SHA24/004002

Echocardiographic Assessment of Adults Atrial Septal defect Congenital Heart Disease

Dr Mohammad Daud Khan Director of Paed & ACHD Catheter Intervention Sheikh Khalifa Medical City, Cleveland Clinic, Abu Dhabi, U.A.E

Echo Assessment of ASD • This talk..

• Types of ASD & Atrial Septum • Rims, Margin & Location of ASD • The Role Trans oesophageal Echocardiography in ASD • Few Cases- different types ASD • 3-D & Ice if time permit…

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Echo Assessment of ASD • Initial Transthoracic Scan in clinic Poor subcostal windows in Adults?

• Trans Oesophageal Echocardiogram Most informative 2-D, 3-D & 4-D • Intra Operative TOE 2-D, 3-D for assessment / intervention • Post Operative TOE

Echo Assessment of ASD Types of ASDs • Secundum Septal defects- ASD • Fenestrated & Windsock ASD • Coronary Sinus ASD • Sinus Venosus ASD • Aneurysmal AS with ASD / PFO • High / Low / Ant / Sup / Inf / Ant-sup / Post- inf / etc • Mixed variety

Echo Assessment of ASD What to Assess & Look • • • • • • • • • •

The Functional Integrity & Flow The Normal Atrial Septum / Septal length Thick / Thin / Aneurysm / floppy Atrial Septum Muscular septa ( Asso with thrombus ) Thrombus / clots in Appendages Flow in Pul vein, MV, TV, SVC, IVC, TR & CS Vent Function, Size of all Chambers, Eust Valve Any other anomaly need to look? Ebs Number / diameter of the defects Misc.

Echo Assessment of ASD

Echo Assessment of ASD •

Echo Assessment of ASD / PFO •

Think of Ant Defects in close proximiy with Aortic root

Echo Assessment of ASD • Gg

Echo Assessment of ASD • Write as u

Echo Assessment of ASD • Write as u

Echo Assessment of ASD • Write as u

OEcho Assessment of ASDVAL

Echo Assessment of ASD • From R At side and Lt at side

Echo Assessment of ASD • The Intra Operative TOE • All the margins, location, number • • • •

Balloon sizing & residual shunt Change in the cardiac struc / Function Mechanical & closure rates Pericardial effusion / Temponade

• Device position ( nearby damage )

• Thrombus / clots / perforation • Migration / embolisation • Misc.

Echo Assessment of ASD •

Echo Assessment of ASD • TOE Different views for ASD Assessment

Audit on Cardiac Catheter at SKMC •

More Views

Echo Assessment of ASD Rims around the defect

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 Posterior-inferior (towards the IVC)

 Posterior-superior (towards the SVC)  Inferior (towards the AV valves)  Anterior-superior (towards the aorta)  Superior (to the PVs)  Towards –C Sinus

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Echo Assessment of ASD ďƒ˜

Rims around the defect

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Echo Assessment of ASD •

ASD ( O S ) Good Rims

Echo Assessment of ASD

Fenestrated ASDs & E V! •

Beware Eus Valve

Echo Assessment of ASD • Large ASD with Reasonable IVC Rim

Echo Assessment of ASD

Echo Assessment of ASD •

Large ASD near to deficient Coronary sinus rim

ASD deficient Aortic Rim •

ASD deficient Aortic Rim

ASD deficient Aortic Rim •

Device Closure

Echo Assessment of ASD Surgery in 100% of pts with absent or truly deficient     

IVC rim SVC rim superior rim (PVs rim) coronary sinus rim inferior (AV valves) rim

 Deficient Anterior rim (aortic rim):

TC device Closure generally feasible

Large ASD deficient Ant Rim • Device “pops” through the defect • common issue with large ASD and deficient anterior rim • Large ASD with deficient anterior rim

Echo Assessment of ASD • •

Deficient Inferior rim

3-D echo Assessment of ASD • Why bother ?

• One of the fundamental aims of 3D echocardiography is to gain increased understanding of cardiac morphology • Ideally this would translate into better outcome from intervention / surgery • 3D intra-operative echo has major attractions – High quality 3-D images • No patient movement Patient under GA – • No respiratory artefacts Temporary interruption of ventilation – • Cardiologist / Surgeon in the same room

3-D echo Assessment of ASD • Practicalities for intra-operative studies • • • • • •

Operator who will value this information Surgeon or cardiologist /physiologist to Obtain datasets Cardiologist familiar with 3-D model Reconstructions Needs to be rapid & accurate

3-D echo Assessment of ASD • Limitations at present • Technical • Probe frequency Now resolved

• Highest possible frame rates Higher than previously

• Small footprint Resolved with paediatric probe

• Personnel • Not all staff are trained in 3D / 4D yet • Intra operative studies need an experienced operator • Interpretation in short time frame • Senior level discussion regarding decision

Large ASD deficient IVC Rim •

Deficient IVC Rim

Echo Assessment of ASD •

Intracardiac echocardiography ( Ice )

Echo Assessment of ASD • Intracardiac echocardiography ( Ice )

Echo Assessment of ASD

Conclusions Absent Aortic Rim is usually not a problème for closing ASD

Echocardiography has limitations in évaluation the IVC rim Balloon sizing is very useful to understand tissue

characteristics and size The Role of 3-d & Ice is very helpful if available.

« If there is a waist there is a way! »

EROSION Amin Z et al Catheter Cardiovac Interv 2004;63:496 25/28 ( 89%) deficient anterior superior rim

- RA roof - Aorta -

LA roof - Aorta RA and LA roofs Aortic-atrium fistula RUPV Site not identified

Mean device size 8 mm > ASD size (not stretched)

6 12 1 3 1 5

Know your limits!

Audit on Cardiac Catheter at SKMC • Write as u • Remove 9

Audit on Cardiac Catheter at SKMC • Write as u

Echo Assessment of ASD •

ASD ( O S ) Good Rims

Echo Assessment of ASD • Write as u

Echo Assessment of ASD • Gg

Echo Assessment of ASD • Write as u

Echo Assessment of ASD • Write as u

 Number of defects (single, multiple, multi

fenestrated)  Diameter of defect(s)  Lenght of interatrial septum

Audit on Cardiac Catheter at SKMC • Write as u

CONCLUSION •

Complications continue to be associated in Cong Heart Catheter

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Efforts should be directed to improving equipment for flexibility and size, and finding alternative methods for vascular access.

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Patient age and Inter studies are risk factors – M & M

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The complication burden change as we push on to deal with smaller and smaller babies?

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Many are avoidable with care and a meticulous approach, availability of all new technology and equipment's

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Stocks of all life saving equipment's in cath Lab The learning curve of the operator and the team contribution

ASD deficient Aortic Rim

• This talk..

Surgical correction for TGA- A brief history • Cross-sectional imaging- MRI & CT. • Complications and follow-up of patients- post Arterial Switch, Atrial Switch and Rastelli.

• Cases- with emphasis on MRI imaging •