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ECHO ASSESSMENT OF ATRIAL SEPTAL DEFECT

ECHO ASSESSMENT OF ATRIAL SEPTAL DEFECT. DR JULIAN JOHNY THOTTIAN. VARIOUS ECHO MODALITIES. TTE CONTRAST ECHOCARDIOGRAPHY TEE 3D ECHO ICE. 4 TYPES OSTIUM SECUNDUM- 66% OSTIUM PRIMUM- 15% SINUS VENOSUS-10%- superior and posterior part of septum DEFECTS NEAR CORONARY SINUS.

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ECHO ASSESSMENT OF ATRIAL SEPTAL DEFECT

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  1. ECHO ASSESSMENT OF ATRIAL SEPTAL DEFECT DR JULIAN JOHNY THOTTIAN

  2. VARIOUS ECHO MODALITIES • TTE • CONTRAST ECHOCARDIOGRAPHY • TEE • 3D ECHO • ICE

  3. 4 TYPES OSTIUM SECUNDUM- 66% OSTIUM PRIMUM- 15% SINUS VENOSUS-10%- superior and posterior part of septum DEFECTS NEAR CORONARY SINUS

  4. ASD

  5. WHEN TO SUSPECT IN 2D ECHO • RIGHT VENTRICULAR DILATION ABNORMAL MOTION OF IVS- brisk anterior movement in early systole or flattened movement throughout systole • ? IAS DROP OUT IN APICAL 4C VIEW • RELATIVE ATRIAL INDEX

  6. 2D ECHO RA RV VOLUME OVERLOAD SEPTAL FLATTENING IN DIASTOLE

  7. RELATIVE ATRIAL INDEX • Standard apical 4C views- right atrial area divided by left atrial area • ROC curve analysis - cutoff value of >0.92 predicted patients with ASDs v/s matched controls with 99.1% sensitivity and 90.5% specificity. After closure, significant atrial remodeling occurred immediately, with a reduction in the mean RAI at day 1 to 0.93 ± 0.16 (P < .0001) and complete normalization at early follow-up to 0.81 ± 0.12.

  8. The Relative Atrial Index (RAI)—A Novel, Simple, Reliable, and Robust Transthoracic Echocardiographic Indicator of Atrial Defects Natalie A Kelly -Journal of the American Society of EchocardiographyVolume 23, Issue 3 , Pages 275-281, March 2010

  9. SUB COSTAL 4C VIEW • To go for the subcostal 4C – Keeps the atrial septum perpendicular to the ultrasound beam • Distinguishes OS , OP & SV ASDs • SV ASD are consistently visualised in the SUBCOSTAL 4C VIEW • Measurements of the septum can be taken • Anomalous drainage of pulmonary veins • Atrialseptal aneurysm

  10. TTE -views for ASD • PSAX-IAS separates Rt &Lt atrium and runs posteriorly from NCC of aortic valve. Not seen in entirety as a result of drop out artefact • APICAL 4C- Posterior aspect of Interatrial septum is clearly delineated in this view but drop out artefact is seen in region of fossaovalis. • Pulmonary venous drainage- 3 veins draining to LA • APICAL 5C VIEW- Anterior aspect of interatrial septum

  11. PSAX VIEW IAS AGAINST NCC OF AORTA APICAL 4C VIEW SHOWING THE IAS AND 3 VEINS DRAINING TO LA, RT LOWER PULMONARY VEIN IS USUALLY NOT SEEN

  12. SUB COSTAL 4C VIEW- Useful in patients with COPD and ventilated patients Viewed with breath held in inspiration- index marker in 3o` clock position. No IAS drop outs SUB COSTAL SHORT AXIS- Index marker at 12o`clock position and sweeping the transducer from midline to Rt side of patient

  13. SUBCOSTAL 4C VIEW SUB COSTAL SHORT AXIS VIEW ALSO SHOWS IVC DRAINING TO RA AND EUSTACHIAN VALVE

  14. Other important views • To visualise SVC- Suprasternal short axis –index marker in 4 o`clock position • L-SVC is seen from ltsupraclvicular fossa or suprasternal short axis • Suprasternal short axis to visualise the the pulmonary veins draining into left atrium • Cleft mitral valve in AVCD in 12o`clock position in PSAX

  15. SUPRASTERNAL SHORT AXIS

  16. `Crab view` showing absent Rt upper and Rt lower pulmonary vein

  17. En face view in 2D • First the apical 4c view was taken. The image index marker was at approximately kept at 1 o'clock. Keeping the atrial septum and ASD in the region of interest, the transducer was rotated counterclockwise approximately 45° to 60° Xinseng et al Journal of the American Society of Echocardiography Volume 23, Issue 7 , Pages 714-721, July 2010

  18. A-4c view & B-En face view

  19. Ostiumprimum ASD • Defect in lower part of IAS • Associated sometimes with inlet VSD • Cleft mitral valve • AV Valve regurgitation • Partial attachment of mitral valve to IVS

  20. Fig 5 Primum ASD LV RV RA LA Apical four chamber view demonstrating a primum atrial septal defect Colour Doppler flow image from same view illustrating left-to-right shunt across the primum atrial septal defect

  21. CLEFT MITRAL VALVE IN PSAX VIEW POSTERIORLY DIRECTED JET OF MR

  22. OstiumSecundum ASD • 10 morphological variations of defects MC- Deficient aortic rim (42.1%). Central defects (24.2%) Deficient Inferoposterior rim (12.1%) Perforated aneurysm of the septum (7.9%) Multiple defects (7.3%) Combined deficiency of mitral and aortic rims (4.1%), Deficient SVC rim (1%), Deficient coronary sinus rim (1%). Podnar T, Martanovic P, GavoraP,Masura J. Morphological variations of secundum-type atrialseptal defects: feasibility for percutaneous closure using Amplatzerseptaloccluders. Catheter CardiovascInterv 2001;53:386 –91.

  23. Centrally located ASD imaged at 0°

  24. ASD with deficient Aortic margin

  25. Large ASD with deficient posterior and Aortic margins

  26. Multiple ASDs; larger anterior defect (block arrow) and a smaller posterior defect

  27. Sinus venosus ASD A – INTACT IAS B- COLOUR DOPPLER SHOWS DEFECT IN THE UPPER PART OF IAS AT ENTRANCE OF SVC TEE

  28. CORONARY SINUS ASD DILATED CORONARY SINUS TEE 120 DEGREES

  29. ATRIAL SEPTAL ANEURYSM CRITERIA A-PROTRUSION OF ANEURYSM ATLEAST 15MM OF PLANE OF IAS OR IAS SHOWING 15MM OF PHASIC EXCURSION DURING CARDIORESPIRATORY CYCLE B- BASE WIDTH≥ 15MM

  30. PATENT FORAMEN OVALE TEE -0 DEGREE TEE-90 DEGREES

  31. PFO WITH SECONDARY SEPTUM

  32. COLOUR DOPPLER • Shows the direction of the shunt • Caveat- FP results due to improper gain and caval flow streaming near septum can be misdiagnosed as ASD. • PULSED DOPPLER- demonstrates the flow from L to R in mid systole to mid diastole with second phase in atrial systole. Some R to L shunting occurs in early systole • QUANTIFICATION OF SHUNT – Qp /Qs

  33. OS ASD VIA DOPPLER SINUS VENOSUS ASD VIA DOPPLER

  34. CONTRAST ECHOCARDIOGRAPHY • APICAL 4C VIEW IS USED • AGITATED SALINE USED- 5ml in each 10ml syringe, 0.5ml of air taken in the syringe and agitated to create microbubbles.

  35. ARROW SHOWS NEGATIVE CONTRAST EFFECT DIRECT EVIDENCE OF SHUNT- NON CONTRAST BLOOD IN RA Extent of shunting tend to focus on numbers of bubbles seen in a single still frame in the left atrium. Shunt grading incorporates : Grade 1: 5 bubbles; Grade 2: 5 to 25 bubbles; Grade 3:25 bubbles; Grade 4: Opacificationof chamber Echocardiographic Evaluation of Patent Foramen OvalePrior to Device Closure Bushra et al JACC 2010 VOL. 3, NO. 7, 2010

  36. RIMS OF ASD Aortic - SuperoanteriorAtrioventricular (AV) valve -mitral or inferoanterior Superior Vena Caval SVC – Superoposterior Inferior venacaval (IVC or Inferoposterior) Posterior (from the posterior free wall of the atria).

  37. IVC AND SVC RIMS

  38. OTHER RIMS TTE TEE

  39. TEE 2D & 3D

  40. 2D TEE at 0o

  41. TEE at 0° to Evaluate the Posterior and Anterior Rims of the Defect- SVC RAA level

  42. TEE at 0° to Evaluate the Posterior and Anterior Rims of the Defect- mid septum level

  43. TEE at 0° to Evaluate the Posterior and Anterior Rims of the Defect- At the level of the AV valvesatrioventricular valves

  44. TEE at 90° to Evaluate the SVC and IVC Rims AORTIC RIM IS SEEN IN TEE 45 DEGREES

  45. Probe to 30-40o right

  46. Probe rotated 30-40o left

  47. Special tee views for Inferoposterior rims No Infero posterior rim with probe in normal position

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