Live/Real Time Three-Dimensional Transesophageal Echocardiography in Percutaneous Closure of Atrial Septal Defects

Atrial Septal Aneurysms - A Clinically Relevant Enigma?

Atrial septal aneurysms (ASAs) are often seen during routine cardiac imaging, though their clinical relevance has been poorly defined. The aneurysmal, and often mobile, inter-atrial septum is frequently associated with other clinically relevant structural cardiac abnormalities, particularly patent foramen ovale (PFO). Whilst ASAs have previously been considered an incidental finding, a well-endowed atrial septum provides more than visual interest, including insights into atrial function and intra-atrial pressures, and has important clinical implications in PFO-associated stroke, migraines, and arrhythmias. This review outlines diagnostic challenges when assessing ASAs using all imaging modalities and the clinical implications of this common anatomical variant.

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.

Applications of three-dimensional transesophageal echocardiography in congenital heart disease

Three-dimensional echocardiography allows for presurgical planning for congenital heart disease, reduces radiation using fusion imaging in catheter interventions, and provides guidance during catheter interventions and lead placements or extractions. The purpose of this review is to detail applications of three-dimensional transesophageal echocardiography in presurgical planning of congenital heart disease, guidance of catheter interventions such as fusion imaging, and guidance in electrophysiology lead extractions or placements.

Three-dimensional echocardiographic demonstration of aortic wall erosion after percutaneous atrial septal defect closure

Although late complications of percutaneous closure of atrial septal defect (ASD), including cardiac erosion and thrombosis, are rare, they are the most lethal. Data are still lacking regarding the usefulness of new imagining modalities, such as three-dimensional echocardiography (3DE), for the detection of these complications. Here, we report the case of a 57-year-old woman in whom cardiac erosion was very well visualized by 3D transesophageal echocardiography (3D TEE) after percutaneous ASD closure.

General Concepts in Adult Congenital Heart Disease

Congenital heart disease in adults (adult congenital heart disease) is a growing burden for healthcare systems. While infant mortality due to congenital heart disease in the last four decades decreased by almost 3-fold, adult congenital heart disease prevalence increased by more than 2-fold in United States. Adult congenital heart disease prevalence is expected to increase steadily until 2050 in projections. Adult congenital heart disease is a multifaceted problem with many dimensions. This manuscript aims to provide an overview of the common adult congenital heart diseases and summarize important points in management of these diseases with possible problems and complications that the patients and the physicians face.

Innovation in 3D Echocardiographic Imaging

PURPOSE OF REVIEW

The purpose of this review is to detail three-dimensional echocardiographic (3DE) innovations in pre-surgical planning of congenital heart disease, guidance of catheter interventions such as fusion imaging, and functional assessment of patients with congenital heart disease.

RECENT FINDINGS

Innovations in 3DE have helped us delineate the details of atrioventricular valve function and understand the mechanism of atrioventricular valve failure in patients with atrioventricular septal defect and single ventricle post repair. Advancement in holographic display of 3D datasets allows for better manipulation of 3D images in three dimensions and better understanding of anatomic relationships. 3DE with fusion imaging reduces radiation in catheter interventions and provides presentations of 3DE images in the similar fashion as the fluoroscopic images to improve communication between cardiologists. Lastly, 3DE allows for quantitative ventricular volumetric and functional assessment. Recent innovations in 3DE allow for pre-surgical planning for congenital heart disease, reduce radiation using fusion imaging in catheter interventions, and enable accurate assessment of ventricular volume and function without geometric assumptions.

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.

Three-dimensional Echocardiography in Congenital Heart Disease: An Expert Consensus Document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Three-dimensional echocardiography (3DE) has become important in the management of patients with congenital heart disease (CHD), particularly with pre-surgical planning, guidance of catheter intervention, and functional assessment of the heart. 3DE is increasingly used in children because of good acoustic windows and the non-invasive nature of the technique. The aim of this paper is to provide a review of the optimal application of 3DE in CHD including technical considerations, image orientation, application to different lesions, procedural guidance, and functional assessment.

[Imaging in structural heart disease : Impact on interventional therapy]

For the treatment of structural heart disease, current options in the catheterization laboratory include MitraClip® implantation for treating severe mitral regurgitation, transcatheter aortic valve implantation (TAVI), closure of a patent foramen ovale (PFO) and occlusion of the left atrial appendage (LAA). These treatment options are based on a precise diagnosis provided by modern cardiac imaging, which is indispensable for treatment recommendations. Its importance for supporting the invasive procedures in the catheterization laboratory is less well known. Due to enhanced soft tissue characterization, it complements fluoroscopy and invasive angiography and thus enormously improves the safety of the procedures. In addition, it allows individualized follow-up care. The current article gives an overview of the clinically most frequently used procedures.

Efficacy and Safety of Transthoracic Echocardiography Alone in Transcatheter Closure of Secundum-Type Atrial Septal Defects in Adults

BACKGROUND

On-site transthoracic echocardiography (TTE) to guide the transcutaneous closure of secundum-type atrial septal defects (ASDs) in the catheterization laboratory remains unclear, especially in adults.

METHODS

Between 2005 and 2012, a total of 82 adults underwent transcutaneous closure of ASDs. The initial 15 cases underwent the procedure with both on-site transesophageal echocardiography (TEE) and TTE monitoring. Since January 2008, a total of 67 patients underwent on-site TTE alone to guide the procedure.

RESULTS

Among the 82 adult patients who underwent a transcutaneous closure of the secundum-type ASD procedure, all had successful closure of the defects, and no periprocedural adverse complications occurred. No statistical significance was observed in the successful complete shunt closure rate between the TEE plus TTE and TTE groups during sequential follow-up (postprocedure 24 hour [87% vs. 92%],1 month [93% vs. 95%], 3 month [93% vs. 97%], and 12 month [93% vs. 97%], P > 0.05, respectively) nor was a significant difference observed between the two groups, including decreased right ventricular dimension (29.5 ± 3.3 vs. 32.0 ± 4.9 mm, 26.5 ± 3.0 vs. 28.7 ± 4.6 mm, 26.2 ± 3.1 vs. 28.2 ± 4.8 mm, and 25.6 ± 2.8 vs. 27.7 ± 4.7 mm, P > 0.05, respectively) or increased left ventricular end-diastolic dimension (41.1 ± 2.0 vs. 42.6 ± 3.0 mm, 44.3 ± 2.7 vs. 45.5 ± 3.1 mm, 44.2 ± 2.8 vs. 45.4 ± 3.1 mm, 44.9 ± 2.7 vs. 45.8 ± 2.6 mm, P > 0.05, respectively) before the procedure, and at the 3-, 6-, and 12-month follow-up evaluations.

CONCLUSION

This study showed that TTE guidance alone may be considered efficacious and safe as TEE during a transcutaneous ASD occlusion procedure in select adults.

Interventional imaging: the role of echocardiography

Interventional echocardiography is a rapidly evolving field requiring imaging expertise. An increasing number of structural heart interventions now require real-time imaging guidance for device placement and immediate functional evaluation. Continuous 2- and 3-dimensional transesophageal echocardiography are now required by many heart teams during complex structural interventions, including percutaneous closure of atrial septal defects, left atrial appendage occlusion, transcatheter aortic valve replacement (TAVR), transcatheter repair of paravalvular regurgitation, and percutaneous mitral valve repair. In this review, we describe the role of echocardiography during the initial structural evaluation, throughout the device placement procedure, and for the assessment of acute device function and complications.

Device closure of secundum atrial septal defect's and the risk of cardiac erosion

Cardiac erosion related to transcatheter atrial septal defect closure devices is of increasing concern. Erosion is reported to have occurred with most of currently available occluder devices. Perhaps due to the very large number of implants worldwide, the Amplatzer (St Jude) occluder is associated with the majority of cardiac erosion events reported in the literature. Best current estimates of the incidence of erosion with the St Jude device are between one and three cases per 1000 implants. Most events occur early after implantation and it is rare, although not unheard of, for events to occur after a year following device insertion. It is important that those involved with closure programmes are vigilant for the problem, because device-related erosion is associated with a significant mortality risk. Despite considerable debate, the risk factors (either patient or device) for erosion remain unclear and require further investigation. Currently available data sets have focussed largely on erosion cohorts and are unable to place these cases in appropriate context with non-erosion closure cases. What is certain is that programmes implanting these devices must take care to implant appropriately sized devices and have in place plans to ensure that patients are both well informed and can access help and advice in the event of developing symptoms.

Utility of balloon assisted technique in trans catheter closure of very large (≥35 mm) atrial septal defects

BACKGROUND

Very few published data is available on the outcomes of balloon assisted techniques (BATs) for trans catheter closure (TCC) of very large (Defined as ≥35 mm size) ostium secundum atrial septal defect (ASD).

OBJECTIVE

To study the utility of BAT as against conventional techniques (CT) in TCC of very large ostium secundum ASD (≥35 mm) over the past 5-year period and to find out the association of different morphological features of the defects in relation to TCC outcomes.

STUDY DESIGN AND METHODS

Descriptive single center retrospective study of patients with very large ostium secundum ASD (≥35 mm size) who were subjected to TCC.

RESULTS

Thirty-three out of 36 patients with ≥35 mm ASD and complex morphological features underwent successful TCC. The study patients had high prevalence of absent aortic and posterior rims with posterior mal-alignment of the septum. BAT was successful in 28/31 (90.3%) patients while CT had a success rate of 16%. The mean trans-esophageal echocardiography (TEE) ASD size with BAT success 37 (SD 1.3) mm and CT failure 36.2 (SD 1.1) mm was not different (P=0.06). On univariate analysis of different morphological features, posterior mal alignment of the septum was associated failure of CT (P=0.01). There was no urgent referral for surgery and patients did well on follow up.

CONCLUSIONS

Balloon assisted device closure of (≥35 mm) ASD had 90% success rate. BAT helps in controlled delivery and device alignment in very large ASD with posterior malalignment of the septum and is often helpful when CT fails.

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.