Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure

Summary

Transthoracic (TTE) and transesophageal (TEE) echocardiography represent the basic imaging tools for interatrial septum examination. Three dimensional (3D) TEE provides incremental information in the assessment of the interatrial septum. Further advanced echocardiography techniques using speckle tracking echocardiography are applied for sensitive volumetric and functional assessment of the heart chambers. 

Abstract

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale (PFO) detection, for patient selection for transcatheter ASD/PFO closure, for intraoperative guidance and for long-term follow-up. The size, shape, location and the number of the atrial communications schould be determined. The accuracy of PFO detection can be improved by using agitated saline together with maneuvers to transiently increase the right atrial (RA) pressure. The appearance of microbubbles in the left atrium (LA) within 3 cardiac cycles after opacification of the RA is considered positive for the presence of an intracardiac shunt. Three dimensional TEE identifies further septal fenestrations and describes the dynamic morphology of ASD/PFO and atrial septal aneurysm. Follow-up evaluations with TTE is recommended at 1, 6, and 12 months after the procedure, with a subsequent evaluation every year. Previous studies showed an increased incidence of atrial arrhythmias early after device closure. Speckle tracking analysis may help to understand functional left atrial remodeling following percutaneous closure and its impact on atrial arrhythmias.

Introduction

Patent Foramen Ovale (PFO) is not a true tissue deficiency of atrial septum; it is present in about 20-25% of the adult population, and in most cases it does not have any clinical significance (Figure 1). Cryptogenic stroke accounts for ~30% of ischemic strokes and is defined as a condition without an apparent cause at the early inpatient work-up. Patients under 45 years of age represent 10% of stroke burden with as much as 40% defined as cryptogenic. Secondary prevention of stroke using transcatheter closure technique remains paramount in reducing morbidity and mortality¹.

Atrial septal de....

Protocol

In the following part we describe the protocol steps of clinical and imaging evaluation of atrial communications before transcatheter closure based on international clinical guidelines. These protocols follow the guidelines of the Semmelweis University Regional and Institutional Committee of Science and Research Ethics. Informed written patient consent is needed.

1. Clinical evaluation and workflow of cryptogen stroke and PFO for transcatheter closure

1. For the diagnostic work-up of stroke, determine whether the stroke is ischemic or hemorrhagic in origin using computed tomography scan (CT) or magnetic resonance b....

Results

Clinical evaluation of symptomatic, 41 years old female patient revealed ostium secundum type ASD and floppy atrial septum using TTE and TEE examination
TTE examination showed right ventricular and biatrial enlargement with elevated pulmonary artery systolic pressure. TEE examination was used to estimate the size and shape of ASD using 2D and 3D methods. 2D, 3D native and balloon sizing TEE measurements were compared (Figure 4, Figure 5,

Discussion

Careful patient selection for transcatheter PFO closure represents one of the most challanging steps of the clinical evaluation, as ruling out atrial fibrillation can be difficult. Several trials in the past few years have suggested greater yield with longer term monitoring to detect atrial fibrillation.¹⁸ The Cryptogenic Stroke and Underlying Atrial Fibrillation (CRYSTAL-AF) trial detected increased atrial fibrillation rate in the insertable cardiac monitor group (8,9%) compared with standard mon.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
TomTec Imaging workstation	TomTec Imaging, Unterschleissheim, Germany		4D LALV Function analysing software
Ultrasound machine	Philips Epiq CvX	serial number US81881251	X5-1 and X7 transducers
Wiwe external ECG single chanel recorder	Sanat Metal	5-810-200-1611	external ECG single chanel recorder