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Cardiology – The difficult Art Cardiology – Club Cardiology – The difficult Art

Cardiology – Club TEE Case Presentation By Dr Osama Abd El Raouf Cardiologist-PSCCH

Echo – Club TEE Case Presentation By Dr Osama Abd El Raouf Cardiologist-PSCCH

Atrial Septal Defect ASD is the most common congenital heart disease encountered in adult. ASD occurs in one child per 1,500 live births. ASD is more common in female with ratio of 4:1 .

Types of ASDs There are 4 types of ASD Ostium Secundum. Ostium Primum. Sinus Venosus. Coronary sinus defects.

Secundum defects Secundum defects are the most common, accounting for 6-10% of all congenital lesions.

Atrial Septal Defect (Primum) Ostium primum is the next most common type and is located in the lower portion of the atrial septum. This type of ASD often will have a mitral valve defect associated with it called a mitral valve cleft .

Atrial Septal Defect (Primum)

Sinus Venosus ASD Partial anomalous pulmonary venous connection (right pulmonary veins to junction of superior vena cava and right atrium.

Sinus Venosus ASD Sinus venosus ASD associated with PAPVR.

Sinus Venosus ASD Routine chest X-ray of this 14 year old girl suggests prominent right heart borders on the two views. There is also prominence of the pulmonary artery segment due to pulmonary overcirculation from partial anomalous right pulmonary veins draining into the SVC and an associated atrial sinus venosus defect.

Sinus Venosus ASD Routine chest X-ray of this 14 year old girl suggests prominent right heart borders on the two views. There is also prominence of the pulmonary artery segment due to pulmonary overcirculation from partial anomalous right pulmonary veins draining into the SVC and an associated atrial sinus venosus defect.

Cardiac Auscultation in ASD Increased flow across the PV produces a systolic ejection murmur and fixed splitting of the second heart sound. Fixed splitting of S2 may in part be due to delayed right bundle conduction. Increased flow across the TV produces a diastolic rumble at the mid to lower right sternal border.

CHEST X RAY IN ASD The chest x-ray demonstrates prominent pulmonary vessels and a proximal pulmonary artery segment.

CHEST X RAY IN ASD Chest x-ray of untreated ASD demonstrates prominent pulmonary vessels and a proximal pulmonary artery segment.

Role Of Echocardiography

ME 4 Chamber View The ME 4C view (0°) is obtained by positioning the probe in the mid-esophagus behind the LA. The imaging plane is directed thru the LA, center of the MV and apex of the LV.

ME 4 Chamber View A snapshot of the heart is obtained that includes all 4 chambers (LA, RA, LV, RV), 2 valves (MV, TV), The septums (IAS, IVS) and the inferoseptal and anterolateral LV walls. Segments of the anterior (A2) and posterior (P2) mitral valve leaflets are typically imaged in this view.

ME 4 Chamber View A snapshot of the heart is obtained that includes all 4 chambers (LA, RA, LV, RV), 2 valves (MV, TV), The septums (IAS, IVS) and the inferoseptal and anterolateral LV walls. Segments of the anterior (A2) and posterior (P2) mitral valve leaflets are typically imaged in this view. LA LV RV

ME 4 Chamber View Identify the Following Structures:- Left Atrium (LA) Right Atrium (RA) Left Ventricle (LV): inferoseptal (IS) + anterolateral (AL) walls Right Ventricle (RV) Mitral Valve: anterior(AMVL) + posterior (PMVL) leaflets Tricuspid Valve: septal (STVL) + anterior (ATVL) leaflets

Transesophageal Echo and ASD Diagnosis TEE Diagram showing the entrance of SVC into the right atrium,, notice atrial septum separating both atria.

TEE Bicaval View TEE diagram showing the entrance of SVC into the right atrium Notice intact atrial septum separating both atria.

TEE Bicaval View TEE bicaval view showing the entrance of SVC into the right atrium. Notice intact atrial septum separating both atria.

Transesophageal Echo and ASD Diagnosis TEE Doppler examination showing showing small osteium Secundum ASD with left to right shunt. Notice color flow Doppler.

Transesophageal Echo and ASD Diagnosis

Transesophageal Echo and ASD Diagnosis

Transesophageal Echo and ASD Diagnosis Prominent Eustachian valve. Crista terminals. Pectinate muscle. Always look else where

Structures belong to right atrium Crista Terminalis

Structures belong to right atrium Crista Terminalis Crista Terminalis

Structures That Belong There

Transesophageal Echo ,Bicaval View Do you notice something else?

Percutaneous Closure of an ASD The State of Art Amplatzer ASD closure device.

Amplatzer ASD closure device.

Indications for percutaneous closure of an ASD The basic requirements for percutaneous closure of an ASD include: Secundum defect. Adequate inferior and superior rim around the defect. Therefore, device closure will not impinge upon the superior vena cava , inferior vena cava or AV valves. No significant right to left shunting—closure would reduce cardiac output. No other findings that require open heart surgery. This would lead to surgical closure of the ASD.

Case Study Experience of PSCCH 20 years old Saudi female was diagnosed to have ostium secundum. ASD and was referred from our OPD for closure of the defect.

Large ostium secundom ASD Case Study Experience of PSCCH Large ostium secundom ASD

Ostium Secundum ASD

Ostium Secundum ASD ME 4 chamber view showing big ostium secundom ASD with large left to right shunt.

Inflation of the Balloon

Inflation of the Balloon

Deployment of a ASD Device

Deployment of a ASD Device

Deployment of a ASD Device

Device is in position

Device is in position

Device is in position

Device is in position

Device is in position

Device is in position TEE View Cath View

Device is in position Successful closure of the defect with no significant residual shunt.

Device is in position No interference with aortic and mitral valve function.

Percutaneous Closure of an ASD The State of Art Comparison of the result before and after the procedure.

Team Work What would the interventional wants to know Case- 2

1- Clear Diagnosis - Clear Indication.

2- Are All Pulmonary Veins Normal ?

2- Are All Pulmonary Veins Normal?

2- Are All Pulmonary Veins Normal?

2- Are All Pulmonary Veins Normal?

3- Am I In The Right Position? Can You See The Wire ?

4- Can You Follow Me?

5- Is The Closing Devise In The Right Position?

6- Is There Any Residual Significant Shunt ?

7- What About The Aortic Valve ?

8- Is There Pericardial Effusion ?

ASD Closing Device A4C view The arrow indicates the position of a atrial septal defect closure device.

ASD Closing Device

Complications from percutaneous deployment of a ASD Air embolism. Vascular injury from large sheaths used to deploy the device. Embolization, of thrombus formed on the device, Perforation of the atrial wall, perforation of the aorta, infective endocarditis. Atrial arrhythmias. Malposition of the device requiring surgical retrieval. Residual atrial shunts can occur in one-third of patients.

Place of Antiplatlets During the months when an endothelial layer is expected to develop, thrombus of significant proportion can occur, leading some authors to recommend 6 months of antiplatlets after device implantation.

Reasons Behind Complications Conclusion

Conclusion ASD is the most common congenital heart disease encountered in adult . ASD closing device is increasingly used with very promising results . Team work is mandatory for success of the procedure . Clinical and echocardiographic follow up is necessary after the procedure .

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