Echocardiographic assessment of atrial septal defects

Echocardiography has become the method of choice for the assessment of patients with a known or suspected atrial septal defect. The majority of patients with defects can be identified by this method. In patients with inconclusive transthoracic studies, transesophageal echocardiography is useful for identification or exclusion of a defect. Echocardiography is useful for quantification of left-to-right shunting, identification of associated anomalies, and estimation of pulmonary pressure. Cardiac catheterization can be reserved for patients who require measurement of pulmonary vascular resistance, those who have a significant risk of coronary artery disease, and those with complex congenital heart disease.     

Echocardiographic Guidance of Percutaneous Patent Foramen Ovale Closure: Head‐to‐Head Comparison of Transesophageal versus Rotational Intracardiac Echocardiography

Background: Transesophageal (TEE) and intracardiac (ICE) echocardiography are commonly used to guide percutaneous patent foramen ovale (PFO) closure. The study aim was to perform a head‐to‐head comparison between TEE and rotational ICE echocardiography in the measurement of the fossa ovalis and device selection. Methods: In 45 patients with cryptogenic stroke or peripheral embolism and PFO with large right‐to‐left shunt, fossa ovalis dimensions were assessed preoperatively by TEE and intraoperatively by rotational ICE. The Amplatzer devices, deployed on the basis of ICE, were compared with those that would have been selected by TEE. Results: A good correlation between TEE and rotational ICE was observed for both longitudinal and transverse fossa ovalis dimensions (TEE four‐chamber vs. ICE four‐chamber: r = 0.75; TEE bicaval vs. ICE four‐chamber: r = 0.77; TEE aorta vs. ICE aorta: r = 0.59; P < 0.001 for all). However, no such correlation was found in 13 patients with atrial septal aneurysm (ASA) (TEE four‐chamber vs. ICE four‐chamber: r = 0.33; TEE bicaval vs. ICE four‐chamber: r = 0.49; TEE aorta vs. ICE aorta: r = 0.05; P = NS for all). At Bland‐Altman analysis, slight systematic differences with wide limits of agreement for each comparison were observed, particularly in patients with ASA, suggesting that the two imaging modalities cannot be used interchangeably. As regards device selection, a moderate agreement was found between TEE‐ and ICE‐guided device size (72%, κ= 0.53, P < 0.001), except in patients with ASA (36%, κ= 0.02, P = NS). Conclusions: Our study suggests a significant disagreement between TEE and rotational ICE in measuring fossa ovalis and selecting the device for PFO closure, particularly in patients with ASA.     

Real-time intracardiac two-dimensional echocardiography: an experimental study of in vivo feasibility, imaging planes, and echocardiographic anatomy

The traditional transthoracic and transesophageal echocardiographic examination have proven to be useful imaging tools for studying cardiac morphology, pathology, and function. Recently, catheter-based ultrasound transducers have been available for intravascular ultrasonic imaging. We supposed that echocardiographic examination performed from within the heart itself can provide useful information about cardiac structure and function, especially in settings where transthoracic or transesophageal echocardiography may be technically difficult to perform or poorly tolerated by the patient. To explore this concept, we performed intracardiac echocardiography in vivo in 22 dogs using both 5-MHz and 20-MHz transducers. High-quality images were obtained in all animals. Using the higher frequency transducer, detailed images with only a limited depth of field were obtained. With the 5-MHz transducer, a comprehensive cardiac examination was feasible from within the right atrium and inferior vena cava. We were able to visualize the great vessels, all cardiac valves, and cardiac chambers in a multitude of imaging planes. Alterations in ventricular function were instantly recognized. Color Doppler capabilities allowed visualization of flow abnormalities as well. We conclude that intracardiac echocardiography is feasible and could be potentially useful in certain clinical situations. With further research and development, this technique may have an important clinical impact in cardiac therapy and diagnosis.     

Intracardiac echocardiography: current uses and future directions

Advances in transducer technology have enabled development of catheter-based ultrasound imaging devices that produce very high resolution images of vessels and cardiac structures. Although the majority of clinical use has been in the evaluation of the coronary and peripheral vasculature, a broad spectrum of cardiac applications continue to develop, including evaluations of the ventricles, valves, and great vessels, as well as the guidance of electrophysiological procedures. Specifically, introduction of the ultrasound catheter into the heart results in dynamic, real-time images for assessment and quantitation of ventricular systolic function, severity of valve stenosis, and extent of regurgitant orifices. The intracardiac applications have the potential to become the gold standard for quantitation of valve dynamics and a critical tool in the ICU for prolonged monitoring of cardiac physiology.     

Full performance of modern echocardiography within the heart: in-vivo feasibility study with a new intracardiac, phased-array ultrasound-tipped catheter.

BACKGROUND: Intracardiac echocardiography with full performance of high-resolution two-dimensional-, M-mode-, colour, pulsed and continuous wave Doppler and Doppler tissue imaging has not been previously demonstrated. AIMS: This first European in-vivo study was designed to determine the utility and feasibility of a new ultrasound-tipped catheter for intravascular and intracardiac echocardiography. METHODS: The miniaturized, multi-modal, multiple-frequency (5-10MHz) transducer tipped 10Fr (3.3mm) catheter was tested in five anaesthetized mongrel dogs linked to a standard echocardiographic platform. The catheter was introduced through an 11 Fr femoral venous sheath into the inferior vena cava and right heart chambers and the pulmonary artery under limited fluoroscopic and catheter ultrasound guidance. RESULTS: Abdominal and thoracic aorta as well as their branches, both ventricles and atrias with their appendices, all valves, pulmonary arteries and all veins could be visualized with excellent quality. All Doppler signals and the determined haemodynamics, global and regional wall motion and Doppler tissue imaging were of high diagnostic quality. Coronary flow reserve could also be determined. CONCLUSIONS: Intracardiac echocardiography is feasible and potentially useful for assessing functional and morphological disorders, and probably for the guidance of interventional procedures as well as monitoring of cardiac function. A new window to the heart has been opened.     

Transvascular and intracardiac two-dimensional echocardiography

Recent developments in transesophageal and catheter-based ultrasound instrumentation have allowed invasive ultrasound imaging. This experimental study presents a new application of invasive ultrasound, transvascular and intracardiac ultrasound imaging. In six pigs, we introduced a 7-mm, 5-MHz esophageal ultrasound probe into both the abdominal aorta and inferior vena cava and explored the imaging potential of this approach. Transvascular imaging from the aorta allowed visualization of the various cardiac structures, the neural canal and interspaces, and peritoneal anatomy. Advancement of the transducer to the level of the aortic valve or into the left ventricle yielded images of the cardiac valves and chambers. With transvascular imaging from the inferior and superior vena cava, the aorta, neural canal, pancreas, and liver were well visualized. Intracardiac imaging from the inferior venae cavae and various regions of the right heart, the left heart structures could be visualized. This in vivo feasibility study demonstrates the potential application of transducer-tipped catheters for transvascular and intracardiac imaging.     

Coronary artery fistulas in adults: Incidence,angiographic characteristics,natural history

The incidence, angiographic characteristics, and natural history of coronary artery fistulas in patients undergoing diagnostic cardiac catheterization have not been well defined. Of 33,600 patients who had diagnostic cardiac catheterization, 34 (0.1%) had coronary artery fistula. Nineteen fistulas originated from the right, 11 from the left anterior descending, and 4 from the circumflex coronary arteries, respectively. The mean ratio of pulmonary to systemic flow was 1.19 ± 0.33. Only one patient with coexistent atrial septal defect had a pulmonic to systemic flow ratio >1.5. Right and left heart pressures, with the exception of three patients in whom left ventricular end-diastolic pressure was >12 mm Hg, were within normal limits. During a mean follow-up period of 6.3 years (range 2–14 years), there were no complications related to coronary artery fistula. It was concluded that the incidence of coronary artery fistulas detected during diagnostic coronary angiography is very low. Coronary artery fistulas originate predominantly from the right coronary artery and are not associated with hemodynamic abnormalities or other congenital heart diseases. The prognosis of coronary artery fistulas in adults is good. © 1995 Wiley-Liss, Inc.     

Transseptal left heart catheterisation guided by intracardiac echocardiography

OBJECTIVE—To develop a novel approach of transseptal puncture guided by intracardiac echocardiography and to assess its efficacy.
METHODS—Transcatheter intracardiac echocardiography with a 9 MHz rotating transducer was performed to guide transseptal puncture in 12 patients (mean age 43.1 years, range 31-68) who underwent radiofrequency catheter ablation of left sided accessory pathways. Initially, the echocardiography and transseptal catheters were placed adjacent to each other in the superior vena cava and were withdrawn to the level of the fossa ovalis.
RESULTS—The successful puncture site was associated with visualisation of the fossa ovalis (12 patients, 100%) and the aorta (12 patients, 100%), tenting of the fossa (six patients, 50%), penetration of the needle visualised by the ultrasound catheter (12 patients, 100 %), and echocardiographic contrast material applied in the left atrium (12 patients, 100%). The characteristic jump of the needle onto the fossa ovalis was observed simultaneously with fluoroscopy and intracardiac ultrasound (12 patients, 100%). All procedures were successful. There were no complications associated with the transseptal procedure.
CONCLUSIONS—Intracardiac echocardiography is feasible to guide transseptal puncture. The optimal puncture site can be assessed by simultaneous detection of the characteristic downward jump of the transseptal needle onto the fossa ovalis by intracardiac ultrasound and fluoroscopy.


Keywords: intracardiac echocardiography; transseptal catheterisation     

Use of the monoplane intracardiac imaging probe in high-risk infants during congenital heart surgery

Imaging options are limited in high‐risk infants with small or abnormal oropharyngeal anatomy during congenital heart surgery. Methods: All cases in which the monoplane intracardiac echo probe was used for transesophageal intraoperative imaging over a 15‐month period at a single institution were reviewed. Results: Eleven patients underwent intraoperative imaging using the intracardiac probe. Patient weight ranged from 1.96 kg to 4 kg. Adequate images of the anatomy relevant to the surgical repair were obtained in all cases. No adverse events related to probe use occurred. Conclusion: Transesophageal echocardiography using the monoplane intracardiac echo probe provides safe and effective imaging in patients who are not candidates for standard transesophageal echocardiography.     

Platypnoea-orthodeoxia syndrome in association with an ascending aortic aneurysm.

Platypnoea-orthodeoxia syndrome is a uncommon condition presenting with dyspnoea and cyanosis that are characteristically worse in the upright posture and improved by lying supine. We present the case of a patient with a thoracic aortic aneurysm and a patent foramen ovale who presented with platypnoea-orthodeoxia syndrome. Diagnosis was established using transoesophageal echocardiography. We suggest a mechanism for the development of dyspnoea and hypoxia in patients with this disorder.     

Platypnoea-orthodeoxia syndrome. Diagnosis,etiology, treatment

Platypnoea-orthodeoxia (P.O.) syndrome is the association of dyspnoea and arterial oxygen desaturation aggravated in the erect position and relieved in the supine position. Initially considered very rare (20 cases reported over fifty years) and occurring essentially in patients having undergone pneumonectomy, it in fact occurs much more frequently if only it is looked for (20 extra cases reported in a single year). Some new aetiologies have been described, in particular dilatations or aneurysms of the ascending aorta. Diagnosis is made easier if the oxygen saturation is measured in the supine position when it is normal, and in the erect position when it falls considerably. Another argument is added by the small effect of inspiration of high concentrations of oxygen. Contrast echocardiography confirms the right-left shunt and allows estimation of the site. This is usually situated at the atrial level, via an inter-atrial communication or more often a patent foramen ovale; as a rule the area of dehiscence having been modified by the associated pathology allowing the right-left shunt despite normal right pressures. Exceptionally the shunt is situated at the vascular or pulmonary parenchymal level. Poor tolerance of P.O. syndrome justifies a therapeutic procedure; this is usually closure of the septal fault with an occluder introduced percutaneously; the results are generally highly spectacular.     

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.     

Bilateral coronary artery to left ventricular fistulas

Congenital coronary artery fistulas are important coronary artery anomalies. Bilateral coronary artery fistulas are very rare and coronary artery to left ventricular communications are even more infrequent. This report describes a patient with bilateral right and left coronary artery fistulas draining into a common channel and emptying into the left ventricular cavity.     

Percutaneous closure of an aorta to left atrium fistula with an Amplatzer duct occluder.

We describe percutaneous closure of an unusual paravalvular leak, with a communication from the noncoronary cusp of the aortic valve to the left atrium adjacent to a St. Jude mitral valve prosthesis, in the absence of an infection. The patient presented with worsening dyspnea and edema. The anatomic location of the valve annulus adjacent to the noncoronary cusp underlies the etiology of this communication. Outcomes from surgical repair are associated with high mortality. We performed percutaneous closure of the defect, using general anesthesia and transesophageal echo guidance. An Amplatzer duct occluder was placed in the fistula, with immediate and complete closure of the shunt. While no devices specific for closure of paravalvular leaks have been designed, growing experience with a variety of devices and the use of echo guidance have allowed successful therapy in many complex cases.     

Use of echocardiography as an essential tool for targeted transcatheter biopsy of cardiac masses

Echocardiography has emerged as an essential tool to guide targeted, transcatheter biopsy of cardiac masses. Options for imaging include transthoracic or transesophageal echocardiography and intracardiac echocardiography, with appropriate use being dictated by specific patient characteristics and institutional experience. The authors present a case of three‐dimensional (3‐D) transesophageal echocardiography‐guided transcatheter biopsy of a right ventricular mass and review the current use of echocardiography to guide these procedures.