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Pre-Procedural Imaging to Characterize the PFO- TTE, TEE, TCD.pptx
- 1. Pre-Procedural Imaging to Characterizethe PFO: TTE, TEE, TCD Zahid Amin, MD William B. Strong Endowed Chair Augusta University; Children’s Hospital of Georgia, Augusta, GA
- 2. Disclosure Statement ofFinancial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Consulting Fees/Honoraria Abbott Vascular; W.L. Gore & Associates
- 3. Characterize the PFO •Characterize means: to describe the distinctive nature and features of.. • By using TTE, we can diagnose PFO but we may not be able to elaborate on it – Extension – Tunnel length – Size – Aneurysmal nature (we can a little, but it may not be crisp)
- 4. PFO Potential For Opening •Lack of apposition between septum secundum and primum that results in PFO – May be small and slit like – May be long and lunar in shape • Potential For Overlap – Significant overlap = Long tunnel – No overlap means no tunnel • Potential For Other issues – Aneurysmal (redundant septum primum) – Large defect – Difficult to cross occasionally
- 5. RA LA Atrial Septum Foramen Ovale Inprofile RV LV ‘Septum Primum’
- 6. Atrial Septum AV valve Foramen Ovale RightAtrial View
- 7. Atrial Septum Left Atrialview Foram en Ovale ‘Flap valve’ FRONT BACK
- 8. Atrial Septum 4- ChamberView Patent Foramen Ovale RA LA RV LV narrow oblique channel
- 9. PFO • Defect “anatomic”characteristics – Size – Extension – Location • Tunnel characteristics – Type 0, I , II, III chest spine head feet
- 10. TTE • Usually usedfor initial evaluation of PFO – For detection and diagnostic purposes – Sufficient in pediatric patients • Images may not be “good enough” to characterize the atrial septum and hence the anatomy of PFO
- 11. TTE • Good forDetecting PFO: – Adequate to appreciate lack of apposition between septum primum and secundum – Color flow at the atrial level • Diagnosis – Demonstration of right to left shunt by • Color flow • Saline bubble contrast study that shows right to left shunt by the first three heart beats
- 12. TTE Bubble Study-4chamber Bubbles in LA by the third beat Bubbles returning from lung after the 4th beat
- 13. Aneurysmal Atrial SeptumParasyernal SAX Aneurysmal septum > 10 mm excursion
- 14. Aneurysmal Septum Seenin Parasternal LAX view
- 15. Post Device BubbleStudy No right to left Shunt (bubble)
- 16. TEE Standard views 0 Degree:4 chamber 30 Degrees: SAX 90 Degrees: Bi-caval
- 17. Transesophageal echocardiography PFO morphology ALA RA LV RV B LA RA AV RVOT C LA RA SVC RA LA PFO Septum 1º Septum 2º Septum primum separation from the AV valve, aortic and the SVC rims
- 18. 0 Degrees –4 Chamber View and the Atrial Septum
- 19. TEE 0º Inferior 0Degrees – 4 Chamber View (Caudal)
- 20. 0 Degrees –4 Chamber View (Cranial)
- 21. T0º 45 Degrees -Short Axis View
- 22. 90-120 Degrees –Bicaval View
- 23. TEE-in summary • Excellentmodality to characterize PFO diagnosis, it’s morphology, saline contrast echocardiography • Excellent modality to help in closing PFO • Excellent modality to assess for post procedure complications – Device edges in relationship to the transverse sinus, tenting of the atrial free wall, relationship to the aortic root, etc.
- 24. TCD • Doppler ultrasonographymeasures the velocity of blood flow through the brain's blood vessels by measuring the echoes of ultrasound waves • Sickle Cell • Ischemic cerebral issues • Subarachnoid hemorrhage • AVM • Perioperative management of infection • Right to left shunting at atrial level
- 25. TCD • Need trainedpersonnel • Access vein (antecubital) • Agitated saline contrast mixed with 1 ml blood • Valsalva • Once saline is injected, monitor Doppler signal during Valsalva maneuver
- 26. TCD • Four (five)-levelvisual categorization: (i) Grade 0: no occurrence of micro-embolic signals (ii) grade I, 1-10 signals; (iii) grade II, >10 signals but no curtain pattern (iv) grade III, curtain pattern. • Test negative: no microbubble • Low grade shunt: 1–10 microbubbles • Medium grade shunt: >10 microbubbles but without “curtain effect” • High grade shunt: curtain effect, seen when the microbubbles are so numerous as to be no longer distinguishable separately
- 27. TCD method ofgrading R to L shunts
- 28. TCD Grades ofshunt Grade 0 Grade 1
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- 31. To Summarize • TCDis not used commonly • Physicians who use it are strong supporters • Requires trained personnel • It does not have higher specificity • Grade 3 or higher shunts have high specificity • Not an absolute requirement to have TCD but can be useful
- 32.