Atrial septum
CASE 14-1
Anatomy and imaging of atrial septum
CASE 14-2
PFO device closure for recurrent transient neurological events
About 3 years ago this 44-year-old female had an episode of transient dysarthria with a CT scan revealing evidence of a small cerebral infarct at that time. About 6 months ago, she had several brief episodes of right lower extremity paresthesias with the longest episode lasting several minutes in association with significant weakness in the right leg. She refused warfarin anticoagulation and has been managed with antiplatelet therapy. Transesophageal echocardiography demonstrated a patent foramen ovale, and after consenting, she was referred for transcatheter closure.
Comments
TEE or intracardiac echocardiography (ICE) is an essential for transcatheter closure of atrial septal defects or a patent foramen ovale. As illustrated by these cases, the echo images allow visualization of the atrial septum including identification of the size, location, and shape of the atrial septal defect. During the procedure, imaging allows guidance of catheter position and correct placement of the device in the atrial septum. After device deployment, color Doppler and saline contrast imaging allow diagnosis of any residual shunt flow.
Suggested reading
- 1.
Tobis J, Shenoda M: Percutaneous treatment of patent foramen ovale and atrial septal defects, J Am Coll Cardiol 60:1722–1732, 2012.
- 2.
Saric M, Perk G, Purgess JR, et al: Imaging atrial septal defects by real-time three-dimensional transesophageal echocardiography: Step-by-step approach, J Am Soc Echocardiogr 23:1128–1135, 2010.
- 3.
Faletra FF, Nucifora G, Yen S: Imaging the atrial septum using real-time three-dimensional transesophageal echocardiography: Technical tips, normal anatomy, and its role in transseptal puncture, J Am Soc Echocardiogr 24:593–599, 2011.
- 4.
Silvestry FE, Cohen MS, Armsby LB, et al: Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale, J Am Soc Echocardiogr 28:910–958, 2015.
CASE 14-3
Embolization of ASD closure device
This 40-year-old man was recently diagnosed with a large atrial septal defect resulting in significant right ventricular dysfunction and dilation. He was referred for transcatheter closure of the defect.
CASE 14-4
Prolapsing atrial septal defect closure device
This 59-year-old man had two previous neurologic events. Five years ago, he had 1 minute of aphasia and was treated with aspirin. Then 3 months before admission he had left leg weakness that lasted approximately 3 minutes. Echocardiography showed an atrial septal defect with an enlarged right atrium and ventricle, and mildly decreased right ventricular function, with mildly elevated pulmonary pressures of 30 mm Hg.
Comments
Complications after transcatheter atrial septal defect closure occur in less than 5% of cases. The most common complication is a mild residual shunt, detectable by color Doppler or saline contrast imaging. Device embolization is rare but is more likely to occur with very large defects (diameter > 32 mm), or with an insufficient rim of tissue around the defect to adequately anchor the transcatheter closure device. Thus major imaging goals are accurate measurement of defect size in order to choose the correct size of closure device along with assessment of the rim of tissue around the defect. The tissue rim may not be well appreciated on en face 3D images. Instead a full 3D volume should be acquired with careful assessment to the tissue rim in tomographic views derived from the full 3D volume.
Suggested reading
- 1.
Pineda AM, Mihos CG, Singla S, et al: Percutaneous closure of intracardiac defects in adults: State of the art, J Invasive Cardiol 27(12):561–572, 2015.
- 2.
Seo JS, Kim YH, Park DW, et al: Effect of atrial septal defect shape evaluated using three-dimensional transesophageal echocardiography on size measurements for percutaneous closure, J Am Soc Echocardiogr 25:1031–1034, 2012.
- 3.
Lee WC, Fang CY, Huang CF, et al: Predictors of atrial septal defect occluder dislodgement, Int Heart J 56(4):428–431, 2015.
Ventricular septum
CASE 14-5
Anatomy and imaging of ventricular septum
CASE 14-6
Closure of VSD secondary to myocardial infarction
The patient is a 64-year-old gentleman who suffered a large apical and inferior wall myocardial infarction complicated by a postmyocardial infarction ventricular septal defect. Cardiogenic shock ensued and required resuscitation with mechanical ventilation, ionotropic support, and the placement of an Impella percutaneous cardiac support device through left femoral arterial access. Because of his unstable state and the prohibitive risk of open operative repair, he consented to transcatheter closure of the defect.