Cardiology ClubCardiology The difficult Art

TEE Case PresentationByDr Osama Abd El RaoufCardiologist-PSCCHCardiology Club

TEE Case PresentationByDr Osama Abd El RaoufCardiologist-PSCCHEcho Club

ASD is the most common congenital heart disease encountered in adult.Atrial Septal Defect ASD occurs in one child per 1,500 live births. ASD is more common in female with ratio of 4:1 .

There are 4 types of ASDOstium Secundum.Ostium Primum.Sinus Venosus.Coronary sinus defects.Types of ASDs

Secundum defects are the most common, accounting for 6-10% of all congenital lesions.Secundum defects

Atrial Septal Defect (Primum) Ostium primum is the next most common type and is located in the lower portion of the atrial septum. This type of ASD often will have a mitral valve defect associated with it called a mitral valve cleft .

Atrial Septal Defect (Primum)

Partial anomalous pulmonary venous connection (right pulmonary veins to junction of superior vena cava and right atrium.Sinus Venosus ASD

Sinus venosus ASD associated with PAPVR.Sinus Venosus ASD

Routine chest X-ray of this 14 year old girl suggests prominent right heart borders on the two views. There is also prominence of the pulmonary artery segment due to pulmonary overcirculation from partial anomalous right pulmonary veins draining into the SVC and an associated atrial sinus venosus defect.Sinus Venosus ASD

Routine chest X-ray of this 14 year old girl suggests prominent right heart borders on the two views. There is also prominence of the pulmonary artery segment due to pulmonary overcirculation from partial anomalous right pulmonary veins draining into the SVC and an associated atrial sinus venosus defect.Sinus Venosus ASD

Increased flow across the PV produces a systolic ejection murmur and fixed splitting of the second heart sound. Fixed splitting of S2 may in part be due to delayed right bundle conduction. Increased flow across the TV produces a diastolic rumble at the mid to lower right sternal border.Cardiac Auscultation in ASD

The chest x-ray demonstrates prominent pulmonary vessels and a proximal pulmonary artery segment. CHEST X RAY IN ASD

Chest x-ray of untreated ASD demonstrates prominent pulmonary vessels and a proximal pulmonary artery segment. CHEST X RAY IN ASD

Role Of Echocardiography

The ME 4C view (0) is obtained by positioning the probe in the mid-esophagus behind the LA.

The imaging plane is directed thru the LA, center of the MV and apex of the LV. ME 4 Chamber View

A snapshot of the heart is obtained that includes all 4 chambers (LA, RA, LV, RV), 2 valves (MV, TV),

The septums (IAS, IVS) and the inferoseptal and anterolateral LV walls.

Segments of the anterior (A2) and posterior (P2) mitral valve leaflets are typically imaged in this view.ME 4 Chamber View

A snapshot of the heart is obtained that includes all 4 chambers (LA, RA, LV, RV), 2 valves (MV, TV),

The septums (IAS, IVS) and the inferoseptal and anterolateral LV walls.

Segments of the anterior (A2) and posterior (P2) mitral valve leaflets are typically imaged in this view.ME 4 Chamber ViewLALVRV

Left Atrium (LA) Right Atrium (RA) Left Ventricle (LV): inferoseptal (IS) + anterolateral (AL) walls Right Ventricle (RV) Mitral Valve: anterior(AMVL) + posterior (PMVL) leafletsTricuspid Valve: septal (STVL) + anterior (ATVL) leafletsIdentify the Following Structures:-ME 4 Chamber View

Transesophageal Echo and ASD DiagnosisTEE Diagram showing the entrance of SVC into the right atrium,,notice atrial septum separating both atria.

TEE Bicaval ViewTEE diagram showing the entrance of SVC into the right atriumNotice intact atrial septum separating both atria.

TEE bicaval view showing the entrance of SVC into the right atrium. Notice intact atrial septum separating both atria. TEE Bicaval View

TEE Doppler examination showing showing small osteium Secundum ASD with left to right shunt. Notice color flow Doppler.Transesophageal Echo and ASD Diagnosis

Transesophageal Echo and ASD Diagnosis

Transesophageal Echo and ASD Diagnosis

Always look else where Prominent Eustachian valve. Crista terminals. Pectinate muscle.Transesophageal Echo and ASD Diagnosis

Crista TerminalisStructures belong to right atriumCrista Terminalis

Structures belong to right atriumCrista TerminalisCrista Terminalis

Structures That Belong There

Do you notice something else?Transesophageal Echo ,Bicaval View

Percutaneous Closure of an ASDThe State of Art

Amplatzer ASD closure device.

The basic requirements for percutaneous closure of an ASD include: Indications for percutaneous closure of an ASD Secundum defect. Adequate inferior and superior rim around the defect. Therefore, device closure will not impinge upon the superior vena cava , inferior vena cava or AV valves. No significant right to left shuntingclosure would reduce cardiac output. No other findings that require open heart surgery. This would lead to surgical closure of the ASD.

Case StudyExperience of PSCCH20 years old Saudi female was diagnosed to have ostium secundum. ASD and was referred from our OPD for closure of the defect.

Case StudyExperience of PSCCHLarge ostium secundom ASD

Ostium Secundum ASD

ME 4 chamber view showing big ostium secundom ASD with large left to right shunt.Ostium Secundum ASD

Inflation of the Balloon

Inflation of the Balloon

Deployment of a ASD Device

Deployment of a ASD Device

Deployment of a ASD Device

Device is in position

Device is in position

Device is in position

Device is in position

Device is in position

Device is in positionCath View

Device is in positionSuccessful closure of the defect with no significant residual shunt.

Device is in positionNo interference with aortic and mitral valve function.

Comparison of the result before and after the procedure.Percutaneous Closure of an ASDThe State of Art

What would the interventional wants to knowTeam WorkCase- 2

1- Clear Diagnosis - Clear Indication.

2- Are All Pulmonary Veins Normal ?

2- Are All Pulmonary Veins Normal?

2- Are All Pulmonary Veins Normal?

2- Are All Pulmonary Veins Normal?

3- Am I In The Right Position?Can You See The Wire ?

4- Can You Follow Me?

5- Is The Closing Devise In The Right Position?

6- Is There Any Residual Significant Shunt ?

7- What About The Aortic Valve ?

8- Is There Pericardial Effusion ?

A4C view The arrow indicates the position of a atrial septal defect closure device.ASD Closing Device

ASD Closing Device

Air embolism.Complications from percutaneous deployment of a ASD Vascular injury from large sheaths used to deploy the device. Embolization, of thrombus formed on the device, Perforation of the atrial wall, perforation of the aorta, infective endocarditis. Atrial arrhythmias. Malposition of the device requiring surgical retrieval. Residual atrial shunts can occur in one-third of patients.

During the months when an endothelial layer is expected to develop, thrombus of significant proportion can occur, leading some authors to recommend 6 months of antiplatlets after device implantation.

Place of Antiplatlets

Reasons Behind ComplicationsConclusion

ASD is the most common congenital heart disease encountered in adult . ASD closing device is increasingly used with very promising results . Team work is mandatory for success of the procedure . Clinical and echocardiographic follow up is necessary after the procedure .Conclusion

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