TTE AND TEE
ASSESSMENT FOR
ASD CLOSURE
Dr . Rahul C

Introduction
 Atrial septal defect (ASD) is the second most
common congenital heart disease in adults.
 Approximately 10% of all congenital heart lesions.
 Isolated ASD results from abnormal development
of the septa that partition the common atrium of
the developing heart into right and left chambers.
 70% of ASDs are of the ostium secundum variety.
 The incidence of ASD is approximately 3 per
10,000 live births.

Embryology
 The interatrial septum forms during the
first and second months of fetal
development.
 Stage I is the formation of the septum
primum.
 The septum primum walls off a crescent-
shaped portion of the hole between the
right and left atria.
Foramen primum (also called the ostium
primum) stays open
 The remaining part of the opening
between the right and left atria is closed
by the septum secundum.
 The 2 tissue layers overlap like a flap,
allowing blood flow to continue during
fetal life.
 Changes in circulation at birth, closes
the flap permanently.

Anatomy and Physiology
 Extends from cavo-
atrial junction with
superior and inferior
vena cavae
 Ends near the atrio-
ventricular canal
near the tricuspid
valve

Ostium Secundum
 Most common type of
ASD
 Center of the septum
between the right and
left atrium

Ostium Primum
 Next most common type
 Located in the lower
portion of the atrial
septum.
 Will often have a mitral
valve defect associated
with it called a mitral valve
cleft.
 A mitral valve cleft is a slit-
like or elongated hole
usually involves the

Sinus Venosus
 Least common type of ASD
 Located in the upper portion of
the atrial septum.
 Association with an abnormal
pulmonary vein connection
 Four pulmonary veins, two from
the right lung and two from the
left lung, normally return red
blood to the left atrium.
 Usually with a sinus venosus
ASD, a pulmonary vein from the
right lung will be abnormally
connected to the right atrium
instead of the left atrium.
 This is called an anomalous
 ..asd-veno.jpg

Foramen Ovale
 Remnant of fetal
circulation
 Behaves like flap
valve
 Opens during
increased intra-
thoracic pressure

VARIOUS ECHO MODALITIES
 TTE
 CONTRAST ECHOCARDIOGRAPHY
 TEE
 3D ECHO
 ICE

 4 TYPES
OSTIUM SECUNDUM- 66%
OSTIUM PRIMUM- 15%
SINUS VENOSUS-10%- superior and posterior
part of septum
DEFECTS NEAR CORONARY SINUS

ASD

WHEN TO SUSPECT IN 2D
ECHO
 RIGHT VENTRICULAR DILATION
ABNORMAL MOTION OF IVS- brisk anterior
movement in early systole or flattened
movement throughout diastole
 ? IAS DROP OUT IN APICAL 4C VIEW
 RELATIVE ATRIAL INDEX

2D ECHO
RA RV VOLUME OVERLOAD
SEPTAL FLATTENING IN DIASTOLE

RELATIVE ATRIAL INDEX
 Standard apical 4C views- right atrial area divided by
left atrial area
 Cutoff value of >0.92 predicted patients with ASDs
v/s matched controls with 99.1% sensitivity and 90.5%
specificity.
 After closure, significant atrial remodeling occurred
immediately, with a reduction in the mean RAI at day
1 to 0.93 ± 0.16 (P < .0001) and complete
normalization at early follow-up to 0.81 ± 0.12.

The Relative Atrial Index (RAI)—A Novel, Simple,
Reliable, and Robust Transthoracic Echocardiographic
Indicator of Atrial Defects
Natalie A Kelly -Journal of the American Society of
Echocardiography

 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

 Accurate measurement of the defect size plays a key
role in closing ASD using a percutaneous occluder
device.
 It is possible to determine the size of the defect by
transesophageal echocardiography (TEE), which is a
noninvasive technique.
 In the literature, it has been emphasized that TEE is a
gold standard in transcatheter closure of ASD and
thus should be used in analyzing septal defect and
rims during the process.

 Therefore, using echocardiographic parameters
affecting success of closure may prevent possible
complications in percutaneous closure of ASDs.
 In terms of success, there is no definite ASD size or
predictor as the size of ASD differs from 1 patient to
another.
 Determining other predictors along with the measured
ASD size and evaluating the closure together with
such predictors would increase the chance of
success.

 Conventionally, the rims of a secundum ASD are
labeled as
 aortic (superoanterior),
 atrioventricular (AV) valve (mitral or
inferoanterior),
 superior venacaval (SVC or superoposterior),
 inferior venacaval (IVC or inferoposterior), and
 posterior (from the posterior free wall of the atria,
coronary sinus rim).

 By conventional definition, a margin 5 mm is considered to be adequate.
 Podnar et al. defined 10 morphological variations of defects,
 the most common type being the defect with deficient aortic rim (42.1%).
 The other variants included
 central defects (24.2%),
 deficient inferoposterior rim (12.1%),
 perforated aneurysm of the septum (7.9%),
 multiple defects (7.3%),
 combined deficiency of mitral and aortic rims (4.1%),
 Deficient SVC rim (1%), and
 deficient coronary sinus rim (1%).

SUB COSTAL 4C VIEW
 To go for the subcostal 4C – Keeps the atrial
septum perpendicular to the ultrasound
beam
 Distinguishes OS , OP & SV ASDs
 Measurements of the septum can be taken
 Anomalous drainage of pulmonary veins
 Atrial septal aneurysm

TTE -views for ASD
 PSAX- IAS separates Rt &Lt atrium and runs
posteriorly from NCC of aortic valve.
 Not seen in entirety as a result of drop out artefact
 APICAL 4C- Posterior aspect of Interatrial septum is
clearly delineated in this view but drop out artefact is
seen in region of fossa ovalis.
 Pulmonary venous drainage- 3 veins draining to LA
 APICAL 5C VIEW- Anterior aspect of interatrial
septum

PSAX VIEW
IAS AGAINST NCC
OF AORTA
APICAL 4C VIEW
SHOWING THE IAS AND 3
VEINS DRAINING TO LA, RT
LOWER PULMONARY VEIN
IS USUALLY NOT SEEN

 SUB COSTAL 4C VIEW- Useful in patients with COPD and
ventilated patients.
 Viewed with breath held in inspiration- index marker in 3o`
clock position.
 No IAS drop outs
 SUB COSTAL SHORT AXIS- Index marker at 12o`clock
position and sweeping the transducer from midline to Rt side
of patient

SUBCOSTAL 4C VIEW
SUB COSTAL SHORT
AXIS VIEW ALSO SHOWS
IVC DRAINING TO RA
AND EUSTACHIAN VALVE

Other important views
 To visualise SVC- Suprasternal short axis –index
marker in 4 o`clock position
 L-SVC is seen from left supraclvicular fossa or
suprasternal short axis
 Suprasternal short axis to visualise the the pulmonary
veins draining into left atrium
 Cleft mitral valve in AVCD in 12o`clock position in
PSAX

SUPRASTERNAL SHORT
AXIS

En face view in 2D
 First the apical 4c view was taken.
 The image index marker was at approximately
kept at 1 o'clock.
 Keeping the atrial septum and ASD in the region
of interest, the transducer was rotated
counterclockwise approximately 45° to 60°.
Xinseng et al Journal of the American Society of Echocardiography Volume 23, Issue 7 , Pages 714-
721, July 2010

A-4c view & B-En face view

Ostium primum ASD
 Defect in lower part of IAS
 Associated sometimes with inlet VSD
 Cleft mitral valve
 AV Valve regurgitation
 Partial attachment of mitral valve to IVS

Primum ASD
LARA
LV
RV
Apical four chamber view demonstrating
a primum atrial septal defect
Colour Doppler flow image from same view
illustrating left-to-right shunt across the primum
atrial septal defect
Fig 5

CLEFT MITRAL VALVE IN PSAX VIEW POSTERIORLY DIRECTED JET
OF MR

Ostium Secundum ASD
 10 morphological variations of defects
 MC- Deficient aortic rim (42.1%).
 Central defects (24.2%)
 Deficient Inferoposterior rim (12.1%)
 Perforated aneurysm of the septum (7.9%)
 Multiple defects (7.3%)
 Combined deficiency of mitral and aortic rims (4.1%),
 Deficient SVC rim (1%),
 Deficient coronary sinus rim (1%).
Podnar T, Martanovic P, Gavora P,Masura J. Morphological variations of secundum-
type atrial septal defects: feasibility for percutaneous closure using Amplatzer septal
occluders. Catheter Cardiovasc Interv 2001;53:386 –91.

Centrally located ASD imaged
at 0°

ASD with deficient Aortic margin

Large ASD with deficient posterior
and Aortic margins

Multiple ASDs; larger anterior
defect (block arrow) and a smaller
posterior defect

Sinus venosus ASD
A – INTACT IAS
B- COLOUR DOPPLER SHOWS DEFECT IN
UPPER PART OF IAS AT ENTRANCE OF S
TEE

Sinus venosus ASD -Color doppler
in TEE

CORONARY SINUS ASD
DILATEDCORONARYSINUS
TEE 120 DEGREE

ATRIAL SEPTAL ANEURYSM
CRITERIA
A- PROTRUSION OF
ANEURYSM ATLEAST 15MM
OF PLANE OF IAS
OR
IAS SHOWING 15MM OF
PHASIC EXCURSION
DURING
CARDIORESPIRATORY
CYCLE
B- BASE WIDTH≥ 15MM

COLOUR DOPPLER
 Shows the direction of the shunt
 Caveat- False Positive results due to improper gain and caval
flow streaming near septum can be misdiagnosed as ASD.
 PULSED DOPPLER- demonstrates the flow from L to R in
mid systole to mid diastole with second phase in atrial
systole. Some R to L shunting occurs in early systole
 QUANTIFICATION OF SHUNT – Qp /Qs

OS ASD VIA DOPPLER SINUS VENOSUS ASD VIA DOPPLER

CONTRAST
ECHOCARDIOGRAPHY
 APICAL 4C VIEW IS USED
 AGITATED SALINE USED- 5ml in each 10ml
syringe, 0.5ml of air taken in the syringe and
agitated to create microbubbles.

• ARROW SHOWS NEGATIVE
CONTRAST EFFECT
• DIRECT EVIDENCE OF SHUNT-
NON
CONTRAST BLOOD IN RA
•Extent of shunting tend to focus on
numbers of bubbles seen in a single
still frame in the left atrium.
Shunt grading incorporates :
Grade 1: 5 bubbles;
Grade 2: 5 to 25 bubbles;
Grade 3: >25 bubbles;
Grade 4: Opacification of chamber
Echocardiographic Evaluation of Patent Foramen Ovale Prior to Device
Closure
Bushra et al JACC 2010 VOL. 3, NO. 7, 2010

RIMS OF ASD
 Aortic - Superoanterior
 Atrioventricular (AV) valve -mitral or inferoanterior
 Superior Vena Caval SVC – Superoposterior
 Inferior venacaval (IVC or Inferoposterior) Posterior
(from the posterior free wall of the atria).

RIMS
TEE TTE

TEE

2D TEE at 0o

 The transesophageal echocardiography (TEE) probe is at the
mid-lower esophageal level.
 The posterior and the mitral rims are best evaluated in
this view.
 Rotating the probe to 30° to 40° towards the left will best
profile the aortic (Ao) rim.
 The margins are evaluated by carefully moving the probe in
and out and obtaining sections at various levels.
 At the level of the
 atrioventricular valves (C), the septum forms once again. This
suggests that the ASD is likely to have adequate margins for
catheter closure.

In the highest plane (A), the superior venacaval (SVC)-right
atrial junction and the ascending (Asc) aorta are seen; the
atrial septum is visualized as intact.

At the mid-level (B), the septum breaks and the
margins(posterior and anterior) of the atrial septal
defects (ASD) (arrows) are clearly seen.

At the level of the atrioventricular valves (C), the septum
forms once again.
This suggests that the ASD is likely to have adequate
margins for catheter closure.

TEE at 90° to Evaluate the SVC
and IVC Rims
AORTIC RIM IS SEEN
TEE 45 DEGREES

 This view is best for evaluating the SVC and IVC
rims.
 The margins are evaluated by rotating the probe
while keeping it at more or less the same level.
 Here the defect is seen with the probe rotated
leftward (B, margins of the ASD shown by the
arrows), while septum is seen to form when the
probe is rotated to the right (A).
 The 45°-view is helpful in assessing the posterior
and the aortic rims and often helps to determine
the maximum size of the defect.

Probe to 30-40o right

Probe rotated 30-40o left

STOP FLOW METHOD –DEVICE
SIZING

DEVICE SELECTION

TEE IMAGES OF ASD DEVICE
CLOSURE

POST PROCEDURE
COMPLICATIONS
RESIDUAL SHUNT POST PROCEDURE

DEVICE MISPLACEMENT

IMPINGEMENT OF THE DEVICE ON
AORTIC ANNULUS- CAN LEAD TO
EROSION?

Morphological characteristics
of septal rims affecting
successful transcatheter
atrial septal defect
closure in children and adults

Conclusion
 Echocardiography plays a critical role for patient
selection, guidance, and post-deployment evaluation
for transcatheter closure of ASDs.
 Understanding the echoanatomic corelation by
transesophageal echocardiography is perhaps the
most essential requisite to ensure a successful
procedure.
 3D echocardiography and ICE (intra-cardiac echo) are
likely to further this understanding in the future
especially in difficult cases like multiple defects and
defects with deficient margins.

THANK
YOU

Natural history of ASD
 Natural history of ASD diagnosed in childhood is that the ASD
diameter when untreated increases in 65% of cases, and
30% will have more than a 50% increase in diameter.
 Only 4% of ASDs close spontaneously .
 A patient with isolated secundum ASD is often asymptomatic
until the third and fourth decade of life.
 Typical symptoms that ensue include decreased exercise
capacity, fatigue, syncope and palpitations.
 Patients with significant shunting may develop right
ventricular failure, atrial tachycardia, pulmonary hypertension
and embolic events all of which can lead to significant
morbidity and potential mortality.

 The age at which a patient becomes symptomatic is highly variable
and does not correlate well with shunt size .
 The pressure gradient between the two atria and the amount of
shunt flow depend upon both the size of the defect, and the
compliance of the right and left sides of the heart.
 Left untreated over time, even small ASDs can develop increased
left-toright shunting due to progressive increase in left ventricular
(LV) diastolic pressure with aging, which causes increased left atrial
pressure.
 In patients who develop pulmonary hypertension (PHTN) from their
ASD, approximately 10% will progress to Eisenmenger’s syndrome.
 Due to the chronic nature of the disease and patient compensation
over time many patients remain unaware of their decreased
exercise capacity and only realize their symptom improvement post
procedure .

FOETAL CIRCULATION

CIRCULATION AFTER BIRTH

PATENT FORAMEN OVALE
TEE -0 DEGREE
TEE-90 DEGREES

PFO WITH SECONDARY
SEPTUM

Special tee views for
Inferoposterior rims
No Infero posterior rim with probe in normal position

Under
TEE Guidance
K.S. Remadevi, MD, FNB, Edwin Francis, DM, and Raman Krishna
Kumar, DM, FACC . Catheterization and Cardiovascular Interventions
(2008)
Retroflexed probe in the stomach and bought towards the esophagus and viewed
In the 70-90o view