Transesophageal Echocardiigraphic in Adults

Detection of Atrial Septal Defect

Shoa-Lin Lin, MD, Chih-Tai Ting, MD, Tsui-Leih Hsu, MD, Chen-Huan Chen, MD, Mau-Song Chang, MD, Chung-Yin Chen, MD, and Benjamin N. Chiang, MD any studies have described the detection and quantitation of atria1 septal defect (ASD) by 2dimenM sional and Doppler color flow echocardiography.r-I2 Subxyphoid 2-dimensional echocardiography provides excellent imaging of the interatrial septum in infants and children, but thii approach often does not visualize MD in adu1ts.r r Recently, transesophageal echocardiography (TEE) has provided a new acoustic window to the heart and high-quality imaging of the interatrial septum is easily obtained.13-18 This study assessesthe sensitivity, specificity and accuracy of TEE and transthoracic echocardiography (TTE) in the diagnosis of ASD in adult patients. One hundred and twenty-two consecutive patients who underwent TTE and TEE were enrolled in this study. Patients were divided into 2 groups: group 1 consisted of 80 patients (34 men and 46 men, aged 17 to 77 years [mean 46 f 14) who had various diseases; group 2 consisted of 42patients (10 men and 32 women, aged 28 to 70 years [mean 48 f 131) with mitral stenosis who were candidates for balloon mitral valvuloplasty. Group 2 was used as a control group. Cardiac catheterization was performed in all I22 patients and surgery was performed in 66 of them. Among the 80 patients in group 1, 1 patient had both an ostium primum and secundum ASD, 38 patients had an ASD, and 41 patients had no ASD. TTE was performed using either an Advanced Technology Laboratory Ultramark 6 system or a HewlettPackard 7702OA Ultrasound imaging system with a 2.5 or 3.5 MHz transducer. The parasternal long-axis, short-axis, apical 4- and 2-chamber views, subcostal, and modified apical long- and short-axis planes were studied. The ASD was categorized as sinus venosus, ostium secundum or ostium pn’mum defect according to whether the defect location was in the superior, middle or lower portion of the atria1 septum. The echocardiographic data were studied by an observer unaware of the catheterization Jindings. TEE was performed with a 5 MHz phased-array transducer attached to the tip of a modified endoscope. The scope was connected to a Hewlett-Packard cardiac ultrasound system (7702OA). Each patient was premedicated with 10% lidocaine spray to the posterior pharynx and sedated with diazepam. Food intake was withheld for at 14 hours before procedure. The ASD was catego-

rized as sinus venosus, ostium secundum or ostium pn’mum defect depending on the defect location (Figure I). Cardiac catheterizations with full oximetric and left and right heart hemodynamic studies were performed on all 122 patients. A step-up in oxygen saturation at the right atrium by >7% indicated the presence of an ASD.19 Multiple oximetry samplings (3 to 5 samples) in the

From the Division of Cardiology, Department of Internal Medicine, Veterans General Hosoital-Taipei and Kaohsiuna and National Yang Ming Medical College, Kaohkung City, Taiwan, Republic of Chin; Thii report was supported in part by grant NSC 79-0412-RO75-75 from the National Science Council, and VGH Grant 8024 Taiwan, Republic of China. Dr. Link address is: Division of Cardiology, Department of Internal Medicine. Veterans General Hcsoital-Kaohsiuna, No. 386 Da&hung 1st Road, Kaohsiung City, Taiwan 80780, Republic of China. Manuscript received June 27,199l; revised manuscript received and accepted September 16,199l. 280









right atrium were obtained with meticulous care in all strated to have a large secundum ASD after operation patients. Surgery was performed in 66 patients: 25 with (Figure 2, bottom). In addition, a primum ASD in 4 and 41 without ASDs. The 25patients with ASD had 26 patients was clearly identified. TTE accurately classified ASD in 34 patients (4 missed, 1 overdiagnosed, defects including 19 with a secundum, 3 with a primum, 2 with a sinus venosus and 1 patient with both a secun- accuracy = 94%). TTE identified ASD at the superior atria1 septum in dum and primum ASD. 2 patients with a sinus venosus ASD, but did not visualTransthoracic 2-dimensional echocardiography ize the associated anomalous pulmonary venous connecidentified 33 of 39 patients with an ASD (sensitivity 85%). The addition of color flow imaging identified 2 tion. Cardiac catheterization and operation found that more patients who were classified as doubtful ASD cases the right upper pulmonary vein was connected to the superior vena cava in one and the right lower pulmonary by 2-dimensional echocardiography alone. Color Doppler echocardiography increased the diagnostic sensitivity vein was connected to the junction of both atria in the other patient. to 90%. There were nofalse-positive cases;the specificity was 100% in the diagnosis of ASD by TTE (Table I). Defects in 4 patients were not detected by TTE: 3 paTABLE I Comparison of Transthoracic and Transesophageal tients were technically difficult to study; the defect in Echocardiography in the Diagnosis of Atrial Septal Defect another patient was missed because of a small secundum TTE TEE ASD. A patient with a large secundum ASD was falsely diagnosed as having both a primum and a secundum ASD (+) ASD (0) ASD (+I ASD (0) ASD by TTE because of the underestimation of the ASD (+) 35 4 39 0 lower interatrial septum (Figure 2, top). TEE identified ASD (0) 0 41 0 41 the residual lower septum clearly and he was demonASD = atrial septal defect; TEE = tramesophageal echocardiography: transthoracic echocardiography; + = positive; 0 = negative.


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TEE identified 38 of 39patients with ASD (sensitivity 97%). One small defect (0.3 cm in size) was visualized with the assistance of color jlow imaging. Two patients were initially suspected of having a ventricular septal defect and an ASD. TTE and TEE both identified the ventricular septal defect with left to right shunt jlow, tricuspid regurgitation, right ventricular enlargement and paradoxical septal motion, but without transatrial septal shunt flow (Figure 3). Cardiac catheterization demonstrated that they had a step-up in oxygen saturation at both the atria1 and ventricular levels as well as easy passage of the catheter from right to left atrium, suggesting the presence of a ventricular septal defect and an ASD. Howwer, only a ventricular septal defect was found at the time of surgical interventions. With a combination of colorflow and anatomic imaging, TEE had a sensitivity of 100%, specificity of 100% and accuracy of 100% in detecting and localizing the ASD (Table I). TEE clearly visualized the sinus venosus defects in 2 patients and an anomalous pulmonary vein draining into the junction of both atria in one (Figure 4), but not in another patient with connection to the superior vena cava. Group 2 patients had rheumatic mitral stenosis and all underwent TTE, TEE and cardiac catheterization. Although echo dropout of the thin fossa ovalis membrane from the TTE approach was common, the addition of color flow imaging avoided the false diagnosis of ASD. Both TTE and TEE had a specificity of 100% in excluding the diagnosis of ASD in this control group. TEE provided excellent visualization of the ASD noninvasively. The ability of color flow imaging to visualize the shunt flow across an ASD is further proof of the diagnosis. Although TTE, using 2diiensional and Doppler color flow imaging, has allowed direct visualization of ASD with a sensitivity of 70 to 97%,2*3*9-l’ both falsepositive and falsenegative results due to suboptimally recorded images occur. Our study found that TIE had a sensitivity of 85% in identifying ASD and the addition of color flow imaging increased the diagnostic sensitivity to 90%. TIE accurately localized ASDs in 34 of 39 patients (accuracy 94%). TEE visualized all ASDs (sensitivity lOO’%,specificity lOO%, and accuracy 100%) in these 39 patients. Based on our experience, we believe that cardiac catheterization may not be necessary in adult patients with ASD, particularly at the present time, when pulmonary artery pressure can be estimated accurately and noninvasively with Doppler echocardiography. In conclusion, TEE is more sensitive, specific and accurate than TTE in detecting and localizing ASD. TEE







may be particularly useful whenever the precordial ap preach fails to confirm the cliically suspected case of ASD.

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15. 1992

Transesophageal echocardiographic detection of atrial septal defect in adults.

Transesophageal Echocardiigraphic in Adults Detection of Atrial Septal Defect Shoa-Lin Lin, MD, Chih-Tai Ting, MD, Tsui-Leih Hsu, MD, Chen-Huan Chen...
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