title: Supplementing transesophageal echocardiography with transthoracic echocardiography for monitoring transcatheter closure of atrial septal defects with attenuated anterior rim: a case series.
abstract: The use of transesophageal echocardiography (TEE) for guidance of transcatheter closure of secundum-type atrial septal defect (ASD) is increasingly becoming a routine procedure. ASD with attenuated anterior superior (SA) rim is a variant of secundum-type ASD and is suitable for transcatheter closure. The success rate of TEE guidance for device deployment in these patients is not known. Therefore, we assessed 124 consecutive patients with ASD (57 secundum-type, 67 with attenuated SA rim) closed with an Amplatzer Septal Occluder under TEE guidance. Our results show that the TEE was successful in depicting all 4 corners and corresponding edges of each Amplatzer disk, as well as the septal rims of all 57 secundum-type ASDs. However, in 6 of 67 ASDs (9%) with attenuated SA rim in which TEE failed to visualize the adequate placement of occluder on the anterior inferior (IA) rim, the additional use of transthoracic echocardiography helped to resolve this inadequacy. Four of these six patients had the unusual morphology of the IA rim tissue. Two had severe right axis deviation of the heart with large Q angle (>90 degrees ). The SA rim was absent in 35 of 67 ASDs with attenuated SA rim and in these cases TEE demonstrated the anterior surface of the disk against the wall of the aorta but without distortion. We conclude that TEE can be useful for confirming successful deployment of the occluder in most patients with ASDs. In a small number of ASDs with attenuated SA rim who have unusual IA morphology, supplemental transthoracic echocardiography is required to verify successful deployment of the occluder when TEE visualization fails to reliably diagnose adequate placement of the occluder.
  
  
  CONCLUSIONS
  Transesophageal echocardiography can be useful for confirming successful deployment of the occluder in the majority of patients with atrial septal defect. In a small number of atrial septal defects with attenuated anterior superior rim which have unusual anterior inferior morphology, supplemental transthoracic echocardiography is required to verify successful deployment of the occluder when transesophageal echocardiography visualization fails to reliably diagnose adequate placement of the occluder.
authors.affiliation: Departments of *Anesthesiology and †Pediatrics, ‡National Taiwan University, School of Medicine; §National Yang-Ming University, School of Medicine and Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Su-Man
authors.initials: SM
authors.lastname: Lin
authors.forename: Shen-Kou
authors.initials: SK
authors.lastname: Tsai
authors.forename: Jou-Kou
authors.initials: JK
authors.lastname: Wang
authors.forename: Yin-Yi
authors.initials: YY
authors.lastname: Han
authors.forename: Wei-Horng
authors.initials: WH
authors.lastname: Jean
authors.forename: Yu-Chang
authors.initials: YC
authors.lastname: Yeh
mesh_terms: D000293:Adolescent; D000328:Adult; D000768:Anesthesia, General; D006328:Cardiac Catheterization; D002648:Child; D002675:Child, Preschool; D004452:Echocardiography; D017548:Echocardiography, Transesophageal; D005260:Female; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging* / Q000601:surgery*; D006346:Heart Septum / Q000000981:diagnostic imaging; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D019919:Prosthesis Implantation / Q000379:methods*