Value of Transesophageal Color Doppler Echocardiography for Detection of Different Types of Atrial Septal Defect in Adults Dirk Hausmann, MD, Werner G. Daniel, MD, Andreas Mugge, MD, Gerhard Ziemer, MD, and Alan S. Pearlman, MD, Hannover, Germany, and Seattle, Washington
In 121 adults, the value of transthoracic and transesophageal color Doppler echocardiography for detection of different types of atrial septal defect (ASD) or of partial anomalous pulmonary venous return was analyzed. The 121 patients had a total of 129 defects with left-to-right atrial shunting (including eight patients with two types of defects). All of six cases with primum-type ASD were diagnosed correctly by both echocardiographic methods. Ninety-seven patients showed a secundum-type ASD during transesophageal echocardiography: by transthoracic echocardiography, only eight (20%) of the 40 small defects (diameter 10 mm. A sinus venosus-type ASD was evident by transesophageal echocardiography in 11 patients, of which only one (9%) was demonstrated by the transthoracic approach. Partial anomalous pulmonary venous return was seen by transesophageal echocardiography in 13 patients but missed in two other patients in whom anomalous pulmonary venous return was subsequently identified by surgery (both with anomalous return of the upper right pulmonary vein into the superior vena cava). By use of the transthoracic technique, partial anomalous venous return was detected in only two cases, both of which had "scimitar syndrome." Compared with transthoracic echocardiography, the transesophageal approach is clearly superior in the detection of small secundum-type ASD, sinus venosus-type ASD, and partial anomalous pulmonary venous return. (JAM Sac EcHOCARDIOGR 1992;5:481-8.)
Transthoracic echocardiography is widely used for noninvasive detection of atrial septal defects (ASD). With this technique, the anatomic defect may be visualized directly by two-dimensional imaging, 1 the abnormal shunt may be detected by calor flow Doppler mapping, 2 and the magnitude of the left-to-right shunt may be estimated by Doppler flow measurements. 3•4 However, transthoracic echocardiography has limited ability to detect sinus venosus-type ASD and associated partial anomalous venous return. 5 •6 From the Department of Internal Medicine, Division of Cardiology, and the Department ofThoracic Surgery, Hannover Medical School; and the Division of Cardiology, Department of Internal Medicine, University of Washington. Presented in part at the 63rd Scientific Sessions of the American Heart Association, Dallas, Texas, November 12-15, 1990. Reprint requests: Werner G. Daniel, MD, Department oflnternal Medicine, Division of Cardiology, Hannover Medical School, Konstanty-Gutschow-Str. 8, 3000 Hannover 61, Germany. 27/1139074
Moreover, in some patients poor image quality on transthoracic echocardiography impedes diagnostic visualization of secundum- or primum-type ASD. Recent studies have shown that transesophageal echocardiography, when compared with transthoracic echocardiography, provides superior visualization of the interatrial septum and both atria in virtually all patients. 7 Therefore, the present prospective study was performed to compare the diagnostic value of transesophageal and transthoracic echocardiography in different types of ASD.
METHODS Patients
The study population consisted of 121 patients (55 men, 66 women) with a mean age of 43 ± 16 years (range 18 to 81 years) who underwent both transthoracic and transesophageal echocardiography be481
Journal of the American Society of Echocardiography
482 Hausmann et al.
tween January 1987 and July 1991 at Hannover Medical School. In these patients, echocardiographic studies were requested to evaluate for clinically suspected ASD (n = 91) that were either primary (n = 68), residual after surgery (n = 13), or after transseptal mitral balloon valvuloplasty (n = 10). In 30 patients, ASD was not suspected clinically. In these cases, echocardiography was performed because of mitral (n = 13) or aortic valve disease (n = 9), cardiomyopathy (n = 4), cardiac tumor (n = 2), or ischemic heart disease (n = 2). No patient had clinical evidence for right-to-left shunting. Fifty-six patients (9 men, 47 women) with a mean age of 54 ± 14 years (range 23 to 76 years) served as a control group. These patients had severe mitral valve stenosis and were candidates for percutaneous mitral valvuloplasty. Transthoracic and transesophageal echocardiography was performed to exclude intraatrial thrombi before the valvuloplasty procedure. Echocardiography
Transthoracic echocardiographic studies were performed by standard techniques with a 2.25 or 3.5 MHz phased-array transducer system. For transesophageal echocardiography a Hewlett Packard 21362 A instrument (5.0 MHz phased-array transducer, Hewlett Packard Co, Andover, Mass.), an Acuson 128 Cardiovascular System (5.0 MHz phased-array transducer, Acuson Computed Sonography, Mt. View, Calif.), or an Ultramark 9 (5.0 MHz phased-array transducer, Advanced Technology Laboratories, Bothel, Wash.) was used, with the transducer mounted at the tip of a modified gastroscope. A horizontal plane was used for transesophageal echocardiography. Patients fasted for at least 4 hours and received a local pharyngeal anesthesia ( 1o/o lidocaine spray) as the only premedication. Informed consent was obtained from all patients and the investigations were carried out with the patient in the supine left lateral position without any complications. The transesophageal echocardiographic examination was usually completed within 5 to 10 minutes. During transthoracic echocardiography the interatrial septum was visualized from subcostal and apical examining windows as well as in the parasternal short-axis view. During transesophageal echocardiography the interatrial septum was examined in the transatrial four-chamber view. The connections of the pulmonary veins to the left or right atrium were carefully evaluated with both transthoracic and transesophageal techniques. During the transesophageal
examination all four pulmonary veins were imaged individually and followed concerning a potential connection, in particular to the superior vena cava right above the level of the right atrium. An atrial septal defect was diagnosed when a discontinuity was observed in the interatrial septum through which Doppler flow signals were directed from the left to the right atrium. ASD was considered to be of the primum type when the discontinuity was immediately cephalad to the atrioventricular valves, of the secundum type when the discontinuity was in the middle of the septum, and of the sinus venosus type when the discontinuity was adjacent to the entry of the inferior or superior vena cava into the right atrium. Anomalous pulmonary venous return was diagnosed when at least one pulmonary vein was identified to connect to the right atrium or the superior or inferior vena cava. All echocardiograms were carefully evaluated for the presence or absence of an ASD by two independent observers: the operator performing the examinations evaluated the transthoracic and transesophageal studies immediately after the procedure, and a second physician evaluated the video tape recordings without knowledge of the results of the first evaluation. In cases with initial discrepancies (n = 5), both observers reevaluated the studies together and a consensus was found. Cardiac Catheterization
Cardiac catheterization was performed in 66 (55%) of the 121 study patients and in 54 control patients. Pressures and oxygen saturations were measured in the inferior and superior vena cava, the right atrium and ventricle, and the pulmonary artery. The pulmonary to systemic flow (Qp/Q) was determined by the Pick method. Contrast material was injected in the pulmonary artery to define the type of atrial septal
In 121 adults, the value of transthoracic and transesophageal color Doppler echocardiography for detection of different types of atrial septal defect (ASD) or of partial anomalous pulmonary venous return was analyzed. The 121 patients had a total of 129 defects with left-to-right atrial shunting (including eight patients with two types of defects). All of six cases with primum-type ASD were diagnosed correctly by both echocardiographic methods. Ninety-seven patients showed a secundum-type ASD during transesophageal echocardiography: by transthoracic echocardiography, only eight (20%) of the 40 small defects (diameter 10 mm. A sinus venosus-type ASD was evident by transesophageal echocardiography in 11 patients, of which only one (9%) was demonstrated by the transthoracic approach. Partial anomalous pulmonary venous return was seen by transesophageal echocardiography in 13 patients but missed in two other patients in whom anomalous pulmonary venous return was subsequently identified by surgery (both with anomalous return of the upper right pulmonary vein into the superior vena cava). By use of the transthoracic technique, partial anomalous venous return was detected in only two cases, both of which had "scimitar syndrome." Compared with transthoracic echocardiography, the transesophageal approach is clearly superior in the detection of small secundum-type ASD, sinus venosus-type ASD, and partial anomalous pulmonary venous return. (JAM Sac EcHOCARDIOGR 1992;5:481-8.)
Transthoracic echocardiography is widely used for noninvasive detection of atrial septal defects (ASD). With this technique, the anatomic defect may be visualized directly by two-dimensional imaging, 1 the abnormal shunt may be detected by calor flow Doppler mapping, 2 and the magnitude of the left-to-right shunt may be estimated by Doppler flow measurements. 3•4 However, transthoracic echocardiography has limited ability to detect sinus venosus-type ASD and associated partial anomalous venous return. 5 •6 From the Department of Internal Medicine, Division of Cardiology, and the Department ofThoracic Surgery, Hannover Medical School; and the Division of Cardiology, Department of Internal Medicine, University of Washington. Presented in part at the 63rd Scientific Sessions of the American Heart Association, Dallas, Texas, November 12-15, 1990. Reprint requests: Werner G. Daniel, MD, Department oflnternal Medicine, Division of Cardiology, Hannover Medical School, Konstanty-Gutschow-Str. 8, 3000 Hannover 61, Germany. 27/1139074
Moreover, in some patients poor image quality on transthoracic echocardiography impedes diagnostic visualization of secundum- or primum-type ASD. Recent studies have shown that transesophageal echocardiography, when compared with transthoracic echocardiography, provides superior visualization of the interatrial septum and both atria in virtually all patients. 7 Therefore, the present prospective study was performed to compare the diagnostic value of transesophageal and transthoracic echocardiography in different types of ASD.
METHODS Patients
The study population consisted of 121 patients (55 men, 66 women) with a mean age of 43 ± 16 years (range 18 to 81 years) who underwent both transthoracic and transesophageal echocardiography be481
Journal of the American Society of Echocardiography
482 Hausmann et al.
tween January 1987 and July 1991 at Hannover Medical School. In these patients, echocardiographic studies were requested to evaluate for clinically suspected ASD (n = 91) that were either primary (n = 68), residual after surgery (n = 13), or after transseptal mitral balloon valvuloplasty (n = 10). In 30 patients, ASD was not suspected clinically. In these cases, echocardiography was performed because of mitral (n = 13) or aortic valve disease (n = 9), cardiomyopathy (n = 4), cardiac tumor (n = 2), or ischemic heart disease (n = 2). No patient had clinical evidence for right-to-left shunting. Fifty-six patients (9 men, 47 women) with a mean age of 54 ± 14 years (range 23 to 76 years) served as a control group. These patients had severe mitral valve stenosis and were candidates for percutaneous mitral valvuloplasty. Transthoracic and transesophageal echocardiography was performed to exclude intraatrial thrombi before the valvuloplasty procedure. Echocardiography
Transthoracic echocardiographic studies were performed by standard techniques with a 2.25 or 3.5 MHz phased-array transducer system. For transesophageal echocardiography a Hewlett Packard 21362 A instrument (5.0 MHz phased-array transducer, Hewlett Packard Co, Andover, Mass.), an Acuson 128 Cardiovascular System (5.0 MHz phased-array transducer, Acuson Computed Sonography, Mt. View, Calif.), or an Ultramark 9 (5.0 MHz phased-array transducer, Advanced Technology Laboratories, Bothel, Wash.) was used, with the transducer mounted at the tip of a modified gastroscope. A horizontal plane was used for transesophageal echocardiography. Patients fasted for at least 4 hours and received a local pharyngeal anesthesia ( 1o/o lidocaine spray) as the only premedication. Informed consent was obtained from all patients and the investigations were carried out with the patient in the supine left lateral position without any complications. The transesophageal echocardiographic examination was usually completed within 5 to 10 minutes. During transthoracic echocardiography the interatrial septum was visualized from subcostal and apical examining windows as well as in the parasternal short-axis view. During transesophageal echocardiography the interatrial septum was examined in the transatrial four-chamber view. The connections of the pulmonary veins to the left or right atrium were carefully evaluated with both transthoracic and transesophageal techniques. During the transesophageal
examination all four pulmonary veins were imaged individually and followed concerning a potential connection, in particular to the superior vena cava right above the level of the right atrium. An atrial septal defect was diagnosed when a discontinuity was observed in the interatrial septum through which Doppler flow signals were directed from the left to the right atrium. ASD was considered to be of the primum type when the discontinuity was immediately cephalad to the atrioventricular valves, of the secundum type when the discontinuity was in the middle of the septum, and of the sinus venosus type when the discontinuity was adjacent to the entry of the inferior or superior vena cava into the right atrium. Anomalous pulmonary venous return was diagnosed when at least one pulmonary vein was identified to connect to the right atrium or the superior or inferior vena cava. All echocardiograms were carefully evaluated for the presence or absence of an ASD by two independent observers: the operator performing the examinations evaluated the transthoracic and transesophageal studies immediately after the procedure, and a second physician evaluated the video tape recordings without knowledge of the results of the first evaluation. In cases with initial discrepancies (n = 5), both observers reevaluated the studies together and a consensus was found. Cardiac Catheterization
Cardiac catheterization was performed in 66 (55%) of the 121 study patients and in 54 control patients. Pressures and oxygen saturations were measured in the inferior and superior vena cava, the right atrium and ventricle, and the pulmonary artery. The pulmonary to systemic flow (Qp/Q) was determined by the Pick method. Contrast material was injected in the pulmonary artery to define the type of atrial septal
