TEE FOR ATRIAL SEPTAL DEFECT

Transesophageal Echocardiography for Atrial Septal Defect (ASD)

Assess for -

1.Site of ASD

2.Size of ASD

3. Number of ASDs

4. RA and RV dilatation

5 .PA Pressures

6.Tricuspid regurgitation

7. Paradoxical  motion and flattening of interventricular septum 

8.Pulmonary venous drainage  

9. Pulmonary stenosis

10. Overriding of aorta (Pentalogy of Fallot )

11.Associated lesions–

·       Mitral Stenosis (Lutembacher Syndrome)

·       MR (MVP, cleft AML) in primum ASD

·       VSD,PDA, coarctation of aorta

·       LSVC

12.Interatrial septal aneurysm

13.QP/QS = Stroke volume PV / Stroke volume AV

                    PV Area x PV _VTI /  AV Area x AV _VTI

Rims of ASD are assessed in-

Anterosuperior rim - ME AV SAX view

Posterior rim - ME 4 chamber view

Inferoanterior rim - ME 4 chamber view

Superoposterior rim - ME bicaval view

Further assessment -

1.    Lack of inferior or posterior rim is unfavorable.

2.    Assess device stability , proper positioing

3.    Leak around device

4.    Residual shunting

5.    See for AV valve incompetence

6.    Unobstructed systemic & pulmonary veins

7.    See for orifices of SVC, IVC and Pulmonary veins

Retroflexed TEE view for inferoposterior or IVC rim – TEE probe is advanced in the stomach, retroflexed and slowly withdrawn to lower esophagus at 70-90⁰ and IVC rim can be seen.

TEE Views -

1.ME 4 chamber view

2.ME RV inflow outflow view

3.ME Bicaval view

Color Doppler -

1. Left to right shunt or Bidirectional shunt

2. Laminar or turbulent flow – Restrictive or Non-restrictive

Saline Contrast study –

3 to 10 ml of saline is agitated with < 1 ml of air and injected rapidly into central or arm vein.

ASD if present with R-L shunting microbubbles appear in LA within 5 heart beats [Positive study]

If it takes 5 -10  beats or more, pulmonary arteriovenous malformations may be present [False positive study]

If non-contrast blood appears in the contrast filled RA it represents L – R shunting [Negative study]

Saline contrast detects PFO at rest and with raised RA pressure

Transesophageal Echocardiography Views -

1.Ostium secundum- ME 4 chamber view ,ME RV inflow outflow view, ME Bicaval view

2.Ostium primum ME 4C view

3.Sinus venosus – ME bicaval view, ME modified bicaval view - PAPVC of RUPV can be seen

4.Coronary sinus defect

 LSVC appears as wedge shaped echo free space between LUPV and LAA in ME midcommissural  View. Contrast echo opacifies LSVC.

After  Surgical Correction-

1.    See intact ASD patch

2.    No residual shunt

3.    SVC and IVC draining in RA as in case of deficient inferior rim IVC may get routed to LA

4.    In  SVC type sinus venosus ASD confirm that there is no turbulence to SVC flow, as re routing of RUPV may be done

5.    Pulmonary vein PWD should show normal pattern of S and D waves as they are re-routed to LA

6.    lVC type of SV ASD - PAPVC with right lower pulmonary veins is present Confirm IVC draining into the RA.

Abbreviations -

PFO – Patent foramen ovale

PAPVC- Partial anomalous pulmonary venous connection

References -

Vaidyanathanetal. TEE for Device Closure of ASD. JACC: CARDIOVASCULAR IMAGING, VOL. 2, NO. 10,OCTOBER 2009:1238 – 42.

Transesophageal echocardiography of Congenital Heart Diseases – Poonam Malhotra Kapoor, Sarvesh Pal Singh.

- by Dr Amarja