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(Circulation. 2004;109:e320-e321.)
© 2004 American Heart Association, Inc.

Images in Cardiovascular Medicine

Real-Time Subcostal 3-Dimensional Echocardiography for Guided Percutaneous Atrial Septal Defect Closure

Kevin S. Roman, MD; Masaki Nii, MD; Fraser Golding, MD; Lee N. Benson, MD; Jeffrey F. Smallhorn, MD

From the Division of Cardiology and Variety Club Cardiac Catheterization Laboratories, The Hospital for Sick Children, Toronto, Ontario, Canada; and University of Toronto School of Medicine, Toronto, Ontario, Canada.

Correspondence to Dr Jeffrey F. Smallhorn, Division of Cardiology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada. E-mail jsmallho{at}sickkids.on.ca

We report the closure of a secundum atrial septal defect (ASD) using subcostal real-time 3-dimensional (3D) echocardiographic guidance. A 6-year-old girl (wt 22.6 Kg) with a 9- mm ASD underwent percutaneous closure. The indication for intervention was a dilated right ventricle with an increased end-diastolic dimension for her age. The ASD was assessed using a new, truly real-time, 3D imaging system (Philips Sonos 7500 with live 3D). Subcostal 3D views, supplemented by 2-dimensional Doppler color flow mapping were utilized. A sterile barrier between the echocardiographic probe and the interventional field permitted catheter guidance under direct 3D imaging. Clear visualization of the defect was possible using live imaging rotation (Figure 1A). Sheath position from the inferior caval vein across the ASD was shown (Figure 2). The defect was balloon-sized at 13 mm, and a 15-mm Amplatzer device was deployed. The discs were deployed with ease using 3D imaging only. Concern arose after the right atrial disc seemed to tilt into the left atrium (Figure 3A). Using 3D imaging, correct device position with atrial septum traversing between the 2 discs was confirmed (Figure 3B), in particular the inferior margin, which is frequently poorly delineated by transesophageal echocardiography. The device was subsequently released in a suitable position (Figure 1B). The benefits were a reduction in fluoroscopy time, better delineation of the shape of the ASD, lack of need for transesophageal echocardiography, and greater confidence in positioning of the ASD device. With greater experience this technique could potentially play a significant role in interventional ASD closure.

View larger version (60K): [in this window] [in a new window]   Figure 1. A, Subcostal 3D view showing interatrial septum with elliptical atrial septal defect. IAS indicates interatrial septum; LA, left atrium. B, 3D-view of device well positioned within the ASD after release. LD indicates left atrial disc.

View larger version (124K): [in this window] [in a new window]   Figure 2. Image of guiding catheter positioned across defect. IAS indicates interatrial septum; C, catheter; and IVC, inferior vena cava.

View larger version (61K): [in this window] [in a new window]   Figure 3. A, Amplatzer device before release. Note the tilt of the device into the left atrium, making its correct position within the interatrial septum questionable. RD indicates right atrial disc; DS, delivery sheath. B, Inferior septum is clearly shown to traverse between device disks. I-IAS indicates inferior margin of interatrial septum. *Right and left atrial device discs.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Roman, K. S. Articles by Smallhorn, J. F. Search for Related Content PubMed PubMed Citation Articles by Roman, K. S. Articles by Smallhorn, J. F. Related Collections Echocardiography Related Article