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echocardiography in case selection and monitoring PFO / ASD procedures. Bushra Rana Consultant Cardiologist Clinical Lead of Non-Invasive Cardiology Papworth Hospital NHS Trust, Cambridge. overview. role of echocardiography in percutaneous atrial septum closure. ♥ pre-operative checklist

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echocardiography in case selection and monitoring pfo asd procedures

echocardiography in case selection and monitoring PFO / ASD procedures

Bushra Rana

Consultant Cardiologist

Clinical Lead of Non-Invasive Cardiology

Papworth Hospital NHS Trust, Cambridge

slide3
overview

role of echocardiography in percutaneous atrial septum closure

♥ pre-operative checklist

TOE protocol

detailed assessment of defect

♥ TOE during the procedure

some important considerations

♥ case examples

highlighting important phenotypes

slide4
overview

role of echocardiography in percutaneous atrial septum closure

complexity of anatomy…

crossing defect…

device sizing …

device positioning…

complications…

pre operative checklist
pre-operative checklist

tunnel length

thickened secondary septum

LA multiple openings

STEP 1 confirm defect is secundum type

STEP 2 surgery better option?

anomalous pulmonary venous drainage

mitral valve pathology

STEP 3 detailed assessment of defect

defect size

number of defects

surrounding rims

atrial septal aneurysm

STEP 4 interference during device placement?

Eustachian valve and ridge

Chiari network

slide6
transoesophageal echocardiography

define anatomy

assess suitability for device closure

right atrium

superior vena cava

aortic root

inferior vena cava

coronary sinus

tricuspid valve

left atrium

right upper pulmonary vein

mitral valve

SVC

AO

ASD

CS

IVC

Rana et al, JACC CVI 2010; 3 (7): 749-60

0 degrees transverse plane
TOE protocol0 degrees transverse plane

SVC

AO

high

mid

low

FO

CS

IVC

Rana et al, JACC CVI 2010; 3 (7): 749-60

90 degrees longitudinal plane
TOE protocol90 degrees longitudinal plane

SVC

high

mid

low

AO

FO

CS

IVC

IVC

Rana et al, JACC CVI 2010; 3 (7): 749-60

specialist views mid oesophagus
TOE protocolspecialist viewsmid oesophagus

AO

50

degrees

SVC

120

degrees

CS

slide10
detailed assessment of defect

surrounding rims >5mm

right atrium

SVC (90-120)

aortic root (50)

IVC (90)

CS (120)

TV

left atrium

RUPV (0 &135)

MV

slide11
detailed assessment of defect

defect size….

PK McCarthy et al Im Paed Car 2003;15:1-24

slide12
detailed assessment of defect

defect size….

PK McCarthy et al Im Paed Car 2003;15:1-24

slide13
detailed assessment of defect

number of defects….how many holes are there?

McCarthy et al Images Paediatr Cardiol 2003;15:1-24

slide14
detailed assessment of defect

number of defects….how many holes are there?

McCarthy et al Images Paediatr Cardiol 2003;15:1-24

slide15
detailed assessment of defect

number of defects….how many holes are there?

McCarthy et al Images Paediatr Cardiol 2003;15:1-24

detailed assessment of defect
detailed assessment of defect

atrial septal aneurysm…mobility, margins

need for over sizing to grip firm part of septum & ensure device stability

slide18
imaging during procedure

wire position LAA/PV’s

balloon inflation, defect sizing

LA disc deployment

RA disc deployment

Position check

working view 50 degrees

slide19
imaging during procedure

wire position LAA/PV’s

balloon inflation, defect sizing

LA disc deployment

RA disc deployment

Position check

Balloon inflation

♦with colour Doppler

♦ when flow stops balloon stops

slide20
imaging during procedure

wire position LAA/PV’s

balloon inflation, defect sizing

LA disc deployment

RA disc deployment

Position check

Balloon inflation

♦with colour Doppler

♦ when flow stops balloon stops

♦ at waist outer edge-outer edge

slide21
imaging during procedure

wire position LAA/PV’s

balloon inflation, defect sizing

LA disc deployment

RA disc deployment

Position check

Repeat protocol 0/50/90/120

♦ device profile

♦ completely gripped septum

♦ abnormal flow

slide23
complex anatomy

enface view from left atrium

Rana et al Euro J Echocard 2010; 11: i19–i25

slide24
Ao

RUPV

MV

slide25
complex anatomy

left atrium view

Rana et al Euro J Echocard 2010; 11: i19–i25

slide26
complex anatomy

left atrium view

Rana et al Euro J Echocard 2010; 11: i19–i25

slide27
SVC

FO

ER

CS

IVC

Rana et al Euro J Echocard 2010; 11: i19–i25

slide28
complex anatomy

right atrium view

Rana et al Euro J Echocard 2010; 11: i19–i25

slide29
complex anatomy

RUPV

MV

Rana et al Euro J Echocard 2010; 11: i19–i25

slide30
complex anatomy

LA view

Rana et al Euro J Echocard 2010; 11: i19–i25

slide31
complex anatomy

LA view

Rana et al Euro J Echocard 2010; 11: i19–i25

slide32
complex anatomy

LA view

Rana et al Euro J Echocard 2010; 11: i19–i25

slide33
complex anatomy

LA view

Rana et al Euro J Echocard 2010; 11: i19–i25

slide34
defect position

Rana et al Euro J Echocard 2010; 11: i19–i25

slide37
defect position

Rana et al Euro J Echocard 2010; 11: i19–i25

slide38
summary

complex anatomy…

crossing defect…

device sizing …

device positioning…

complications…

slide39
summary

complex anatomy…

crossing defect…

device sizing …

device positioning…

complications…

role of echocardiography
role of echocardiography

patient

assessment for suitability of device closure

diagnosis

TTE ±bubble contrast

detailed imaging

intra-procedural guidance device sizing/position complications

pre-procedural

TOE

intra-procedural

TOE

ICE

GA

Rana et al, JACC CVI 2010; 3 (7): 749-60

detailed assessment of defect total length of atrial septum
detailed assessment of defecttotal length of atrial septum

Transverse 00 Longitudinal 900

mid oesophagus view mid oesophagus view

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