Tte and tee assessment for asd closure 2

ASD

1. TTE AND TEE ASSESSMENT FOR ASD CLOSURE Dr . Rahul C

2. Introduction Atrial septal defect (ASD) is the second most common congenital heart disease in adults. Approximately 10% of all congenital heart lesions. Isolated ASD results from abnormal development of the septa that partition the common atrium of the developing heart into right and left chambers. 70% of ASDs are of the ostium secundum variety. The incidence of ASD is approximately 3 per 10,000 live births.

3. Embryology The interatrial septum forms during the first and second months of fetal development . Stage I is the formation of the septum primum . The septum primum walls off a crescent-shaped portion of the hole between the right and left atria . F o ramen primum (also called the ostium primum ) stays open The remaining part of the opening between the right and left atria is closed by the septum secundum . The 2 tissue layers overlap like a flap, allowing blood flow to continue during fetal life . Changes in circulation at birth , closes the flap permanently.

4. Anatomy and Physiology Extends from cavo-atrial junction with superior and inferior vena cavae Ends near the atrio-ventricular canal near the tricuspid valve

5. Ostium Secundum Most common type of ASD Center of the septum between the right and left atrium

6. Ostium Primum Next most common type Located in the lower portion of the atrial septum. Will often have a mitral valve defect associated with it called a mitral valve cleft. A mitral valve cleft is a slit-like or elongated hole usually involves the anterior leaflet of the mitral valve.

7. Sinus Venosus Least common type of ASD Located in the upper portion of the atrial septum. Association with an abnormal pulmonary vein connection Four pulmonary veins, two from the right lung and two from the left lung, normally return red blood to the left atrium. Usually with a sinus venosus ASD, a pulmonary vein from the right lung will be abnormally connected to the right atrium instead of the left atrium. This is called an anomalous pulmonary vein. ..\asd-veno.jpg

8. Foramen Ovale Remnant of fetal circulation Behaves like flap valve Opens during increased intra-thoracic pressure

9. VARIOUS ECHO MODALITIES TTE CONTRAST ECHOCARDIOGRAPHY TEE 3D ECHO ICE

10. 4 TYPES OSTIUM SECUNDUM- 66% OSTIUM PRIMUM- 15% SINUS VENOSUS-10%- superior and posterior part of septum DEFECTS NEAR CORONARY SINUS

11. ASD

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

13. 2D ECHO RA RV VOLUME OVERLOAD SEPTAL FLATTENING IN DIASTOLE

14. RELATIVE ATRIAL INDEX Standard apical 4C views- right atrial area divided by left atrial area Cutoff value of >0.92 predicted patients with ASDs v/s matched controls with 99.1% sensitivity and 90.5% specificity. After closure, significant atrial remodeling occurred immediately, with a reduction in the mean RAI at day 1 to 0.93 ± 0.16 ( P < .0001) and complete normalization at early follow-up to 0.81 ± 0.12.

15. The Relative Atrial Index (RAI)—A Novel, Simple, Reliable, and Robust Transthoracic Echocardiographic Indicator of Atrial Defects Natalie A Kelly -Journal of the American Society of Echocardiography

16. The role of echocardiography Indication – RV – volume load (TTE) Screening for feasibility of intervention Native ASD size – septal size on LV aspect Number of ASD`s Position of ASD – rims (aorta, AV-valve, SVC/IVC, right pulmonary veins) Monitoring of the procedure Follow-up echocardiography

17. Accurate measurement of the defect size plays a key role in closing ASD using a percutaneous occluder device. It is possible to determine the size of the defect by transesophageal echocardiography (TEE), which is a noninvasive technique. In the literature, it has been emphasized that TEE is a gold standard in transcatheter closure of ASD and thus should be used in analyzing septal defect and rims during the process.

18. Therefore, using echocardiographic parameters affecting success of closure may prevent possible complications in percutaneous closure of ASDs. In terms of success, there is no definite ASD size or predictor as the size of ASD differs from 1 patient to another. Determining other predictors along with the measured ASD size and evaluating the closure together with such predictors would increase the chance of success.

19. Conventionally, the rims of a secundum ASD are labeled as aortic ( superoanterior ), atrioventricular (AV) valve (mitral or inferoanterior ), superior venacaval (SVC or superoposterior ), inferior venacaval (IVC or inferoposterior ), and posterior (from the posterior free wall of the atria, coronary sinus rim).

20. By conventional definition, a margin 5 mm is considered to be adequate. Podnar et al. defined 10 morphological variations of defects, the most common type being the defect with deficient aortic rim (42.1%). The other variants included central defects (24.2%), deficient inferoposterior rim (12.1%), perforated aneurysm of the septum (7.9%), multiple defects (7.3%), combined deficiency of mitral and aortic rims (4.1%), Deficient SVC rim (1%), and deficient coronary sinus rim (1%).

21. SUB COSTAL 4C VIEW To go for the subcostal 4C – Keeps the atrial septum perpendicular to the ultrasound beam Distinguishes OS , OP & SV ASDs Measurements of the septum can be taken Anomalous drainage of pulmonary veins Atrial septal aneurysm

22. 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

23. 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

24. SUB COSTAL 4C VIEW- Useful in patients with COPD and ventilated patients. Viewed with breath held in inspiration- index marker in 3o` clock position. No IAS drop outs SUB COSTAL SHORT AXIS- Index marker at 12o`clock position and sweeping the transducer from midline to Rt side of patient

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

26. Other important views To visualise SVC - Suprasternal short axis –index marker in 4 o`clock position L-SVC is seen from left supraclvicular fossa or suprasternal short axis Suprasternal short axis to visualise the the pulmonary veins draining into left atrium Cleft mitral valve in AVCD in 12o`clock position in PSAX

27. SUPRASTERNAL SHORT AXIS

28. 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

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

30. Ostium primum ASD Defect in lower part of IAS Associated sometimes with inlet VSD Cleft mitral valve AV Valve regurgitation Partial attachment of mitral valve to IVS

31. Primum ASD LA RA LV RV Apical four chamber view demonstrating a primum atrial septal defect Colour Doppler flow image from same view illustrating left-to-right shunt across the primum atrial septal defect Fig 5

32. CLEFT MITRAL VALVE IN PSAX VIEW POSTERIORLY DIRECTED JET OF MR

33. Ostium Secundum ASD 10 morphological variations of defects MC- Deficient aortic rim (42.1%). Central defects (24.2%) Deficient Inferoposterior rim (12.1%) Perforated aneurysm of the septum (7.9%) Multiple defects (7.3%) Combined deficiency of mitral and aortic rims (4.1%), Deficient SVC rim (1%), 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.

34. Centrally located ASD imaged at 0°

35. ASD with deficient Aortic margin

36. Large ASD with deficient posterior and Aortic margins

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

38. Sinus venosus ASD A – INTACT IAS B- COLOUR DOPPLER SHOWS DEFECT IN THE UPPER PART OF IAS AT ENTRANCE OF SVC TEE

39. Sinus venosus ASD -Color doppler in TEE

40. CORONARY SINUS ASD DILATED CORONARY SINUS TEE 120 DEGREES

41. 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

42. COLOUR DOPPLER Shows the direction of the shunt Caveat- False Positive results due to improper gain and caval flow streaming near septum can be misdiagnosed as ASD. PULSED DOPPLER- demonstrates the flow from L to R in mid systole to mid diastole with second phase in atrial systole. Some R to L shunting occurs in early systole QUANTIFICATION OF SHUNT – Qp /Qs

43. OS ASD VIA DOPPLER SINUS VENOSUS ASD VIA DOPPLER

44. CONTRAST ECHOCARDIOGRAPHY APICAL 4C VIEW IS USED AGITATED SALINE USED- 5ml in each 10ml syringe, 0.5ml of air taken in the syringe and agitated to create microbubbles .

45. ARROW SHOWS NEGATIVE CONTRAST EFFECT DIRECT EVIDENCE OF SHUNT- NON CONTRAST BLOOD IN RA Extent of shunting tend to focus on numbers of bubbles seen in a single still frame in the left atrium. Shunt grading incorporates : Grade 1: 5 bubbles; Grade 2: 5 to 25 bubbles ; Grade 3 : >25 bubbles ; Grade 4: Opacification of chamber Echocardiographic Evaluation of Patent Foramen Ovale Prior to Device Closure Bushra et al JACC 2010 VOL . 3, NO. 7, 2010

46. 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).

47. RIMS TEE TTE

48. TEE

49. 2D TEE at 0 o

50. The transesophageal echocardiography (TEE) probe is at the mid-lower esophageal level. The posterior and the mitral rims are best evaluated in this view . Rotating the probe to 30° to 40° towards the left will best profile the aortic ( Ao ) rim . The margins are evaluated by carefully moving the probe in and out and obtaining sections at various levels. At the level of the atrioventricular valves (C), the septum forms once again. This suggests that the ASD is likely to have adequate margins for catheter closure.

51. In the highest plane (A), the superior venacaval (SVC)-right atrial junction and the ascending ( Asc ) aorta are seen; the atrial septum is visualized as intact.

52. At the mid-level (B), the septum breaks and the margins(posterior and anterior) of the atrial septal defects (ASD) (arrows) are clearly seen.

53. At the level of the atrioventricular valves (C), the septum forms once again. This suggests that the ASD is likely to have adequate margins for catheter closure.

54. TEE at 90° to Evaluate the SVC and IVC Rims AORTIC RIM IS SEEN IN TEE 45 DEGREES

55. This view is best for evaluating the SVC and IVC rims. The margins are evaluated by rotating the probe while keeping it at more or less the same level. Here the defect is seen with the probe rotated leftward (B, margins of the ASD shown by the arrows), while septum is seen to form when the probe is rotated to the right (A). The 45°-view is helpful in assessing the posterior and the aortic rims and often helps to determine the maximum size of the defect.

56. Probe to 30-40 o right

57. Probe rotated 30-40 o left

58. STOP FLOW METHOD –DEVICE SIZING

59. DEVICE SELECTION

60. TEE IMAGES OF ASD DEVICE CLOSURE

61. POST PROCEDURE COMPLICATIONS RESIDUAL SHUNT POST PROCEDURE

62. DEVICE MISPLACEMENT

63. IMPINGEMENT OF THE DEVICE ON AORTIC ANNULUS- CAN LEAD TO EROSION?

64. Morphological characteristics of septal rims affecting successful transcatheter atrial septal defect closure in children and adults

65. Conclusion Echocardiography plays a critical role for patient selection, guidance, and post-deployment evaluation for transcatheter closure of ASDs. Understanding the echoanatomic corelation by transesophageal echocardiography is perhaps the most essential requisite to ensure a successful procedure. 3D echocardiography and ICE (intra-cardiac echo) are likely to further this understanding in the future especially in difficult cases like multiple defects and defects with deficient margins.

66. THANK YOU

67. Natural history of ASD Natural history of ASD diagnosed in childhood is that the ASD diameter when untreated increases in 65% of cases, and 30% will have more than a 50% increase in diameter. Only 4% of ASDs close spontaneously . A patient with isolated secundum ASD is often asymptomatic until the third and fourth decade of life. Typical symptoms that ensue include decreased exercise capacity, fatigue, syncope and palpitations. Patients with significant shunting may develop right ventricular failure, atrial tachycardia, pulmonary hypertension and embolic events all of which can lead to significant morbidity and potential mortality.

68. The age at which a patient becomes symptomatic is highly variable and does not correlate well with shunt size . The pressure gradient between the two atria and the amount of shunt flow depend upon both the size of the defect, and the compliance of the right and left sides of the heart. Left untreated over time, even small ASDs can develop increased left- toright shunting due to progressive increase in left ventricular (LV) diastolic pressure with aging, which causes increased left atrial pressure. In patients who develop pulmonary hypertension (PHTN) from their ASD, approximately 10% will progress to Eisenmenger’s syndrome. Due to the chronic nature of the disease and patient compensation over time many patients remain unaware of their decreased exercise capacity and only realize their symptom improvement post procedure .

69. FOETAL CIRCULATION

70. CIRCULATION AFTER BIRTH

71. PATENT FORAMEN OVALE TEE -0 DEGREE TEE-90 DEGREES

72. PFO WITH SECONDARY SEPTUM

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

74. 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