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A Case of Transcatheter Closure of an Atrial Septal Defect Guided by Three Dimensional Echocardiography
Available online at www.sciencedirect.com
Journal of Cardiovascular Echography 22 (2012) 179–182 www.elsevier.com/locate/jcecho
Case report
A Case of Transcatheter Closure of an Atrial Septal Defect Guided by Three Dimensional Echocardiography Ramanjit Kaur a, Abhishek Mewada a, Shaun Cardozo b, Deepti Bhandare b, Thomas Forbes c, Luis Afonso b,* a
Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan b Department of Cardiology, Wayne State University School of Medicine, Detroit, Michigan c Department of Pediatric Cardiology, Wayne State University School of Medicine, Detroit, Michigan Received 21 May 2012; accepted 27 August 2012; available online 5 October 2012
Abstract Real time three dimensional transthoracic echocardiography (RT3DE) is rapidly emerging as the imaging modality of choice for assessment of atrial septal defects. This novel imaging modality provides incremental information about the morphology of atrial septal defects (ASD), allowing precise characterization of septal defects. Our case highlights the limitations of conventional echo imaging and the advantages of RT3DE in planning percutaneous ASD closure. # 2012 Published by Elsevier Srl. on behalf of Societa` Italiana di Ecografia Cardiovascolare. Key words: Atrial septal defect; 3D echocardiography; Transcatheter closure; 2D echocardiography; Transesophageal echocardiography.
Riassunto: Un caso di chiusura transcatetere di difetto del setto interatriale guidata dall’ecocardiografia 3D Attualmente, l’ ecocardiografia tridimensionale transtoracica (RT3DE) sta rapidamente emergendo come la modalita` di imaging di scelta per la valutazione dei difetti del setto interatriale (ASD). Questa modalita` di imaging fornisce informazioni incrementali sulla morfologia di tali difetti, consentendo una loro precisa caratterizzazione. Il caso illustrato evidenzia i limiti dell’ eco convenzionale e i vantaggi della tecnica RT3DE nella pianificazione della chiusura percutanea degli ASD. # 2012 Pubblicato da Elsevier Srl. a nome di Societa` Italiana di Ecografia Cardiovascolare. Parole chiave: Difetto del setto interatriale; Ecocardiografia 3D; Chiusura transcatetere; Ecocardiografia 2D; Ecocardiografia transesofagea.
1. Introduction
2. Case Report
Atrial septal defect (ASD) is the second most common congenital lesion in adults.1 Data regarding the use of real time three dimensional transthoracic echocardiography (RT3DE) in the evaluation of ASDs and pre-procedural planning is sparse.2 RT3DE can facilitate precise appraisal of ASD anatomy and guide treatment options.3 We describe a case of failed transcatheter ASD closure which highlights the advantages of RT3DE over other imaging modalities in the assessment of an ASD.
A 46 year old male was admitted for a 5 month history of exertional dyspnea and lower extremity pitting edema. His past medical history was significant for chronic atrial fibrillation. Physical exam revealed a hyperdynamic right ventricle, a widely fixed split second heart sound and a diastolic rumble over the left parasternum, accentuated by inspiration. Two dimensional transthoracic echocardiogram (TTE) demonstrated a large secundum ASD measuring 21 x 22 mm, with predominant left to right flow. Right ventricular dilation with elevated pulmonary pressures and normal biventricular systolic function were noted. A transesophageal echocardiogram (TEE) was performed which confirmed the ASD. Since the patient had a secundum type defect measuring 21 mm with no anomalous pulmonary venous connection,
* Corresponding author. E-mail address: [email protected] (L. Afonso).
2211-4122/$ – see front matter # 2012 Published by Elsevier Srl. on behalf of Societa` Italiana di Ecografia Cardiovascolare. http://dx.doi.org/10.1016/j.jcecho.2012.08.001
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R. Kaur et al. / Journal of Cardiovascular Echography 22 (2012) 179–182
Figure 1. A) An anteroposterior view of the chest showing the dislodged Amplatzer occluder device within the right pulmonary artery. B) Parasternal long axis view showing the Amplatzer device entrapped within the sub-mitral chordal apparatus.
transcatheter Amplatzer septal occluder (ASO) device closure was planned. A 17 mm ASO was used to obliterate the defect with no residual shunt observed post procedure. The Amplatzer Septal Occluder consists of a waist, right disc and left disc. Conventionally the ASO is sized at the waist which is usually much smaller than right and left discs, accordingly, 17 mm ASO was considered adequate to obliterate the defect and post procedure, no residual shunt observed (In the case of 17 mm device the size of right disc would be 6mm+ 17mm+ 6mm = 29 mm while the left disc size would measure out as 7mm + 17mm + 7mm = 31mm). However, the following day, device embolization with migration to the pulmonary artery occurred (Fig. 1A). The device was retrieved percutaneously from the right pulmonary artery without any complications with a wire loop snare. A larger 22 mm ASO device was deployed for closure of the ASD. On the day after implantation, the patient was noted to have multiple ectopic ventricular beats. An immediate TTE showed the ASO to be located in the left ventricular cavity in the submitral area entrapped between papillary muscles and chordae (Fig. 1B). The device was immediately retrieved for the second time without complication. It was hypothesized that miscalculation of the defect size and device undersizing was responsible for recurrent device embolization. Subsequently, RT3DE was performed which demonstrated an ovoid shaped secundum ASD that measured 4.2 cm by 2.2 cm with an inferior rim that was partially deficient (Fig. 2). Finally, an ASO device measuring 37 mm was successfully deployed. A repeat echocardiogram confimed that the device was well anchored and in stable position. The patient’s heart failure symptoms gradually improved after the closure of the ASD. 3. Discussion Secundum atrial septal defect is one of the more common isolated cardiac defects, accounting for 5% to 15% of all congenital heart malformations.4 Adequate imaging of the anatomic features of the ASD is imperative in deciding the
method of ASD closure. Successful transcatheter closure requires establishment of two key parameters; the maximal diameter of the defect and the tissue rim dimensions around the defect to allow adequate anchoring of the device.4 Prior cases have highlighted the need for proper defect assessment to determine surgical versus percutaneous closure.5 Although TEE is still considered the gold standard imaging modality for transcatheter device closure interventions, it has inherent limitations being a relatively invasive procedure typically requiring conscious sedation.6 Previous studies have demonstrated that RT3DE is a viable option in guiding percutaneous device closure.3 Our case underscores the potential complications associated with errors in sizing and emphasizes the incremental value of RT3DE in guiding transcatheter closure interventions. Frequent drawbacks noted with TTE and TEE are poor delineation of the tissue rim and incomplete ASD measurements secondary to the limited number of visualized cut planes resulting in potential underestimation of ASD size.7 As illustrated in our case, TEE failed to reveal the major dimension of the ASD resulting in an undersizing of the ASD occluder device. Such a situation might arise if the cut plane of the ultrasound beam cannot be steered across or does not transect the largest diameter of the ASD, especially in cases where the defect is oval with a high degree of eccentricity (as evident in our case judged by differences in minor and major diameters of the defect shown in figure 2). In fact, 3D-TTE helps to ascertain the true ASD dimensions by providing an en-face view of the defect, thus revealing the true size and shape of the ASD. Aside from precise sizing of ASDs, RT3DE allows anatomic delineation of the ASD with respect to atrial superior, inferioranterior and posterior limbic band tissue and its relationship to the AV valves simultaneously in three dimensions.8 Unique three dimensional views reveal the spatial orientation of these defects permitting reconstruction of viewing planes not otherwise seen with TTE. While 2D imaging is based on scanning a single cross-sectional plane at a time giving dynamic 2D views of the heart, 3D imaging scans a pyramidal volume.
R. Kaur et al. / Journal of Cardiovascular Echography 22 (2012) 179–182
181
Figure 2. Composite panel illustrating the three-dimensional visualization of the atrial septal defect in multiplanar review mode cropped from a RT3DE full volume acquisition. The bottom right panel shows the 3 D dataset, which is being transected in three different planes, displayed in the remaining three color-coded panels. The green (left upper panel) is an off axis, 4-chamber perspective akin to what might be visualized with 2D-echocardiography (note diameter D3: 2.0 cm). The right upper (red) and left lower (blue) panels show the secundum ASD en face (right atrial perspective) with significantly different major (D1: 4.2 cm) and minor (D2: 2.2 cm) dimensions; also note, partially deficient rim in the vicinity of the inferior vena cava** (red panel). The cut planes may be moved by the operator across the dataset, in order to display the structure under study.
This volumetric data can be rendered from multiplanar viewpoints or viewed in dynamic manner from a fixed viewpoint.8 The increased accuracy in measuring the maximal diameter and defining rims of atrial septal defects largely stems from the ability of RT3DE to visualize the defects enface. Additional information provided by RT3DE includes ASD area changes during the cardiac cycle and distance from the secundum ASD to the posterior wall, superior vena cava and tricuspid valve.2 Of note, 3D-transesophageal echocardiography has recently also been shown to be a clinically useful alternative option to 2D-TEE for the pre-procedural definition of ASD morphology and for intraprocedural guidance of transcatheter interventions.9
4. Conclusion RT3DE allows precise assessment of ASD dimensions and spatial relationships making it the imaging modality of choice for guiding transcatheter ASD device closure. Disclosures None Conflict of Interest The authors have no conflicts of interest to disclose.
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R. Kaur et al. / Journal of Cardiovascular Echography 22 (2012) 179–182
References 1. Du ZD, Cao QL, Rhodes J, Heitschmidt M, Hijazi ZM. Choice of device size and results of transcatheter closure of atrial septal defect using the amplatzer septal occluder. J Interv Cardiol 2002 Aug;15(4):287–92. 2. Marx GR, Sherwood MC, Fleishman C, Van Praagh R. Three-dimensional echocardiography of the atrial septum. Echocardiography 2001;18:433–43. 3. Chen FL, Hsiung MC, Hsieh KS, Li YC, Chou MC. Real time threedimensional transthoracic echocardiography for guiding Amplatzer septal occluder device deployment in patients with atrial septal defect. Echocardiography 2006;23:763–70. 4. Benson LN, Freedom RM. Atrial septal defect. In: Freedom RM, Benson LN, mallhorn JF, editors. Neonatal heart disease. London: Springer-Verlag; 1992. p. 633–44. 5. Shub C, Dimopoulos IN, Seward JB, Callahan JA, Tancredi RG, Schattenberg TT, et al. Sensitivity of two-dimensional echocardiography in the direct visualization of atrial septal defect utilizing the subcostal approach: experience with 154 patients. J Am Coll Cardiol 1983;2:127–35.
6. Konstantinides S, Kasper W, Geibel A, Hofmann T, Ko¨ster W, Just H. Detection of left-to-right shunt in atrial septal defect by negative contrast echocardiography: a comparison of transthoracic and transesophageal approach. Am Heart J 1993;126:909–17. 7. Pandian NG, Vogel M, Cao QL. Dynamic multidimensional visualization of acquired and congenital abnormalities of the aortic valve, aortic root and related structures in children and adults: direct depiction of the pathomorphology by transthoracic and transesophageal threedimensional echocardiography [abstract]. J Am Coll Cardiol 1994; 23:l0A. 8. Marx GR, Fulton DR, Pandian NG, Vogel M, Cao QL, Ludomirsky A, et al. Delineation of site, relative size and dynamic geometry of atrial septal defects by real-time three-dimensional echocardiography. J Am Coll Cardiol 1995;25:482–90. 9. Taniguchi M, Akagi T, Watanabe N, Okamoto Y, Nakagawa K, Kijima Y, et al. Application of real-time three-dimensional transesophageal echocardiography using a matrix array probe for transcatheter closure of atrial septal defect. J Am Soc Echocardiogr 2009 Oct;22(10):1114–20.
Journal of Cardiovascular Echography 22 (2012) 179–182 www.elsevier.com/locate/jcecho
Case report
A Case of Transcatheter Closure of an Atrial Septal Defect Guided by Three Dimensional Echocardiography Ramanjit Kaur a, Abhishek Mewada a, Shaun Cardozo b, Deepti Bhandare b, Thomas Forbes c, Luis Afonso b,* a
Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan b Department of Cardiology, Wayne State University School of Medicine, Detroit, Michigan c Department of Pediatric Cardiology, Wayne State University School of Medicine, Detroit, Michigan Received 21 May 2012; accepted 27 August 2012; available online 5 October 2012
Abstract Real time three dimensional transthoracic echocardiography (RT3DE) is rapidly emerging as the imaging modality of choice for assessment of atrial septal defects. This novel imaging modality provides incremental information about the morphology of atrial septal defects (ASD), allowing precise characterization of septal defects. Our case highlights the limitations of conventional echo imaging and the advantages of RT3DE in planning percutaneous ASD closure. # 2012 Published by Elsevier Srl. on behalf of Societa` Italiana di Ecografia Cardiovascolare. Key words: Atrial septal defect; 3D echocardiography; Transcatheter closure; 2D echocardiography; Transesophageal echocardiography.
Riassunto: Un caso di chiusura transcatetere di difetto del setto interatriale guidata dall’ecocardiografia 3D Attualmente, l’ ecocardiografia tridimensionale transtoracica (RT3DE) sta rapidamente emergendo come la modalita` di imaging di scelta per la valutazione dei difetti del setto interatriale (ASD). Questa modalita` di imaging fornisce informazioni incrementali sulla morfologia di tali difetti, consentendo una loro precisa caratterizzazione. Il caso illustrato evidenzia i limiti dell’ eco convenzionale e i vantaggi della tecnica RT3DE nella pianificazione della chiusura percutanea degli ASD. # 2012 Pubblicato da Elsevier Srl. a nome di Societa` Italiana di Ecografia Cardiovascolare. Parole chiave: Difetto del setto interatriale; Ecocardiografia 3D; Chiusura transcatetere; Ecocardiografia 2D; Ecocardiografia transesofagea.
1. Introduction
2. Case Report
Atrial septal defect (ASD) is the second most common congenital lesion in adults.1 Data regarding the use of real time three dimensional transthoracic echocardiography (RT3DE) in the evaluation of ASDs and pre-procedural planning is sparse.2 RT3DE can facilitate precise appraisal of ASD anatomy and guide treatment options.3 We describe a case of failed transcatheter ASD closure which highlights the advantages of RT3DE over other imaging modalities in the assessment of an ASD.
A 46 year old male was admitted for a 5 month history of exertional dyspnea and lower extremity pitting edema. His past medical history was significant for chronic atrial fibrillation. Physical exam revealed a hyperdynamic right ventricle, a widely fixed split second heart sound and a diastolic rumble over the left parasternum, accentuated by inspiration. Two dimensional transthoracic echocardiogram (TTE) demonstrated a large secundum ASD measuring 21 x 22 mm, with predominant left to right flow. Right ventricular dilation with elevated pulmonary pressures and normal biventricular systolic function were noted. A transesophageal echocardiogram (TEE) was performed which confirmed the ASD. Since the patient had a secundum type defect measuring 21 mm with no anomalous pulmonary venous connection,
* Corresponding author. E-mail address: [email protected] (L. Afonso).
2211-4122/$ – see front matter # 2012 Published by Elsevier Srl. on behalf of Societa` Italiana di Ecografia Cardiovascolare. http://dx.doi.org/10.1016/j.jcecho.2012.08.001
180
R. Kaur et al. / Journal of Cardiovascular Echography 22 (2012) 179–182
Figure 1. A) An anteroposterior view of the chest showing the dislodged Amplatzer occluder device within the right pulmonary artery. B) Parasternal long axis view showing the Amplatzer device entrapped within the sub-mitral chordal apparatus.
transcatheter Amplatzer septal occluder (ASO) device closure was planned. A 17 mm ASO was used to obliterate the defect with no residual shunt observed post procedure. The Amplatzer Septal Occluder consists of a waist, right disc and left disc. Conventionally the ASO is sized at the waist which is usually much smaller than right and left discs, accordingly, 17 mm ASO was considered adequate to obliterate the defect and post procedure, no residual shunt observed (In the case of 17 mm device the size of right disc would be 6mm+ 17mm+ 6mm = 29 mm while the left disc size would measure out as 7mm + 17mm + 7mm = 31mm). However, the following day, device embolization with migration to the pulmonary artery occurred (Fig. 1A). The device was retrieved percutaneously from the right pulmonary artery without any complications with a wire loop snare. A larger 22 mm ASO device was deployed for closure of the ASD. On the day after implantation, the patient was noted to have multiple ectopic ventricular beats. An immediate TTE showed the ASO to be located in the left ventricular cavity in the submitral area entrapped between papillary muscles and chordae (Fig. 1B). The device was immediately retrieved for the second time without complication. It was hypothesized that miscalculation of the defect size and device undersizing was responsible for recurrent device embolization. Subsequently, RT3DE was performed which demonstrated an ovoid shaped secundum ASD that measured 4.2 cm by 2.2 cm with an inferior rim that was partially deficient (Fig. 2). Finally, an ASO device measuring 37 mm was successfully deployed. A repeat echocardiogram confimed that the device was well anchored and in stable position. The patient’s heart failure symptoms gradually improved after the closure of the ASD. 3. Discussion Secundum atrial septal defect is one of the more common isolated cardiac defects, accounting for 5% to 15% of all congenital heart malformations.4 Adequate imaging of the anatomic features of the ASD is imperative in deciding the
method of ASD closure. Successful transcatheter closure requires establishment of two key parameters; the maximal diameter of the defect and the tissue rim dimensions around the defect to allow adequate anchoring of the device.4 Prior cases have highlighted the need for proper defect assessment to determine surgical versus percutaneous closure.5 Although TEE is still considered the gold standard imaging modality for transcatheter device closure interventions, it has inherent limitations being a relatively invasive procedure typically requiring conscious sedation.6 Previous studies have demonstrated that RT3DE is a viable option in guiding percutaneous device closure.3 Our case underscores the potential complications associated with errors in sizing and emphasizes the incremental value of RT3DE in guiding transcatheter closure interventions. Frequent drawbacks noted with TTE and TEE are poor delineation of the tissue rim and incomplete ASD measurements secondary to the limited number of visualized cut planes resulting in potential underestimation of ASD size.7 As illustrated in our case, TEE failed to reveal the major dimension of the ASD resulting in an undersizing of the ASD occluder device. Such a situation might arise if the cut plane of the ultrasound beam cannot be steered across or does not transect the largest diameter of the ASD, especially in cases where the defect is oval with a high degree of eccentricity (as evident in our case judged by differences in minor and major diameters of the defect shown in figure 2). In fact, 3D-TTE helps to ascertain the true ASD dimensions by providing an en-face view of the defect, thus revealing the true size and shape of the ASD. Aside from precise sizing of ASDs, RT3DE allows anatomic delineation of the ASD with respect to atrial superior, inferioranterior and posterior limbic band tissue and its relationship to the AV valves simultaneously in three dimensions.8 Unique three dimensional views reveal the spatial orientation of these defects permitting reconstruction of viewing planes not otherwise seen with TTE. While 2D imaging is based on scanning a single cross-sectional plane at a time giving dynamic 2D views of the heart, 3D imaging scans a pyramidal volume.
R. Kaur et al. / Journal of Cardiovascular Echography 22 (2012) 179–182
181
Figure 2. Composite panel illustrating the three-dimensional visualization of the atrial septal defect in multiplanar review mode cropped from a RT3DE full volume acquisition. The bottom right panel shows the 3 D dataset, which is being transected in three different planes, displayed in the remaining three color-coded panels. The green (left upper panel) is an off axis, 4-chamber perspective akin to what might be visualized with 2D-echocardiography (note diameter D3: 2.0 cm). The right upper (red) and left lower (blue) panels show the secundum ASD en face (right atrial perspective) with significantly different major (D1: 4.2 cm) and minor (D2: 2.2 cm) dimensions; also note, partially deficient rim in the vicinity of the inferior vena cava** (red panel). The cut planes may be moved by the operator across the dataset, in order to display the structure under study.
This volumetric data can be rendered from multiplanar viewpoints or viewed in dynamic manner from a fixed viewpoint.8 The increased accuracy in measuring the maximal diameter and defining rims of atrial septal defects largely stems from the ability of RT3DE to visualize the defects enface. Additional information provided by RT3DE includes ASD area changes during the cardiac cycle and distance from the secundum ASD to the posterior wall, superior vena cava and tricuspid valve.2 Of note, 3D-transesophageal echocardiography has recently also been shown to be a clinically useful alternative option to 2D-TEE for the pre-procedural definition of ASD morphology and for intraprocedural guidance of transcatheter interventions.9
4. Conclusion RT3DE allows precise assessment of ASD dimensions and spatial relationships making it the imaging modality of choice for guiding transcatheter ASD device closure. Disclosures None Conflict of Interest The authors have no conflicts of interest to disclose.
182
R. Kaur et al. / Journal of Cardiovascular Echography 22 (2012) 179–182
References 1. Du ZD, Cao QL, Rhodes J, Heitschmidt M, Hijazi ZM. Choice of device size and results of transcatheter closure of atrial septal defect using the amplatzer septal occluder. J Interv Cardiol 2002 Aug;15(4):287–92. 2. Marx GR, Sherwood MC, Fleishman C, Van Praagh R. Three-dimensional echocardiography of the atrial septum. Echocardiography 2001;18:433–43. 3. Chen FL, Hsiung MC, Hsieh KS, Li YC, Chou MC. Real time threedimensional transthoracic echocardiography for guiding Amplatzer septal occluder device deployment in patients with atrial septal defect. Echocardiography 2006;23:763–70. 4. Benson LN, Freedom RM. Atrial septal defect. In: Freedom RM, Benson LN, mallhorn JF, editors. Neonatal heart disease. London: Springer-Verlag; 1992. p. 633–44. 5. Shub C, Dimopoulos IN, Seward JB, Callahan JA, Tancredi RG, Schattenberg TT, et al. Sensitivity of two-dimensional echocardiography in the direct visualization of atrial septal defect utilizing the subcostal approach: experience with 154 patients. J Am Coll Cardiol 1983;2:127–35.
6. Konstantinides S, Kasper W, Geibel A, Hofmann T, Ko¨ster W, Just H. Detection of left-to-right shunt in atrial septal defect by negative contrast echocardiography: a comparison of transthoracic and transesophageal approach. Am Heart J 1993;126:909–17. 7. Pandian NG, Vogel M, Cao QL. Dynamic multidimensional visualization of acquired and congenital abnormalities of the aortic valve, aortic root and related structures in children and adults: direct depiction of the pathomorphology by transthoracic and transesophageal threedimensional echocardiography [abstract]. J Am Coll Cardiol 1994; 23:l0A. 8. Marx GR, Fulton DR, Pandian NG, Vogel M, Cao QL, Ludomirsky A, et al. Delineation of site, relative size and dynamic geometry of atrial septal defects by real-time three-dimensional echocardiography. J Am Coll Cardiol 1995;25:482–90. 9. Taniguchi M, Akagi T, Watanabe N, Okamoto Y, Nakagawa K, Kijima Y, et al. Application of real-time three-dimensional transesophageal echocardiography using a matrix array probe for transcatheter closure of atrial septal defect. J Am Soc Echocardiogr 2009 Oct;22(10):1114–20.