Comprehensive assessment of morphology and severity of atrial septal defects in adults by CT

The importance of pre-ablation atrial septal evaluation for a patient with surgical patch closure history

Limited studies report on the status of surgical closure patches for atrial septal defect (ASD) in the remote period. In our case, transthoracic echocardiography revealed a fistula of ASD patch before pulmonary vein isolation for atrial fibrillation. Preoperative Imaging examinations aid in evaluating the effect of the needle puncture around the artificial material of the atrial septum and catheter manipulation for patients with a history of ASD closure.

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.

Usefulness of cardiac fusion imaging with computed tomography and Doppler echocardiography in the assessment of conduit stenosis in complex adult congenital heart disease

BACKGROUND

Noninvasive assessment of stenotic lesions in patients with complex adult congenital heart disease (ACHD) is challenging due to its complex morphology. The simultaneous two-screen display of multidetector-computed tomography (MDCT) and real-time echogram (STDME) technology can display a virtual multi-planar reconstruction from MDCT corresponding to the same cross-sectional image from transthoracic echocardiography (TTE). We investigated the usefulness of the STDME technology for stenosis severity assessment in complex ACHD patients.

METHODS

Twenty-four complex ACHD patients with stenotic lesions were enrolled in this study. All patients underwent TTE and the STDME technology within a week after MDCT. Peak velocity and pressure gradient (PG) across the stenotic site were measured using continuous wave Doppler. Cardiac catheterization was performed in 17 patients.

RESULTS

Nine out of the twenty-four patients had undergone repair with a conduit. Peak velocity and PG from the STDME technology were higher than those from TTE (peak velocity: 3.1 ± 1.1 vs. 2.8 ± 1.0 m/s; peak PG: 43 ± 28 vs. 34 ± 21 mmHg; both p < 0.01). Peak PG from the STDME technology showed significant correlations with those from catheterization in patients with a conduit (n=7) and those without a conduit (n=10) (r = 0.795 and 0.880, respectively; both p < 0.05), while peak PG from TTE was correlated with catheterization measurements only in patients without a conduit (r = 0.850, p < 0.05).

CONCLUSIONS

The STDME technology enables more accurate assessment of conduit stenosis severity than does TTE in complex ACHD patients.

Transcatheter Closure of Atrial Septal Defects with Cardiac Computed Tomography Sizing: Eight-Year Single-Center Practice

INTRODUCTION

An accurate evaluation of atrial septal defect (ASD) is important for the success of interventional treatment. Cardiac computed tomography (CT) has unique advantages for ASD assessment, although transesophageal echocardiography (TEE) remains the accepted method.

OBJECTIVE

This study aimed to evaluate the safety and feasibility of transcatheter closure of ASD with cardiac CT sizing but without TEE measurement.

METHODS

Among 134 patients undergoing transcatheter closure, 13 underwent TEE in addition to a cardiac CT examination, and 121 underwent only cardiac CT. Propensity score matching was used to analyze the outcomes of the groups treated with (group 1) or without (group 2) TEE examinations. The success rate and complications among the 121 ASD patients with only cardiac CT sizing were recorded and analyzed. The maximal diameters of the defects remeasured on CT images were compared to the echocardiography results and correlated with the device size by Student t test and Pearson's linear regression analysis, respectively.

RESULTS

No significant differences (p > 0.05) were found between groups 1 and 2 in the success rate, complications, or ratio of the device size to the maximum diameter of the defect measured by cardiac CT. In group 1, the maximum diameters of the ASD derived from cardiac CT and TEE were comparable (22.08 ± 9.68 vs. 21.50 ± 10.24; p = 0.351). The success rate among the 121 patients who underwent transcatheter closure with only cardiac CT sizing was 99.2%; however, within 1 month of follow-up, 2 patients had arrhythmia, 1 patient had residual shunting, 1 patient had an infection, and 1 patient had a hematoma, but all patients recovered within a short time.

CONCLUSIONS

Cardiac CT seems to be comparable to TEE in the assessment of ASD, and transcatheter closure of ASD based on CT sizing alone is safe and feasible.

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document (J Am Coll Cardiol 2017;70:1647-1672) addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities.Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines.A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario.The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document¹ addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Computed Tomography for Structural Heart Disease and Interventions

Transcatheter cardiac interventions are a fast evolving field. The past decade has seen the development of transcatheter aortic valve replacement, transcatheter mitral valve repair and replacement, septal defect closure devices and left atrial appendage closure devices for thromboprophylaxis. More than ever, medical imaging is taking a central role in the care of patients with structural heart disease. In this review article we outline the use of MSCT as a tool for diagnosis of structural heart interventions, as well as patient selection, pre-procedural planning, device sizing and post-procedural assessment. We focus on procedures targeting the aortic valve, the mitral valve, the inter-atrial septum and the left atrial appendage.