Three-dimensional transesophageal echocardiography of the atrial septal defects

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Imaging acquisition was carried out with a multiplane 5-MHz TEE transducer connected to commercially available equipment (system Sonos 5500, Philips Electronics, Koninklijke, N). Images were acquired with the rotational scanning method every 3° and synchronized with the R-wave of electrocardiographic lead II and with the respiration rate and depth. The TEE transducer was placed at the mid-esophageal level to obtain an optimal view of the atrial septum. Once the target structure was identified, the transducer was adjusted to place the region of interest as close to the centre of the scan as possible and a sweep test was obtained to ensure that the region of interest would be captured by the most centered scan lines. 2D images were stored in magnetic optical disks for off-line analysis using the commercially available Echo-Scan v4.0 system (Tom-Tec Gmb H, Munich, Germany). When the 3D reconstruction was completed, it was possible to determine completely the endocardial surface of the interatrial septum.

The 2D and 3D images were compared and the pathologic specimens were examined. Analysis included time of image acquisition, image quality, size and shape of the defects and its relation with adjacent structures such as embryological remnants. 3DTEE images were compared with analogous anatomic specimens selected from the Museum of Pathology at the “Instituto Nacional de Cardiologia”, a collection of 1,000 anatomic pieces collected over the past 55 years. The pieces were selected in a blind way by the pathologist based on the location and type of the defect exclusively.

The multiplane rotational acquisition extended the TEE examination by 4 to 6 minutes. An additional time of 15 minutes was necessary for off-line analyses of the 3D images. There were no complications attributed to the TEE procedure. Imaging quality and the corresponding 3D reconstructed structures were considered of good technical quality in all 5 studies. We noticed a high degree of reliability in the 3D TEE reconstructions.

In the first case (Figure 1) 3D TEE showed that the shunt was secondary to a residual orifice due to an extension of the defect not well evaluated initially with 2D TEE study. In the second case was possible to observe spatial relationships between ASD, coronary sinus orifice and a prominent Eustachian valve, forming part of the “Koch triangle”, (Figure 2a). In another view of 3D reconstruction, we could visualize the entire endocardial surface of the defect and the dimensions of the 5 portions of the septal rim (Figure 2b) as has been proposed by Mathewson and co-workers 8. In the OP case, the spatial relationship between the defect and the mitral valve internal comissure was successfully displayed (Figure 3). In the SV case, the defect was associated with anomalous right upper pulmonary venous drainage and one interesting aspect of the 3D reconstruction was the possibility of visualizing it from different angles (Figure 4). 3D reconstruction of the CA allowed to appreciate the absence of right AV connection and could accurately display simultaneously the exact geometry of a large ventricular septal defect (Figure 5), that closely resembles the surgeon`s vision. In the last case, the lack of atrial septal tissue in the 3D image was easily appreciated as well as the distance between the defect and the venous drainage through a dilated coronary sinus orifice (Figure 6).


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