Atrial septal defect echocardiography
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Atrial septal defect echocardiography On the Web | |
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American Roentgen Ray Society Images of Atrial septal defect echocardiography | |
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Risk calculators and risk factors for Atrial septal defect echocardiography | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3] Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [4]
Overview
Echocardiography is the preferred diagnostic tool in the evaluation of an atrial septal defect. Out of the different types of echocardiographic modalities that can be used, transesophageal echocardiography can be used for all types of atrial septal defects. Trials have shown transesophageal echocardiography to be superior in diagnosing sinus venosus ASD compared to transthoracic echocardiography[1][2]. Other modalities like transthoracic echocardiography can be used for identification of the secundum type of atrial septal defects. During imaging the entire atrial septum from the orifice of the superior vena cava to the orifice of the inferior vena cava should be visualized. This helps in detecting sinus venosus defects and large ostium secundum defects that might extend up to that area. As an evaluative tool, echocardiograms can: locate the defects, identify the direction of shunting, identify associated anomalies, evaluate atrial and ventricular enlargement. In general, an atrial septal defect patient will present symptomatic evidence of hemodynamic disruptions between the left and right atrium.
Echocardiography
- Echocardiography is the preferred diagnostic imaging method for the evaluation of many congenital heart diseases, including atrial septal defect. An echocardiogram allows for identification of the functional issues with the heart's anatomy. In suspected atrial septal defect patients, an echocardiogram can locate the defect, identify the direction of shunting, associated anomalies, evaluate atrial and ventricular enlargement.
- Think about anomalous pulmonary veins, if echocardiography shows volume overload and no ASD is seen.
Advantages of Echocardiography
Echocardiography is one of the preferred modalities for diagnosing congenital heart defects including atrial septal defects. It provides with information that helps to do accurate diagnosis of the type of atrial septal defect along with any associated anomalies. Also, it helps in making therapeutics decisions about the condition.
Echocardiography can provide:
- Direct visualization of the defect in a subcostal 2-dimension view
- A visualization, when right ventricular volume overload is present, of:
- Pulmonary arterial dilatation
- Right ventricular dilatation
- Anterior systolic/paradoxic septal motion
- Imaging of an associated anomalies.
- Identify associated anomalies
- Evaluate atrial enlargement
- Evaluate ventricular enlargement
- Locate and size of defects
- Doppler flowechocardiography can identify:
- Shunt ratios
- Shunt volume
- Direction of shunt
- Pulmonary artery pressure
If the individual has adequate echocardiographic windows, it is possible to use the echocardiogram to measure the cardiac output of the left ventricle and the right ventricle independently. In this way, it is possible to estimate the shunt fraction using echocardiography.
Transesophageal Echocardiography
Transesophageal echocardiography (TEE) has had a notable positive impact on both, the care and management of a patient with congenital heart disease, such as an atrial septal defect patient. TEE has been evaluated in all age groups and is determined to be safe for pediatrics and adults. Trials have showntransesophageal echocardiography to be superior in diagnosing sinus venosus ASD compared to transthoracic echocardiography.[1]
- Transesophageal echocardiography is the preferred diagnostic tool in atrial septal defect.
- To accurately diagnose the different types of atrial septal defects and associated anomalies a two-dimensional imaging of the atrial septum from different views like parasternal, apical, and subcostal views should be used.
- A color Doppler along with TEE helps to demonstrate amount and directions of shunting.
- Atrial septal defects in adults could be best visualized by subcostal views with deep inspiration and high right parasternal views.
- Ideally the entire atrial septum from the orifice of the superior vena cava to the orifice of the inferior vena cava should be visualized. This helps in detecting sinus venosus defects and large ostium secundum defects that might extends up-to that area.
- It also helps in identifying pulmonary veins morphology that could be helpful in sinus type of atrial septal defects and assocaiated lesions.
- In case of diagnostic dilemmas with adults with transthoracic echocardiography, TEE helps in exact localization, size of the ASD and measurement of septal rims. All these details also help in making surgical decisions.
- The entire coronary sinus roof should be imaged to diagnose sinus atrial septal defect. A large coronary sinus orifice with evidence of atrial shunting may indicate a defect in the roof of the coronary sinus.
- With pulmonary artery hypertension, the low velocity of the shunt flow across the coronary sinus defect may be difficult to distinguish from other low-velocity flow within the atria.
TEE in Pediatrics
- Research has indicated that TEE is a considerably safe procedure in pediatric populations.
- Caution is recommended in inserting a probe into a neonate weigh less than or equal to 3 kg.[3]
- The reported incidence of development of complications during TEE performance is between 1-3%.
Advantages
TEE is a highly recommended method of imaging modality for atrial septal defect. It can provide:
- Precise identification of the location
- Precise information regarding lesion morphology
- Identification of:
- Number of atrial septal defects
- Extent of surrounding atrial septal tissue
- Location of adjacent structures
This information allows an interventional cardiologist to determine the best method and devise for closure.[3]
Complications
- The most common complications include:
- Less common complications:
- Perforation/laceration of the oropharynx, hypopharynx, esophagus and stomach
- Arrhythmias
- Pulmonary complications
- Circulatory derangement
- Endocarditis
The Task Force of the Pediatric Council of the American Society of Echocardiography recommendations - Atrial Septal Defect
The Task Force of the Pediatric Council of the American Society of Echocardiography recommends the following.
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A preoperative transthoracic echocardiogram be performed in every patient undergoing a transesophageal echocardiogram during congenital heart surgery. The results of the TTE should be evaluated prior to the TEE. A TEE is not recommended as the only diagnostic imagining method as there are limitations that are better identified in methods such as TTE.[3] |
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Supportive Trial Data
In a study done on forty one patients with clinical diagnosis of atrial septal defect, transesophageal echocardiography was able to diagnose all the patients whereas transthoracic echocardiography was only able to diagnose 80% of them. Interestingly, 3 out of the 4 undiagnosed cases with trans-thoracic echocardiography were sinus venosus ASD. Transesophageal echocardiography is recommended when an atrial septal defect is clinically suspected but cannot be visualized by transthoracic echocardiography.[1]
2008 ACC / AHA Guidelines - Evaluation of the Unoperated Patient- Atrial Septal Defect (DO NOT EDIT)[4]
| Class I |
| "1. ASD should be diagnosed by imaging techniques with demonstration of shunting across the defect and evidence of RV volume overload and any associated anomalies. (Level of Evidence: C) " |
Trans-thoracic echocardiography
Trans-thoracic echocardiography is an effective two-dimensional modality that can be used to identify suspected atrial septal defects.
- Effective two-dimensional modality for visualizing an ostium secundum atrial septal defect.
- Types:
- Apical four chamber view
- Subcoastal four chamber view
- Provides imaging of:
- Right ventricular enlargement
- Paradoxical motion involving the ventricular septum
- Right atrium enlargement
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Advantages
- Determines which type of defect exists.
- Necessary to evaluate for anomalous pulmonary veins.
- Evaluates for an atrial septal aneurysm.
Disadvantages
- Apical four chamber view involves a parallel angle of the echocardiographic beams onto the atrial septum causing artifact in the echo
- Subcostal four chamber view can be ineffective in overweight/obese patients.
- Size of the defect seen in a TTE does not parallel the measurement of shunt flow from cardiac catheterization.
Sensitivity
- One study found that subcostal approach could successfully visualize the majority of ostium primum and ostium secundum atrial septal defects.[5]
- Visualization of sinus venosus atrial septal defect is less successful, less than 50% of the cases were properly imaged.[5]
ACC / AHA Guidelines - Evaluation of the Unoperated Patient (DO NOT EDIT)[4]
| “ |
Class I1) ASD should be diagnosed by imaging techniques with demonstration of shunting across the defect and evidence of RV volume overload and any associated anomalies. (Level of Evidence: C) |
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Modalities
Trans-esophageal Echocardiography (TEE)
Trans-thoracic Echocardiography (TTE)
Contrast Echocardiography
M-mode
Doppler
Videos showing echocardiographic findings in specific defects: Ostium primum | Ostium secundum | Patent foramen ovale | Sinus venosus
References
- ↑ 1.0 1.1 1.2 Kronzon I, Tunick PA, Freedberg RS, Trehan N, Rosenzweig BP, Schwinger ME (1991). "Transesophageal echocardiography is superior to transthoracic echocardiography in the diagnosis of sinus venosus atrial septal defect". J Am Coll Cardiol. 17 (2): 537–42. PMID 1991912.
- ↑ Mehta RH, Helmcke F, Nanda NC, Pinheiro L, Samdarshi TE, Shah VK (1991). "Uses and limitations of transthoracic echocardiography in the assessment of atrial septal defect in the adult". Am J Cardiol. 67 (4): 288–94. PMID 1990793.
- ↑ 3.0 3.1 3.2 Ayres NA, Miller-Hance W, Fyfe DA, Stevenson JG, Sahn DJ, Young LT; et al. (2005). "Indications and guidelines for performance of transesophageal echocardiography in the patient with pediatric acquired or congenital heart disease: report from the task force of the Pediatric Council of the American Society of Echocardiography". J Am Soc Echocardiogr. 18 (1): 91–8. doi:10.1016/j.echo.2004.11.004. PMID 15637497.
- ↑ 4.0 4.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.
- ↑ 5.0 5.1 Shub C, Dimopoulos IN, Seward JB, Callahan JA, Tancredi RG, Schattenberg TT; et al. (1983). "Sensitivity of two-dimensional echocardiography in the direct visualization of atrial septal defect utilizing the subcostal approach: experience with 154 patients". J Am Coll Cardiol. 2 (1): 127–35. PMID 6853907.