Clinical Application Of Echocardiography In Transcatheter Closure Of Congenital Atrial Septal Defect

Part One Clinical Study of Two-dimensional Echocardiography in Transcatheter Closure of Atrial Septal DefectObjective:To evaluate the clinical application of two-dimensional echocardiography(2-DE)in transcatheter closure of atrial septal defect(TCASD)using Amplatzer septal occluder(ASO).To investigate the methodology of echocardiography in transcatheter closure of complex atrial septal defects:deficiency rim,larger defect,multiple defects and with aneurysmal septum.To discuss the accuracy of the ASD's maximum diameters measured by transthoracic echocardiography(TTE)and transesophageal echocardiography(TEE);To know whether there were statistical significance and linear correlation between them and which one inosculated most with the intervention.To observe the changes of cardiac morphology and function before and after transcatheter closure of atrial septal defects using TTE.Methods:Between July 2005 and February 2008,229 patients with atrial sepal defect(ASD)(73 males and 156 females),diagnosed by clinical and 2-DE,were studied.The mean age of the patients was 26.5±16.4 years(ranged from 2-64 years). These patients were divided into two groups according to selection of the size of Amplatzer occluder based on TTE or TEE sizing.In Adult group(age＞14 years,n=163), the patients had the procedure by TTE and TEE sizing.In Child group(age≤14 years, n=66),TTE sizing was used as the sole tool for selecting device size.In both two groups,TTE and/or TEE largest ASD diameters were made correlation analysis with diameters of Ampalatzer occluders respectively.The regression equations were achieved.All patients underwent TCASD guided by TTE and X-ray.They were assesed with transthoracic echocardiography before,immediately after transcatheter closure and at follow-up in 3 days,3 months,6 months and 1 year.Results:1.The ASOs were deployed successfully in 218 patients.The success rate of the procedure was 95.2%.The maximal diameter of ASDs was 21.6±8.3mm(3-38mm),the ASOs were 26.0±8.9 mm(6-42mm).The complications in procedure included acute pericardial tamponade in 1,ASO malposition requiring emergency surgical removal in 1,and 2 cases with mitral regurgitation.The immediate residual shunt occured in 15 patients(6.9%)detected by TTE,and all residual shunts were dispeared at the follow-up of 1 year.2.TCASD in patients with complex anatomy:①141 patients with ASD associated with deficient rim(＜5mm).Of 123 patients with superior- anterior(SA)rim deficiency,119 patients(96.7)were successfully implanted with ASOs.10 patients with deficient posterosuperior rims underwent successful TCASD.Half of 8 patients(50%) with deficient posteroinferior and posterior rim were successfully implanted with ASOs.②9 patients with a large defect(TEE measure maximum diameter＞34mm) underwent closure.The procedure was successful in 6 patients(67.8%).The maximum diameter of ASD measured by TEE ranged from 34 to 38 mm(36.3±1.9mm).The mean size of implanted devices was 39.6±2.2mm(36～42mm).③Of 11 patients who had multiple ASDs were diagnosed by TEE and TTE,8 had two defects and 3 and three defects.All patients(100%)were successfully implanted with one occluder respectively and small to moderate residual shunt was found in 3 cases.During 3 month-1 years follow-up,there was no evidence of residual shunt.④Of 12 patients who had ASD associated with an aneurysmal septum,4 had multiple orifices.The placement of the occluders were successful in all patients.Immediately after the procedure,examined by TTE,small residual shunt was found in 2 cases respectively.During 3 month-1 year follow-up,All residual shunt was disappeared.3.The relationship between TTE and TEE measure the ASD's maximum diameters and the diameter of Amplatzer occluders:(1)In adult's group:A good correlation was found between TTE and ASO size(y=1.013x+7.679,R~2=0.857),and between TEE size and ASO size(y=0.975x+5.494,R~2=0.908).(2)In children group,a statistical correlation between TTE and ASO(y=0.969x+3.163,R~2=0.906).4.In all patients,the diameter of right atrium(RA)and right ventricle(RV), pulmonary artery systolic pressure(PSP)significantly decreased 3 days after the procedure(P＜0.01),thus the volume load of RV reduced.The diameter of left atium(LA) and left ventricle(LV)increased significantly 3 months after closure(P＜0.01),and LVEF increased significantly 3 days after closure only(P＜0.01).Conclusions:1.2-DE play a very important role in selection of patients and ASOs for TCASD,in the monitoring of deployment of ASO during TCASD,and in patients follow up.2.TEE is vital in the recognition of morphologic variations of the ASD,which is essential for safe and effective transcatheter ASD closure.This is especially important in patients with complex defect,such as:deficient rim,large ASDs,multiple ASDs and those with atrial septal aneurysm.3.In adult group,the ASD's maximum diameters TTE measured is better to guide the selection of diameters of Amplatzer occluder.But,in some times,TEE is a needed in addition to TTE.In children group,TTE sizing is a ideal method to accurately measure the exact size of ASD and choose the occluding device,respectively.4.TTE are simple and valuable method for observation on the effect of ASD occlusion.Especially,it is special on observing hemodynamic,cardiac chamber and function changes before and after occlusion. Part two Transcatheter Closure of Atrial Septal Defect Guided by Combined Transthoracic Echocardiography and Real-time Three Dimensional Echocardiography without X-rayObjective:To discuss the feasibility and efficiency of transthoracic echocardiography(TTE)combined with real-time three dimensional echocardiography (RT-3DE)in independently guiding closure of Atrial septal defect(ASD)without X-ray.Methods:Eleven selected patients(median age 24 years,range 12 to 45 years) with atrial septal defects,suited for transcatheter closure,underwent the procedure guided by TTE combined with RT-3DE only.The results were compared with those guided by conventional method(TTE and X-ray).Results:Median of the maximal diameter of ASDs measured by 2-DE was 19mm(15—25mm),the diameter of ASO was 23 mm(19—29mm).All the operations were held successfully.The complications of remnant diffluence, atthythmia,cardiac tamponade,embolism and the shedding of occluder were not observed.Compared with the conventional procedure of a control group of patients, procedure times were significantly prolonged.(66 versus 40 minutes;P＜0.01).Conclusion:TTE combined RT-3DE can guild and monitor the transcatheter closure of ASD accurately without X-ray,the procedure was safe and effective.