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… •
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
:
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 •