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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5761_Библиотеки_им_академика_М_И_Перельмана
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13
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_5, © Springer International Publishing Switzerland 2015
A 34-year-old woman with a history of one episode of transient ischemic attack was referred to our echocardiography
laboratory for the evaluation of its cause. Physical examination revealed the fi xed splitting of S2 and a holosystolic murmur (grade II/VI) at the left sternal border.
Transthoracic echocardiography (TTE) showed atrial
situs solitus and atrioventricular and ventriculoarterial concordance, as well as a normal left ventricular size and function, mild mitral regurgitation, and moderate right ventricular
dilation with a normal systolic function.
Atrial Septal Defect (Ostium
Secundum Type) During
Device Closure
Case 5
Fig. 5.1 A large defect ( arrow ) can be detected in the middle portion
of the interatrial septum with the fl ow moving through it from the left
atrium toward the right atrium ( red color on TTE); this is in favor of a
left-to-right shunt fl ow across an ASD (ostium secundum type) in the
subcostal short-axis view by two-dimensional echocardiography ( left )
and by color Doppler fl ow study ( right ). RA right atrium, LA left atrium
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_5 ) contains supplementary
material, which is available to authorized users
14
ab
c
Fig. 5.2 The ASD size is approximately 7 mm in 0° ( a ), 14 mm in the
short-axis view ( b ), and 20 mm in the bicaval view ( c ) by transesopha-
geal echocardiography (TEE). RAA right atrial appendage, AOV aortic
valve, LA left atrium, RA right atrium. Note that the ASD fl ow is blue in
color on TEE ( c )
Fig. 5.3 TEE ( short-axis view ) shows that the atrial depth is approxi-
mately 35 mm. This view is obtained in order to prevent injury to the
left atrium during the ASD device closure. Also, the rim to the aortic
valve is small. AOV aortic valve
Case 5 Atrial Septal Defect (Ostium Secundum Type) During Device Closure
15
Comment
Because the size of the ASD was not too large (12) (about
20 mm) and there were adequate rims, the patient was
referred for the ASD device closure. Intra Cath-Lab TEE
was performed.
a b
Fig. 5.4 This is the balloon sizing of the ASD on TEE ( short-axis
view ). The balloon is infl ated until it has stopped the shunt fl ow. Defect
sizing is thereafter performed by measuring the waist of the balloon,
which is about 23.1 mm ( a ). This is a schematic illustration of the bal-
loon sizing of the ASD on TEE ( short-axis view ) ( b ). RA right atrium,
AO aorta
Fig. 5.5 A delivery sheath is passed through the ASD over a guide-
wire. RA right atrium, AOV aortic valve
Case 5 Atrial Septal Defect (Ostium Secundum Type) During Device Closure
16
ab
Fig. 5.6 The delivery sheath is pulled back, and subsequently the fi rst left atrial disk ( arrow ) ( a ), followed by the right atrial disk ( arrow ) ( b ), is
deployed ( a , b ). TEE ( short-axis view ). RA right atrium
Fig. 5.7 TEE ( short-axis view ) presents an assessment of the fi nal
result before the release of the device ( arrow ). AOV aortic valve
Fig. 5.8 TEE (10°) illustrates the fi nal result, with the position of the
interatrial septum being just between the two disks of the device
( arrow ). RA right atrium
Case 5 Atrial Septal Defect (Ostium Secundum Type) During Device Closure
17
Fig. 5.9 TEE (114°) shows no compressive effect and a non-turbulant
fl ow in the left upper and left lower pulmonary veins. LUPV left upper
pulmonary vein, LLPV left lower pulmonary vein
The ASD device closure was conducted with a 26-mm
device.
Diagnosis
The patient was symptomatic and was diagnosed with an
ASD (ostium secundum type). The maximum size of the
ASD was about 20 mm [ 12 ], and there were adequate rims.
She underwent successful ASD device closure under intra
Cath-Lab TEE guidance. The occlusive diameter of the balloon was 23 mm, and the fi nal device size was 26 mm.
Lesson
1. The ASD may have been the cause of the patient’s tran-
sient ischemic attack owing to paradoxical emboli.
2. The fi nal device size was 1–3 mm larger than the occlusive
diameter of the balloon on TEE. According to the fl exibility
of the surrounding rims, the mean of the occlusive diameter
of the balloon on TEE was about 3 mm (mean) greater than
the mean of the size of the ASD on TEE [ 3 , 4 , 13 ].
3. The size of the ASD may completely differ between mul-
tiple views.
4. The only rim that is not important for the ASD device
closure is the rim to the aorta [ 5 , 14 , 15 ].
5. Very large devices may produce necrosis of the interatrial
septum [ 16 ].
Case 5 Atrial Septal Defect (Ostium Secundum Type) During Device Closure
19
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_6, © Springer International Publishing Switzerland 2015
A middle-aged woman with a history of palpitation and dyspnea on exertion (functional class II) was referred to our
echocardiography laboratory. A previous transthoracic echocardiographic examination had shown an ASD (ostium
secundum type), and she was referred for transesophageal
echocardiography (TEE) to evaluate suitability for the ASD
device closure.
Atrial Septal Defect (Ostium
Secundum Type) Closure
by the Amplatzer
Case 6
Fig. 6.1 No interatrial septal (IAS) defect can be detected on TEE
(0°); therefore, it is not possible to evaluate the rim to the mitral valve.
Biatrial enlargement is evident in this view
Fig. 6.2 TEE ( short-axis view ) demonstrates that the ASD/IAS is
20/51 mm. AO aorta
20
Comment
Given the patient’s good rims and suitable size of the ASD,
device closure was recommended.
The device was deployed without any complications.
The following TEE images were obtained after device
implementation:
Lesson
The position of the two plates of the device between the IAS
is of great signifi cance in intra Cath-Lab TEE.
a
c
b
Fig. 6.4 The IAS is laid out between the two plates of the device on TEE 0° ( a ), short-axis view ( b ), and bicaval view ( c ). The contrast injection
shows no residual shunt across the IAS ( b , c ). RA right atrium
Fig. 6.3 TEE ( short-axis view ) shows that the occlusive diameter of
the balloon is about 19.5 mm. AO aorta
Case 6 Atrial Septal Defect (Ostium Secundum Type) Closure by the Amplatzer
21
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_7, © Springer International Publishing Switzerland 2015
A 45-year-old woman with a history of one episode of
transient ischemic attack and several long-standing palpitations was referred to our center. Physical examination
revealed the fi xed splitting S2 and a pansystolic murmur
(grade III/VI) at the left sternal border. Echocardiography
showed a normal left ventricular size and systolic function
and a severely dilated right ventricle with a good systolic
function.
Atrial Septal Defect (Ostium
Secundum Type) Unsuitable
for Device Closure
Case 7
a
b
Fig. 7.1 A large atrial septal
defect (ASD) (ostium secundum
type) with a left-to-right shunt
can be seen in the apical
four-chamber view ( a ) and the
subcostal short-axis view
( arrows ) ( b ). The size of the
defect is about 29 mm in the
apical four-chamber view ( a ). LA
left atrium, LV left ventricle, RA
right atrium, RV right ventricle
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_7 ) contains supplementary
material, which is available to authorized users.
22
Diagnosis
The patient was symptomatic and was diagnosed with an
ASD (ostium secundum type) that was not suitable for device
closure.
Comment
Given the patient’s small rim to the inferior vena cava and
some degree of interatrial septum malalignment [ 17 ], surgical ASD closure was recommended.
Lesson
In addition to the size of the ASD and rims, if there is
malalignment of the interatrial septum, the device closure
will be more diffi cult [ 17 ].
ab
Fig. 7.2 The rim to the inferior vena cava is small (5 mm) ( a ), and also there is some degree of interatrial septum malalignment (about 5 mm) ( b )
on this transesophageal echocardiography (bicaval view). LA left atrium, RA right atrium
Case 7 Atrial Septal Defect (Ostium Secundum Type) Unsuitable for Device Closure
23
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_8, © Springer International Publishing Switzerland 2015
A 29-year-old man presented with only atypical chest pain
during exercise. Physical examination revealed a fi xed splitting of S2. Echocardiography showed atrioventricular and
ventriculoarterial concordance, normal left ventricular size
and function, moderately dilated right atrium and ventricle,
and the Qp/QS of about 1.8.
Fenestrated Interatrail Septum “Swiss
Cheese-like Atrial Septal Defect”
Case 8
Fig. 8.1 The subcostal four-chamber view illustrates multiple small
defects ( arrows ) in the interatrial septum (IAS). LA left atrium, LV left
ventricle, RA right atrium, RV right ventricle
Fig. 8.2 Transesophageal echocardiography (TEE) (0°) reveals a
partially aneurysmal IAS of about 5 mm. At fi rst glance, this view does
not reveal an atrial septal defect (ASD). AO aortic valve, LA left atrium,
RA right atrium
Fig. 8.3 An ASD (ostium secundum type) is detected near the aorta on
TEE (0°) by some clockwise rotation. LA left atrium, RA right atrium,
AO aorta
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_8 ) contains supplementary
material, which is available to authorized users.
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