Date post: | 20-Mar-2017 |
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Echocardiographic Assessment of ASD
Md. Mashiul AlamPhase B resident
UCC
Chairperson: Assoc. Prof. Naveen Sheikh
Atrial Septal Abnormalities
1. Atrial septal defect (ASD)---- 5 to 10% of CHD2. Patent foramen ovale (PFO)3. Atrial septal aneurysm
Types of ASD
1. ASD secundum2. ASD primum3. Sinous venosus4. Coronary sinus variety
1. 80% secundeum, located in the region of the fossa ovalis and its surrounding
2. 15% Primum, located near the crux, AV valves malformed with regurgitation
3. 5% SVC type sinus venosus, defect located near to SVC, assocaited with anomalous pulmonary venous return
4. <1% IVC type sinus venosus, defect located near IVC5. <1% Unroofed coronary sinus, separation from the LA
partially or completely missing
Associations of other…
• Secundum ASD: MVP• Primum ASD: AV canal defect (Down syndrome)• Sinus venosus: Partial anomalous pulmonary
venous retrun• Conornary sinus variety: complete AV septal
defect, absence of coronary sinus, left SVC that drains into the left atrium
Facts about ASD
• Asymptomatic until adulthood• Symptoms beyond the fourth decade• Life expectency reduced• Quality of life decreased• Eisenmenger rare (<5%)
Echocardiography in ASD
• To identify and confirm ASD• To identify associated anomalies• To diagnose complications of ASD• For therapeutic purpose
Echocardiographic modalities
1. Transthoracic echocardiogram (TTE)2. Transoesophgeal echocardiogram (TEE)3. Intracardiac echocardiogram (ICE)
Modes:2D, M mode, Doppler study, 3D
• TEE > TTE
• TTE-----Subcostal view
• TEE-----High transverse and longitudinal planes
Routine measurement and report
• ASD type• Doppler flow- presence of shunt• ASD size• ASD location• Measure all rims• Shape of ASD---round, oval, irregular
Calculate
• ASD measurements • Qp/Qs• Pulmonary hypertension
Common views in TTE
• Subxiphoid Frontal (Four-Chamber)• Subxiphoid Sagittal• Left Anterior Oblique• Apical Four-Chamber• Modified Apical Four-Chamber• Parasternal Short-Axis• High Right Parasternal View
TTE views for ASD
• Subxiphoid Frontal (Four-Chamber) The subxiphoid frontal (four-chamber) view
allows imaging of the atrial septum along its anterior–posterior axis from the SVC to the AV valves.
• Subxiphoid Sagittal The subxiphoid sagittal TTE view is acquired by
turning the transducer 90 clockwise from the frontal view. This view can be used to measure the rim from the defect to the SVC and IVC and is an excellent window to image a sinus venosus type defect
• Apical Four-Chamber : This view is used to assess the hemodynamic
consequences of ASDs, such as RA and RV dilation, and to estimate RV pressure using the tricuspid valve regurgitant jet velocity. This view is also used to evaluate for right-to-left shunting with agitated saline
• Parasternal Short-AxisThis view is ideal to identify the aortic rim of the
defect. It also highlights the posterior rim (or lack thereof) in sinus venosus and posteroinferior secundum defects.
• Left Anterior Oblique.The left anterior oblique is acquired by turning
the transducer approximately 45 counterclockwise from the frontal (four-chamber) view. This view allows imaging of the length of the atrial septum and is therefore ideal to identify ostium primum ASDs and for assessment of coronary sinus dilation
• Modified Apical Four-Chamber (Half Way in Between Apical Four-Chamber and
Parasternal Short-Axis View): In the patients in whom the subcostal views are
difficult to obtain, the modified apical four-chamber view is an alternative method for imaging the atrial septum
• High Right Parasternal View. The high right parasternal view is a parasagittal
view performed with the patient in the right lateral decubitus position with the probe in the superior–inferior orientation. In this view, the atrial septum is aligned perpendicular to the beam and is ideal for diagnosing sinus venosus defects, particularly when the subxiphoid windows are inadequate
ASD secundum rims
• SVC or superior margin• IVC or inferior margin• Posterior margin• Anterior or retroaortic margin• Mitral rim
Views to identify the ASD rims
PSAX view at great vessel level:Aortic and Post rim
A4CV:Mitral Rim
Subcostal view: SVC and IVC rim
Qp/Qs
• Qp – pulmonary flow• Qs – systemic flow• Qp/Qs = 1 in normal• Qp/Qs > 1.5 significant shunt
• Qp = VTI, RVOT diameter• Qs = VTI, LVOT diameter
Pulmonary hypertension
by TR if no RVOT obstruction
Also by PR max velocity or RVOT acceleration time
ASD with Eisenmenger syndrome
• pulmonary hypertension,• reversal of flow, • and cyanosis
ASD secundum Device closureCRITERIA:
1. “Significant” ASDs (Qp/Qs >1.5 or ASDs associated with right ventricular volume overload) should be closed
2. Secundum ASD that has a stretcheddiameter of less than 38 mm and more than 10 mm
3. Adequate rims (5 mm) to enable securedeployment of the device
4. Anomalous pulmonary venous connectionor proximity of the defect to the AV valves or coronary sinus or systemic venous drainag, intracardiac thrombie absent
Device in situ
Device in situ
Follow up echo after device closureAfter device closure, patients require 6 months of aspirin and
endocarditis prophylaxis until the device endothelializes, following which, assuming that no residual shunt is present
all patients who have undergone device closure should probably have an echocardiogram taken every 5 years or so because of the possibility of late issues, especiallyerosion.
Ref: Braunwald 10th ed
ASD after surgical closure
TEE for ASD
THANK YOU