Background: The aortic and pulmonary valves are both tricuspid valves. All cusps of the aortic valve can be imaged in the parasternal short-axis view but the pulmonary valve cusps are not routinely imaged during trans-thoracic echocardiography. Methods: We evaluated the feasibility of imaging all three pulmonary valve cusps in the short-axis by a modified parasternal view in 100 consecutive children below the age of 5 years. Results: A satisfactory short-axis imaging of the pulmonary valve was possible in 96 of 100 consecutive children in whom a complete echocardiogram study was performed. This detected abnormalities in the pulmonary valve in 10 children. This included bicuspid pulmonary valves, tricuspid pulmonary valves with unequal cusps, and a quadricuspid pulmonary valve. Visualization of the pulmonary valve permitted preoperative planning of pulmonary valve repair in one infant with a concomitant large ventricular septal defect. Conclusion: An adequate visualisation of the pulmonary valve leaflets by a modified parasternal view during trans-thoracic echocardiography was feasible in a vast majority of young children. The modified pulmonary short-axis view should hence be included as the part of a comprehensive pediatric echocardiographic protocol.

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.

An unrestricted interatrial septal orifice is required in many heart diseases in order to maintain hemodynamics. A variety of interventions have been described to achieve the above goal. This review summarizes each of them briefly. Of these, balloon atrial septostomy and interatrial stenting are the most commonly performed procedures. Echocardiography plays a pivotal role not only in the preprocedural evaluation and patient selection but also in intraprocedural guidance. The outcome of the procedure can also be evaluated immediately by echo on table allowing further attempts or changes in strategy. This review highlights the role of echocardiography in improving accuracy, feasibility, and safety of these procedures.

Patent ductus arteriosus is a common congenital heart disease. The disease has varied presentations, ranging from severe respiratory distress and ventilatory requirements in preterm babies to asymptomatic ducts in older children. Echocardiography is the primary tool for diagnosis and assessment of its hemodynamic significance. The decision on the need for and timing of duct closure is made after integrating clinical and echocardiographic findings. Echocardiography is also utilized for planning percutaneous closure where the size and shape of the duct is key. During transcatheter closure, echocardiography helps assess device placement and impingement of nearby structures. This approach makes arterial access dispensable in experienced hands and is particularly helpful in preterm babies and young infants.

Patent ductus arteriosus stenting has been acknowledged as a reliable alternative to palliative shunt surgeries in neonates with duct-dependent circulation. This procedure is technically challenging and can have serious complications; hence, a thorough evaluation of the case and preprocedural planning is required. Transthoracic echocardiography (TTE) remains the first diagnostic modality for all congenital heart defects. This article focuses on the role of TTE in diagnosis and transcatheter management of duct-dependent lesions.

Aortic valve obstruction accounts for majority of left ventricular outflow tract obstruction. When present in neonatal age group, presentation is more severe and is mostly due to unicomissural aortic valve while at later age, bicuspid aortic valve is the most common cause for aortic stenosis. Echocardiography plays an importance role in the diagnosis and to assess the anatomy for suitability for balloon valvuloplasty. Its role also extends to assess the left ventricle size and function, to diagnose associated lesions and to suggest the suitable plan of management. Echocardiography also plays an important role immediately after balloon dilatation and during follow up to assess adequacy of dilatation and resultant complications. Balloon dilation of bicuspid aortic valves is associated with better outcome and lesser need for reinvention as compared to unicuspid valves.

Aortic arch anomalies are suspected on echocardiography, though the final diagnosis may need additional investigative modalities such as cardiac catheterization, computed tomography angiography or rarely magnetic resonance imaging. Most of the interevntions are however planned on the basis of echocardiography. Suprasternal and subcoastal views are particularly important for evaluation, although other indirect parameters such as pressure effects (ventricular hypertrophy) and ventricular dysfunction etc. may serve as indirect markers of the arch lesion. This review provides an overview of the role of echocardiography in planning aortic arch interventions.

The treatment strategies and timing of corrective or palliative procedures for patients with right ventricular outflow tract (RVOT) obstruction vary depending on the lesion and also on the severity of the patient's symptoms. A wide variety of right heart obstructive lesions ranging from severe valvar pulmonary stenosis, pulmonary atresia with intact ventricular septum, and tetralogy of Fallot can be treated effectively with corrective or palliative interventions in the catheterization laboratory. Interventional procedures to relieve right ventricular outflow obstruction and/or to augment antegrade pulmonary blood flow include balloon pulmonary valvotomy, pulmonary valve perforation, and RVOT stenting. In all these interventions, echocardiography plays an essential role, not only in the preprocedural assessment and case selection but also during the actual procedure in the catheter laboratory. With proper use, a transthoracic echocardiogram can minimize radiation exposure, help in stent positioning in the RVOT, and even detect complications instantaneously. This manuscript reviews the role of echocardiography in transcatheter interventions of the RVOT.

Ruptured sinus of Valsalva (RSOV) aneurysm is a rare but well-known entity. It is a form of left-to-right shunt due to the rupture of aortic sinus into cardiac chambers, more commonly right sided. Hemodynamic effects are acute and severe. Surgical repair of RSOV aneurysm is an established treatment option and is being done with excellent results. Over the last two decades, there are case reports and case seriers describing percutaneous closure of RSOV aneurysm with promising results. Before planning percutaneous closure of RSOV aneurysm, it is imperative to know the detailed anatomy of the defect and its hemodynamic effects and to rule out associated defects requiring surgical intervention. Echocardiography plays a crucial role in defining the lesion in detail and helps in decision-making.

Transcatheter edge-to-edge repair (TEER) has emerged as a viable treatment option for patients with degenerative or functional severe mitral regurgitation (MR) who are at high risk for mitral valve surgery but have mitral valve anatomy suitable for TEER. The MitraClip and Pascal repair system are the two TEER devices currently approved for clinical use for transcatheter treatment of MR in selected patients. Of these two, the MitraClip has become a more established modality for TEER and is currently available in India. This review describes the role of echocardiography in patient selection and procedural guidance during TEER with MitraClip.

The recent technical advances have revolutionized the field of percutaneous structural heart disease interventions. Multimodality imaging is pivotal to the success of these procedures and echocardiography is an integral part of this imaging. Echocardiography is essential for preprocedural evaluation as well as postprocedure assessment and follow-up of all such patients. In addition, for mitral valve interventions, echocardiography is also indispensable for intra-procedural guidance, although its role in guiding transcatheter aortic valve replacement (TAVR) has diminished lately. A thorough understanding of echocardiography, especially for valvular assessment, and a high level of expertise in intraprocedural imaging are necessary for facilitating these procedures. This review describes the role of echocardiography in guiding TAVR and transcatheter mitral valve-in-valve replacement- the two most commonly performed percutaneous valve replacement procedures at present.

Transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve replacement (TMVR) are catheter-based interventional techniques for treating patients having high risk for surgical aortic or mitral valve replacement, respectively. While TAVR is a technique for treating severe aortic stenosis, TMVR is primarily used for treating mitral regurgitation. Echocardiography is the initial imaging modality used for a detailed assessment of the mitral and aortic valve lesions. Multidetector computed tomography (MDCT) is then used as a complementary tool to provide additional information essential for pre-procedure planning. High spatial resolution and good temporal resolution of MDCT along with multiplanar reconstruction technique permit a comprehensive assessment relevant for the multiple aspects of preprocedural planning. The current article outlines the MDCT acquisition protocols, reconstruction techniques, and assessment of various essential parameters for TAVR and TMVR.

Transesophageal echocardiography (TEE) has unique advantages over conventional transthoracic echocardiography (TTE). Compared with TTE, TEE generally provides excellent quality images, especially of the posteriorly situated cardiac structures, such as atria, pulmonary veins, mitral valve, and left atrial appendage. TEE also offers a useful alternative to TTE in patients in whom transthoracic acoustic windows are suboptimal. Furthermore, TEE is the most suited imaging modality for use in the operating rooms and cardiac catheterization labs for guiding cardiac surgical or interventional procedures. However, specific training and competence are required for performing TEE successfully, smoothly, safely and with minimum patient discomfort. This document describes the basic principles of TEE examination, including patient selection and preparation, periprocedural monitoring, and probe handling and maneuvers. Commonly recommended views and the techniques to obtain these views are described in detail, followed by evaluation of specific cardiac structures. Finally, the role of TEE in certain specific clinical settings, such as during advanced circulatory support, is also discussed.

Alcohol septal ablation (ASA) is an effective treatment for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). Although routine use of myocardial contrast echocardiography (MCE) in guiding ASA has been recommended by guidelines, it has not come into common clinical practice. Here, we present three cases of HOCM where MCE helped in decision-making.