 0.001; bias, 0.13 ± 2.0 mm, P < 0.001). In the second tier, the device size derived from the formula was used in all patients, with the exception of one patient who showed a deficient rim on the aorta and superior sides and ASD that was not on a single plane. Two patients with unfavourable morphologies for device implantation experienced embolization of the device. Of the 193 patients with procedural success (99.0%), 2 suffered from haemopericardium caused by atrial wall erosion by the device. There were no procedure-related deaths.

Conclusion

The transcatheter closure of ASD using the 3D TOE-derived formula without balloon sizing is clinically feasible and safe. However, caution should be taken to exclude unfavourable features of ASD (ClinicalTrials.gov number NCT 02097758).

How to Size ASDs for Percutaneous Closure

Percutaneous closure is the treatment of choice for secundum-type atrial septal defects (ASD). Balloon sizing (BS) has been the method of choice for deciding on device size. Improved 2D- and 3D-transesophageal echocardiographic (TEE) imaging challenged the necessity of BS. Balloon sizing was performed with two additional techniques to measure the stretched dimension of the ASD. The 1st method uses a stiff guide wire which stretches the ASD and 2D TEE. The second technique uses 3D TEE. Two hundred and thirty-six patients with minimum 1-year follow-up were enrolled. The population was classified into three groups: BS (group 1) n = 90, 2D-TEE (group 2) n = 87, and 3D-TEE (group 3) n = 59. All groups showed a distinct correlation between the maximum baseline dimensions and the device size (R = 0.821). The relative expansion rate did not differ between BS and 3D-TEE. Group 2 (2D-TEE) showed a significantly lower expansion rate. Procedural success and complications did not differ statistically between the 3 groups. 2D TEE sizing was the simplest method without loss of accuracy. 3D sizing offers the advantage of accurate and fast shape assessment, but resulted in more undersizing. Accurate sizing of ASDs with a floppy septum remains a challenge.

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.

Imaging Techniques in Percutaneous Cardiac Structural Interventions: Atrial Septal Defect Closure and Left Atrial Appendage Occlusion

Because of advances in cardiac structural interventional procedures, imaging techniques are playing an increasingly important role. Imaging studies show sufficient anatomic detail of the heart structure to achieve an excellent outcome in interventional procedures. Up to 98% of atrial septal defects at the ostium secundum can be closed successfully with a percutaneous procedure. Candidates for this type of procedure can be identified through a systematic assessment of atrial septum anatomy, locating and measuring the size and shape of all defects, their rims, and the degree and direction of shunting. Three dimensional echocardiography has significantly improved anatomic assessments and the end result itself. In the future, when combined with other imaging techniques such as cardiac computed tomography and fluoroscopy, 3-dimensional echocardiography will be particularly useful for procedure guidance. Percutaneous closure of the left atrial appendage offers an alternative for treating patients with atrial fibrillation and contraindication for oral anticoagulants. In the future, the clinical focus may well turn to stroke prevention in selected patients. Percutaneous closure is effective and safe; device implantation is successful in 94% to 99% of procedures. However, the procedure requires an experienced cardiac structural interventional team. At present, 3-dimensional echocardiography is the most appropriate imaging technique to assess anatomy suitability, select device type and size, guide the procedure alongside fluoroscopy, and to follow-up the patient afterwards.

The Changing Paradigm in the Treatment of Structural Heart Disease and the Need for the Interventional Imaging Specialist

Percutaneous interventions in structural heart diseases are emerging rapidly. The variety of novel percutaneous treatment approaches and the increasing complexity of interventional procedures are associated with new challenges and demands on the imaging specialist. Standard catheterisation laboratory imaging modalities such as fluoroscopy and contrast ventriculography provide inadequate visualisation of the soft tissue or three-dimensional delineation of the heart. Consequently, additional advanced imaging technology is needed to diagnose and precisely identify structural heart diseases, to properly select patients for specific interventions and to support fluoroscopy in guiding procedures. As imaging expertise constitutes a key factor in the decision-making process and in the management of patients with structural heart disease, the sub-speciality of interventional imaging will likely develop out of an increased need for high-quality imaging.

The relation between atrial septal defect shape, diameter, and area using three-dimensional transoesophageal echocardiography and balloon sizing during percutaneous closure in children

BACKGROUND

A trans-catheter closure of an atrial septal defect (ASD) is efficient. Balloon sizing (BS) during the catheterization leads to an overestimation of ASD size. Three-dimensional transoesophageal echocardiography (3D-TEE) allows the ASD morphology to be assessed comprehensively. The aim of this study was to assess the relationships between the shape and the measurements of ASDs by 2D-, 3D-TEE, and BS in children.

METHODS AND RESULTS

Thirty children who underwent percutaneous closures of a single ASD were enrolled. ASD diameters were measured by 2D-transthoracic echocardiography (TTE), 2D-TEE, 3D-TEE and compared with BS. The ASD area was measured on 3D-TEE images after multi-planar reconstruction. ASD was estimated as round or oval on 3D-TEE 'en-face' view. 2D-TTE, 2D-TEE, and 3D-TEE(max) ASD diameters were well correlated with BS (r = 0.75; 0.80, and 0.85, respectively). Mean diameters were all significantly smaller than the mean BS. The mean difference between the balloon area and 3D-TEE area was 1.6 ± 1.4 cm(2) (P < 0.0001). The mean difference between BS and 3D-TEE(max) diameters was higher in round ASDs than in oval ASDs (4.0 ± 3.3 vs. 1.1 ± 3.3, P = 0.02). With multivariate linear regression analysis, two formulas were built to predict BS. The first model was BS = 1.07 × 3D-TEE(max)- 3.1 × ASDshape + 3. The ASD shape was 0 for round and 1 for oval ASDs. A second model was BS = 4.5 × ASDarea + 11.5.

CONCLUSION

The ASD shape is accurately estimated by 3D-TEE and influences the relationship between echocardiographic measurements and BS. The ASD shape, its maximal diameter and the area assessed by 3D-TEE may be sufficient to determine the device size without BS in children.

Transcatheter closure of complex atrial septal defects is efficient under intracardiac echocardiographic guidance

BACKGROUND

Studies on intracardiac echocardiography for transcatheter closure of secundum atrial septal defect (ASD) only include ASDs ≤38mm diameter without rim deficiency.

AIMS

To assess transcatheter closure of complex ASDs under intracardiac echocardiography guidance.

METHODS

Retrospective study from January 2006 to January 2012 in all consecutive adult patients referred to our centre for percutaneous device closure of ASD. Complex cases were defined as defect>38mm and/or defect with rim deficiency other than the anterior-superior rim.

RESULTS

Transcatheter closure was performed in 93 consecutive adult patients (59 women) with a median age of 48 (18-88) years. Complex cases comprised 17 patients (18%) with a median age of 54 (20-81) years and a median weight of 58 (45-99) kg. Thirteen cases had one or more deficient rims other than the anterior-superior rim, whereas nine had an ASD size>38mm. Transcatheter closure was successful in 14 cases, whereas three cases failed (18%). Minor complications occurred in three patients (18%). All the other non-complex ASDs were successfully closed percutaneously. Among the 93 patients, rim deficiency other than the anterior-superior rim tended to be associated with failure of transcatheter closure (P=0.058).

CONCLUSION

Transcatheter closure of complex ASDs is safe and effective under intracardiac echocardiographic guidance.

Comprehensive understanding of atrial septal defects by imaging studies for successful transcatheter closure

Transcatheter closure of atrial septal defects has become a popular procedure. The availability of a preprocedural imaging study is crucial for a safe and successful closure. Both the anatomy and morphology of the defect should be precisely evaluated before the procedure. Three-dimensional (3D) echocardiography and cardiac computed tomography are helpful for understanding the morphology of a defect, which is important because different defect morphologies could variously impact the results. During the procedure, real-time 3D echocardiography can be used to guide an accurate closure. The safety and efficiency of transcatheter closures of atrial septal defects could be improved through the use of detailed imaging studies.

Transcatheter closure of atrial septal defects: how large is too large?

Transcatheter closure has become an accepted alternative to surgical repair for ostium secundum atrial septal defects (ASD). However, large ASDs (>38 mm) and defects with deficient rims are usually not offered transcatheter closure but are referred for surgical closure. Several studies have reported the feasibility of transcatheter closure in complex cases with a variety of modified implantation methods such as balloon assisted technique (BAT). AA Pillai and co-authors report the transcatheter closure of ASD ≥35 mm with the BAT. However, the true significance of their study is rather in demonstrating the superiority of BAT to conventional technique and other modified implantation techniques in patients with ASD rather than feasiblity of transcatheter closure of large defect. Finally, a single dimension does not reflect the true ASD size because many defects are not round in shape but rather oval or even crescentric. Hence, future studies will need not only to demonstrate the ideal implantation method but also the appropriate 3-dimensional (3D) imaging definition of the defect in this patient population.

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.

Imaging of congenital heart disease in adults: choice of modalities

Major advances in noninvasive imaging of adult congenital heart disease have been accomplished. These tools play now a key role in comprehensive diagnostic work-up, decision for intervention, evaluation for the suitability of specific therapeutic options, monitoring of interventions and regular follow-up. Besides echocardiography, magnetic resonance (CMR) and computed tomography (CT) have gained particular importance. The choice of imaging modality has thus become a critical issue. This review summarizes strengths and limitations of the different imaging modalities and how they may be used in a complementary fashion. Echocardiography obviously remains the workhorse of imaging routinely used in all patients. However, in complex disease and after surgery echocardiography alone frequently remains insufficient. CMR is particularly useful in this setting and allows reproducible and accurate quantification of ventricular function and comprehensive assessment of cardiac anatomy, aorta, pulmonary arteries and venous return including complex flow measurements. CT is preferred when CMR is contraindicated, when superior spatial resolution is required or when "metallic" artefacts limit CMR imaging. In conclusion, the use of currently available imaging modalities in adult congenital heart disease needs to be complementary. Echocardiography remains the basis tool, CMR and CT should be added considering specific open questions and the ability to answer them, availability and economic issues.