Euroecho2010 intracardiac-shunts
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Transcript of Euroecho2010 intracardiac-shunts
Intracardiac shunts
Piotr HoffmanAd lt Congenital Hea t Disease Depa tmentAdult Congenital Heart Disease Department
Institute of CardiologyWarsaw - Anin
• Atrial Septal Defects (ASD)• Patent Foramen Ovale (PFO)Patent Foramen Ovale (PFO)• Ventricular Septal Defects (VSD)
Atrial septal defectAtrial septal defect
Atrial septal defectAtrial septal defect80% S d l t d i th • 80% Secundum, located in the region of the fossa ovalis and its surrounding
• 15 % Primum located near the • 15 % Primum, located near the crux, AV valves malformed with regurgitation
• 5% Superior sinus venosuspdefect located near to SVC,associated with PAPVC
• <1% Inferior sinus venosusd f l d IVCdefect located near IVC
• <1% Unroofed coronary sinus – separation from the LApartially or completely missingpartially or completely missing
Atrial septal defectAtrial septal defect
A i il ECHO• Asymptomatic until adulthood
• ECHO
– Key diagnostic technique
• Symptoms beyond the fourth decade – Diagnosis and
quantification
• Life expectancy reduced, – RV volume overload
• QoL decreased – Qp/Qs
– Pulmonary pressures• Eisenmenger rare (<5%)
Pulmonary pressures…
Atrial septal defect morphologyAtrial septal defect – morphology
• Imaging planes:
– Subcostal– Apical ASD II. Apical 4CH viewp– Parasternal short
axis
ASD II. Subcostal view
Atrial septal defect morphologyAtrial septal defect - morphology
• Imaging planes:
– Apical– Subcostal– Parasternal short
axis
ASD I. Apical 4CH view
Atrial septal defect morphologyAtrial septal defect - morphology
• TEE > TTEASD sinus venosus VCS
Subcostal view
• Imaging planes (TTE)– Subcostal view
• Imaging planes (TEE)High transverse and – High transverse and longitudinal plane (VCS)
Atrial septal defect morphologyAtrial septal defect - morphology
• TEE > TTEASD sinus venosus VCS
Subcostal view
• Imaging planes (TTE)– Subcostal view
ASD sinus venosus VCS
• Imaging planes (TEE)High transverse and
ASD sinus venosus VCSTEE
– High transverse and longitudinal plane (VCS)
Atrial septal defect morphologyAtrial septal defect - morphology
ASD sinus venosus VCI TTE• TEE > TTE ASD sinus venosus VCI. TTE
• Imaging planes (TTE)– Subcostal view
• Imaging planes (TEE)High transverse and – High transverse and longitudinal plane (VCS)
Atrial septal defect morphologyAtrial septal defect - morphology
ASD sinus venosus VCI TTE• TEE > TTE ASD sinus venosus VCI. TTE
• Imaging planes (TTE)– Subcostal view
• Imaging planes (TEE)High transverse and
ASD sinus venosus VCI. TEE
– High transverse and longitudinal plane (VCS)
Atrial septal defect – evaluation of haemodynamics
• Presence of RV volume overload
• Qp/QsQp/Qs
Pulmonary • Pulmonary pressures RV dilatation due to volume
overload. Significant left-to-right shunt
Atrial septal defect – evaluation of haemodynamics
RV dilatation due to volume overload. Significant left-to-
RV volume overload. High TAPSE. Color Doppler - g
right shuntpp
significant left-to-right shunt
Atrial septal defect – evaluation of haemodynamics. Qp/Qs
Q l fl E h /D l l ti• Qp – pulmonary flow
• Qs – systemic flow
• Echo/Doppler evaluation
• Pulmonary flowQ y
• Qp/Qs = 1 in normals
– VTI– RVOT diameter (D)– Qp = VTI x π1/2D2
• Qp/Qs > 1.5 – significant shunt
• Systemic flow– VTI
LVOT di t (D)– LVOT diameter (D)– Qs = VTI x π1/2D2
Atrial septal defect – evaluation of haemodynamics. Qp/Qs
QsLAX - LVOT diameter 5CH – PD Doppler
RVOT diam
pp
QpSAX RVOT diameter + PD Doppler
Atrial septal defect – evaluation of systolic pulmonary artery pressure
PAP RVSP if RVOTO i • sPAP = RVSP, if RVOTO is absent
• Vmax of TR is requiredmax o s equ ed• sPAP=RVSP=4Vmax
2 + RAP
Mild tricuspid regurgitationRVSP PAP 31 + 5 mmHg no m l RVSP=sPAP= 31 + 5 mmHg - normal
Atrial septal defect – If TR not present?
• No RVH ~ normal pulmonary vascular resistance (PVR)resistance (PVR)
• Find PR estimate Find PR, estimate mPAP
• mPAP < 25 mmHg, normal PVR mPAP – 12 mmHg + RAP (~3mmHg)
mPAP ~ 15 mm Hg, normalg,
Atrial septal defect. Indications for intervention
Si ifi t h t (RV l • Significant shunt (RV volume overload) and PVR < 5 WU, regardless of symptoms
IBIB
Atrial septal defect.
Si ifi t h t (RV l ASD d
Indications for intervention• Significant shunt (RV volume
overload) and PVR < 5 WU, regardless of symptoms
IB
• ASD secundum
• Significant left-to-right IB g gshunt– RV overload– Qp/Qs 4.1Qp/Qs 4.1– SPAP ~36 mmHg
• Defect should be closed –which method?
ASD secundum. Indications for device closure
Si ifi t h t (RV l D i l i fi t h i • Significant shunt (RV volume overload) and PVR < 5 WU, regardless of symptoms
IB
• Device closure is first choice for secundum defect closure, when feasible from morphologyIB
• Device closure is the method of choice for ASD secundum
morphology
– stretched diameter < 38 mm ( thl b)of choice for ASD secundum
when applicableIC
(cathlab)
– sufficient rim of 5 mm expect towards the aorta • All ASDs with suspicion of
paradoxical embolism should be considered for intervention
II C
towards the aorta.
IIaC•
ASD secundum Device closure?ASD secundum. Device closure?
ASD diameter 19 mmapical 4CH view
ASD diameter 27 mmsubcostal imaging apical 4CH viewsubcostal imaging
ASD secundum diameter always measuredASD secundum diameter always measuredin several studying planes!
ASD secundum Device closure?ASD secundum. Device closure?
ASD diameter 19 mmapical 4CH view
TEEASD diameter 34 mm
ASD diameter 27 mmsubcostal imaging apical 4CH view ASD diameter 34 mm,
Inferior rim < 5mmSurgical closure
subcostal imaging
ASD secundum diameter always measuredASD secundum diameter always measuredin several studying planes!
ASD secundum Device closureASD secundum. Device closure
Preprocedural evaluation
ASD secundum Device closureASD secundum. Device closure
Preprocedural evaluation
Balloon inflation - stretched diameter
ASD secundum Device closureASD secundum. Device closure
Preprocedural evaluation
TEE monitoring of the procedure
Balloon inflation - stretched diameter
TEE monitoring of the procedure.
Patent Foramen Ovale PFOPatent Foramen Ovale - PFO
• PFO = ASD!• PFO = ASD!
• Haemodynamically insignificant interatrial insignificant interatrial communication
• During fetal life blood is h ti f i ht t l ft shunting from right to left
atrium
• Postnatally PFO closes in • Postnatally PFO closes in ~75%
• In reminder, PFO may serve
Autopsy prevalence of PFO
, yas a conduit for paradoxical embolization
Patent Foramen Ovale PFOPatent Foramen Ovale - PFO
Morphology• Morphology– Size– ASA
Eustachian Valve and Chiari’s network– Eustachian Valve and Chiari s network
• ShuntMicrobubbles seen in the left sided – Microbubbles seen in the left-sided chambers within three cardiac cycles from the maximum right atrial opacification
• Manouvers– Valslava– Caughingg g
• Transcranial Doppler
Patent Foramen Ovale PFOPatent Foramen Ovale - PFO
Transoesophageal echocardiographyTransoesophageal echocardiography
Contrast study with agitated salineContrast study with agitated saline
P f d l f tl• Performed less frequently
• Still useful in difficult situationssituations
– Vessel & chambers identification
– Shunt detection (PFO > ASD)Shunt detection (PFO > ASD)– Negative contrast in left-to-
right shunt– Contrast in LA/LV in right-to
l f hleft shunt
• Injection 10-15 ml agitated saline into the left decubital
LSVC emptying directly into the LA
saline into the left decubital vein
Coexistence of two different ASDsCoexistence of two different ASDs
Secundum and Primum Atrial Septal Defect
Ventricular septal defect Ventricular septal defect Th t it l O t d VSD ith ith t • The most common congenital heart disease at birth (30-40%)
• Operated VSD with or without residual shunt
Small insignificant L R shunt • Spontaneous closure is
frequent
• Small, insignificant L-R shunt, no LV volume overload and pulmonary hypertension
• Multiple defects may occur
Direction/magnitude of the
• L-R shunt, pulmonary hypertension, various degree of LV volume overload• Direction/magnitude of the
shunt determined by PVR, size of the defect, LV/RV systolic/diastolic function,
of LV volume overload
• Eisenmengery / ,
RVOTO
Ventricular septal defectVentricular septal defect
• Perimembranous ~ 80%• Muscular/trabecular ~15-20%Muscular/trabecular 15 20%• Outlet supracristal ~ 5%
Inlet/AV canal/AVSD type 1%• Inlet/AV canal/AVSD type ~1%
Muscular and inlet VSD
Perimembranous VSDPerimembranous VSD
Modified 4CH view Apical 5CH view Subcostal imigingLVOT plane
Apical 5CH viewleft–to-right shuntCW dopler
Ventricular septal defect outlet supracristal. TEE
Ao
MPA
VSD, L-R shunt
Indications for intervention in VSDIndications for intervention in VSD
• Symptoms attributed to L-R shunt without pulmonary vascular disease IC
• Asymptomatic with LV volume overload L-R shunt IC
h h f• With history of IE IIa
• With VSD-associated prolaps of the aortic cusp IIa
• VSD +PAH, Qp:Qs>1.5, PVR <2/3 systemic values IIa
Eisenmenger syndromeEisenmenger syndromeCHD ith i iti ll l • CHD with initially large systemic-to-pulmonary shunt
– severe pulmonary vascular disease
– PAH resulting in reversal of the shunt direction and central cyanosiscentral cyanosis
Eisenmenger syndrome. ASD sinus venosus
Female 34 years old Recent history of progressive SOB
Dilated RV RVSP 105 mmHg Shortened RVOTacceleration time77
RVH 7 mm
77 ms
Eisenmenger syndrome. ASD sinus venosus
Female 34 years old Recent history of progressive SOB
ASD sv
Eisenmenger syndrome, other examples…
Female 30 years oldInlet and muscular VSD
mPAP – 72 mmHgdPAP 47 mmHgdPAP – 47 mmHgsPAP – 122 mmHg
Intracardiac shunts. Echocardiography
E h di h (TTE TEE) i f l fi t li • Echocardiography (TTE+TEE) is powerful first line imaging modality in morphological and functional evaluation of intracardiac shuntse a uat o o t aca d ac s u ts
• In majority such a cases provides complete set of j y p pdata enabling clinical decision making
l i f b h i i l d i i l• Evaluation of both interatrial and interventricular shunt requires multiplane imaging