Asd echo assessment

Echocardiographic assessment of Atrail septal defect. Mainly by transthoracic echocardiogram.

1. Echocardiographic Assessment of ASD Md. Mashiul Alam Phase B resident UCC Chairperson: Assoc. Prof. Naveen Sheikh

2. Atrial Septal Abnormalities Atrial septal defect (ASD)---- 5 to 10% of CHD Patent foramen ovale (PFO) Atrial septal aneurysm

3. Types of ASD ASD secundum ASD primum Sinous venosus Coronary sinus variety

4. 80% secundeum , located in the region of the fossa ovalis and its surrounding 15% Primum , located near the crux, AV valves malformed with regurgitation 5% SVC type sinus venosus , defect located near to SVC, assocaited with anomalous pulmonary venous return <1% IVC type sinus venosus , defect located near IVC <1% Unroofed coronary sinus, separation from the LA partially or completely missing

5. Associations of other… Secundum ASD: MVP Primum ASD: AV canal defect (Down syndrome) Sinus venosus : Partial anomalous pulmonary venous retrun Conornary sinus variety: complete AV septal defect, absence of coronary sinus, left SVC that drains into the left atrium

6. Facts about ASD Asymptomatic until adulthood Symptoms beyond the fourth decade Life expectency reduced Quality of life decreased Eisenmenger rare (<5%)

7. Echocardiography in ASD To identify and confirm ASD To identify associated anomalies To diagnose complications of ASD For therapeutic purpose

8. Echocardiographic modalities Transthoracic echocardiogram (TTE) Transoesophgeal echocardiogram (TEE) Intracardiac echocardiogram (ICE) Modes: 2D, M mode, Doppler study, 3D

9. TEE > TTE TTE----- Subcostal view TEE-----High transverse and longitudinal planes

10. Routine measurement and report ASD type Doppler flow- presence of shunt ASD size ASD location Measure all rims Shape of ASD---round, oval, irregular

11. Calculate ASD measurements Qp /Qs Pulmonary hypertension

12. Common views in TTE Subxiphoid Frontal (Four-Chamber) Subxiphoid Sagittal Left Anterior Oblique Apical Four-Chamber Modified Apical Four-Chamber Parasternal Short-Axis High Right Parasternal View

13. TTE views for ASD Subxiphoid Frontal (Four-Chamber) The subxiphoid frontal (four-chamber) view allows imaging of the atrial septum along its anterior–posterior axis from the SVC to the AV valves.

14. Subxiphoid Sagittal The subxiphoid sagittal TTE view is acquired by turning the transducer 90 clockwise from the frontal view. This view can be used to measure the rim from the defect to the SVC and IVC and is an excellent window to image a sinus venosus type defect

15. Apical Four-Chamber : This view is used to assess the hemodynamic consequences of ASDs, such as RA and RV dilation , and to estimate RV pressure using the tricuspid valve regurgitant jet velocity. This view is also used to evaluate for right-to-left shunting with agitated saline

16. Parasternal Short-Axis This view is ideal to identify the aortic rim of the defect. It also highlights the posterior rim (or lack thereof) in sinus venosus and posteroinferior secundum defects.

17. Left Anterior Oblique. The left anterior oblique is acquired by turning the transducer approximately 45 counterclockwise from the frontal (four-chamber) view. This view allows imaging of the length of the atrial septum and is therefore ideal to identify ostium primum ASDs and for assessment of coronary sinus dilation

18. Modified Apical Four-Chamber (Half Way in Between Apical Four-Chamber and Parasternal Short-Axis View): In the patients in whom the subcostal views are difficult to obtain, the modified apical four-chamber view is an alternative method for imaging the atrial septum

19. High Right Parasternal View. The high right parasternal view is a parasagittal view performed with the patient in the right lateral decubitus position with the probe in the superior–inferior orientation. In this view, the atrial septum is aligned perpendicular to the beam and is ideal for diagnosing sinus venosus defects, particularly when the subxiphoid windows are inadequate

20. ASD secundum rims SVC or superior margin IVC or inferior margin Posterior margin Anterior or retroaortic margin Mitral rim

21. Views to identify the ASD rims PSAX view at great vessel level: Aortic and Post rim A4CV: Mitral Rim Subcostal view: SVC and IVC rim

22. Qp /Qs Qp – pulmonary flow Qs – systemic flow Qp /Qs = 1 in normal Qp /Qs > 1.5 significant shunt Qp = VTI, RVOT diameter Qs = VTI, LVOT diameter

23. Pulmonary hypertension by TR if no RVOT obstruction Also by PR max velocity or RVOT acceleration time

24. ASD with Eisenmenger syndrome pulmonary hypertension, reversal of flow, and cyanosis

25. ASD secundum Device closure CRITERIA: “Significant” ASDs ( Qp /Qs >1.5 or ASDs associated with right ventricular volume overload) should be closed Secundum ASD that has a stretched diameter of less than 38 mm and more than 10 mm Adequate rims (5 mm) to enable secure deployment of the device Anomalous pulmonary venous connection or proximity of the defect to the AV valves or coronary sinus or systemic venous drainag , intracardiac thrombie absent

26. Device in situ

27. Device in situ

28. Follow up echo after device closure After device closure, patients require 6 months of aspirin and endocarditis prophylaxis until the device endothelializes , following which, assuming that no residual shunt is present all patients who have undergone device closure should probably have an echocardiogram taken every 5 years or so because of the possibility of late issues, especially erosion. Ref: Braunwald 10 th ed

29. ASD after surgical closure

30. TEE for ASD

31. THANK YOU