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