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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 171-180

Role of echocardiography in the transcatheter closure of atrial septal defect


Department of Pediatric and Congenital Heart Disease, Medica Super Specialty Hospital, Kolkata, West Bengal, India

Date of Submission15-Jan-2022
Date of Acceptance25-Jan-2022
Date of Web Publication29-Sep-2022

Correspondence Address:
Dr. Anil Kumar Singhi
Department of Pediatric and Congenital Heart Disease, Medica Super Specialty Hospital, Mukundapur, Kolkata - 700 099, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_4_22

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  Abstract 

Transcatheter closure of secundum atrial septal defect (ASD) is one of the most common structural cardiac interventions. Imaging the defect is the cornerstone of the procedure at different stages of the intervention. The imaging modalities most commonly used are transthoracic and transesophageal echocardiography (TTE and TEE, respectively). Less commonly used are intracardiac echocardiogram and fusion navigation techniques. From the planning stage, a detailed anatomic and hemodynamic assessment of ASD is required for deciding suitability of device closure. Intraprocedural imaging guidance again is essential for a successful device deployment. Various assisted techniques like balloon assistance also require live TEE guidance. Confirming an acceptable device deployment is imaging dependent. Long-term follow-up of the patient for different parameters is done with the help of echocardiographic screening. A detailed understanding of echocardiographic imaging at different stages of the ASD device closure is the key for success.

Keywords: Atrial septal defect, device closure, echocardiography, imaging


How to cite this article:
Singhi AK. Role of echocardiography in the transcatheter closure of atrial septal defect. J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:171-80

How to cite this URL:
Singhi AK. Role of echocardiography in the transcatheter closure of atrial septal defect. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2023 Feb 4];6:171-80. Available from: https://jiaecho.org/text.asp?2022/6/3/171/357591




  Introduction Top


Atrial septal defect (ASD) is one of the common intracardiac shunt lesions accounting for 7%–10% of congenital heart diseases.[1] Ostium secundum ASD is the dominant type of ASD. Last two decades have seen a revolution in the nonsurgical closure of the secundum ASDs that are suitable for intervention. The suitability of ASD is decided based on appropriate imaging of the anatomy. Transthoracic echocardiography (TTE) is the basic initial imaging modality which confirms the anatomy and analyzes the defect for suitability of device closure. In the pediatric population, a good imaging window makes TTE a good guide to decide and do device closure. In the adult population and pediatric population with difficult anatomy and poor acoustic window, help from a detailed transoesophageal echocardiography (TEE) is needed. Two- and three-dimensional TEE delineate the anatomy and adjacent structures in detail.[2],[3] Recently, intracardiac echocardiogram (ICE) and fusion imaging techniques have come as an add-on imaging guide. The present review will concentrate on more common imaging modalities such as TTE and TEE.


  Role of Imaging in Atrial Septal Defect Device Closure Top


  1. During planning of the procedure
  2. Intraprocedural imaging guidance
  3. Postprocedural follow-up and surveillance.


During planning of the procedure

Understanding of ASD device closure starts from the initial assessment of the echocardiographic anatomy and hemodynamics keeping in mind the age, clinical symptoms, and signs. TTE assessment provides the most crucial evaluation at the baseline and helps in decision-making for device closure. In children, TTE will usually be adequate whereas in adults supplementary information with the help of a TEE is required.[2],[3]

What to look for in the echocardiogram?

Size of the defect

Size of the defect is very important to decide device closure. Measurement is also influenced by the shape of the defect. Usually, the size of the defect is assessed in two orthogonal planes. For circular defects, it is the single measurement but for elliptical defects (more common) there are two dimensions (maximum/minimum). Conventionally, in children, defect size (in mm) 2 times the weight (in kg) is the upper limit for device closure. However, the decision to perform device closure in any patient is usually based on individual assessment.

Location of the defect and the margin

Ideal defects for closure are centrally located with good margins all around. A 5 mm margin is considered adequate.[4] The margins of the ASD are seen in multiple views of TTE and TEE. The important margins are anterior or aortic margin, posterior margin, superior or superior vena cava margin, posterior inferior or inferior vena cava margin, anterior inferior or atrioventricular valve margin. The superior and inferior margins are best seen in subcostal bicaval view in TTE and 90-degree view in TEE. The anterior inferior or atrioventricular valve rim is seen in the four-chamber view. The posterior rim and anterior rim (aortic rim) are seen in parasternal short axis and 0/45 degree view in TEE [Figure 1], [Figure 2], [Figure 3].
Figure 1: (a) Subcostal short axis view during transthoracic echocardiogram showing an ostium secundum atrial septal defect (asterisk) with superior margin which is also known as superior vena cava margin (white arrow) and inferior margin (Inferior vena cava margin, red arrow).(b) Apical four chamber view showing anterior inferior or atrioventricular valve margin (green arrow) and postero-superior margin (yellow arrow).(c) Parasternal short axis view showing the deficient aortic margin (orange notched arrow) and posterior margin (light green arrow)

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Figure 2: Transesophageal echocardiogram delineating the margin of the atrial septal defect in different views. (a and b) Transesophageal echocardiogram in 0 degree view showing the posterior (white arrow) and anterior aortic margin (red arrow). (b) The deficient posterior margin is seen (white notched arrow). (c) The Atrioventricular valve margin (antero inferior margin) marked with yellow arrow. (d and e) 45 degree view showing the posterior (green arrow) rim; the deficient aortic margin is also seen marked with maroon arrow. (f) Transesophageal echocardiogram in 90 degree (bicaval view) showing inferior margin (orange arrow) and deficient superior margin (superior vena cava margin, blue arrow)

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Figure 3: Schematic diagram of the anatomy of atrial septal defect and adjacent anatomy and margins. Ant: Anterior margin; AV: Atrioventricular; CS: Coronary sinus; Inf:, Inferior margin; IVC: Inferior vena cava; Post: Posterior margin; Sup: Superior margin; SVC: Superior vena cava; TV: Tricuspid valve

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Frequently, the ASD is situated anterosuperiorly. In such cases, common rim deficiency is deficient to absent aortic margin. The difficult substrates have a deficient and floppy posterior inferior margin. It is essential to delineate the margins to decide on an intervention. A significantly deficient posteroinferior rim is not a suitable candidate for device closure. Subcostal views are good to evaluate the inferior rim in the TTE. A retroflexed TEE probe adds to the information.

Shape of atrial septal defect

The shape helps in deciding the device size. Visualization in two-dimensional echocardiogram helps to build a mental image of the shape after assessment in multiple orthogonal views. Three-dimensional TEE is usually superior for showing the shape. An elliptical hole may need a relatively smaller device than a circular hole.

Number of atrial septal defects

ASD usually is a single defect but there can be two or more, like a sieve. It is essential to assess the anatomy of multiple defects to decide size, distance between defects, shape, etc. The decision on closing the large defect with a larger device to cover a smaller one versus use of multiple devices is based on detailed imaging assessment. Enface three-dimensional assessment on TEE helps to visualize the shapes of multiple defects which helps in device closure planning.

Shunting across the defect

The degree of left to right shunt should be correlated to the size of the defect and should explain the clinical and hemodynamic features. Any disproportionate shunt compared to size of the defect and significant gradient across the shunt merit detailed evaluation. Any bidirectionality or reversal of shunt is also extremely important.

Right heart evaluation

A very important feature to analyze in ASD is the associated right heart dilatation. It should be proportionate to the quantum of shunt. Small ASD and significant right heart dilatation merit evaluation for anomalous pulmonary venous drainage, or high pulmonary artery pressure. Any dysfunction of the right ventricle (RV) is also important to note as seen in the cases of higher right ventricular pressure. Any gradient across the pulmonary outflow tract should be evaluated as it can elevate the RV systolic pressure.

Assessment of pulmonary artery hypertension

The assessment of pulmonary artery pressure in echocardiogram is an integral part of device suitability assessment. Tricuspid valve regurgitation jet gives indirect of pulmonary artery pressure in the absence of significant pulmonary stenosis. RV function should also be taken into consideration as assessment of elevated pulmonary artery pressure in the presence of RV dysfunction can be fallacious.

Associated mitral and aortic valve disease

Prolapse of the mitral valve leaflet can be seen in ASD. This is attributed to the mitral vulvar-ventricular mismatch. Detailed mitral valve and aortic valve assessment is important to rule out significant valvular pathology and also help in postprocedure follow-up.

Additional structure delineation

Anatomically documenting pulmonary veins draining in the left atrium is very important as there may be associated partial anomalous pulmonary venous connection (PAPVC). The presence of PAPVC directs the closure to the surgical pathway. Sometimes in the TTE, all pulmonary veins may not be well visualized. A detailed TEE will help to document all pulmonary veins. Disproportionate right ventricular dilatation in relation to the size of ASD also warrants detailed imaging for searching for possible anomalous pulmonary veins. Chiari network and Eustachian valve require delineation if present, as these can be mistaken for defect margin.

Left ventricular diastolic dysfunction

Stiffness of left ventricular (LV) myocardium and impairment of LV diastolic function may occur in a long-standing ASD. Echocardiographic assessment of LV diastolic function is usually done by evaluation of mitral inflow velocities, ratio of early diastolic to late diastolic mitral inflow velocity, mitral annular velocity using tissue Doppler imaging, etc. In the presence of decompressing ASD, it may not be possible to assess LV diastolic function accurately. Any gradient across the ASD, which is more than 2 mmHg (mean), is considered significant and may indicate left atrial hypertension. It is thought to result from LV diastolic dysfunction. A balloon occlusion test in a suspected diastolic dysfunction patient can reveal the concealed LV diastolic dysfunction. Imaging guidance is helpful to ensure complete occlusion of the defect by balloon.

Intraprocedural imaging guidance

During the ASD device closure, the baseline anatomy is reconfirmed by a good transthoracic or TEE as applicable in the individual patient. A good intraprocedural imaging guidance is key for success. It provides live monitoring of the septum and device position, device alignment with the septum, and appropriate deployment. TEE is superior for continuous high quality imaging unhindered by fluoroscopic time interruption as seen in the TTE.[3]

Intraprocedural echocardiogram helps not only in selecting the appropriate size device but also in positioning the device across the ASD and postdeployment checking. In multi-fenestrated ASD, the crossing of the appropriate hole by wire is confirmed through echocardiogram. In case of balloon assistance for a deficient ASD margin, the inflation of the balloon across ASD is also confirmed by a TEE.

Balloon occlusion technique to stretch and occlude an aneurysmal interatrial septum (IAS) helps to decide the correct size of the device. A stop flow across the defect on balloon occlusion is ensured by good intraprocedural imaging. Balloon occlusion and stop flow also help to assess the hemodynamic changes after ASD occlusion like any change in pulmonary artery pressure and left ventricular end-diastolic pressure (LVEDP). Imaging plays a pivotal role in ensuring temporary complete occlusion of the defect.

Postprocedural follow-up and surveillance

After device closure of an ASD, imaging continues to play a major role in the follow-up and surveillance. It helps to understand final device positioning, device configuration, any residual flow, and impact of the device on adjacent structures like any aortic regurgitation or mitral valve regurgitation. Any change in the hemodynamic parameters like pulmonary artery hypertension or left ventricular diastolic dysfunction can also be detected during the follow-up. Long-term rare complications like aortic perforation and erosion (incidence 0.01%–0.03%) can also be monitored with the help of a good imaging modality.[3] Usually, after the predischarge detailed assessment, the patient is evaluated at 1 month, 6-month and then yearly unless required to be seen at more frequent intervals, in individual cases.


  Modalities of Imaging Top


  1. Transthoracic echocardiogram (TTE)
  2. Transesophageal echocardiogram ( TEE)
  3. Intracardiac Echocardiogram ( ICE)
  4. Echo-fluoroscopic fusion – Navigation.


Transthoracic echocardiogram

TTE is the backbone of imaging assessment in the device closure of ASD. The advantage of TTE as the basal modality is that it is easily available. It has good imaging capability in the pediatric population, and reasonable delineation in the adult population. It helps in the initial assessment of the defect to decide initial suitability for the device closure. The subcostal assessment, if permitted by a good imaging window, can delineate the atrial septum well with special focus on the inferior margin of the ASD.

Transesophageal echocardiogram

TEE is an important imaging supplement to the baseline TTE. In all stages of the device closure, it has a unique role to play. It gives a very good delineation of the atrial septal anatomy in multiple planes at 10–15-degree sweep. TTE has its own limitations in the adult population and the size of ASD decided by TTE may not be truly reflective of the actual measurement. In view of the limitation of the TTE In the adult population, it is very essential to have a detailed TEE assessment before the device closure. In the pediatric population, in special cases like deficient margin or very large defect or multiple defects, TEE can add value to the assessment and decision making [Figure 1]. TEE also helps in assisted techniques like balloon-assisted closure or ensuring complete occlusion of the defect by balloon to analyze the hemodynamic features as discussed earlier. Three-dimensional assessment adds to its power to understand the shape of the defects. Three-dimensional imaging immensely helps to confirm the crossing of the appropriate defect during closure.[2],[3],[5],[6]

Intracardiac echocardiogram

ICE is a recent addition to the imaging armamentarium, which visualizes cardiac structures with the help of intra-atrial special imaging catheter. The special catheter requires introduction through femoral venous access. The advantage of ICE is that there is no need for anesthesia as required for TEE. Therefore, in situations where TEE is contraindicated, an ICE can be of help. The disadvantage is the cost of the imaging catheter and limited expertise with this new modality.[2],[3]

Echo-fluoroscopic fusion– (Echonavigator)

A fusion technology combining TEE with fluoroscopy in the Philips Cath lab system called Echonavigator™ (Philips healthcare, Best, The Netherlands) is becoming popular. It is a software package which can fuse the live echocardiographic images with the fluoroscopic images and allows placing marker on the screen. It helps to understand the device's position better and overall improves the performance of the intervention.[7]

Contrast echocardiogram for patent foramen ovale

Echocardiographic imaging of the atrial septum gets another dimension when agitated saline contrast (autologous blood, saline) is injected into the upper extremity vein. Any right to left shunt across the IAS, if present, can be delineated using agitated saline contrast, often combined with the Valsalva maneuver. Like ASD device, patent foramen ovale device closure is similarly helped by good TTE and TEE imaging.


  Illustrated Case Scenarios Top


Imaging of a patient with ASD is usually done in multiple views of different imaging modalities such as TTE, TEE. Some patients with different types of ASD anatomy and associated hemodynamic features are discussed in detail as illustrative case scenarios to explain the role of imaging in the process of device closure of the ASD.

Patient # 1

A 54-year-old man had exertional intolerance (functional class II) and episodic palpitations. He had a large ASD with aneurysmally dilated right heart chambers. The defect was analyzed with a detailed TEE which showed a large 37 mm ASD with a very thin and floppy inferior margin [Figure 4]a, [Figure 4]b, [Figure 4]c and [Movie 1]. The patient was taken for diagnostic cardiac catheterization, coronary angiogram and followed by device closure of ASD with balloon assistance. The coronary angiogram showed normal coronary arteries. The pulmonary artery pressure as well as LVEDP were normal. With the help of 33 mm equalizer balloon assistance under TEE and fluoroscopic guidance, a large 46 mm device was deployed. The device sat satisfactorily without any residual flow [Figure 4]d, [Figure 4]e, [Figure 4]f and [Movie 1]. During the 6 years follow up, the symptoms of effort intolerance and palpitations have disappeared. The RV is normalized in size and function. The incremental value of imaging in device closure of ASD in the adult is well established.
Figure 4: (a) Echocardiogram of the patient #1 in apical four chamber view showing aneurysmally dilated right atrium [yellow arrow] and the right ventricle.(b) Subcostal short axis view showing large atrial septal defect with very thin and floppy Inferior margin [white arrow].(c) Transesophageal echocardiogram showing a large atrial septal defect and very thin and flimsy inferior margin [white arrow].(d) A balloon was inflated across the atrial septal defect and transesophageal echocardiogram was done to confirm the position of the balloon as well as occlusion of the defect.(e) Balloon assisted device closure of a large atrial septal defect.(f) Post-device deployment echocardiogram showing good device position with no residual flow

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[Additional file 1]

Movie 1: (a) Echocardiogram of patient #1 in apical four chamber view showing an aneurysmally dilated right atrium and the right ventricle. (b) Subcostal short axis echocardiogram showing large atrial septal defect with very thin and floppy inferior margin (c) Transesophageal echocardiogram showing a large septal defect and very thin and flimsy inferior margin. (d) A balloon was inflated across the atrial septal defect and transesophageal echocardiogram was done to confirm the position of the balloon as well as occlusion of the defect. (e) Balloon assisted device closure of a large atrial septal defect. (f) Post-release echocardiogram showing good device position with no residual flow.

Patient # 2

A 7-year-old asymptomatic girl was incidentally found to have an ASD on TTE. Her atrial septum was found to be aneurysmal and sail-like, which was moving from left atrium to right atrium in different phases of the cardiac cycle. There were multiple holes in the septum. Two of the atrial septal connections were more prominent. Right atrium and RV were dilated [Figure 5]a, [Figure 5]b, [Figure 5]c and [Movie 2]. The device closure of these defects was extremely challenging in view of a multi-fenestrated septum. The anatomy was confirmed in TEE [Figure 5]d, [Figure 5]e and [Movie 2]. Under TEE guidance and fluoroscopic monitoring, a wire catheter combination was advanced across the atrium septum, through the superior relatively larger defect. A larger appropriate-sized device was deployed across the defect. The aneurysmal IAS got covered by the two discs of the device. The device attained good position, without any residual flow. It was difficult to appreciate any sign of aneurysmal septum after device closure as the septum was engulfed within the device [Figure 5]f,[Figure 5]g and [Movie 2]. Detailed imaging again proved to be essential in the device closure of this ASD.
Figure 5: (a) Echocardiogram of the patient #2 in the subcostal short axis view with a color Doppler showing an aneurysmal interatrial septum with multiple fenestrated atrial septal defects, shunting left to right [white arrows].(b) The sail-like aneurysmal interatrial septum moving towards the left atrium in some stages of the cardiac cycle.(c) Apical four chamber view showing aneurysmal interatrial septum and atrial septal defect shunting left to right [arrow].(d) Transesophageal echocardiogram confirming the aneurysmal interatrial septum along with multiple atrial septal defects marked with arrows.(e) Wire and catheter combination seen crossing through the relatively larger superior hole [arrow].(f and g) Postdevice deployment echocardiogram transesophageal echocardiogram and transthoracic apical four chamber view showing good device position with no residual flow

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[Additional file 2]

Movie 2: (a) Echocardiogram of the patient #2 in the subcostal short axis view with color Doppler showing aneurysmal interatrial septum with multi fenestrated atrial septal defects, shunting left to right. (b) The sail-like aneurysmal interatrial septum moving towards the left atrium in some stages of the cardiac cycle.(c) Apical four chamber view showing aneurysmal interatrial septum and atrial septal defect shunting left to right. (d) Transesophageal echocardiogram confirming the aneurysmal interatrial septum along with multiple interatrial septum defects. (e) Wire and catheter combination seen crossing through the relatively larger superior hole (f and g) Post-device deployment transesophageal echocardiogram and transthoracic apical four chamber view showing good device position with no residual flow.

Patient # 3

A 56-year-old female had functional class II symptoms. She was diagnosed with a large secundum ASD and was referred for device closure of the ASD. TTE revealed large ASD with a deficient posteroinferior margin, dilated right heart chambers, and, in addition, LV diastolic dysfunction [Figure 6]a and [Figure 6]b and [Movie 3]. Detailed TEE revealed a large defect with a deficient posterior inferior margin [Figure 6]c and [Figure 6]d and [Movie 3]. She was taken for cardiac catheterization (hemodynamic study) followed by device closure of ASD if found suitable. The basal pulmonary pressure was 68/28 mmHg (mean of 44 mmHg). The LVEDP was significantly elevated to 25 mmHg. The pulmonary to systemic blood flow ratio (Qp:Qs) was 3 with a calculated pulmonary vascular resistance of 3.73 Wood unit/m2. Balloon occlusion of ASD was done to monitor hemodynamics. Both pulmonary artery pressure and LVEDP showed a declining trend. In view of significantly elevated pulmonary blood flow, it was decided to close the ASD with a large (40 mm) septal occluder with 5 mm hand-made fenestration. The device was deployed with 33 mm equalizer balloon assistance under TEE monitoring and fluoroscopic guidance [Figure 6]e and [Figure 6]f and [Movie 3]. Postdeployment, the pulmonary artery pressure reduced to 37/21 mmHg (mean of 28 mmHg) and LVEDP reduced to 18 mmHg and the fenestration was seen shunting left to right. Detail Imaging once again proven pivotal in deciding and performing the device closure in this case.
Figure 6: (a) Echocardiogram of the patient #3 in the subcostal short axis view showing a large inferiorly located secundum atrial septal defect [yellow arrow] with deficient inferior margin.(b) Apical four chamber view showing significantly dilated right atrium [green arrow] and right ventricle, moderate tricuspid regurgitation and posteriorly located atrial septal defect.(c and d) Transesophageal echocardiogram in 90 degree and 0 degree view delineating the large inferiorly located atrial septal defect [arrow].(e and f) Postdevice closure echocardiogram in apical four chamber and subcostal view showing good device position and configuration.(f) The small shunt visible through the fenestration

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[Additional file 3]

Movie 3: (a) Echocardiogram of the patient #3 in the subcostal short axis view showing a large inferiorly located secundum atrial septal defect with deficient inferior margin.(b) Apical four chamber view showing significantly dilated right atrium (green arrow) and right ventricle, moderate tricuspid regurgitation and posteriorly located atrial septal defect.(c and d) Transesophageal echocardiogram in 90 degree and 0 degree views delineating the large inferiorly located atrial septal defect.(e and f) Post-device closure echocardiogram in apical four chamber and subcostal view showing good device position and configuration.(f) The small shunt visible through the fenestration.

Patient # 4

A 10-year-old boy was referred for device closure of an ASD. Clinically, the child had evidence of significant left to right shunt. On TTE, he had an aneurysmal IAS and two prominent superoinferiorly located ASD s [Figure 7]a and [Movie 4]. The child was taken for device closure of the ASD under TEE guidance. The anatomy was delineated in TEE. The most important part was to ensure the closure of the larger superior hole with a large device so that the inferior defect would get covered. The superior hole was crossed with a wire catheter combination under live TEE guidance and fluoroscopic navigation. Under wire assistance in a right pulmonary venous approach, an appropriately sized septal occluder was deployed [Figure 7]b, [Figure 7]c, [Figure 7]d and [Movie 4]. The occluder nicely encompassed the aneurysmal septum. The device had good configuration and position. There was mild residual flow through the inferior margin of the septum which disappeared during the follow-up [Figure 7]e, [Figure 7]f, [Figure 7]g and [Movie 4]. This cases again highlighted the role of TEE as an important supplementary imaging modality for device closure of the multiple ASDs.
Figure 7: (a) Transthoracic echocardiogram of the patient #4 in the subcostal short axis view showing two atrial septal defects with floppy atrial septum [arrows]. (b) Transesophageal echocardiogram with color Doppler in 90 degree view showing two atrial septal defects [green arrows]. (c) Under transesophageal echocardiogram guidance, a wire is advanced through the superior hole [white arrow].(d) Fluoroscopic view [arrow] showing wire assisted septal occluder delivery through the right pulmonary vein approach. (e) Postdeployment echocardiogram showing mild residual flow through the inferior part of the septum which is reduced on follow-up.(f and g) Follow up echocardiogram in parasternal short axis and apical four chamber views showing good device position and good occluder configuration

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[Additional file 4]

Movie 4: (a) Transthoracic echocardiogram of the patient #4 in the subcostal short axis view showing two atrial septal defects with floppy atrial septum. (b) Transesophageal echocardiogram with color Doppler in 90 degree view showing two defects across interatrial septum. (c) Under transesophageal echocardiogram guidance a wire is advanced through the superior hole. (d) Fluoroscopic view [arrow] showing wire assisted septal occluder delivery through the right pulmonary vein approach. (e) Post-deployment echocardiogram showing mild residual flow through the inferior part of the septum which is reduced on follow-up.(f and g) Follow up echocardiogram in parasternal short axis and apical four chamber views showing good device position and good occluder configuration.

Patient # 5

A 28-year-old female, a known case of ASD, presented with a history of mild effort intolerance. The initial TTE showed evidence of significant right atrial and RV enlargement. However, the ASD was found to be relatively small and was unable to explain either the right heart chamber dilatation or the symptoms [Figure 8]a and [Figure 8]b and [Movie 5]. TEE was done to delineate the anatomy which surprisingly showed, in addition to a relatively small secundum defect, an unrestrictive sinus venosus defect [Figure 8]c and [Figure 8]d, [Movie 5]. The sinus venosus defect was not easily demonstrable in the traditional view. The right heart dilatation and symptoms could be easily explained with this double defect. The patient was sent for surgical repair and had a successful surgical recovery. The TEE including the three-dimensional echocardiography helped to identify the etiology of right heart dilatation and helped in management decision.
Figure 8: (a) Transthoracic echocardiogram of the patient #5 in the subcostal short axis view showing evidence of a relatively small atrial septal defect with left to right shunt [white arrow].(b) Apical four chamber view showing significant right atrial [arrow] and right ventricular enlargement.(c) Transesophageal echocardiogram in the bicaval view showing, in addition to a small secundum atrial septal defect [green arrow], a superiorly located sinus venosus atrial septal defect with left to right shunt [red arrow]. (d) Three-dimensional echocardiography delineated both the defects- ostium secundum atrial septal defect and the sinus venosus defect

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[Additional file 5]

Movie 5: (a) Transthoracic echocardiogram of the patient #5 in the subcostal short axis view showing evidence of a relatively small atrial septal defect with left to right shunt.(b) Apical four chamber view showing significant right atrial and right ventricular enlargement.(c) Transesophageal echocardiogram in a bicaval view showing, in addition to a small secundum atrial septal defect, a superiorly located sinus venosus atrial septal defect with left to right shunt.(d) Three-dimensional echocardiography delineated both the defects- ostium secundum atrial septal defect and the sinus venosus defect.

Patient # 6

This lady had a large secundum ASD which was predominantly shunting left to right [Figure 9]a and [Figure 9]b, [Movie 6]. She was taken for hemodynamic evaluation. In cardiac catheterization, her pulmonary artery pressure was moderately elevated (60/20 mmHg with a mean of 30 mmHg). The LVEDP was 20 mmHg at the baseline. The pulmonary blood flow was mildly elated (Qp: Qs ~ 1.54) and pulmonary vascular resistance was in the acceptable range. A balloon was inflated to check hemodynamics under TEE guidance [Figure 9]c, [Movie 6]. The LVEDP increased to 26 mmHg and the patient developed significant symptoms of respiratory distress [Figure 9]d. In view of significantly elevated LVEDP, and symptomatic status, the idea of device closure with the fenestrated septal occluder was abandoned. She was kept on medical follow-up. Thus, imaging and on-table balloon occlusion under guidance of TEE proved crucial for appropriate clinical decision making.
Figure 9: (a) Transesophageal echocardiogram of the patient #6 showing a large superiorly located atrial septal defect. Significant echo contrast is seen in the right atrium [*].(b) Color doppler showing bi-directional flow across the atrial septal defect.(c) Balloon occlusion with an equalizer balloon (arrow) was done under transesophageal echocardiographic guidance which confirmed the appropriate position of the balloon as well as complete occlusion.(d) Post-balloon occlusion, the left ventricular end diastolic pressure increased to 26 mmHg

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[Additional file 6]

Movie 6: (a) Transesophageal echocardiogram of the patient #6 showing a large superiorly located atrial septal defect. Significant echo contrast is seen in the right atrium.(b) Color doppler showing bi-directional flow across the atrial septal defect.(c) Balloon occlusion with an equalizer balloon was done under transesophageal echocardiographic guidance which confirmed the appropriate position of the balloon as well as complete occlusion.(d) Post-balloon occlusion, the left ventricular end diastolic pressure increased to 26 mmHg.

Patient #7

A 63-year-old male presented with a history of effort intolerance. His peripheral oxygen saturation was 96%. Clinically, there were features of cardiomegaly. The second heart sound was wide-split with 2/6 systolic murmur in the left lower sternal border. A detailed echocardiographic evaluation revealed two ASDs. The defects were very close by, and shunting predominantly left to right. The right atrium and the RV were significantly dilated and there was moderate-to-severe tricuspid regurgitation [Figure 10]a, [Figure 10]b, [Figure 10]c and [Movie 7]. The right ventricular systolic pressure assessed from tricuspid regurgitation jet was approximately 75 mmHg. There was, in addition, mild grade II aortic regurgitation and mild mitral regurgitation. The systemic veins were congested [Figure 10]d, [Figure 10]e, [Figure 10]f and [Movie 7]. To delineate the anatomy, a TEE was done. It confirmed the diagnosis and delineated the double ASDs very nicely in different echocardiographic views. There was predominantly left to right shunting with transient right to left shunting during some stages of the cardiac cycle. Three-dimensional TEE beautifully delineated the inferiorly situated two circular holes [Figure 11]a, [Figure 11]b, [Figure 11]c, [Figure 11]d, [Figure 11]e, [Figure 11]f and [Movie 8]. The patient was taken for diagnostic cardiac catheterization. He had moderately elevated pulmonary artery pressure and though pulmonary artery flow was increased, overall pulmonary arterial resistance was also elevated. Hence, he was kept on medical follow-up. Thus, comprehensive assessment of the echocardiographic anatomy supplemented with hemodynamic information helped in decision-making.
Figure 10: (a) Subcostal short axis view of the patient #7 with color Doppler showing an atrial septal defect [white arrows].(b) Apical four chamber view showing moderate to severe tricuspid regurgitation, aneurysmally dilated right atrium and the right ventricle along with atrial septal defect.(c) Tricuspid regurgitation jet continuous wave Doppler suggestive of elevated right ventricle systolic pressure.(d and e) Parasternal long axis view showing grade II aortic regurgitation and mild mitral regurgitation (f) Subcostal siew showing congested inferior vena cava

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Figure 11: Transesophageal echocardiogram of the patient #7 in different views (a-d) showing two, closely located atrial septal defects (arrows) shunting predominantly left to right.(e) Transient right to left shunt seen.(f) Three-dimensional transesophageal echocardiogram showing two closely situated atrial septal defects (arrows)

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[Additional file 7]

Movie 7: (a) Subcostal short axis view of the patient #7 with color Doppler showing an atrial septal defect (b) Apical four chamber view showing moderate to severe tricuspid regurgitation, aneurysmally dilated right atrium and the right ventricle along with the atrial septal defect.(c) Tricuspid regurgitation jet continuous wave Doppler suggestive of elevated right ventricle systolic pressure. (d and e) Parasternal long axis view showing grade II aortic regurgitation and mild mitral regurgitation (f) Subcostal siew showing congested inferior vena cava.

[Additional file 8]

Movie 8: Transesophageal echocardiogram of the patient #7 in different views (a-d) showing two, closely located atrial septal defects shunting predominantly left to right.(e) Transient right to left shunt is seen. (f) Three-dimensional transesophageal echocardiogram showing two closely situated atrial septal defects (arrows).


  Conclusion Top


Clinical imaging is the pillar of success in the device closure of ASD. Detailed analysis of the anatomy as well as the hemodynamics in a patient with ASD is very important in the decision-making and final outcome. A thorough assessment of relevant associated structures like pulmonary veins, mitral and aortic valve, etc., and the pulmonary artery pressure is part of a comprehensive assessment. From preprocedure assessment to intraprocedural guidance and postdevice closure surveillance, echocardiographic imaging shows the light to the operator and ensures a favorable outcome to the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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Abstract
Introduction
Role of Imaging ...
Modalities of Im...
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