Echocardiographic assessment of Atrail septal defect. Mainly by transthoracic echocardiogram.

1. Echocardiographic Assessment of
ASD
Md. Mashiul Alam
Phase B resident
UCC
Chairperson: Assoc.
Prof. Naveen Sheikh

2. Atrial Septal Abnormalities
1. Atrial septal defect (ASD)---- 5 to 10% of CHD
2. Patent foramen ovale (PFO)
3. Atrial septal aneurysm

3. Types of ASD
1. ASD secundum
2. ASD primum
3. Sinous venosus
4. Coronary sinus variety

7. 1. 80% secundeum, located in the region of the
fossa ovalis and its surrounding
2. 15% Primum, located near the crux, AV valves
malformed with regurgitation
3. 5% SVC type sinus venosus, defect located near
to SVC, assocaited with anomalous pulmonary
venous return
4. <1% IVC type sinus venosus, defect located near
IVC
5. <1% Unroofed coronary sinus, separation from
the LA partially or completely missing

9. Associations of other…
• Secundum ASD: MVP
• Primum ASD: AV canal defect (Down syndrome)
• Sinus venosus: Partial anomalous pulmonary
venous retrun
• Conornary sinus variety: complete AV septal
defect, absence of coronary sinus, left SVC that
drains into the left atrium

10. Facts about ASD
• Asymptomatic until adulthood
• Symptoms beyond the fourth decade
• Life expectency reduced
• Quality of life decreased
• Eisenmenger rare (<5%)

11. Echocardiography in ASD
• To identify and confirm ASD
• To identify associated anomalies
• To diagnose complications of ASD
• For therapeutic purpose

12. Echocardiographic modalities
1. Transthoracic echocardiogram (TTE)
2. Transoesophgeal echocardiogram (TEE)
3. Intracardiac echocardiogram (ICE)
Modes:
2D, M mode, Doppler study, 3D

13. • TEE > TTE
• TTE-----Subcostal view
• TEE-----High transverse and longitudinal
planes

14. Routine measurement and report
• ASD type
• Doppler flow- presence of shunt
• ASD size
• ASD location
• Measure all rims
• Shape of ASD---round, oval, irregular

15. Calculate
• ASD measurements
• Qp/Qs
• Pulmonary hypertension

16. Common views in TTE
• Subxiphoid Frontal (Four-Chamber)
• Subxiphoid Sagittal
• Left Anterior Oblique
• Apical Four-Chamber
• Modified Apical Four-Chamber
• Parasternal Short-Axis
• High Right Parasternal View

17. TTE views for ASD
• Subxiphoid Frontal (Four-Chamber)
The subxiphoid frontal (four-chamber) view
allows imaging of the atrial septum along its
anterior–posterior axis from the SVC to the
AV valves.

20. • Subxiphoid Sagittal
The subxiphoid sagittal TTE view is acquired by
turning the transducer 90 clockwise from the
frontal view. This view can be used to measure
the rim from the defect to the SVC and IVC
and is an excellent window to image a sinus
venosus type defect

23. • Apical Four-Chamber :
This view is used to assess the hemodynamic
consequences of ASDs, such as RA and RV
dilation, and to estimate RV pressure using
the tricuspid valve regurgitant jet velocity. This
view is also used to evaluate for right-to-left
shunting with agitated saline

26. • Parasternal Short-Axis
This view is ideal to identify the aortic rim of the
defect. It also highlights the posterior rim (or
lack thereof) in sinus venosus and
posteroinferior secundum defects.

28. • Left Anterior Oblique.
The left anterior oblique is acquired by turning
the transducer approximately 45
counterclockwise from the frontal (four-
chamber) view. This view allows imaging of
the length of the atrial septum and is
therefore ideal to identify ostium primum
ASDs and for assessment of coronary sinus
dilation

33. • Modified Apical Four-Chamber
(Half Way in Between Apical Four-Chamber and
Parasternal Short-Axis View):
In the patients in whom the subcostal views are
difficult to obtain, the modified apical four-
chamber view is an alternative method for
imaging the atrial septum

34. • High Right Parasternal View.
The high right parasternal view is a parasagittal
view performed with the patient in the right
lateral decubitus position with the probe in
the superior–inferior orientation. In this view,
the atrial septum is aligned perpendicular to
the beam and is ideal for diagnosing sinus
venosus defects, particularly when the
subxiphoid windows are inadequate

35. ASD secundum rims
• SVC or superior margin
• IVC or inferior margin
• Posterior margin
• Anterior or retroaortic
margin
• Mitral rim

36. Views to identify the ASD rims
PSAX view at great vessel level:
Aortic and Post rim
A4CV:
Mitral Rim
Subcostal view: SVC and IVC rim

40. Qp/Qs
• Qp – pulmonary flow
• Qs – systemic flow
• Qp/Qs = 1 in normal
• Qp/Qs > 1.5 significant shunt
• Qp = VTI, RVOT diameter
• Qs = VTI, LVOT diameter

42. Pulmonary hypertension
by TR if no RVOT obstruction
Also by PR max velocity or RVOT acceleration
time

43. ASD with Eisenmenger syndrome
• pulmonary hypertension,
• reversal of flow,
• and cyanosis

46. ASD secundum Device closure
CRITERIA:
1. “Significant” ASDs (Qp/Qs >1.5 or ASDs associated with right
ventricular volume overload) should be closed
2. Secundum ASD that has a stretched
diameter of less than 38 mm and more than 10 mm
3. Adequate rims (5 mm) to enable secure
deployment of the device
4. Anomalous pulmonary venous connection
or proximity of the defect to the AV valves or coronary sinus
or systemic venous drainag, intracardiac thrombie absent

47. Device in situ

48. Device in situ

49. Follow up echo after device closure
After device closure, patients require 6 months of aspirin and
endocarditis prophylaxis until the device endothelializes,
following which, assuming that no residual shunt is present
all patients who have undergone device closure should
probably have an echocardiogram taken every 5 years or so
because of the possibility of late issues, especially
erosion.
Ref: Braunwald 10th ed

50. ASD after surgical closure

52. TEE for ASD

53. THANK YOU