1. ECHO ASSESSMENT OF ATRIAL SEPTAL DEFECT
DR JULIAN JOHNY THOTTIAN

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

3. SINUS VENOSUS-10%- superior and posterior part of septum
4 TYPES
OSTIUM SECUNDUM- 66%
OSTIUM PRIMUM- 15%
SINUS VENOSUS-10%- superior and posterior part of septum
DEFECTS NEAR CORONARY SINUS
OSTIUM SECUNDUM- MIDDLE OF ATRIAL SEPTUM
OSTIUM PRIMUM – LOWER PART OF ATRIAL SEPTUM

4. ASD

5. 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

6. 2D ECHO
RA RV VOLUME OVERLOAD
SEPTAL FLATTENING IN DIASTOLE

7. RELATIVE ATRIAL INDEX
Standard apical 4C views- right atrial area divided by left atrial area
ROC curve analysis - 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.

8. 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 Volume 23, Issue 3 , Pages , March 2010

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

10. 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

11. 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

12. 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

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

14. Other important views
To visualise SVC- Suprasternal short axis –index marker in 4 o`clock position
L-SVC is seen from lt 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

15. SUPRASTERNAL SHORT AXIS

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

17. 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 , July 2010

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

19. 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

20. Primum ASD Fig 5 Apical four chamber view demonstratingLV RV RA LA
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

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

22. 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.

23. Centrally located ASD imaged at 0°

24. ASD with deficient Aortic margin

25. Large ASD with deficient posterior and Aortic margins

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

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

29. CORONARY SINUS ASD
DILATED CORONARY SINUS
TEE 120 DEGREES

30. 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

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

32. PFO WITH SECONDARY SEPTUM

33. COLOUR DOPPLER Shows the direction of the shunt
Caveat- FP 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

34. OS ASD VIA DOPPLER
SINUS VENOSUS ASD VIA DOPPLER

36. 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.

37. 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

39. 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).

40. IVC AND SVC RIMS

41. OTHER RIMS
TTE
TEE

42. TEE 2D & 3D

43. 2D TEE at 0o

44. TEE at 0° to Evaluate the Posterior and Anterior Rims of the Defect- SVC RAA level

45. TEE at 0° to Evaluate the Posterior and Anterior Rims of the Defect- mid septum level

46. TEE at 0° to Evaluate the Posterior and Anterior Rims of the Defect- At the level of the AV valves atrioventricular valves

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

48. Probe to 30-40o right

49. Probe rotated 30-40o left

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

51. 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 70-90o view

52. STOP FLOW METHOD –DEVICE SIZING

53. DEVICE SELECTION

54. TEE IMAGES OF ASD DEVICE CLOSURE

55. 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

56. 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

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

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

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

60. ATRIAL SEPTUM ANEURYSM
WITH ASD
MULTIPLE ASDs

61. DEFECT NEAR THE IVC

62. 3D echo- En face 3D reconstruction of a secundum ASD with a relatively deficient IVC and posterior rim

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

64. Measuring the ASD Images Paediatr Cardiol. 2011 Jul-Sep; 13(3): 1–18.
Three-dimensional trans-esophageal Echocardiographic Evaluation of Atrial Septal Defects: A Pictorial Essay
Vinay K Sharma, S Radhakrishnan, and S Shrivastava

65. Deployment of ASD device

66. INTRACARDIAC ECHO(ICE)
9-10MHz frequency
TWO TYPES- ROTATING AND PHASED ARRAY
ROTATING TYPE -9F ,9MHz PHASED ARRAY MHz
ROTATING – 360o ALONG THE TRANSVERSE PLANE & DEPTH OF IMAGING 5CM
PHASED ARRAY MHz, SECTOR OF 90o DEPTH OF IMAGING 12CM
SHEATH SIZE 8F,9F,10F

67. IAS between RA & LA Long axis view
Tenting of IAS (long arrow) by needle (short arrow) approaching it from right atrium (RA)

68. Measurement of ASD size along long axis
Balloon stretched diameter

69. ADVANTAGES Assess ASD size and rims Pulmonary veins assessment
Position of sheath and guide wire can be determined.
Additional defects can also be assessed
Plan for closure

70. POST PROCEDURE COMPLICATIONS
RESIDUAL SHUNT POST PROCEDURE

71. DEVICE MISPLACEMENT

72. IMPINGEMENT OF THE DEVICE ON AORTIC ANNULUS- CAN LEAD TO EROSION?
CONCEPT OF `MINNESOTA WIGGLE`

73. DEVICE DISLODGEMENT AND ATTEMPETED SNARING

76. 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)

77. THANK YOU

78. MCQ

79. QUESTION 1 To view the IVC rim better we need to keep the TEE probe in
Neutral position in mid esophagus
Anteflexed position in mid esophagus
Retroflexed position in stomach
Neutral position in high esophagus

80. QUESTION 2 Cleft mitral valve is seen in
PSAX with index marker at 12 o` clock position
PSAX with index marker at 4 o` clock position
Subcostal short axis at 12 o` clock position
Subcostal short axis at 12 o`clock position

81. QUESTION 3 Enface view of ASD in 2D echo is seen in Apical 4c view
Parasternal short axis view
Subcostal short axis
Right parasternal view

82. QUESTION 4 Most common type of ostium secundum ASD
Deficient aortic rim
Central defect
Deficient posterosuperior rim
Combined deficient mitral and aortic rim

83. QUESTION 5 ATRIAL SEPTAL ANEURYSM- FALSE IS
a) Protrusion of aneurysm at least 15mm
b) IAS showing 15mm of phasic excursion during cardiorespiratory cycle
C) Base WIDTH≥ 15MM
D) RA/ RV overload should always be demonstrated

84. QUESTION 6 IVC rim and SVC rim is evaluated in (TEE) mid esophageal

85. QUESTION 7 Posterior and anterior rims are assessed in (TEE) 0o 50o

86. QUESTION 8
Relative atrial index - A cutoff value of predicted patients with ASDs v/s matched controls with 99.1% sensitivity and 90.5% specificity
0.78
0.92
0.62
0.52

87. QUESTION 9 Maximum diameter of ASD is in Early systole Late systole
Early diastole
Late diastole

88. QUESTION 10 Aortic rim In TEE is seen in Mid esophageal 0o
Gastroesophageal jn retroflexed