Euroecho2010 intracardiac-shunts

Intracardiac shunts

Piotr HoffmanAd lt Congenital Hea t Disease Depa tmentAdult Congenital Heart Disease Department

Institute of CardiologyWarsaw - Anin

• Atrial Septal Defects (ASD)• Patent Foramen Ovale (PFO)Patent Foramen Ovale (PFO)• Ventricular Septal Defects (VSD)

Atrial septal defectAtrial septal defect

Atrial septal defectAtrial septal defect80% S d l t d i th • 80% Secundum, located in the region of the fossa ovalis and its surrounding

• 15 % Primum located near the • 15 % Primum, located near the crux, AV valves malformed with regurgitation

• 5% Superior sinus venosuspdefect located near to SVC,associated with PAPVC

• <1% Inferior sinus venosusd f l d IVCdefect located near IVC

• <1% Unroofed coronary sinus – separation from the LApartially or completely missingpartially or completely missing

Atrial septal defectAtrial septal defect

A i il ECHO• Asymptomatic until adulthood

• ECHO

– Key diagnostic technique

• Symptoms beyond the fourth decade – Diagnosis and

quantification

• Life expectancy reduced, – RV volume overload

• QoL decreased – Qp/Qs

– Pulmonary pressures• Eisenmenger rare (<5%)

Pulmonary pressures…

Atrial septal defect morphologyAtrial septal defect – morphology

• Imaging planes:

– Subcostal– Apical ASD II. Apical 4CH viewp– Parasternal short

axis

ASD II. Subcostal view

Atrial septal defect morphologyAtrial septal defect - morphology

• Imaging planes:

– Apical– Subcostal– Parasternal short

axis

ASD I. Apical 4CH view


• TEE > TTEASD sinus venosus VCS

Subcostal view

• Imaging planes (TTE)– Subcostal view

• Imaging planes (TEE)High transverse and – High transverse and longitudinal plane (VCS)


• TEE > TTEASD sinus venosus VCS

Subcostal view


ASD sinus venosus VCS

• Imaging planes (TEE)High transverse and

ASD sinus venosus VCSTEE

– High transverse and longitudinal plane (VCS)


ASD sinus venosus VCI TTE• TEE > TTE ASD sinus venosus VCI. TTE


• Imaging planes (TEE)High transverse and – High transverse and longitudinal plane (VCS)


ASD sinus venosus VCI TTE• TEE > TTE ASD sinus venosus VCI. TTE


• Imaging planes (TEE)High transverse and

ASD sinus venosus VCI. TEE

– High transverse and longitudinal plane (VCS)

Atrial septal defect – evaluation of haemodynamics

• Presence of RV volume overload

• Qp/QsQp/Qs

Pulmonary • Pulmonary pressures RV dilatation due to volume

overload. Significant left-to-right shunt

Atrial septal defect – evaluation of haemodynamics

RV dilatation due to volume overload. Significant left-to-

RV volume overload. High TAPSE. Color Doppler - g

right shuntpp

significant left-to-right shunt

Atrial septal defect – evaluation of haemodynamics. Qp/Qs

Q l fl E h /D l l ti• Qp – pulmonary flow

• Qs – systemic flow

• Echo/Doppler evaluation

• Pulmonary flowQ y

• Qp/Qs = 1 in normals

– VTI– RVOT diameter (D)– Qp = VTI x π1/2D2

• Qp/Qs > 1.5 – significant shunt

• Systemic flow– VTI

LVOT di t (D)– LVOT diameter (D)– Qs = VTI x π1/2D2

Atrial septal defect – evaluation of haemodynamics. Qp/Qs

QsLAX - LVOT diameter 5CH – PD Doppler

RVOT diam

pp

QpSAX RVOT diameter + PD Doppler

Atrial septal defect – evaluation of systolic pulmonary artery pressure

PAP RVSP if RVOTO i • sPAP = RVSP, if RVOTO is absent

• Vmax of TR is requiredmax o s equ ed• sPAP=RVSP=4Vmax

2 + RAP

Mild tricuspid regurgitationRVSP PAP 31 + 5 mmHg no m l RVSP=sPAP= 31 + 5 mmHg - normal

Atrial septal defect – If TR not present?

• No RVH ~ normal pulmonary vascular resistance (PVR)resistance (PVR)

• Find PR estimate Find PR, estimate mPAP

• mPAP < 25 mmHg, normal PVR mPAP – 12 mmHg + RAP (~3mmHg)

mPAP ~ 15 mm Hg, normalg,

Atrial septal defect. Indications for intervention

Si ifi t h t (RV l • Significant shunt (RV volume overload) and PVR < 5 WU, regardless of symptoms

IBIB

Atrial septal defect.

Si ifi t h t (RV l ASD d

Indications for intervention• Significant shunt (RV volume

overload) and PVR < 5 WU, regardless of symptoms

IB

• ASD secundum

• Significant left-to-right IB g gshunt– RV overload– Qp/Qs 4.1Qp/Qs 4.1– SPAP ~36 mmHg

• Defect should be closed –which method?

ASD secundum. Indications for device closure

Si ifi t h t (RV l D i l i fi t h i • Significant shunt (RV volume overload) and PVR < 5 WU, regardless of symptoms

IB

• Device closure is first choice for secundum defect closure, when feasible from morphologyIB

• Device closure is the method of choice for ASD secundum

morphology

– stretched diameter < 38 mm ( thl b)of choice for ASD secundum

when applicableIC

(cathlab)

– sufficient rim of 5 mm expect towards the aorta • All ASDs with suspicion of

paradoxical embolism should be considered for intervention

II C

towards the aorta.

IIaC•

ASD secundum Device closure?ASD secundum. Device closure?

ASD diameter 19 mmapical 4CH view

ASD diameter 27 mmsubcostal imaging apical 4CH viewsubcostal imaging

ASD secundum diameter always measuredASD secundum diameter always measuredin several studying planes!

ASD secundum Device closure?ASD secundum. Device closure?

ASD diameter 19 mmapical 4CH view

TEEASD diameter 34 mm

ASD diameter 27 mmsubcostal imaging apical 4CH view ASD diameter 34 mm,

Inferior rim < 5mmSurgical closure

subcostal imaging

ASD secundum diameter always measuredASD secundum diameter always measuredin several studying planes!

ASD secundum Device closureASD secundum. Device closure

Preprocedural evaluation



Balloon inflation - stretched diameter



TEE monitoring of the procedure

Balloon inflation - stretched diameter

TEE monitoring of the procedure.

Patent Foramen Ovale PFOPatent Foramen Ovale - PFO

• PFO = ASD!• PFO = ASD!

• Haemodynamically insignificant interatrial insignificant interatrial communication

• During fetal life blood is h ti f i ht t l ft shunting from right to left

atrium

• Postnatally PFO closes in • Postnatally PFO closes in ~75%

• In reminder, PFO may serve

Autopsy prevalence of PFO

, yas a conduit for paradoxical embolization


Morphology• Morphology– Size– ASA

Eustachian Valve and Chiari’s network– Eustachian Valve and Chiari s network

• ShuntMicrobubbles seen in the left sided – Microbubbles seen in the left-sided chambers within three cardiac cycles from the maximum right atrial opacification

• Manouvers– Valslava– Caughingg g

• Transcranial Doppler


Transoesophageal echocardiographyTransoesophageal echocardiography

Contrast study with agitated salineContrast study with agitated saline

P f d l f tl• Performed less frequently

• Still useful in difficult situationssituations

– Vessel & chambers identification

– Shunt detection (PFO > ASD)Shunt detection (PFO > ASD)– Negative contrast in left-to-

right shunt– Contrast in LA/LV in right-to

l f hleft shunt

• Injection 10-15 ml agitated saline into the left decubital

LSVC emptying directly into the LA

saline into the left decubital vein

Coexistence of two different ASDsCoexistence of two different ASDs

Secundum and Primum Atrial Septal Defect

Ventricular septal defect Ventricular septal defect Th t it l O t d VSD ith ith t • The most common congenital heart disease at birth (30-40%)

• Operated VSD with or without residual shunt

Small insignificant L R shunt • Spontaneous closure is

frequent

• Small, insignificant L-R shunt, no LV volume overload and pulmonary hypertension

• Multiple defects may occur

Direction/magnitude of the

• L-R shunt, pulmonary hypertension, various degree of LV volume overload• Direction/magnitude of the

shunt determined by PVR, size of the defect, LV/RV systolic/diastolic function,

of LV volume overload

• Eisenmengery / ,

RVOTO

Ventricular septal defectVentricular septal defect

• Perimembranous ~ 80%• Muscular/trabecular ~15-20%Muscular/trabecular 15 20%• Outlet supracristal ~ 5%

Inlet/AV canal/AVSD type 1%• Inlet/AV canal/AVSD type ~1%

Muscular and inlet VSD

Perimembranous VSDPerimembranous VSD

Modified 4CH view Apical 5CH view Subcostal imigingLVOT plane

Apical 5CH viewleft–to-right shuntCW dopler

Ventricular septal defect outlet supracristal. TEE

Ao

MPA

VSD, L-R shunt

Indications for intervention in VSDIndications for intervention in VSD

• Symptoms attributed to L-R shunt without pulmonary vascular disease IC

• Asymptomatic with LV volume overload L-R shunt IC

h h f• With history of IE IIa

• With VSD-associated prolaps of the aortic cusp IIa

• VSD +PAH, Qp:Qs>1.5, PVR <2/3 systemic values IIa

Eisenmenger syndromeEisenmenger syndromeCHD ith i iti ll l • CHD with initially large systemic-to-pulmonary shunt

– severe pulmonary vascular disease

– PAH resulting in reversal of the shunt direction and central cyanosiscentral cyanosis

Eisenmenger syndrome. ASD sinus venosus

Female 34 years old Recent history of progressive SOB

Dilated RV RVSP 105 mmHg Shortened RVOTacceleration time77

RVH 7 mm

77 ms

Eisenmenger syndrome. ASD sinus venosus

Female 34 years old Recent history of progressive SOB

ASD sv

Eisenmenger syndrome, other examples…

Female 30 years oldInlet and muscular VSD

mPAP – 72 mmHgdPAP 47 mmHgdPAP – 47 mmHgsPAP – 122 mmHg

Intracardiac shunts. Echocardiography

E h di h (TTE TEE) i f l fi t li • Echocardiography (TTE+TEE) is powerful first line imaging modality in morphological and functional evaluation of intracardiac shuntse a uat o o t aca d ac s u ts

• In majority such a cases provides complete set of j y p pdata enabling clinical decision making

l i f b h i i l d i i l• Evaluation of both interatrial and interventricular shunt requires multiplane imaging

Euroecho2010 intracardiac-shunts

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