(Circulation. 1999;99:E11.)
© 1999 American Heart Association, Inc.
Circulation Electronic Pages |
Three-Dimensional Transesophageal Echocardiography for Secundum Atrial Septal Defects With a Large Eustachian Valve
Yasuki V. Maeno, MD;
Christine Boutin, MD;
Lee N. Benson, MD;
David Nykanen, MD;
Jeffrey F. Smallhorn, MBBS
From the Division of Cardiology, The Hospital for Sick Children, and the
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
A9-year-old girl
underwent transesophageal
echocardiography (TEE) to determine whether there
was an indication for transcatheter closure of her secundum
atrial septal defect (ASD). She had been diagnosed as having a single
defect by transthoracic
echocardiography at 6 months of age. During
previous clinic visits, her parents often complained that she had
occasional episodes of central cyanosis, although her oxygen saturation
by pulse oximeter was 98 in the outpatient clinic. Two-dimensional TEE
revealed 2 secundum ASDs, 1 at the fossa ovale and the other near the
junction of the inferior vena cava, with a prominent
eustachian valve. Three-dimensional (3D)
echocardiographic images from the right atrium clearly
demonstrated a large eustachian valve that covered a large portion of
the atrial septum (Figure 1
). The
inferior defect could not be seen from the right atrium,
even with a steep angle, looking down toward the orifice of the
inferior vena cava (Figure 2). A 3D image from the right atrium
after erasure of the eustachian valve (Figure 3) and an image from the left atrium
(Figure 4) clearly demonstrated the
position of the inferior defect. Despite this, the 3D
information was not reviewed with the surgical group before
intervention, because this technique is still in its infancy with
regard to decision making. At surgery, through a ministernotomy, the
fossa ovalis defect was closed; however, the inferior
defect was missed. A subsequent intraoperative TEE using Doppler
and contrast confirmed the presence of the inferior defect
with bidirectional shunting. This defect was then closed through the
same incision. other abbreviations as in Figure 1.
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Figure 1. A 3D echocardiographic image
looking from right atrium toward atrial septum. Large eustachian valve
(*) covers more than half of atrial septum. AO indicates ascending
aorta; ASD, (superior) atrial septal defect; CS, coronary
sinus; SVC, superior vena cava; sup., superior; and ant.,
anterior.
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Figure 2. View from right atrium with a steep angle looking
down toward orifice of inferior vena cava. Only small
superior portion of inferior defect can be seen (small
arrow) behind eustachian valve (*). TV indicates tricuspid orifice;
other abbreviations as in Figure 1 .
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Figure 3. Eustachian valve was removed with computer
graphics. A 3D image from right atrium demonstrates a large, oval
inferior defect (*) close to junction of
inferior vena cava (IVC) and an orifice of coronary
sinus. Abbreviations as in previous figures.
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Figure 4. A 3D echocardiographic image
looking from left atrium toward atrial septum demonstrates both ASD and
inferior defect (arrows). MV indicates mitral valve; other
abbreviations as in previous figures.
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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 Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
