Transesophageal Three-Dimensional Echo Assessment of Sinus Venosus Atrial Septal Defect

Transesophageal Three-Dimensional Echo Assessment of Sinus Venosus Atrial Septa1 Defect NAVIN C. NANDA, M.D., KAMLESH ANSINGKAR, M.D., MIGUEL ESPINAL, M.D., AJAY JINDAL, M.D., VIRENDER PURI, M.D., SRINIVASA AALURI, M.D., O S W MUKHTAR, M.D., TAO YU LEE, M.D., ADITYA K. SAMAL, M.D., MAHESH M. BHAMBORE, M.D., and ALBERT D. PACIFICO, M.D." Division of Cardiovascular Disease, *Division of Cardiovascular and Thoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama

The incremental value of three-dimensional echocardiography over transesophageal multiplane two-dimensional imaging i n the assessment of sinus venosus atrial septal defect is demonstrated i n the present study. (ECHOCARDIOGRAPm, Volume 16, November 1999) three-dimensional echocardiography, sinus venosus atrial septal defect, transesophageal echocardiOgraPhY The patient was a 40-year-old male physician who was referred for surgical closure of a sinus venosus atrial septal defect (ASD). Intraoperative transesophageal echocardiography was performed in a standard mannerly2using a 5- to 7-MHz multiplane probe and a HewlettPackard 5500 untrasound system (Andover, Mass). A large defect measuring 2 em in maximum size was noted in the superior portion of the atrial septum typical of a sinus venoms defe~t.3,~ The right superior pulmonary vein (PV) was not well visualized. A large left-sided superior vena cava (SVC) was seen entering the coronary sinus. For three-dimensional (3-D) reconstruction, the probe was manipulated to bring the defect as close to the middle of the sector scan as possible and the ultrasonic beam was rotated from 0" to 180" in 3" increments using (ECG) and respiration gating. As described previously,5 all images were acquired and stored in a magneto-optical disc using a

Address for correspondence and reprint requests: Navin C . Nanda, M.D., University of Alabama at Birmingham, Heart Station SW/S102, Birmingham, AL 35233. Fax: 205934-6747.

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special software incorporated in the ultrasound system. Subsequently, a Tom Tec Echo-Scan was used for 3-D reconstruction.6 The 3-D reconstructed images clearly and vividly demonstrated not only the defect but also its relationship to the SVC and the anomalous right superior PV, which was seen entering the defect at the caval atrial junction. In addition, orthogonal 3-D views of the defect permitted assessment of both the shape and the size of the defect. The maximal dimension and the area of the defect measured 2.15 cm and 3.69 cm2, respectively (Fig. 1). At surgery, the sinus venosus defect measured 2 cm in diameter. The anomalous right superior PV was found to enter the caval atrial junction at the site of the defect. In addition, a large left-sided SVC was noted draining into the coronary sinus. The defect was closed with a patch of autologous pericardium. The patient did well and was discharged home in a satisfactory condition. The 3-D echocardiography has been found useful in a number of cardiac disease entities including secundum ASDs.7-15 It allows accurate measurement of the area of the secundum

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NANDA, ET AL.

Figure 1. Multiplane transesophageal 3 - 0 reconstruction of sinus venosus ASD. A. The arrowhead points to the large defect in the superior portion of the atrial septum. The arrow shows the right superior PV entering the SVC-atrial junction at the site of the defect. (B. and C.) Orthogonal views demonstrating the size of the defect (ASD), which measured 3.69 cm2 in area, The maximal dimension of the defect was 2.15 cm, which corresponded to the diameter of 2 cm measured at surgery. The top arrowhead in B. points to the right superior PV, and the bottom arrowhead points to the defect. ASD = atrial septa1 defect; SVC = superior vena cava; LA = left atrium; RA = right atrium.

defect as well as distances to adjacent cardiac structures. In this regard, it has been found superior to transesophageal multiplane 2-D imaging.16.17 This is of practical clinical significance because exact sizing of the secundum defect is important when considering catheter closure.18 To our knowledge, there are no reports so far illustrating the usefulness of 3-D echocardiography in the evaluation of sinus ve-

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nosus ASDs. In our patient, 3-D echocardiography provided a more comprehensive assessment of the sinus venosus defect and its relationship t o surrounding structures as compared with multiplane 2-D imaging. It permitted visualization of the shape of the defect as well as assessment of its size. On the other hand, neither the shape nor the area of the defect could be evaluated by transesophageal

ECHOCARDIOGRAPHY:A Jrnl. of CV Ultrasound & Allied Tech.

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3-D ECHO ASSESSMENT OF SINUS VENOSUS ASD

2-D echocardiography. In addition, 3-D views provided a dramatic display of the terminal portions of the SVC and anomalous superior PV and their exact relationship to the defect. The entrance of the right superior PV at the site of the defect at the caval atrial junction was not appreciated using multiplane 2-D imaging. Both 2-D and 3-D measurements of the maximum dimension of the defect correlated well with the surgical diameter of 2 cm. In conclusion, 3-D echocardiography provides additional information as compared with transesophageal multiplane 2-D imaging in the evaluation of sinus venuous ASD. Further studies using a large number of patients are needed to delineate the exact role of this technique in the assessment of this lesion. References 1. Seward JB, Khandheria BK, Freeman WK, et al: Multiplane transesophageal echocardiography: Image orientation, examination technique, anatomic correlation, and clinical applications. Mayo Clin Proc 1993;68:523-551. 2. Nanda NC, Domanski M J Atlas of Transesophageal Echocardiography. Williams and Wilkins, Baltimore, Md, 1998:l-5. 3. Maxted W, Finch A, Nanda NC, et al: Multiplane transesophageal echocardiographic detection of sinus venoms atrial septal defect. Echocardiography 1995;12:139-143. 4. Pascoe RD, Oh JK, Warnes CA, et al: Diagnosis of sinus venoms atrial septal defect with transesophageal echocardiography. Circulation 1996;94:1049-1055. 5 . Samal AK, Nanda NC, Thakur AC, et al: 3-D echocardiographic assessment of Lambl’s excrescences on the aortic valve. Echocardiography 1999;15:695-701. 6. Echo-Scan Version 3:O: Operating Instructions. Tom Tec Imaging Systems, Inc., Boulder, Colo, 1995. 7. Ghosh A, Nanda NC, Maurer G Three-dimensional reconstruction of echocardiographic images using the rotation method. Ultrasound Med Biol 1982;6:665-661. 8. Raqueno R, Ghosh A, Nanda NC, et al: Fourdimensional reconstruction of two-dimensional echocardiographic images. Echocardiography 1989;6:323-337.

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9. King DL, King DL Jr, Shao MY: Three-dimensional spatial registration and interactive display of position and orientation of real time ultrasound images. J Untrasound Med 1990;9: 525-532. 10. Wang XF, Li ZA, Cheng TO, et al: Clinical application of three-dimensional transesophageal echocardiography. Am Heart J 1994;123: 380-388. 11. Flachskampf FA, Handschumakertr M, Vandervoort PM, et al: Dynamic three-dimensional reconstruction of the mitral annulus using a multiplane transesophageal echo-transducer. Circulation 1991;84:II-686. 12. Nanda NC, Pinheiro L, Sanyal R, et al: Multiplane transesophageal echocardiographic imaging and three-dimensional reconstruction. Echocardiography 1992;9:667-676. 13. Wollschlager H, Zeiher AM, Klein HP, et al: Transesophageal echo computer tomography: A new method for dynamic three-dimensional imaging of the heart. In: Computers in Cardiology 1989. IEEE Computer Society, Salt Lake City, Utah, 1990, p. 39. 14. Pandian NC, Nanda NC, Schwartz SL, et al: Three-dimensional and four-dimensional transesophageal echocardiographic imaging of heart and aorta in humans using a computed tomographic imaging probe. Echocardiography 1992;9:677-687. 15. Pandian NG, Roelandt J, Nanda NC, et al: Dynamic three-dimensional echocardiography: Methods and clinical potential. Echocardiography 1994;11:237-259. 16. Nanda NC, Abd-El Rahman SM, Khatri G, et al: Incremental value of three-dimensional echocardiography over transesophageal multiplane two-dimensional echocardiography in qualitative and quantitative assessment of cardiac masses and defects. Echocardiography 1995;12:619-628. 17. Franke A, Kuhl HP, Rulands D, et al: Quantative analysis of the morphology of secundumtype atrial septal defects and their dynamic change using transesophageal three-dimensional echocardiography. Circulation 1997;II: 323-327. 18. Rosenfield HM, van der Velde ME, Sanders SP, et al: Echocardiographic predictors of candidacy for successful transcatheter atrial septal defect closure. Cathet Cardiovasc Diagn 1995; 34~29-34.

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