atrial septal defects: imaging and device closure 11 m vo… · atrial septal defects: imaging and...
TRANSCRIPT
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M. VogtM. Vogt
Atrial Septal defects:Imaging and device closure
Atrial Septal defects:Imaging and device closure
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The role of echocardiography
• Indication – RV – volume load (TTE)• Screening for feasibility of intervention
• Native ASD size – septal size on LV aspect• Number of ASD`s• Position of ASD – rims (aorta, AV-valve, SVC/IVC,
right pulmonary veins)
• Monitoring of the procedure• Follow-up echocardiography
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Indications for ASD closure
• ASD II: sign. l/r shunt (Qp / Qs < 1.5)
• Echo: enlarged RA / RV / PA, paradoxical septal movement
• ASD II complex: cyanosis r/l shunt
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Echo M-ModeEcho M-Mode
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Echo: RV volume load
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ASD: native size
Native size: TTE 22, TEE 14 mm, BOD: 19 mm (BOD= 1.35 x native)
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Echo criteria „ideal „ ASD
• Within the middle of the oval fossa• Native size x 1,5 + 14 mm< septal length (LA)• Sufficient rims
– Ant. Inf. -> mitral valve– Ant. Sup. -> aortic valve– Post. Inf. -> IVC– Post. Sup.-> SVC, right pulmonary veins
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„Ideal“ ASD„Ideal“ ASD
Coronary sinusdefect
Confines oftrue atrialseptum
Inferiorsinus venosus
defectOval fossa defect
Atrioventricularseptal defect
(„ostium primum“)
Superoir sinus venosusdefect
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AnatomyAnatomy
Thanks to Bob Anderson
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Echo: „ideal“ ASDEcho: „ideal“ ASD
RA SVC
LATEE 90°
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Echo: „ideal“ ASDEcho: „ideal“ ASD
TEE 0°LA
RARV
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„Ideal ASD“
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„Ideal ASD“
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Procedure: Ballon sizing
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Procedure: Ballon sizing
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Echo: AmplatzerEcho: Amplatzer
RA
LATEE 180°
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AmplatzerAmplatzer
Grösse : 4 - 38 mmMaterial : 3 PolyestermembranenGrösse : 4 - 38 mmMaterial : 3 Polyestermembranen
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Procedure: „simple“ ASD
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„simple“ ASD
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„simple“ ASD
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„simple“ ASD
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„simple“ ASD
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„simple“ ASD
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Unsuitable Anatomy
• Defekt too big (46% of abandoned procedure): nativ Diameter x 1,5 + 14 mm < lenght of IAS
• No adaequate rims– Ant. Inf. -> mitral valve– Ant. Sup. -> aortic valve– Post. Inf. -> IVC– Post. Sup.-> SVC, right pulmonary veins
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Anatomy of big ASD IIAnatomy of big ASD II
Thanks to Bob Anderson
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Large ASD
TTE native 31; Septum 50 mm, TEE 26 mm
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Large ASD
BOD: more than 32 mm: OP-indication
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Echo: posterior ASDEcho: posterior ASD
TEE 0°
Pv re
RARA
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TEE: post rim
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Lack of posterior rim
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Echo: anterior - sup ASDEcho: anterior - sup ASD
RA AoAo
LATEE 45°
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Lack of ant. sup. rim
JACC 2005:45;1213-8
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Lack of ant. sup. rim:
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Difficult anatomy
What´s the right hole??
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Multiple ASD IIMultiple ASD IITEE 90°
RA
SVC
LA
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Multiple ASD`s
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ASD II plus PFOASD II plus PFO
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ASD II plus PFOASD II plus PFO
10 mm Amplatzer ASD Occluder plus 25 mm PFO Occluder
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Multifenestrated oval fossaMultifenestrated oval fossa
Thanks to Bob Anderson
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TEE 80°
RA
LA
Multifenestrated fossa ovalisMultifenestrated fossa ovalis
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Multifenestrated fossa ovalisMultifenestrated fossa ovalis
8 y boy, multifenestrated ASD, small ant-inf rim -> OP
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Shit happens….
25 y fem., 2 ASD 14-16 and 9 mm
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Shit happens….
BOD 28 mm, Amplatzer 32 mm
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Shit happens….
1 minute later ……… call for surgery
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Superior sinus venosus defect
18 y girl, RA/RV enlargement no intervention possible
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Cyanosis after „PFO-occlusion“
25 y woman, stroke, „PFO-occlusion
RA
LA
SVC
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Summary
• Echocardiography is the leading tool in diagnosisand therapy of ASD/PFO
• TEE is superior to TTE in presentation of morphology
• Interventionalist is the „hand“ of the procedure, the sonographer „the brain“
• Surgical support should be availabel for all interventions
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Thanks!Thanks!
Klinik für Kinderkardiologie und angeborene HerzfehlerDeutsches Herzzentrum
Klinik an der Technischen Universität München
Klinik für Kinderkardiologie und Klinik für Kinderkardiologie und angeborene Herzfehlerangeborene HerzfehlerDeutsches HerzzentrumDeutsches Herzzentrum
Klinik an der Technischen Universität Klinik an der Technischen Universität MünchenMünchen
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7358
67
39
51 46 5566625648 47
3439
27
5028
0
20
40
60
80
100
120
140
160
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Interventionchirurgischer Verschluss
ASD IIChirurgie vs. Intervention
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ASD + LV Dysfunktion
PV inflow before ballon PV inflow with ballon
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ASD + LV Dysfunktion
MR during ballonocclusion
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ASD + LV Dysfunktion
MR before ballonocclusion
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Zusammenfassung
• Echokardiografie entscheidend beim interventionellen ASD-Verschluß– TTE als Screening Methode – TEE vor/während/nach Intervention– Idealer ASD: singulär, nicht zu groß, mittig gelegen– Schwierig: große oder multiple ASD II– Fehlender Randsaum
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Abbruchgründe - TEEAbbruchgründe - TEE
Defektgröße46,2%
Defektlage7,7%
Defektanzahl16,4%
Randsaum13,2%
anatomische Besonderheiten
4,4%
fehlende Indikation
12,1%
n = 91n = 91
bei 55 Pat. nach dem TEE(Echoabbruchkritierien)
bei 31 Pat. nach dem Herzkatheter(BOD zu groß zur Septumlänge)
bei 5 Pat. wurde das Schirmchenin der gleichen Herzkatheterunter-suchung wieder entfernt
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CardioSeal / StarflexCardioSeal / Starflex
Grösse : 17 - 40 mmMaterial : DacronGrösse : 17 - 40 mmMaterial : Dacron
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HelexHelex
Grösse : 15 - 35 mmMaterial : e-PTFEGrösse : 15 - 35 mmMaterial : e-PTFE
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AnatomyAnatomy
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ASD IIZusammenfassung
AlleerfolgreichenASD aus n = 179
Angel Wings
CardioSeal/Starflex
Pat.-anzahl
DeviceMedian (Range)
BODMedian (Range)
12 mm(3 – 25)
Amplatzer
Helex
23 mm(12– 40)
19 mm(12 – 34)91
22
Nativ TEE Median (Range)
9 mm(9 – 12)
14 mm(12 – 16,5)
22 mm(18 – 30)
10 mm(3 – 16)
17 mm(14 –20)
28 mm(17 – 40)
7
15 mm(16 – 25)
20 mm(13 – 34)
22 mm(12 – 34)
8 mm(9 – 10)
59
3 25 mm(20 – 30)
12 mm(10 – 18)
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Freiheit von Reoperation
Jahre
100
80
60
40
20
0
%
0P 5 10 15 20
Re-ASD-Verschluss n = 12
Langzeitergebnisse ASD II - Verschluss
n = 1298 (1974 – 2001)
SM-Implantation n = 3Mortalität < 1%
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Echo: BallonsizingEcho: Ballonsizing
LA
RAAoAo
TEE 45°
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Echo: BallonsizingEcho: Ballonsizing
RA
LA
![Page 62: Atrial Septal defects: Imaging and device closure 11 M Vo… · Atrial Septal defects: Imaging and device closure Atrial Septal defects: Imaging and device closure. ... defect Confines](https://reader034.vdocuments.mx/reader034/viewer/2022051720/5a789b277f8b9a8c428ded33/html5/thumbnails/62.jpg)
„simple“ ASD
![Page 63: Atrial Septal defects: Imaging and device closure 11 M Vo… · Atrial Septal defects: Imaging and device closure Atrial Septal defects: Imaging and device closure. ... defect Confines](https://reader034.vdocuments.mx/reader034/viewer/2022051720/5a789b277f8b9a8c428ded33/html5/thumbnails/63.jpg)
„simple“ ASD
![Page 64: Atrial Septal defects: Imaging and device closure 11 M Vo… · Atrial Septal defects: Imaging and device closure Atrial Septal defects: Imaging and device closure. ... defect Confines](https://reader034.vdocuments.mx/reader034/viewer/2022051720/5a789b277f8b9a8c428ded33/html5/thumbnails/64.jpg)
„simple“ ASD