ECHO ASSESSMENT OF ASD FOR DEVICE CLOSURE

preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.

1. ECHO ASSESSMENT OF ASD FOR DEVICE CLOSURE DR SASINTHAR SR, CARDIOLOGY JIPMER

2. VARIOUS ECHO MODALITIES TTE TEE 3D ECHO ICE

3. WHEN TO SUSPECT IN 2D ECHO RIGHT VENTRICULAR DILATION ABNORMAL MOTION OF IVS- brisk anterior movement in early systole or flattened movement throughout systole ? IAS DROP OUT IN APICAL 4C VIEW RELATIVE ATRIAL INDEX

4. 2D ECHO RA RV VOLUME OVERLOAD SEPTAL FLATTENING IN DIASTOLE

5. The Relative Atrial Index (RAI)—A Novel, Simple, Reliable, and Robust Transthoracic Echocardiographic Indicator of Atrial Defects Cutoff value of >0.92 predicted patients with ASDs v/s matched controls with 99.1% sensitivity and 90.5% specificity Natalie A Kelly -Journal of the American Society of Echocardiography Volume 23, Issue 3 , Pages 275-281, March 2010

6. SUB COSTAL 4C VIEW Keeps the atrial septum perpendicular to the ultrasound beam Distinguishes OS , OP & SV ASDs SV ASD are consistently visualised in the SUBCOSTAL 4C VIEW Anomalous drainage of pulmonary veins Atrial septal aneurysm Viewed with breath held in inspiration- index marker in 3o` clock position SUB COSTAL SHORT AXIS Index marker at 12o`clock position and sweeping the transducer from midline to Rt side of patient

7. SUBCOSTAL 4C VIEW SUB COSTAL SHORT AXIS VIEW ALSO SHOWS IVC DRAINING TO RA AND EUSTACHIAN VALVE

8. Other TTE -views for ASD PSAX-IAS separates Rt &Lt atrium and runs posteriorly from NCC of aortic valve. Not seen in entirety as a result of drop out artefact APICAL 4C- Posterior aspect of Interatrial septum is clearly delineated in this view but drop out artefact is seen in region of fossa ovalis. Pulmonary venous drainage- 3 veins draining to LA APICAL 5C VIEW- Anterior aspect of interatrial septum

9. PSAX VIEW IAS AGAINST NCC OF AORTA APICAL 4C VIEW SHOWING THE IAS AND 3 VEINS DRAINING TO LA, RT LOWER PULMONARY VEIN IS USUALLY NOT SEEN

10. ANOMALOUS PULMONARY VEIN Can be associated with ASD or can occur as an isolated anomaly 95% of SV ASD a/w RUPV-SVC RUPV-SVC; LUPV- innominate vein ; RLPV- IVC Isolated LLPV – extremely rare

11. `Crab view` showing absent Rt upper and Rt lower pulmonary vein

12. En face view in 2D First the apical 4c view was taken. The image index marker was at approximately kept at 1 o'clock. Keeping the atrial septum and ASD in the region of interest, the transducer was rotated counterclockwise approximately 45° to 60° Xinseng et al Journal of the American Society of Echocardiography Volume 23, Issue 7 , Pages 714-721, July 2010

13. A-4c view & B-En face view

14. Morphological variations 1.MC- Deficient aortic rim (42.1 %) 2.Central defects (24.2%) 3.Deficient Inferoposterior rim (12.1 %) 4.Perforated aneurysm of the septum (7.9 %) 5.Multiple defects (7.3%) 6.Combined deficiency of mitral and aortic rims (4.1%), 7.Deficient SVC rim (1%), 8.Deficient coronary sinus rim (1%). Podnar T, Martanovic P, Gavora P,Masura J. Morphological variations of secundum -type atrial septal defects: feasibility for percutaneous closure using Amplatzer septal occluders . Catheter Cardiovasc Interv 2001;53:386 –91.

15. ATRIAL SEPTAL ANEURYSM CRITERIA A-PROTRUSION OF ANEURYSM ATLEAST 15MM OF PLANE OF IAS OR IAS SHOWING 15MM OF PHASIC EXCURSION DURING CARDIORESPIRATORY CYCLE B- BASE WIDTH≥ 15MM

16. TRANSVERSE PLANE VIEWS VERTICAL PLANE SWEEP TEE

17. Centrally located ASD imaged at 0°

18. ASD with deficient Aortic margin

19. Large ASD with deficient posterior and Aortic margins

20. Multiple ASDs; larger anterior defect (block arrow) and a smaller posterior defect

21. RIMS OF ASD Aortic - Superoanterior Atrioventricular (AV) valve -mitral or inferoanterior Superior Vena Caval SVC – Superoposterior Inferior venacaval (IVC or Inferoposterior) Posterior (from the posterior free wall of the atria).

22. IVC AND SVC RIMS

23. OTHER RIMS TEE TTE

24. Measurement of the ASD rims Atleast 5 mm IVC rim-most important Schematic representation of the locations of the ASD rims

25. TEE 4-chamber view depicting an adequate posterior rim for percutaneous closure of 20 mm. Transesophageal 4-chamber view: The AV rim measures 9.5 mm, which is adequate for PCT

26. TEE upper-esophageal 4-chamber view with rightward (clockwise) rotation of the probe revealing an adequate RUPV rim of 15 mm . Beside, Doppler color image shows in red the inflow of the RUPV (white arrow). Note the correct ECG timing of the measure at the end of the ventricular systole while the atrio -ventricular valves are still closed.

27. Mid-esophageal short axis view of the aortic rim at 56 degrees with an adequate aortic rim (11 mm) for percutaneous closure

28. Absent aortic rim makes the procedure more challenging but does not, preclude device closure of the defect

29. Mid-esophageal bi- caval view at 97 degrees, an adequate SVC rim is noted, measuring 13 mm . Mid-esophageal bi- caval view at 97 degrees with an adequate IVC rim of 10 mm

30. Special tee views for Inferoposterior rims No Infero posterior rim with probe in normal position

31. Catheter Closure of Atrial Septal Defects With Deficient IVC Rim Under TEE Guidance K.S. Remadevi, MD, FNB, Edwin Francis, DM, and Raman Krishna Kumar, DM, FACC . Catheterization and Cardiovascular Interventions (2008) Retroflexed probe in the stomach and bought towards the esophagus and viewed In the 70-90 o view

32. 3D ECHO Matrix transducers – pyramid shaped volumes Full volume 3D dataset in 4-7 cardiac cycles Ideal window is the mid esophageal basal long axis (bicaval view) Subcostal 4c view- enface septum Low parasternal 4c view case of suboptimal windows 3D tee overcomes 3D TTE if suboptimal windows

33. Real-time 3D imaging demonstrates the changing shape of the ASD during a cardiac cycle, with maximum size in diastole As we take the Bicaval view structures – we first remove the right atrial free wall . Images are taken with suspended respiration and ECG gating with optimal gain settings Low gain – drop outs and high gain – blurring of structural details

34. Gain settings For Best view Cropping to Get the IAS

35. TUPLE (TILT UP & LEFT)-ENFACE VIEW OF IAS FROM LT ATRIAL PERSPECTIVE

36. RIMS OF ASD ASD IN VARIOUS PHASES OF CARDIAC CYCLE

37. ATRIAL SEPTUM ANEURYSM WITH ASD MULTIPLE ASDs

38. DEFECT NEAR THE IVC

39. 3D echo- En face 3D reconstruction of a secundum ASD with a relatively deficient IVC and posterior rim

40. multiple ASDs with the thin atrial septum (*) separating the 2 defects

41. The correlations between the ASD maximal diameter by RT-3DE and operation or balloon sizing were excellent ( r > 0.95). All surrounding rims of the atrial septum could be assessed on 3D reconstruction; except for the aortic rim, a cross-sectional reconstruction was created mimicking the transesophageal echocardiographic cross section ( r > 0.92)

42. Maximal criteria for transcatheter closure with ASO device are ( 1) ASD secundum with a maximum TEE diameter of 34 mm ( 2) rims, except the anterosuperior rim, of at least 5 mm, and (3) the dimensions of the total length of the atrial septum were not smaller than the left atrial disk of the chosen device

43. Measurement of ASD size Maximal ASD diameter must be measured at the end of ventricular systole Atleast two orthogonal views SBP = Max in TEE + 4 to 6mm Mid-esophageal 4-chamber view at 0 degree depicting an ostium secundum ASD with a maximal transverse diameter of 18 mm . Mid-esophageal bi- caval view at 97 degrees showing an ASD with a maximal longitudinal diameter of 14 mm

44. Max size of device used -44 mm Device embolisation in 3/169 patients 2- deficient posterior rim and large size (38 mm, 35 mm) were the reasons for instability, In the third patient, the complete absence of aortic rim with malaligned septum made the procedure difficult

45. CONCLUSION Proper case selection It is important to have inferior and posterior rims An anterior rim is not as important as the device will grasp the aorta A superior rim is less important as the device will grasp the SVC orifice