guidelines for the echocardiographic assessment of atrial...

10/9/2016NYU Leon H. Charney Division of Cardiology

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2016 ASE Echo Florida, Orlando, FL

Guidelines for the Echocardiographic Assessment of Atrial Septal Defect and Patent Foramen Ovale

Sunday, October 9, 2016 | 2:30 – 2:45 PM | 15 min

M U H A M E D S A R I Ć , M D , P H D

D i r e c t o r o f E c h o c a r d i o g r a p h y L a b

A s s o c i a t e P r o f e s s o r o f M e d i c i n e

N e w Y o r k U n i v e r s i t y L a n g o n e M e d i c a l C e n t e r

M e d t r o n ic & P h i l i p s S p e a k e r s ’ B u r e a u s

10/9/2016NYU Division of Cardiology

2

Disclosures

10/9/2016NYU Division of Cardiology 3

Frank SilvestryUniversity of Pennsylvania

Guidelines Chair


ANATOMY & EMBRYOLOGY

Atrial septum & septal defects

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ECHO IMAGING

2D/3D TTE & TEE

2

SHUNT ASSESSMENT

Color Doppler & contrast

3

PERCUTANEOUS CLOSURE

Echo guidance

4

Anatomy & Embryology of Atrial Septum

NYU Leon H. Charney Division of Cardiology 10/9/2016

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Septum primum

Ostium primum

Ostium secundum

Ostium secundum

Development of septum secundum Foramen ovale

Septum primum

EMBRYOLOGY OF ATRIAL SEPTUM


ATRIAL SEPTAL DEFECTS

Common atrium


Secundum ASD(Fossa ovalis ASD)

Primum ASD(AV canal spectrum)

Sinus venosus ASD(SVC-type)

ATRIAL SEPTAL

DEFECTS

Amenable to percutaneous closure


*SVC

AV

FO

SVC-TYPE SINUS VENOSUS ASD(Right atrial perspective)*

LV

MV

AV

PRIMUM ASD(Left atrial perspective)

SECUNDUM ASD(Left atrial perspective)

*

SVC

AV~15% of ASDs

~80% of ASDs

~5% of ASDs

ATRIAL SEPTAL DEFECTS

10/9/2016NYU Leon H. Charney Division of Cardiology 10

SECUNDUM ASDsSeen from RA

perspective

SVC

AV

Circular

Ovoid

Triangular

Fenestrated

Multiple holes(< Lat. fenestra

– window)

ATRIAL SEPTAL DEFECTS | SHAPE & SIZE VARIABILITY

Echocardiographic Imagingof Atrial Septum


11


ECHO IMAGING OF ATRIAL SEPTUM

For best imaging of atrial septum, insonation angle should be as perpendicular as possible to the septal plane.

TTE | Subcostal View



As perpendicular as possible to the septal plane >>> Coaxial with Doppler flow.

Large Secundum

ASD



For insonation angle is parallel (coaxial) with the septal plane,image dropouts must be differentiated from true atrial septal defects.

TTE | Apical 4-Chamber View

No ASD Secundum ASD


TEE | ATRIOVENTRICULAR & POSTERIOR ASD RIM

1

2

A

*

RA

RV

LA

3

4

B

*

RA

RV

LA

AV


TEE | AORTIC & POSTERIOR ASD RIM

C

56

*

RA

LA

SVC


TEE | SUPERIOR & INFERIOR ASD RIM


3D TEE | SECUNDUM ASD RIMS

LA Perspective

MV

AV

SVC RUPV

RA Perspective

SVC

AV

IVCTV

Atrial Septum: Associated Findings


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ATRIAL SEPTUM MASQUERADERS

• Eustachian valve• Chiari network • Thebesian valve

HEART TUBE

SINUS VENOSUS VALVE


EUSTACHIAN VALVE | PARTIAL VALVE OF IVC

BARTOLOMEO EUSTACHI

Latinized as Eustachius (1514 -1574)

Italian anatomist

RA

LA

SVCIVC



BARTOLOMEO EUSTACHI


Italian anatomist


CHIARI NETWORK| REMNANT OF SINUS VENOSUS VALVE

RA

LA

RA

LA

HANS CHIARI

(1851 − 1916)Austro-Hungarian

anatomist


ATRIAL SEPTAL ANEURYSM

DEFINITION• Redundancy or saccular

deformity of the atrial septum• Increased mobility of the atrial

septal tissue. • Excursion of the septal tissue

(typically the fossa ovalis) of > 10 mm from the plane of the atrial septum into the RA or LA, or

• A combined total excursion right and left of > 15 mm

RA

LA

PREVALENCE• 2%–3% of humans

ASSOCIATIONS• Increase prevalence of PFO• Increased size of a PFO• Increased prevalence of

cryptogenic stroke• Multiple septal fenestrations

(fenestrated ASD)


ATRIAL SEPTAL ANEURYSM

M mode

Shunt Assessment


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ATRIAL SEPTAL ANEURYSM | PFO SHUNT WITH SALINE CONTRAST


INTRACARDIAC VS. INTRAPULMONARY SHUNT

• PROVOCATIVE MANEUVERS

Agitated saline injections should be performed at rest and provocative maneuvers to increase the right atrial pressure, such as cough and the Valsalva maneuver.

• PFOWithin 3 cardiac cyclesThe presence of PFO is presumed when agitated saline contrast is noted in the left atrium within 3 cardiac cycles after complete opacification of the right atrium.

• INTRAPULMONARY SHUNT

After 5 cardiac cyclesIf the agitated saline contrast is noted after 5 cardiac cycles after complete opacification of the right atrium, pulmonary arteriovenous malformations (AVMs) must be considered.

• LARGE SHUNT

> 20 bubblesVarious classification schemes have been proposed to assess the sizes of shunts, though none have been universally accepted yet. However, >20 bubbles crossing the PFO from the right to left atrium is considered to be a large shunt


PFO VS. INTRAPULMONARY SHUNT

Intrapulmonary Shunt

Intracardiac Shunt (PFO)

Percutaneous Closure of Secundum ASD


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2D/3D Echocardiography in ASD Closure


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BeforeASD Closure

DuringASD Closure

AfterASD Closure

Appropriateness criteria for ASD closure (whether surgical or percutaneous)

ASD details relevant to percutaneous ASD closure

Visualization of guide catheters and ASD closure device as it is being deployed

Assessment of device seatedness and residual shunt

Perk, G, Ruiz, C, Saric, M and Kronzon, I. Current Cardiovascular Imaging Reports 2009;2:363-374.

Pre-procedural Imaging


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CASE PRESENTATION

49-year-0ld woman with progressive dyspnea on exertion over the past year

• History of hypertension

• An atrial septal defect (ASD) and no pulmonary hypertensionwere seen on a transthoracic echocardiograph (TTE)

• Now referred for transesophageal echocardiogram (TEE)


PREPROCEDURAL TEE | VIEW AT 99°


PREPROCEDURAL TEE | BIPLANE VIEW


PREPROCEDURAL TEE | COLOR DOPPLER


PREPROCEDURAL TEE | 4-CHAMBER VIEW


DIAGNOSIS

• Secundum ASD with left-to-right shunt

• Dilated right heart

• No pulmonary hypertension

• Progressive dyspnea on exertion


QUESTION

Has the patient met the clinical & hemodynamic criteria for ASD closure?


QUESTION

Has the patient met the anatomic criteria for percutaneous ASD closure?


PREPROCEDURAL TEE | ATRIOVENTRICULAR & POSTERIOR RIM

1

2

A

*

RA

RV

LA

3

4

B

*

RA

RV

LA

AV


PREPROCEDURAL TEE | AORTIC & POSTERIOR RIM

C

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*

RA

LA

SVC


PREPROCEDURAL TEE | SUPERIOR & INFERIOR RIM


PREPROCEDURAL 3D TEE | SECUNDUM ASD RIMS

LA Perspective

MV

AV

SVC RUPV

RA Perspective

SVC

AV

IVCTV


PREPROCEDURAL 3D TEE | TUPLE MANEUVER

Saric, M, Perk, G, Purgess, JR, Kronzon, I. J Am Soc Echocardiogr 2010;23:1128-35.


PREPROCEDURAL 3D TEE | RA PERSPECTIVE | ASD SIZING


DIAGNOSIS

• Secundum ASD with left-to-right shunt

• ASD Size: 1.85 x 1.25 cm

• Sufficient ASD rims


AMPLATZER

For ASDs up to 38-mm in diameter

LA Disc > RA Disc

Gore-HelexFor ASDs up to

18-mm in diameter

RA Disc = LA Disc

PERCUTANEOUS ASD OCCLUDERS


PERCUTANEOUS ASD CLOSURE PEARLS

A S D B A L L O O N S I Z I N G

Intra-procedural Imaging


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FLUOROSCOPY | ASD SIZING

After obtaining a peripheral venous access, a sizing balloon is inflated inside the ASD

Balloon waist at ASD level


INTRAPROCEDURAL TEE | ASD BALLOON SIZING


ASD SIZING | STOP-FLOW DIAMETER


ASD OCCLUDER SIZING

19-mm Amplatzer ASD occluder was chosen

A S D O C C L U D E R D E P L O Y M E N T

Intra-procedural Imaging


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INTRAPROCEDURAL 3D TEE | DEPLOYMENT OF LA DISC


INTRAPROCEDURAL 2D TEE | AMPLATZER OCCLUDER DEPLOYMENT


INTRAPROCEDURAL ICE| AMPLATZER OCCLUDER DEPLOYMENT


INTRAPROCEDURAL FLUOROSCOPY | AMPLATZER OCCLUDER DEPLOYMENT

A S D O C C L U D E R D E P L O Y M E N T

Post-procedural Imaging


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POST-PROCEDURAL 3D TEE | AMPLATZER DEPLOYED

RA Perspective LA Perspective


POST-PROCEDURAL 2D TEE | AMPLATZER DEPLOYED

Check for para-device leak.


POST PERCUTANEOUS ASD OCCLUDER

Complications are rare……but you must check for them proactively!


POST-PROCEDURAL 2D TTE | ASD OCCLUDER EMBOLIZED

Check for complications.


POST-PROCEDURAL CATH| RETRIEVAL OF ASD OCCLUDER

Thank You!


72

New York University Medical Center

A S D B A L L O O N S I Z I N G

Bonus Slides


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Before ASD Closure


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Part 1

Before ASD Closure: Guidelines for ASD Closure

Class I Recommendations RA or RV enlargement with or without symptoms

Sinus venosus, coronary sinus or primum ASDs should be repaired surgically rather than percutaneously


75

Class II Recommendations Paradoxical embolism Orthodeoxia-platypnea Net left-to-right shunt

when PVR < 2/3 SVR and PAP < 2/3 systemic BP

Class III Recommendations Patients with severe irreversible pulmonary

arterial hypertension and no evidence of a left-to-right shunt should NOT undergo ASD closure

ACC/AHA Guidelines for Adult Congenital Heart Disease, Circulation 2008;118:e714-833.

1. Establish the diagnosis of SECUNDUM ASD

2. Assess for RIGHT HEART DILATATION

3. Document the presence of a net LEFT-to-RIGHT SHUNT

4. Measure pulmonary artery PRESSURE and RESISTANCE

Assessment Before ASD Closure


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RIGHT HEART DILATATION NET LEFT-to-RIGHT SHUNT

Apical 4-Chamber ViewSECUNDUM ASD

ASE/EAE/CSE Guidelines for Right Heart AssessmentJ Am Soc Echocardiogr 2010;23:685-713.

Left-to-Right ShuntSECUNDUM ASD

Secundum ASD: Left-to-Right Shunt


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Spectral DopplerASD Flow in Sinus Rhythm

Color Doppler2D TEE at 30 Degrees

PEAK 1-----------------------------------

End-ventricular systole

PEAK 2-------------Atrial kick

Before ASD Closure: Right Heart Pressures


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TR Jet

TR Jet

3 m/s

PI Jet

1.5 m/s

IVC

RAP=3 mm Hg

PASP = 4 * (3 m/sec)2 + RAP = 39 mm Hg PADP = 4 * (1.5 m/sec)2 + RAP = 12 mm Hg

Before ASD Closure: Pulmonary Vascular Resistance


79

PVR = 0.16 + 10 * (3 m/sec) / (17 cm)

PVR = 1.8 Wood units [or, 1.8 * 80 = 144 SI units]

TR Jet

3 m/sSystolic RVOT VTI = 17 cm

RVOT

RVOT

jetTR

VTI

VPVR

max*1016.0

Abbas MethodJ Am Coll Cardiol 2003;41:1021-7.

Flow

ΔPResistance

PVR and ASD Closure


80

Closure of ASD is usually NOT done when:--------------------------------------PVR > 2/3 * SVR

Normal Resistance Values-------------------------------------PVR = 1-2 Wood unitsSVR = 11-16 Wood units

Paul WoodBritish invasive cardiologist

(1907–1962)Died of acute LAD infarct


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Diagnosis of ASD Per Se

ASD Shape*

ASD Orifice and Rim Size*

Relationship of ASD to surrounding structures


Secundum ASDs: Variety of Shapes

SECUNDUM ASDsSeen from RA

perspective

SVC

AV

Circular

Ovoid

Triangular

Fenestrated

Multiple holes(< Lat. fenestra

– window)

Relationships of Secundum ASDs


84

SVC

AV

*

A B

AV

*

SVC

RA Perspective LA Perspective

SUFFICEINT ASD RIMS Aortic rim > 3 mmOther rims > 7 mm

Orienting 3D TEE Images of Atrial Septum


85TUPLE Maneuver: Tilt Up Then Left

Saric, M, Perk, G, Purgess, JR, Kronzon, I. J Am Soc Echocardiogr 2010;23:1128-35.

Acquisition at 0 Degrees Acquisition at 120 Degrees

Orienting 3D TEE Images of Atrial Septum


86

TUPLE maneuver is now featured in the latest edition of Braunwald textbook of cardiology.

Acquisition at 0 Degrees

Sizing Secundum ASDs: The OLD Way


89

Method #1: Rectangular Grid (2 mm) Method #2: Multiplane Reconstruction (MPR)

ASD 1.6 x 1.4 cm

Sizing Secundum ASDs: The NEW Way


90

Method #3: ASD Sizing Directly on 3D TEE Image

ASD Diameters: 1.6 x 1.4 cmASD Area : 1.8 cm2

ASD Circumference: 5.0 cm

Diameter

Diameter

3D TEEMPR = Multi Plane Reconstruction

Sizing Secundum ASDs: 2D vs. 3D


91

2D TEETends to UNDERESTIMATE the size of

ASD-----------------------------------------Often geometric chord rather than

true diameter is measured.

Chord

RA

LAASD

AV

χορδή = gut, string of a musical instrument (made of gut)

ASD Occluders

Approved for use in the United States

92


Device #1:Amplatzer

LA Disc > RA Disc

Device #2:Gore-Helex

RA Disc = LA Disc


St. Jude Amplatzer ASD Occluder: Sizing based on WAIST size

Kurt Amplatz(b. 1925)

Austrian-born American radiologist


Gore-Helex: Sizing based on DISC size

During ASD Closure


95

Part 2

Percutaneous ASD Closure


96

STEP 1

Femoral venous access

STEP 2

RA

LAASD

Passage of wires & catheters across ASD

Sizing of ASD with balloon

Deployment of ASD closure device

STEP 3

ASD

RA

LA

RA

LA

ASD

VIDEO

Cath_ASD Amplatzer_6.avi

Cath_ASD Amplatzer_6.avi

Cath_ASD Amplatzer_Sizing Balloon_RAO 1 CAUD 2_2.avi

Cath_ASD Amplatzer_LAO 26 CRAN 22_6.avi

AMPLATZER Septal Occluder FDA Panel Review Materials St. Jude Medical.mp4


Balloon Sizing(Stop-flow diameter)

99



ASD Closure Device Deployment

Amplatzer Device Still Attached to Delivery

Catheter

100


RA Perspective

LA Perspective


ASD Closure Device Deployment

Tugging the device

101


Residual Leak

ASD Closure Device: LA Perspective


102

Gore-Helex ASD OccluderResidual Leak

Repositioned Gore-Helex Device: No Leak

ASD Closure: Intracardiac Echo (ICE)


103

Post ASD Closure


104

Part 3

ASD Occluders Seen From LA Side


106

After percutaneous ASD closure, check for complications (e.g. pericardial effusion).

Amplatzer Gore-Helex

Primum ASD


113


PRIMUM ASD

Part of the endocardial cushion

(AV canal) disease spectrum

Associated withDown syndrome

(trisomy 21) disease spectrum

John Langdon Down(1828-1896)

British physician


ENDOCARDIAL CUSHION DISEASE SPECTRUM

NormalAV Canal

Complete AV Canal

PartialAV Canal


PRIMUM ASD | AV CANAL


PRIMUM ASD


PRIMUM ASD + SOMETHING ELSE

PeculiarMitral Regurgitation


Cleft Mitral Valve(LV perspective)

PRIMUM ASD + CLEFT MITRAL VALVE

Relationship between cleft mitral valve and primum ASD


CLEFT MITRAL VALVE: LA PERSPECTIVE


TEACHING POINTS

• Primum ASD is located near the atrioventricular valves

• Rarely an isolated lesion

• Typically associated with elements of endocardial cushion defect disease spectrum• Cleft mitral valve• Inlet VSD

Sinus Venosus ASD


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SINUS VENOSUS ASDS

IVC-typeSinus venosus ASD

SVC-typeSinus venosus ASD

Sinus venosus is an embryologic venous reservoir proximal to the right atrium.


SVC-TYPE SINUS VENOSUS ASD

Markedly dilated right heart without apparent septal defect


SVC-TYPE SINUS VENOSUS ASD | ANOMALOUS PULMONARY VENOUS RETURN

RUPV

SVC


True Atrial Septum

Aortic Valve

SVC

ASD

RA Aspect



SVC-TYPE SINUS VENOSUS ASD + PAPVR

Thank You!


129

New York University Medical Center

guidelines for the echocardiographic assessment of atrial...

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