title: Accuracy of Transthoracic Echocardiography in Assessing Retro-aortic Rim prior to Device Closure of Atrial Septal Defects.
abstract: OBJECTIVE
  Deficient retro-aortic rim has been identified as a risk factor for device erosion following trans-catheter closure of atrial septal defects (ASDs). Transthoracic echocardiography (TTE) is the primary screening method for subjects for possible device closure of ASD, but its reliability in measuring retro-aortic rim size has not been assessed previously.
  
  
  METHODS
  A single-institution cross-sectional analysis of children and adults referred for trans-catheter device closure of single ostium secundum ASD from January 1, 2005 to April 1, 2012 with reviewable TTE and trans-esophageal echocardiogram images was performed. Inter-rater reliability of measurements was tested in a 24% sample. Accuracy of TTE measurement of retro-aortic rim was assessed using a Bland-Altman plot with trans-esophageal echocardiogram measurement as the gold standard. Test characteristics of TTE detection of deficient retro-aortic rim were calculated. Risk factors for misclassification of deficient retro-aortic rim were assessed using receiver operator characteristic curves. Risk factors for measurement error were assessed through multivariate linear regression.
  
  
  RESULTS
  In total, 163 subjects of median age 5 years (range: 0.3-46 years) were included. Trans-thoracic echocardiography had 90% sensitivity, 84% specificity, 90% positive predictive value, and 83% negative predictive value to detect deficient retro-aortic rim. Bland-Altman plot demonstrated no fixed bias (P = .23), but errors in measurement increased on average as the aortic rim increased in size (P < .001). Prespecified patient level risk factors did not affect receiver operator characteristic curve area under the curve, nor were any patient-level risk factors independently associated with increased measurement error on TTE.
  
  
  CONCLUSIONS
  TTE is a sensitive and specific screening test for deficient retro-aortic rim across a range of patient ages and sizes.
authors.affiliation: Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: O'Byrne
authors.affiliation: Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa, USA.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Glatz
authors.affiliation: Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Goldberg
authors.affiliation: The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa, USA.
authors.forename: Russell
authors.initials: R
authors.lastname: Shinohara
authors.affiliation: Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa, USA.
authors.forename: Yoav
authors.initials: Y
authors.lastname: Dori
authors.affiliation: Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa, USA.
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Rome
authors.affiliation: Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa, USA.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Gillespie
mesh_terms: D000293:Adolescent; D000328:Adult; D001011:Aorta / Q000000981:diagnostic imaging*; D019540:Area Under Curve; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation*; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D017548:Echocardiography, Transesophageal; D005260:Female; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging* / Q000628:therapy*; D006801:Humans; D007223:Infant; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D015143:Philadelphia; D011237:Predictive Value of Tests; D012372:ROC Curve; D015203:Reproducibility of Results; D012189:Retrospective Studies; D055989:Septal Occluder Device; D016896:Treatment Outcome; D055815:Young Adult
keywords: Atrial Septal Defect; Echocardiography; Heart Catheterization; Pediatric Cardiology