TTE AND TEE ASSESSMENT

FOR ASD CLOSURE

Dr . Rahul C
Introduction
 Atrial septal defect (ASD) is the second most common
congenital heart disease in adults.

 Approximately 10% of all congenital heart lesions.

 Isolated ASD results from abnormal development of the

septa that partition the common atrium of the
developing heart into right and left chambers.

 70% of ASDs are of the ostium secundum variety.

 The incidence of ASD is approximately 3 per 10,000

live births.
 Embryology
 The interatrial septum forms during the first
and second months of fetal development.

 Stage I is the formation of the septum

primum.

 The septum primum walls off a crescent-

shaped portion of the hole between the right
and left atria.
Foramen primum (also called the ostium
primum) stays open

 The remaining part of the opening between

the right and left atria is closed by the
septum secundum.

 The 2 tissue layers overlap like a flap,

allowing blood flow to continue during fetal
life.

 Changes in circulation at birth, closes the flap

permanently.
Anatomy and Physiology
 Extends from cavo-
atrial junction with
superior and inferior
vena cavae
 Ends near the atrio-
ventricular canal near
the tricuspid valve
 Ostium Secundum
 Most common type of
ASD
 Center of the septum
between the right and
left atrium
 Ostium Primum
 Next most common type

 Located in the lower portion

of the atrial septum.

 Will often have a mitral valve

defect associated with it
called a mitral valve cleft.

 A mitral valve cleft is a slit-

like or elongated hole usually
involves the anterior leaflet of
the mitral valve.
 Sinus Venosus
 Least common type of ASD

 Located in the upper portion of the  ..\asd-veno.jpg

atrial septum.

 Association with an abnormal

pulmonary vein connection

 Four pulmonary veins, two from the

right lung and two from the left lung,
normally return red blood to the left
atrium.

 Usually with a sinus venosus ASD, a

pulmonary vein from the right lung
will be abnormally connected to the
right atrium instead of the left
atrium.

 This is called an anomalous

Foramen Ovale
 Remnant of fetal
circulation
 Behaves like flap valve
 Opens during
increased intra-
thoracic pressure
VARIOUS ECHO MODALITIES
 TTE
 CONTRAST ECHOCARDIOGRAPHY
 TEE
 3D ECHO
 ICE
 4 TYPES
OSTIUM SECUNDUM- 66%
OSTIUM PRIMUM- 15%
SINUS VENOSUS-10%- superior and posterior part
of septum
DEFECTS NEAR CORONARY SINUS
ASD
WHEN TO SUSPECT IN 2D ECHO
 RIGHT VENTRICULAR DILATION
ABNORMAL MOTION OF IVS- brisk anterior
movement in early systole or flattened movement
throughout diastole
 ? IAS DROP OUT IN APICAL 4C VIEW

 RELATIVE ATRIAL INDEX

2D ECHO

RA RV VOLUME OVERLOAD

SEPTAL FLATTENING IN DIASTOLE

RELATIVE ATRIAL INDEX
 Standard apical 4C views- right atrial area divided by left
atrial area

 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.
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

 The role of echocardiography
 Indication – RV – volume load (TTE)

 Screening for feasibility of intervention

 Native ASD size – septal size on LV aspect
 Number of ASD`s
 Position of ASD – rims (aorta, AV-valve, SVC/IVC, right
pulmonary veins)
 Monitoring of the procedure
 Follow-up echocardiography
 Accurate measurement of the defect size plays a key role in
closing ASD using a percutaneous occluder device.

 It is possible to determine the size of the defect by

transesophageal echocardiography (TEE), which is a
noninvasive technique.

 In the literature, it has been emphasized that TEE is a gold

standard in transcatheter closure of ASD and thus should be
used in analyzing septal defect and rims during the process.
 Therefore, using echocardiographic parameters affecting
success of closure may prevent possible complications in
percutaneous closure of ASDs.

 In terms of success, there is no definite ASD size or

predictor as the size of ASD differs from 1 patient to
another.

 Determining other predictors along with the measured ASD

size and evaluating the closure together with such predictors
would increase the chance of success.
 Conventionally, the rims of a secundum ASD are labeled
as
 aortic (superoanterior),
 atrioventricular (AV) valve (mitral or inferoanterior),
 superior venacaval (SVC or superoposterior),
 inferior venacaval (IVC or inferoposterior), and
 posterior (from the posterior free wall of the atria,
coronary sinus rim).
 By conventional definition, a margin 5 mm is considered to be adequate.

 Podnar et al. defined 10 morphological variations of defects,

 the most common type being the defect with deficient aortic rim (42.1%).

 The other variants included

 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%), and
 deficient coronary sinus rim (1%).
SUB COSTAL 4C VIEW
 To go for the subcostal 4C – Keeps the atrial
septum perpendicular to the ultrasound beam
 Distinguishes OS , OP & SV ASDs
 Measurements of the septum can be taken
 Anomalous drainage of pulmonary veins
 Atrial septal aneurysm
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

 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
 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
 SUBCOSTAL 4C VIEW

SUB COSTAL SHORT AXIS

VIEW ALSO SHOWS IVC
DRAINING TO RA AND
EUSTACHIAN VALVE
Other important views
 To visualise SVC- Suprasternal short axis –index marker in
4 o`clock position

 L-SVC is seen from left 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

SUPRASTERNAL SHORT AXIS
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 714-721, July 2010
A-4c view & B-En face view
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
Fig 5

Primum ASD

LV

RV

RA LA

Apical four chamber view demonstrating Colour Doppler flow image from same view
a primum atrial septal defect illustrating left-to-right shunt across the primum
atrial septal defect
CLEFT MITRAL VALVE IN PSAX VIEW POSTERIORLY DIRECTED JET OF MR
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.
Centrally located ASD imaged at
0°
ASD with deficient Aortic margin
Large ASD with deficient posterior and
Aortic margins
Multiple ASDs; larger anterior defect
(block arrow) and a smaller posterior
defect
Sinus venosus ASD

A – INTACT IAS

B- COLOUR DOPPLER SHOWS DEFECT IN THE

UPPER PART OF IAS AT ENTRANCE OF SVC

TEE
Sinus venosus ASD -Color doppler in
TEE
CORONARY SINUS ASD

DILATED CORONARY SINUS

TEE 120 DEGREES
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

COLOUR DOPPLER
 Shows the direction of the shunt

 Caveat- False Positive 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

OS ASD VIA DOPPLER SINUS VENOSUS ASD VIA DOPPLER
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.
 • 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
 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).
RIMS

TEE TTE
TEE
2D TEE at 0 o
 The transesophageal echocardiography (TEE) probe is at the mid-
lower esophageal level.
 The posterior and the mitral rims are best evaluated in this view.
 Rotating the probe to 30° to 40° towards the left will best profile
the aortic (Ao) rim.
 The margins are evaluated by carefully moving the probe in and out
and obtaining sections at various levels.
 At the level of the
 atrioventricular valves (C), the septum forms once again. This
suggests that the ASD is likely to have adequate margins for
catheter closure.
In the highest plane (A), the superior venacaval (SVC)-right atrial
junction and the ascending (Asc) aorta are seen; the atrial septum is
visualized as intact.
At the mid-level (B), the septum breaks and the
margins(posterior and anterior) of the atrial septal
defects (ASD) (arrows) are clearly seen.
At the level of the atrioventricular valves (C), the septum forms
once again.
This suggests that the ASD is likely to have adequate margins for
catheter closure.
TEE at 90° to Evaluate the SVC and
IVC Rims

AORTIC RIM IS SEEN IN

TEE 45 DEGREES
 This view is best for evaluating the SVC and IVC rims.
 The margins are evaluated by rotating the probe while
keeping it at more or less the same level.
 Here the defect is seen with the probe rotated leftward
(B, margins of the ASD shown by the arrows), while
septum is seen to form when the probe is rotated to the
right (A).
 The 45°-view is helpful in assessing the posterior and
the aortic rims and often helps to determine the
maximum size of the defect.
Probe to 30-40o right
Probe rotated o
30-40 left
STOP FLOW METHOD –DEVICE
SIZING
DEVICE SELECTION
TEE IMAGES OF ASD DEVICE CLOSURE
POST PROCEDURE
COMPLICATIONS

RESIDUAL SHUNT POST PROCEDURE

DEVICE MISPLACEMENT
IMPINGEMENT OF THE DEVICE ON AORTIC
ANNULUS- CAN LEAD TO EROSION?
Morphological characteristics of
septal rims affecting successful
transcatheter atrial septal defect
closure in children and adults
Conclusion
 Echocardiography plays a critical role for patient selection,
guidance, and post-deployment evaluation for transcatheter
closure of ASDs.

 Understanding the echoanatomic corelation by

transesophageal echocardiography is perhaps the most
essential requisite to ensure a successful procedure.

 3D echocardiography and ICE (intra-cardiac echo) are

likely to further this understanding in the future especially in
difficult cases like multiple defects and defects with deficient
margins.
THANK
YOU
Natural history of ASD

 Natural history of ASD diagnosed in childhood is that the ASD

diameter when untreated increases in 65% of cases, and 30% will
have more than a 50% increase in diameter.
 Only 4% of ASDs close spontaneously .
 A patient with isolated secundum ASD is often asymptomatic until
the third and fourth decade of life.
 Typical symptoms that ensue include decreased exercise capacity,
fatigue, syncope and palpitations.
 Patients with significant shunting may develop right ventricular
failure, atrial tachycardia, pulmonary hypertension and embolic
events all of which can lead to significant morbidity and potential
mortality.
 The age at which a patient becomes symptomatic is highly variable and
does not correlate well with shunt size .
 The pressure gradient between the two atria and the amount of shunt flow
depend upon both the size of the defect, and the compliance of the right
and left sides of the heart.
 Left untreated over time, even small ASDs can develop increased left-
toright shunting due to progressive increase in left ventricular (LV) diastolic
pressure with aging, which causes increased left atrial pressure.
 In patients who develop pulmonary hypertension (PHTN) from their ASD,
approximately 10% will progress to Eisenmenger’s syndrome.
 Due to the chronic nature of the disease and patient compensation over
time many patients remain unaware of their decreased exercise capacity
and only realize their symptom improvement post procedure .
FOETAL CIRCULATION
CIRCULATION AFTER BIRTH
PATENT FORAMEN OVALE

TEE -0 DEGREE

TEE-90 DEGREES
PFO WITH SECONDARY SEPTUM
Special tee views for Inferoposterior
rims

No Infero posterior rim with probe in normal position

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