C 2009, the Authors
C 2009, Wiley Periodicals, Inc. Journal compilation DOI: 10.1111/j.1540-8175.2009.00948.x
Transesophageal Real Time Three-Dimensional Echocardiography in Assessment of Partial Atrioventricular Septal Defect Radoslaw Piatkowski, M.D.,∗ Anna Budaj-Fidecka, M.D.,∗ Piotr Scislo, M.D., Ph.D.,∗ ´ Janusz Kochanowski, M.D., Ph.D.,∗ Mateusz Spiewak, M.D.,† Grzegorz Opolski, M.D., Ph.D.∗ ∗
Department of Cardiology, Medical University of Warsaw, Poland; and †First Department of Coronary Artery Disease, Cardiac Magnetic Resonance Unit, Institute of Cardiology, Warsaw, Poland We present a practical application of real time three-dimensional transesophageal echocardiography in a 67-year-old male patient with congenital heart disease. (ECHOCARDIOGRAPHY, Volume 26, October 2009) congenital heart defects, atrial septal defects, ASD, 3D TEE, mitral cleft Case Report A 67-year-old man presented with a 6-month history of declining exercise capacity (NYHA II). Clinical examination revealed HR approximately 80/min., BP 130/70 mmHg, pansystolic murmur at the apex and at the left sternal border, and features of pulmonary stasis in the pulmonary circulation. The initial electrocardiogram showed atrial fibrillation, leftward QRS axis, left anterior hemiblock, and “incomplete” right bundle-branch block. Chest x-ray revealed cardiomegaly due to right heart and left atrial dilation, and evidence of increased pulmonary vascularity. The patient had a normal coronary angiography. Transthoracic two-dimensional echocardiography (2D TTE) showed the right and left ventricles as well as left atrium enlargement. TTE also revealed a defect in the most inferior portion of the atrial septum (ostium primum defect—ASD 1) with a significant left to right shunt (Qp/Qs = 3.9:1). (Fig. 1). Both atrioventricular (AV) valves were localized at the same level. In three-dimensional (3D) TTE there was a cleft of the anterior mitral valve (Fig. 2). Transesophageal 2D echocardiography (2D TEE) excluded LVOT obstruction and showed a large ventricular septal
Address for correspondence and reprint requests: Radoslaw Piatkowski, M.D., First Department of Cardiology, Medical University of Warsaw, Poland, Central University Hospital, 1a Banacha Street, 02-097 Warsaw, Poland. Fax: +48 22 599 19 57; E-mail:
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aneurysm (Fig. 3). Color Doppler demonstrated significant eccentric mitral and tricuspid regurgitations with mild pulmonary hypertension. Three-dimensional real time transesophageal echocardiography (3D TEE) revealed an atrial septal defect with the largest diameter of 30 × 12 mm, as well as a cleft mitral valve (Fig. 4 and Video clip 1; Fig. 5 and Video clip 2). Color Doppler 3D TEE demonstrated two large eccentric jets of mitral regurgitation (Fig. 6) and two areas without correct leaflet coaptation. After the 3D TEE, the patient was referred for surgical correction (repair of the cleft mitral valve, closure of the interatrial communication using a pericardium patch, and repair of the interventricular septum aneurysm with a synthetic patch). Discussion The ostium primum defect is within the spectrum of AV septal defects.1 In a patient with ASD 1, there is a common AV junction with two separate valve orifices, formed by fusion of the superior and inferior bridging leaflets.2 Significant mitral regurgitation due to the cleft mitral valve is observed in many patients. Associated defects include disproportion of outlet and inlet dimensions of the left ventricle, left ventricular outflow tract elongation, and malformations of the AV septum (muscular and membranous).3 Symptomatic patients with ASD 1 require a closure of the interatrial defect and repair of the left AV valve.1–4
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3D TEE IN PATIENT WITH ATRIOVENTRICULAR SEPTAL DEFECT
Figure 1. 2D TTE. Right and left ventricle as well as the left atrium enlargement. LA = left atrium; RA = right atrium.
Figure 2. 3D TTE. Cleft anterior leaflet from parasternal short-axis view (arrow). Ant = anterior; lat = lateral; inf = inferior.
Figure 3. 2D TEE. Atrial septal defect and large aneurysm of the membraneous part of the interventricular septum (arrow). LA = left atrium; RA = right atrium.
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Figure 4. 3D TEE. Atrial septal defect seen from the left atrium (arrow). IAS = interatrial septum; ASD 1 = atrial septal defect type I; ant = anterior; post = posterior.
Figure 5. 3D TEE. Three-dimensional view of cleft mitral valve (trileaflet valve) viewed from the left atrium (arrow). IAS = interatrial septum; RA = right atrium.
Figure 6. 3D TEE. Color flow Doppler across the mitral valve demonstrates two large jets of the mitral regurgitation. LA = left atrium; LV = left ventricle.
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Preoperative TTE and TEE with Doppler are essential for diagnosing ASD 1.1,3,5 In patients with an ostium primum defect, 3D TEE has valuable diagnostic utility, provides additional information about the nature of the defects, and allows for en face reconstructions and accurate assessment of the morphology of the septal defect, incompetence of the mitral valve and morphology of the interventricular septum aneurysm.5–7 3D TEE is able to display detailed spatial anatomic and pathologic information similar to a surgical view with online 3D imaging acquisition, and sectional projections and rotations at any plane.8 It also provides views of the ASD, thus allowing its measurement and identifying its spatial relation with neighboring structures. The spatial image resolution enables high-quality display of 3D structures. 3D echocardiography offers a unique chance to view dissects of the left AV valve and AV junction in any desired plane. 3D TEE also provides additional information regarding the origin of the regurgitant jet in patients with mitral regurgitation.7–8 Unique views of the atrial septum and cleft mitral valve in 3D TEE are not usually available when using 2D echocardiography.9 Thus, 3D TEE has practical and clinical applications as a useful complementary technique to conventional 2D TEE for appropriate surgical planning in patients with ASD 1.1,5,10 Due to the rising role of 3D TEE in cardiology diagnostics and the increasing availability of 3D probes, reports on practical and clinical everyday applications of this imagining technique will be increasingly useful to practitioners. References 1. 2.
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Webb G, Gatzoulis MA: Atrial septal defects in the adult: Recent progress and overview. Circulation 2006;114:1645–1653. Sommer RJ, Hijazi ZM, Rhodes JF Jr: Pathophysiology of congenital heart disease in the adult: Part I: Shunt lesions. Circulation 2008;117:1090–1099.
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Craig B: Atrioventricular septal defect: From fetus to adult. Heart 2006;92:1879–1885. Khalid O, Koenig P: The use of echocardiography in congenital heart surgery and intervention. Expert Rev Cardiovasc Ther 2006;4:263–271. Handke M, Heinrichs G, Moser U, et al: Transesophageal real-time three-dimensional echocardiography: Methods and initial in vitro and human in vivo studies. J Am Coll Cardiol 2006;48:2070–2076. Cheng TO, Xie MX, Wang XF, et al: Realtime 3-dimensional echocardiography in assessing atrial and ventricular septal defects: An echocardiographic-surgical correlative study. Am Heart J 2004;148:1091–1095. Van Den Bosch AE, Ten Harkel DJ, McGhie JS, et al: Characterization of atrial septal defect assessed by real time three-dimensional echocardiography. J Am Soc Echocardiogr 2006;19:815–821. Miller PA, Nanda NC, Aaluri S, et al: Threedimensional transesophageal echocardiographic demonstration of anatomical defects in AV septal defect patients presenting for reoperation echocardiography. Echocardiography 2003;20:105–109. Lang RM, Mor-Avi V, Sugeng L, et al: Threedimensional echocardiography: The benefits of the additional dimension. J Am Coll Cardiol 2006;48:2053– 2069. Fraisse A, Massih TA, Kreitmann B, et al: Characteristics and management of cleft mitral valve. J Am Coll Cardiol 2003;42:1988–1993.
Supporting Information Additional Supporting Information may be found in the online version of this article: Video clip 1. 3D TEE. Atrial septal defect seen from the left atrium. Video clip 2. Three-dimensional view of the cleft mitral valve (trileaflet valve) viewed from the left atrium. Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
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