CONGENITAL HEART DISEASE
Transesophageal Echocardiographic Guidance of Transcatheter Closure of Atrial Septal Defect William E. Hellenbrand, MD, John T. Fahey, MD, Francis X. McGowan, MD, Gregory G. Weltin, MD, and Charles S. Kleinman, MD
Transcatheter closure of atrial septal defect (ASD) was accomplished in 10 of 11 patients aged 13 months to 46 years (weight range 11 to 77 kg). Transesophageal echocardiography (TEE) was used simultaneously with fluoroscopic imaging in 4 of these patients aged 4.5 to 46 years (weight range 19 to 77 kg). TEE was used to ascertain defect size, position and number of defects and to ascertain appropriate seating of the defect occluder within the atrial defect. In 2 patients TEE-assisted transcatheter ASD closure was accomplished after previous attempts at transcatheter ASD closure, unaided by TEE, had been unsuccessful. The only unsucc:euful ASD closure procedure occurred in the smallest patient in the series (an U-kg 13month-old), a child who was too small to undergo TEE using our ll-mm diameter endoscopic probe. The concomitant use of TEE with fluoroscopic imaging provides information that is unique and completnentary and may improve the efficacy and safety of the transcatheter technique for ASD closure. The recent availability of a 7-mm diameter TEE probe will extend the use of TEE into the infant age group and may decrease the discomfort and potential morbidity of TEE in older patients. (Am J Cardioll990;66:207-213)
T
ranscatheter therapy for many different types of congenital heart disease has been well described over the past 8 years.l'? Recently, a double umbrella with a clamshell configuration was developed for transcatheter closure of atrial septal defect (ASD) allowing spring tension rather than hooks or locking screws to attach the umbrella to the atrial septum. II In the present study, the technique for double umbrella closure of ASD in children and adults as recently described by Lock et al 12,13 was used. This technique relied on fluoroscopic imaging alone to place the device. The relatively recent development of transesophageal echocardiography (TEE) imaging tranducers interfaced with steerable endoscopes has altered the nature of echocardiography. These "semiinvasive" studies provide high-quality tomographic images of the heart and great vessels, unaffected by superimposed lung tissue and body habitus. The use of TEE during cardiac surgery, in the intensive care unit and in outpatients, in whom precordial echocardiographic studies have been inadequate for diagnostic purposes, has been well described.I' This report describes the combined application of TEE and fluoroscopic imaging for monitoring the transcatheter closure of ostium secundum ASD. These 2 imaging modalities, used simultaneously, are complementary and represent a unique approach. We believe that TEE provides information that makes this interventional catheterization procedure easier, safer and more effective than using fluoroscopic guidance alone. METHODS
From the Departments of Pediatrics, Diagnostic Imaging and Anesthesiology, Yale University School of Medicine, New Haven, Connecticut. Manuscript received December 22, 1989; revised manuscript received and accepted March 6, 1990. Address for reprints: William E. Hellenbrand, MD, Yale University School of Medicine, Section of Pediatric Cardiology, 333 Cedar Street, New Haven, Connecticut 06510.
Study patients: Between March 1 and October 31, 1989, 11 patients, aged 1 to 46 years (median 4.6), ranging in weight from 11 to 77 kg (median 19.3) have undergone attempted transcatheter closure of ASDs at the Yale-New Haven Medical Center (Table I). These procedures were performed under a protocol for human investigation approved by our institutional review board as part of a multicenter study using an investigational device being evaluated under the approval of the Food and Drug Administration (IDE approved). Four of these patients, ranging in age from 45 to 46 years and in weight from 19 to 77 kg, underwent TEE monitoring and guidance of placement of the atrial defect occluder device. In 3 pediatric patients, ranging from 4.5 to 11 years of age, the procedure was performed under general an-
THE AMERICAN JOURNAL OFCARDIOLOGY JULY 15, 1990
207
TABLE I Clinical Information Atrial Septal Defect Size
WT
Pt No.
1 2 3 4 5 6 7 8 9 10 11
(kg)
Precordial Echo (mm)
Diagnosis
Age (yrs)
ASD ASD D-TGA,S/P. arterial switch D-TGA,S/P. arterial switch ASD ASD
12-6/12 29.0 10 9-9/12 50.0 8 1-1/12 11.6 9
ASD ASD PS,ASD Mitral atresia, SIP Fontan ASD
TEE (mm)
Stretched Diameter (mm)
Occluder Size (mm)
QP/QS
Clinical Result
10
15 12 14
28 28 28
2.0 1.5 1.6
Implanted / closed Implanted / closed Not implanted
8
10
23
0.9
Implanted/closed
12 10
17 12
33 23
2.8 1.9
12 18 10 6,4
17 24 13
33 40
28 17,17
2.0 2.1 1.8 0.6
Implanted / closed Implanted/small Residual L-RShunt Implanted/closed Implanted / closed Implanted/closed Implanted/closed
12
14
28
1.8
Implanted / closed
Angiography (mm)
10
6
4--1/12
15.5
2-2/12 4-6/12
12.5 12 19.3 10
8-1/12 45 4--8/12 3-3/12
37.0 10 77.0 15 13.7 8 14.6 4
12 18
10-3/12 42.0 12
12
8 10
ASD = atrial septal defect; D-TGA - D-transposition ofthe great arteries; PS - pulmoruc stenosis; QP/QS - ratio of pulmonary to systemic blood flow; S/P - status post.
esthesia, with the patients intubated and ventilated. In our institution the protocol for transcatheter closure of ASD calls for general inhalation anesthesia for all pediatric patients, regardless of whether TEE is anticipated. The fourth patient, a 46-year-old woman, underwent catheterization and TEE using intravenous sedation and topical oropharyngeal anesthesia consisting of aerosolized lidocaine and viscous lidocaine lubricant on the esophageal probe. All patients were prepared in standard fashion for cardiac catheterization and transcatheter atrial defect closure. Patients fasted overnight and were not premedicated. Anesthesia was induced by inhalational nitrous oxide/oxygen/halothane. Muscle relaxation was accomplished with intravenous vecuronium. The trachea was subsequently intubated with an endotracheal tube appropriate for the child's age and size, and the presence of an air leak around the endotracheal tube at
Transesophageal Echocardiographic Guidance of Transcatheter Closure of Atrial Septal Defect William E. Hellenbrand, MD, John T. Fahey, MD, Francis X. McGowan, MD, Gregory G. Weltin, MD, and Charles S. Kleinman, MD
Transcatheter closure of atrial septal defect (ASD) was accomplished in 10 of 11 patients aged 13 months to 46 years (weight range 11 to 77 kg). Transesophageal echocardiography (TEE) was used simultaneously with fluoroscopic imaging in 4 of these patients aged 4.5 to 46 years (weight range 19 to 77 kg). TEE was used to ascertain defect size, position and number of defects and to ascertain appropriate seating of the defect occluder within the atrial defect. In 2 patients TEE-assisted transcatheter ASD closure was accomplished after previous attempts at transcatheter ASD closure, unaided by TEE, had been unsuccessful. The only unsucc:euful ASD closure procedure occurred in the smallest patient in the series (an U-kg 13month-old), a child who was too small to undergo TEE using our ll-mm diameter endoscopic probe. The concomitant use of TEE with fluoroscopic imaging provides information that is unique and completnentary and may improve the efficacy and safety of the transcatheter technique for ASD closure. The recent availability of a 7-mm diameter TEE probe will extend the use of TEE into the infant age group and may decrease the discomfort and potential morbidity of TEE in older patients. (Am J Cardioll990;66:207-213)
T
ranscatheter therapy for many different types of congenital heart disease has been well described over the past 8 years.l'? Recently, a double umbrella with a clamshell configuration was developed for transcatheter closure of atrial septal defect (ASD) allowing spring tension rather than hooks or locking screws to attach the umbrella to the atrial septum. II In the present study, the technique for double umbrella closure of ASD in children and adults as recently described by Lock et al 12,13 was used. This technique relied on fluoroscopic imaging alone to place the device. The relatively recent development of transesophageal echocardiography (TEE) imaging tranducers interfaced with steerable endoscopes has altered the nature of echocardiography. These "semiinvasive" studies provide high-quality tomographic images of the heart and great vessels, unaffected by superimposed lung tissue and body habitus. The use of TEE during cardiac surgery, in the intensive care unit and in outpatients, in whom precordial echocardiographic studies have been inadequate for diagnostic purposes, has been well described.I' This report describes the combined application of TEE and fluoroscopic imaging for monitoring the transcatheter closure of ostium secundum ASD. These 2 imaging modalities, used simultaneously, are complementary and represent a unique approach. We believe that TEE provides information that makes this interventional catheterization procedure easier, safer and more effective than using fluoroscopic guidance alone. METHODS
From the Departments of Pediatrics, Diagnostic Imaging and Anesthesiology, Yale University School of Medicine, New Haven, Connecticut. Manuscript received December 22, 1989; revised manuscript received and accepted March 6, 1990. Address for reprints: William E. Hellenbrand, MD, Yale University School of Medicine, Section of Pediatric Cardiology, 333 Cedar Street, New Haven, Connecticut 06510.
Study patients: Between March 1 and October 31, 1989, 11 patients, aged 1 to 46 years (median 4.6), ranging in weight from 11 to 77 kg (median 19.3) have undergone attempted transcatheter closure of ASDs at the Yale-New Haven Medical Center (Table I). These procedures were performed under a protocol for human investigation approved by our institutional review board as part of a multicenter study using an investigational device being evaluated under the approval of the Food and Drug Administration (IDE approved). Four of these patients, ranging in age from 45 to 46 years and in weight from 19 to 77 kg, underwent TEE monitoring and guidance of placement of the atrial defect occluder device. In 3 pediatric patients, ranging from 4.5 to 11 years of age, the procedure was performed under general an-
THE AMERICAN JOURNAL OFCARDIOLOGY JULY 15, 1990
207
TABLE I Clinical Information Atrial Septal Defect Size
WT
Pt No.
1 2 3 4 5 6 7 8 9 10 11
(kg)
Precordial Echo (mm)
Diagnosis
Age (yrs)
ASD ASD D-TGA,S/P. arterial switch D-TGA,S/P. arterial switch ASD ASD
12-6/12 29.0 10 9-9/12 50.0 8 1-1/12 11.6 9
ASD ASD PS,ASD Mitral atresia, SIP Fontan ASD
TEE (mm)
Stretched Diameter (mm)
Occluder Size (mm)
QP/QS
Clinical Result
10
15 12 14
28 28 28
2.0 1.5 1.6
Implanted / closed Implanted / closed Not implanted
8
10
23
0.9
Implanted/closed
12 10
17 12
33 23
2.8 1.9
12 18 10 6,4
17 24 13
33 40
28 17,17
2.0 2.1 1.8 0.6
Implanted / closed Implanted/small Residual L-RShunt Implanted/closed Implanted / closed Implanted/closed Implanted/closed
12
14
28
1.8
Implanted / closed
Angiography (mm)
10
6
4--1/12
15.5
2-2/12 4-6/12
12.5 12 19.3 10
8-1/12 45 4--8/12 3-3/12
37.0 10 77.0 15 13.7 8 14.6 4
12 18
10-3/12 42.0 12
12
8 10
ASD = atrial septal defect; D-TGA - D-transposition ofthe great arteries; PS - pulmoruc stenosis; QP/QS - ratio of pulmonary to systemic blood flow; S/P - status post.
esthesia, with the patients intubated and ventilated. In our institution the protocol for transcatheter closure of ASD calls for general inhalation anesthesia for all pediatric patients, regardless of whether TEE is anticipated. The fourth patient, a 46-year-old woman, underwent catheterization and TEE using intravenous sedation and topical oropharyngeal anesthesia consisting of aerosolized lidocaine and viscous lidocaine lubricant on the esophageal probe. All patients were prepared in standard fashion for cardiac catheterization and transcatheter atrial defect closure. Patients fasted overnight and were not premedicated. Anesthesia was induced by inhalational nitrous oxide/oxygen/halothane. Muscle relaxation was accomplished with intravenous vecuronium. The trachea was subsequently intubated with an endotracheal tube appropriate for the child's age and size, and the presence of an air leak around the endotracheal tube at
