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2/12/2018
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Roberto M Lang, MD
2D/3D in Evaluation of Atrial Septum
OSTIUM SECUNDUM ASD: 2D AND 3D TRANSESOPHAGEAL ECHO
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3D Acquisi on Lang RM et al. JASE 2012;25:3‐46.
Biplane views
Acquire 3D volume
3D Display
Display with right upper pulmonary vein at 1 o’clock posi on
Le atrial view Right atrial view
Display with superior vena cava at 11 o’clock posi on
Rotate to en face le atrial view
90° 0°
P
SR
A
SL RA viewLA view
SVC
AoAo
AS
AS
IVC
LAA
RPV
PFO
Inter-atrial Septum – Data Acquisition
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Johri A. Heart 2011;97:1441e1453
Patent foramen ovale (PFO)
THE PATENT FORAMEN OVALE (PFO)
Ao
ASLAA
RPV
PFO
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IAS
FO
MV
LV
90 %
Sugeng L, Lang RM; J Am Coll CardiolLA View
Inter-atrial Septum
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Patent Foramen Ovale
LA view
LV view
IAS
PFO
Right atrial perspective
Left atrial perspective
Patent Foramen Ovale
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SUBTYPES OF ATRIAL SEPTALCOMMUNICATIONS
J Am Soc Echocardiogr 2015;28:910-58
2 - 3%
80-90%
2 - 3%
2 - 3%
<1%
Ostium secundum ASD
Johri A. Heart 2011;97:1441e1453
Ostium Secundum
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OSTIUM SECUNDUM ASD: TRANSTHORACIC ECHOCARDIOGRAPHY
Apical 4-chamber
Parasternal SAX Subxyphoid LAX
• The IAS is parallel to the US beam in the apical 4-CH view and PSAX view
• The preferred view for imaging/measuring the IAS on TTE is the subcostal view. Here the IAS is perpendicular to the US beam
TRANSTHORACIC ECHOCARDIOGRAPHYFOR INTER-ATRIAL SEPTAL DEFECTS
Agitated saline + maneuvers to increase RA pressures (Valsalva, cough)• ASD Microbubbles appear in
the LA < 3-6 heart beats• Intra-pulmonary shunting
Bubbles appear > 3-6 heart beats (confirmed if bubbles seen in pulmonary veins)
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ASD size and dynamic natureASD shapeRimsPresence of fenestrationsPresence of an ASAASD type ASD location
ASD CHARACTERISTICS THAT SHOULD BE REPORTED
SVC
TV
AO
ASD: Surgeons View
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Small Large
Oval
Round
OSTIUM SECUNDUM ASD: 3D TEE
Atrial diastole Atrial systole
Change in size over cardiac cycle3D full volume right side view
RV RV
PAPA
AoAo
A
S
L
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IVCIVC
SVCSVC
TVTV
AOAO
4CH
SAX
LAX
2D TEE
COMPLEX ASD SHAPE: INACCURATE ASSESSMENT WITH 2D IMAGING
MPR quantitation
X
YZ
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Apical 4-chamber
3D zoom: RA perspective
ASD’s : TTE
OSTIUM SECUNDUM ASD: 3D TRANSTHORACIC ECHOCARDIOGRAPHY
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ASD size and dynamic natureASD shape
Presence of fenestrationsPresence of an ASAASD type ASD location
ASD CHARACTERISTICS THAT SHOULD BE REPORTED
TEE 4CH: AV rim
TEE 4CH: Posterior rim TEE MESAX: Aortic rim
ME Bi-Caval: SVC rim
TEE LE: CS rim
ME Bi-Caval: IVC rim
Sobrino A. Arch Cardiol Mex 2012;82(1):37-47
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SVC
IVC
ASD
1
2
34
5
RA en face view LA en face view
Secundum ASD rims: 1.SVC 2. Aortic 3. AV 4. IVC 5.RPV
ASD
LPVRPV
MVLV
Ao5
2
43
1
A
SL
P
SR
5A
LA
RA
SVC RPA
*
SVC
IVC
Ao
SVC
CS
RPV
AoSVC
IVC
*
*
**
S
A
I
R
Secundum ASDRim deficiencies
superior aortic
RPVinferior
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ASD size and dynamic natureASD shapeRims
Presence of an ASAASD type ASD location
ASD CHARACTERISTICS THAT SHOULD BE REPORTED
EHJCi 2011
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COMPLEX ASD REPAIR
COMPLETE ASSESSMENT OF THE INTER-ATRIAL SEPTUM IS IMPORTANT
1. Device deployed2. Residual shunt3. Fenestrations
12
3
RA
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COMPLETE ASSESSMENT OF THE INTER-ATRIAL SEPTUM IS IMPORTANT
ASD size and dynamic natureASD shapeRimsPresence of fenestrations
ASD type ASD location
ASD CHARACTERISTICS THAT SHOULD BE REPORTED
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ATRIAL SEPTAL ANEURYSM
Redundancy or saccular deformity of the atrial septum associated with increased mobility. Defined as an excursion of 10 mm from the plane of the atrial septum into the RA or LA
or a combined excursion right and left of 15 mm
ATRIAL SEPTAL ANEURYSM
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ATRIAL SEPTAL ANEURYSM
Amplatzer device closure
ATRIAL SEPTAL ANEURYSM
1 day post device closure
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RT3DE TEE GUIDANCE OF ASD CLOSURE
FD
LA
Left atrial disc
Delivery system
RA I
IE
Delivery system
RALA
Left atrial disc
Right atrial disc
F
Right atrial disc
Left atrial disc
LA
RA
IAS
C
LARA
Delivery systemLeft atrial disc
IAS
A
IAS
LA
ASD
RA
B
Guide wire
IAS
PERI-INTERVENTIONAL 3D TEEPFO CLOSURE
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ASD size and dynamic natureASD shapeRimsPresence of fenestrationsPresence of an ASA
ASD CHARACTERISTICS THAT SHOULD BE REPORTED
B
D
LA
RARA
RV
LVOT
Occluder
C
E
RARA
RV
LA
LVOT
TV
A
Gerbode Defect
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Partial/complete absence of sinus venosus septum between
SVC and the right upper pulmonary vein (SVC type)
Right lower and middle pulmonary veins and the RA (IVC type)
SINUS VENOSUS ASD
SINUS VENOSUS ASD
An sinus venosus septal defect can be difficult to detect on TTE
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SINUS VENOSUS ASD
An sinus venosus defect can be identified on TEE by the absence of the atrial septum immediately beneath the orifice of the SVC
SUPERIOR SINUS VENOSUS ASD
MRI - Coronal
MRI - Axial
3D
SVC
RUPV
RA
RV
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LA
RA
CS
TEE Color Doppler
Surgical Left Atrium View
CS
LARA
AAO
Cardiac CT
CSLA
RV
3D TEE Right Atrium View
TV
Surgical Right Atrium View
CSLA
RA
CS
3D TEE Left Atrium View
MV CS
LV
RA LA
RA
Normal Abnormal
LARA
CSCS
LARA
Defect
AoAo
CARDIAC CT: UNROOFED CORONARY SINUS DEFECT
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RV
RA
CSDefect
UNROOFED CORONARY SINUS DEFECT: TRANSTHORACIC ECHOCARDIOGRAPHY
Wall of the coronary sinus in the LA is deficient or absent
4-chamber view
1000
RA
RA
RA
LA
LA
CS
Defect
RVRV
UNROOFED CORONARY SINUS DEFECT: 2D TRANS-ESOPHAGEAL ECHO
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3D TEE: THE UNROOFED CORONARY SINUS FROM LEFT TO RIGHT
Defect
CS
RA
LA
THE OPERATING ROOM
