preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.

1. ECHO ASSESSMENT OF ASD FOR
DEVICE CLOSURE
DR SASINTHAR
SR, CARDIOLOGY
JIPMER

2. VARIOUS ECHO MODALITIES
• TTE
• TEE
• 3D ECHO
• ICE

3. WHEN TO SUSPECT IN 2D ECHO
•RIGHT VENTRICULAR DILATION
ABNORMAL MOTION OF IVS- brisk anterior
movement in early systole or flattened
movement throughout systole
•? IAS DROP OUT IN APICAL 4C VIEW
•RELATIVE ATRIAL INDEX

4. 2D ECHO
RA RV VOLUME OVERLOAD
SEPTAL FLATTENING IN DIASTOLE

5. The Relative Atrial Index (RAI)—A Novel, Simple, Reliable, and Robust
Transthoracic Echocardiographic Indicator of Atrial Defects
Cutoff value of >0.92 predicted patients with ASDs v/s matched
controls with 99.1% sensitivity and 90.5% specificity
Natalie A Kelly -Journal of the American Society of Echocardiography
Volume 23, Issue 3 , Pages 275-281, March 2010

6. SUB COSTAL 4C VIEW
• Keeps the atrial septum perpendicular to the ultrasound
beam
• Distinguishes OS , OP & SV ASDs
• SV ASD are consistently visualised in the SUBCOSTAL 4C
VIEW
• Anomalous drainage of pulmonary veins
• Atrial septal aneurysm
• Viewed with breath held in inspiration- index marker in 3o`
clock position
SUB COSTAL SHORT AXIS
• Index marker at 12o`clock position and sweeping the transducer
from midline to Rt side of patient

7. SUBCOSTAL 4C VIEW
SUB COSTAL SHORT AXIS VIEW
ALSO SHOWS IVC DRAINING TO RA
AND EUSTACHIAN VALVE

8. Other 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

9. 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

11. ANOMALOUS PULMONARY VEIN
• Can be associated with ASD or can
occur as an isolated anomaly
• 95% of SV ASD a/w RUPV-SVC
• RUPV-SVC; LUPV- innominate vein ;
RLPV- IVC
• Isolated LLPV – extremely rare

12. `Crab view` showing absent Rt upper
and Rt lower pulmonary vein

13. 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

14. A-4c view & B-En face view

15. Morphological variations
1.MC- Deficient aortic rim (42.1%)
2.Central defects (24.2%)
3.Deficient Inferoposterior rim (12.1%)
4.Perforated aneurysm of the septum (7.9%)
5.Multiple defects (7.3%)
6.Combined deficiency of mitral and aortic rims
(4.1%),
7.Deficient SVC rim (1%),
8.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.

17. 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

18. TRANSVERSE PLANE VIEWS VERTICAL PLANE SWEEP
TEE

19. Centrally located ASD imaged at 0°

22. ASD with deficient Aortic margin

24. Large ASD with deficient posterior and
Aortic margins

25. Multiple ASDs; larger anterior defect
(block arrow) and a smaller posterior
defect

26. 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).

27. IVC AND SVC RIMS

28. OTHER RIMS
TEE
TTE

29. Measurement of the ASD rims
• Atleast 5 mm
• IVC rim-most important
Schematic representation of the
locations of the ASD rims

30. TEE 4-chamber view depicting an adequate
posterior rim for percutaneous closure of
20 mm.
Transesophageal 4-chamber view:
The AV rim measures 9.5 mm, which
is adequate for PCT

31. TEE upper-esophageal 4-chamber view with rightward (clockwise) rotation of
the probe revealing an adequate RUPV rim of 15 mm . Beside, Doppler color
image shows in red the inflow of the RUPV (white arrow). Note the correct ECG
timing of the measure at the end of the ventricular systole while the atrio-
ventricular valves are still closed.

32. Mid-esophageal short axis
view of the aortic rim at 56
degrees with an adequate
aortic rim (11 mm) for
percutaneous closure

33. • Absent aortic rim makes the procedure more
challenging but does not, preclude device
closure of the defect

34. Mid-esophageal bi-caval view at 97
degrees, an adequate SVC rim is noted,
measuring 13 mm .
Mid-esophageal bi-caval view at 97
degrees with an adequate IVC rim
of 10 mm

35. Special tee views for Inferoposterior
rims
No Infero posterior rim with probe in normal position

36. 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

37. 3D ECHO
• Matrix transducers – pyramid shaped volumes
• Full volume 3D dataset in 4-7 cardiac cycles
• Ideal window is the mid esophageal basal long
axis (bicaval view)
• Subcostal 4c view- enface septum
• Low parasternal 4c view case of suboptimal
windows
• 3D tee overcomes 3D TTE if suboptimal windows

38. • Real-time 3D imaging demonstrates the
changing shape of the ASD during a cardiac
cycle, with maximum size in diastole
• As we take the Bicaval view structures – we
first remove the right atrial free wall .
• Images are taken with suspended respiration
and ECG gating with optimal gain settings
• Low gain – drop outs and high gain – blurring
of structural details

39. Gain settings
For
Best view
Cropping to
Get the IAS

40. TUPLE (TILT UP & LEFT)-ENFACE VIEW
OF IAS FROM LT ATRIAL PERSPECTIVE

41. RIMS OF ASD
ASD IN VARIOUS PHASES OF CARDIAC CYCLE

42. ATRIAL SEPTUM ANEURYSM
WITH ASD
MULTIPLE ASDs

43. DEFECT NEAR THE IVC

44. 3D echo- En face 3D reconstruction of a secundum ASD with
a relatively deficient
IVC and posterior rim

45. multiple ASDs with the thin atrial
septum (*) separating the 2 defects

47. The correlations between the ASD maximal diameter by RT-3DE and operation or balloon sizing were excellent
(r > 0.95). All surrounding rims of the atrial septum could be assessed on 3D reconstruction; except for the
aortic rim, a cross-sectional reconstruction was created mimicking the transesophageal echocardiographic
cross section (r > 0.92)

48. • Maximal criteria for transcatheter closure with
ASO device are
(1) ASD secundum with a maximum TEE
diameter of 34 mm
(2) rims, except the anterosuperior rim, of at
least 5 mm, and
(3) the dimensions of the total length of the
atrial septum were not smaller than the left
atrial disk of the chosen device

49. Measurement of ASD size
• Maximal ASD
diameter must be
measured at the end
of ventricular systole
• Atleast two
orthogonal views
• SBP = Max in TEE + 4
to 6mm
Mid-esophageal 4-chamber
view at 0 degree depicting
an ostium secundum ASD
with a maximal transverse
diameter of 18 mm .
Mid-esophageal bi-caval view at
97 degrees showing an ASD
with a maximal longitudinal
diameter of 14 mm

54. • Max size of device used -44 mm
• Device embolisation in 3/169 patients
• 2- deficient posterior rim and large size (38
mm, 35 mm) were the reasons for instability,
• In the third patient, the complete absence of
aortic rim with malaligned septum made the
procedure difficult

55. CONCLUSION
• Proper case selection
• It is important to have inferior and posterior
rims
• An anterior rim is not as important as the
device will grasp the aorta
• A superior rim is less important as the device
will grasp the SVC orifice