Double atrial septal defect: diagnosis and closure guidance with 3D transesophageal echocardiography

Atrial septal defect (ASD) is a common form of congenital heart disease that often persists well into adulthood before discovery or intervention. The authors report the case of a patient referred for routine percutaneous ASD closure that was found on three-dimensional (3D) transesophageal echocardiography to have two large separate ostium secundum defects which were subsequently closed under 3D echocardiographic guidance.     

Atrial Septal Occluder Device Embolization to an Iliac Artery: A Case Highlighting the Utility of Three‐Dimensional Transesophageal Echocardiography during Percutaneous Closure

Percutaneous closure of secundum atrial defects has become an accepted treatment in part because it is minimally invasive and relatively low risk. Despite recent advances in implantation technique and device improvements, complications occur. Here, we report a case of device embolization during percutaneous repair of an atrial septal defect (ASD) with multiple fenestrations. We highlight the value of using live/real time three‐dimensional transesophageal echocardiography to help plan the percutaneous procedure and detect complications.     

Look before you close: atrial septal defect with undiagnosed partial anomalous pulmonary venous return.

The growing and continued success of percutaneous closure of atrial defects is related to its high benefit-to-risk ratio in appropriately selected patients. The following case illustrates a previously undocumented danger, namely, the potential for incomplete correction. A thorough transesophageal examination performed at the time of the planned atrial defect closure suggested the presence of a partial anomalous pulmonary vein insertion, which was then appropriately documented and the incomplete closure was averted.     

Transcatheter closure of a large atrial septal defect under microprobe transesophageal echocardiographic guidance

We present a case of an atrial septal defect (ASD) in a 59-year-old man with an indication for ASD closure who also had a history of chronic obstructive pulmonary disease. Because of his decreased respiratory function with multiple bullae in his lungs, the procedure was performed without general anesthesia under the guidance of fluoroscopy and two-dimensional (2D) transesophageal echocardiography (TEE) using a transesophageal echocardiographic microprobe (micro-TEE) (S8-3t; Philips Medical Systems, Andover, MA, USA). The micro-TEE probe was inserted into the esophagus smoothly and easily in the supine position without sedation. It revealed a deficient superior-anterior rim and adequate rims elsewhere, and the maximal diameter of ASD was measured to be 25 mm. Balloon sizing resulted in a stretched defect diameter of 29 mm using the stop-flow technique. A 30-mm AMPLATZER Septal Occluder (AGA Medical, Plymouth, MN, USA) was deployed. The micro-TEE demonstrated that both disks were on the appropriate sides of the interatrial septum and the device was not interfering with surround cardiac structures. Residual shunt flow was not detected with color Doppler. The device was released successfully without any complications. Recently introduced multiplane micro-TEE can provide adequate information about a large ASD with a less invasive procedure in adult patients. Micro-TEE has a potential to become a novel imaging option for interventions of the interatrial septum.     

Complex Atrial Septal Defect: Percutaneous Repair Guided by Three‐Dimensional Echocardiography

Three‐dimensional transesophageal echocardiography (3D TEE) has been used to guide the percutaneous repair of simple atrial septal defects (ASDs). There has been limited experience in using this imaging modality to guide complex ASD repair. In this report, we describe how 3D TEE was used to guide the repair of a complex, multifenestrated ASD. In a single view, 3D TEE provides a superior anatomic definition when compared to the traditional two‐dimensional echocardiography. We believe that this emerging technology will play a critical role as the number and complexity of percutaneous techniques treating structural heart disease continue to rise. (Echocardiography 2010;27:590‐593)     

Three‐Dimensional Echocardiography Guided Closure of Complex Multiple Atrial Septal Defects

Transcatheter closure of complex multiple atrial septal defects (ASDs) remains a challenge. We describe our clinical experience with staged device deployment in a patient with multiple ASDs using four Amplatzer septal occluder devices. Three‐dimensional transesophageal echocardiography imaging contributed not only to the therapeutic guidance of successful device deployment but also to the decision making for the staged device delivery approach in a case of morphologically complex multiple ASDs.     

Real time three‐dimensional transesophageal echocardiography imaging of crescent‐shaped superior sinus venosus atrial septal defect

Multi‐imaging modalities should be considered in patients with atrial septal defects (ASDs) in which the degree of right ventricular enlargement is not fully explained by the small size of ASD found on conventional transthoracic echocardiography. We report a case of crescent‐shaped superior sinus venosus ASD discriminated using real‐time three‐dimensional transesophageal echocardiography. MDCT confirmed its relationship with the superior vena cava and the absence of combined anomalies, such as the pulmonary venous return anomaly.     

Transcatheter closure of atrial septal defect without balloon sizing

Objective: To evaluate the safety and feasibility of transcatheter closure of atrial septal defect (ASD) without balloon sizing. Methods: A total of 243 patients (group I), aged 2.1–76 years (median 22 years), underwent transcatheter closure of ASD without balloon sizing. The maximal diameter of the defect was measured on transesophageal echocardiographic (TEE) images. The size of device selected was generally 4–6 mm and 5–8 mm larger than the maximal diameter, if the defect was <14 mm and ≥14 mm, respectively. The results of ASD closure in group I were compared with those of 271 patients (group II, median age 11 years) who underwent ASD closure with balloon sizing prior to the study period. Results: Of the 243 patients in group I, the maximal defect diameter ranged from 5.2 to 37 mm (mean 17.5 ± 6.6 mm, median 17 mm). A total of 247 Amplatzer septal occluders were deployed in 240 patients. Two patients were found to develop distal embolization of a device the next day. Therefore, failure occurred in five patients. Comparing the results between group I and group II, there was no significant difference in success rate (238/243 vs. 263/271), incidence of embolization (2/243 vs. 2/271) and complete closure rate at 3‐month follow‐up (94.1% vs. 95.8%). There is significant difference in mean age (26.6 ± 20.2 vs. 19.1 ± 17.6), maximal defect diameter (17.5 ± 6.6 vs. 14.1 ± 5.9 mm) and Q_p/Q_s ratio (2.77 ± 1.11 vs. 2.48 ± 0.97) between group I and II. The mean diameter of device used was significantly larger in group I than in group II (23.1 ± 8.1 vs. 19.6 ± 7 mm, P < 0.001). Conclusions: Balloon sizing may not be necessary in transcatheter closure of ASD. © 2008 Wiley‐Liss, Inc.     

Large Esophageal Hematoma Following Transesophageal Echocardiography‐Guided Device Closure of Atrial Septal Defect

A 47‐year‐old woman with a large ostium secundum atrial septal defect (ASD) and severe pulmonary artery hypertension underwent device closure of ASD under transesophageal echocardiography guidance. She developed a massive esophageal hematoma which was diagnosed 4 days after the procedure. The use of dual antiplatelets after the device closure further aggravated the hematoma. As the patient remained stable and the site of leak could not be identified by contrast studies, she was managed conservatively with nil per mouth, broad‐spectrum antibiotics, and continuous nasogastric aspiration. We were faced with the risk of thromboembolism after stopping antiplatelets versus the risk of increasing peri‐esophageal hematoma if they were continued. With careful monitoring for thrombus formation on the device, the antiplatelets were stopped and the hematoma resolved. The hematoma resolved by 10 days, and the antiplatelets were restarted gradually. Iatrogenic esophageal injury is an important cause of esophageal perforation, which is a condition with high mortality and morbidity. Esophageal perforation following device closure of ASD is particularly challenging as the scenario is worsened by the use of antiplatelets and they have to be discontinued with the attendant risk of thromboembolism.     

Transgastric: A forgotten view for atrial septal defect device closure procedures?

Percutaneous closure of an atrial septal defect in the cardiac catheterization laboratory requires noninvasive imaging to assist in characterization of the atrial septal defect and deployment of the device. Transesophageal echocardiography is the modality most often used in these circumstances. Transesophageal echocardiographic guidelines exist for the assessment and guidance for atrial septal defect closures, but these guidelines do not mention transgastric views. In this case, we demonstrate that transgastric views are helpful in describing the atrial septal defect, especially as it concerns the inferior vena cava rim.     

Incremental Value of Live/Real Time Three‐Dimensional over Two‐Dimensional Transesophageal Echocardiography in the Assessment of Atrial Septal Pouch

An atrial septal pouch (ASP) results from partial fusion of the septum primum and the septum secundum, and depending on the site of fusion, the pouch can be left‐sided (LASP) or right‐sided (RASP). LASPs have been described in association with thrombi found in patients admitted with acute strokes, raising awareness of its potential cardioembolic role, especially in those with no other clearly identifiable embolic source. We retrospectively studied 39 patients in whom the presence of an ASP had been identified by three‐dimensional transesophageal echocardiography (3DTEE) and who had a two‐dimensional transesophageal echocardiogram (2DTEE) performed during the same clinical encounter. The incremental value provided by 3DTEE over 2DTEE included the detection of six ASPs not found by 2DTEE; the detection of two ASPs in the same subject (in four patients) not identified by 2DTEE; larger ASP measurements of length and height in over 80% of the cases; and measurement of the ASP width (elevational axis) for the calculation of the area of the ASP opening, because of its unique capability to view the pouch en face. In addition, the volume of ASP and of the echogenic masses contained in the ASP (four of 39 patients) could be calculated by 3DTEE, which is a superior parameter of size characterization when compared to individual dimensions. One of these patients who presented with ischemic stroke diagnosed by magnetic resonance imaging had a large (>2 cm) mass in a LASP, with echolucencies similar to those seen in thrombi and associated with clot lysis and resolution. This mass completely disappeared on anticoagulant therapy lending credence that it was most likely a thrombus. There was no history of stroke or any other type of embolic event in the other three patients with masses in ASP. In conclusion, this retrospective study highlights the incremental value of 3DTEE over 2DTEE in the comprehensive assessment and characterization of ASPs, which can aid in the clarification of their role in cryptogenic stroke patients.     

Role of Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Percutaneous Epicardial Closure of the Left Atrial Appendage

We are reporting the use of three‐dimensional transesophageal echocardiography as a supplement to two‐dimensional transesophageal echocardiography in the percutaneous suture closure of the left atrial appendage.     

Depicting of a Cleft Mitral Valve by Real Time Three‐Dimensional Transesophageal Echocardiography

We report the usefulness of real time three‐dimensional transesophageal echocardiography in comprehensive delineation of cleft mitral valve. This new technique may be a useful supplement to two‐dimensional and three‐dimensional transthoracic echocardiography in the assessment of this pathology. (Echocardiography 2010;27:356‐358)     

Multiplane Transesophageal Echocardiographic Detection of Sinus Venosus Atrial Septal Defect

We present two case reports of diagnosis and evaluation of sinus venosus atrial septal defects by multiplane transesophageal echocardiography.     

常用超声介导房间隔缺损封堵方法的优缺点比较

房间隔缺损是一种常见的先天性心脏病,经皮房间隔缺损封堵术是全世界首选的微创外科修补治疗方法.超声介导是经皮房间隔缺损封堵术中最重要的技术环节.目前,经食道超声心动图是最常用的超声介导方法,另外,经胸超声心动图以及心腔内超声也在运用.现试从经胸超声心动图、经食道超声心动图及心腔内超声的影像学特点、检查安全性,及并发症、检查费用等方面对上述三种方法进行比较.