Transcript Rana et al, JACC CVI 2010

echocardiography in case selection and
monitoring PFO / ASD procedures
Bushra Rana
Consultant Cardiologist
Clinical Lead of Non-Invasive Cardiology
Papworth Hospital NHS Trust, Cambridge
overview
role of echocardiography in percutaneous atrial septum closure
♥ pre-operative checklist
TOE protocol
detailed assessment of defect
♥ TOE during the procedure
some important considerations
♥ case examples
highlighting important phenotypes
overview
role of echocardiography in percutaneous atrial septum closure
complexity of anatomy…
crossing defect…
device sizing …
device positioning…
complications…
pre-operative checklist
STEP 1 confirm defect is secundum type
STEP 2 surgery better option?
anomalous pulmonary venous drainage
mitral valve pathology
STEP 3 detailed assessment of defect
defect size
number of defects
surrounding rims
tunnel length
thickened secondary septum
LA multiple openings
atrial septal aneurysm
STEP 4 interference during device placement?
Eustachian valve and ridge
Chiari network
transoesophageal echocardiography
define anatomy
assess suitability for device closure
SVC
right atrium
AO
ASD
IVC
CS
superior vena cava
aortic root
inferior vena cava
coronary sinus
tricuspid valve
left atrium
right upper pulmonary vein
mitral valve
Rana et al, JACC CVI 2010; 3 (7): 749-60
TOE protocol
0 degrees transverse plane
SVC
high
AO
mid
FO
low
IVC
CS
Rana et al, JACC CVI 2010; 3 (7): 749-60
TOE protocol
90 degrees longitudinal plane
high
SVC
AO
mid
low
FO
IVC CS
IVC
Rana et al, JACC CVI 2010; 3 (7): 749-60
TOE protocol
specialist views mid oesophagus
AO
50
degrees
SVC
120
degrees
CS
detailed assessment of defect
surrounding rims >5mm
right atrium
SVC (90-120)
aortic root (50)
IVC (90)
CS (120)
TV
left atrium
RUPV (0 &135)
MV
detailed assessment of defect
defect size….
PK McCarthy et al Im Paed Car 2003;15:1-24
detailed assessment of defect
defect size….
PK McCarthy et al Im Paed Car 2003;15:1-24
detailed assessment of defect
number of defects….how many
holes are there?
McCarthy et al Images Paediatr Cardiol 2003;15:1-24
detailed assessment of defect
number of defects….how many
holes are there?
McCarthy et al Images Paediatr Cardiol 2003;15:1-24
detailed assessment of defect
number of defects….how many
holes are there?
McCarthy et al Images Paediatr Cardiol 2003;15:1-24
detailed assessment of defect
atrial septal aneurysm…mobility, margins
need for over sizing to grip firm part of septum & ensure device stability
imaging during procedure
imaging during procedure
wire position LAA/PV’s
balloon inflation, defect sizing
LA disc deployment
RA disc deployment
Position check
working view 50 degrees
imaging during procedure
wire position LAA/PV’s
balloon inflation, defect sizing
LA disc deployment
RA disc deployment
Position check
Balloon inflation
♦ with colour Doppler
♦ when flow stops balloon stops
imaging during procedure
wire position LAA/PV’s
balloon inflation, defect sizing
LA disc deployment
RA disc deployment
Position check
Balloon inflation
♦ with colour Doppler
♦ when flow stops balloon stops
♦ at waist outer edge-outer edge
imaging during procedure
wire position LAA/PV’s
balloon inflation, defect sizing
LA disc deployment
RA disc deployment
Position check
Repeat protocol 0/50/90/120
♦ device profile
♦ completely gripped septum
♦ abnormal flow
complex anatomy
complex anatomy
enface view from left atrium
Rana et al Euro J Echocard 2010; 11: i19–i25
Ao
RUPV
MV
complex anatomy
left atrium view
Rana et al Euro J Echocard 2010; 11: i19–i25
complex anatomy
left atrium view
Rana et al Euro J Echocard 2010; 11: i19–i25
SVC
FO
ER
CS
IVC
Rana et al Euro J Echocard 2010; 11: i19–i25
complex anatomy
right atrium view
Rana et al Euro J Echocard 2010; 11: i19–i25
complex anatomy
RUPV
MV
Rana et al Euro J Echocard 2010; 11: i19–i25
complex anatomy
LA view
Rana et al Euro J Echocard 2010; 11: i19–i25
complex anatomy
LA view
Rana et al Euro J Echocard 2010; 11: i19–i25
complex anatomy
LA view
Rana et al Euro J Echocard 2010; 11: i19–i25
complex anatomy
LA view
Rana et al Euro J Echocard 2010; 11: i19–i25
defect position
Rana et al Euro J Echocard 2010; 11: i19–i25
Rana et al Euro J Echocard 2010; 11: i19–i25
Rana et al Euro J Echocard 2010; 11: i19–i25
defect position
Rana et al Euro J Echocard 2010; 11: i19–i25
summary
complex anatomy…
crossing defect…
device sizing …
device positioning…
complications…
summary
complex anatomy…
crossing defect…
device sizing …
device positioning…
complications…
role of echocardiography
patient
assessment for
suitability of
device closure
TTE ±bubble contrast
diagnosis
detailed imaging
intra-procedural guidance
device sizing/position
complications
pre-procedural
TOE
intra-procedural
TOE
GA
ICE
Rana et al, JACC CVI 2010; 3 (7): 749-60
detailed assessment of defect
total length of atrial septum
Transverse 00
mid oesophagus view
Longitudinal 900
mid oesophagus view