ASSESSMENT OF

ATRIAL SEPTAL DEFECT AND

SHUNT QUANTIFICATION

Pembimbing :
Dr. dr. Lucia Kris Dinarti , Sp.PD, Sp.JP (K)
dr. Hasanah Mumpuni, Sp.PD, Sp.JP (K)
dr. Real K. Marsam Sp.JP
 EMBRYOLOGY OF ATRIAL SEPTUM

After birth, the foramen ovale generally closes within the first 2 months of age. Up to
20%–25% of the normal population has a PFO present in adulthood.
NYU Division of Cardiology 10/9/2016
ATRIAL SEPTAL DEFECT SUBTYPES

Primum ASD
(AV canal spectrum)

Sinus venosus ASD (SVC-type)

Secundum ASD
(Fossa ovalis ASD)
 ATRIAL SEPTAL DEFECTS

~5% of ASDs

~80% of ASDs
SVC * AV

SVC

FO
~15% of ASDs AV
SVC-TYPE
AV * SINUS VENOSUS ASD
* (Right atrial perspective)
MV

LV
SECUNDUM ASD
(Left atrial perspective)
PRIMUM ASD Amenable to
(Left atrial perspective) percutaneous closure
NYU Division of Cardiology 10/9/2016 5
 ATRIAL SEPTAL DEFECTS | SHAPE & SIZE VARIABILITY

SVC

AV

Circular Triangular

SECUNDUM ASDs
Seen from RA
perspective

Ovoid Fenestrated
Multiple holes
(< Lat. fenestra
– window)

NYU Leon H. Charney Division of Cardiology 10 10/9/2016

 ECHO IMAGING OF ATRIAL SEPTUM

• TTE can be used for the initial evaluation of ASD and PFO in adults
• The size, shape, and location of an atrial communication
• The direction and magnitude of shunting (the relative compliance of the RVs
and LVs, and the relative systemic and pulmonary vascular resistances)
• Impact of shunting on the right ventricle
• The relationship of the defect to its surrounding structures (venae cavae,
pulmonary veins, mitral and tricuspid valves, and coronary sinus)
• TEE can identify the margins or rims of the ASD
• Contrast echocardiography with agitated saline plays an important
role in the evaluation of PFO and assessing residual shunts after
transcatheter closure.
• 3D imaging offers the potential to clearly and comprehensively define
the dynamic morphology of the defect, which has been shown to
change during the cardiac cycle.
 ECHO IMAGING OF ATRIAL SEPTUM

Imaging of the atrial septum along its anterior–posterior axis

from the SVC to the AV valves, the insonation angle should be
as perpendicular as possible to the septal plane.

TTE | Subxyphoid Frontal View

NYU Division of Cardiology 12 10/9/2016

 ECHO IMAGING OF ATRIAL SEPTUM

Acquired by turning the transducer 90 clockwise from the

frontal view. For imaging the atrial septum along its
superior–inferior axis in a plane orthogonal.

RSPV
defect

SVC type venosus ASD

NYU Division of Cardiology TTE | Subxyphoid

12 Sagittal View 10/9/2016
 ECHO IMAGING OF ATRIAL SEPTUM

Acquired by turning the transducer 45 clockwise from the frontal view. For imaging
length of the atrial septum and is therefore ideal to identify ostium primum ASDs and
for assessment of coronary sinus dilation

Primum ASD Unroofed coronary sinus

TTE | Subcostal Left Anterior Oblique View

NYU Division of Cardiology 12 10/9/2016

 ECHO IMAGING OF ATRIAL SEPTUM

Acquired by turning the transducer 45 clockwise from the frontal view. For imaging
length of the atrial septum and is therefore ideal to identify ostium primum ASDs and
for assessment of coronary sinus dilation

Secundum ASD

TTE | Subcostal Left Anterior Oblique View

10/9/2016
NYU Division of Cardiology 12
 ECHO IMAGING OF ATRIAL SEPTUM

For insonation angle is parallel (coaxial) with the septal plane,

image dropouts must be differentiated from true atrial septal defects.

No ASD Secundum ASD

TTE | Apical 4-Chamber View

NYU Division of Cardiology 14 10/9/2016

The diagnosis and measurement of ASDs should be avoided
 ECHO IMAGING OF ATRIAL SEPTUM

The atrial septum is visualized posterior to the aortic root running in an

anterior–posterior orientation, ideal to identify the aortic rim

TTE | Parasternal Short-axis View

NYU Division of Cardiology 14 10/9/2016

 ECHO IMAGING OF ATRIAL SEPTUM

The patient is positioned in the right lateral decubitus position with the
probe in a superior-inferior orientation. This view is ideal for detection of
sinus venosus defects.

High Right Parasternal View

Subcostal Sagital View

TTE | SVC type Sinus Venosus ASD

NYU Division of Cardiology 14 10/9/2016
TEE | ATRIOVENTRICULAR & POSTERIOR ASD
RIM
 3D TEE | SECUNDUM ASD
RIMS

SVC SVC RUPV

AV AV

TV MV
IVC

RA Perspective LA Perspective
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Division of Cardiology
10/9/2016 16
 ATRIAL SEPTUM:
ASSOCIATED FINDINGS
 ATRIAL SEPTUM | EMBRIOLOGY

• Eustachian valve
• Chiari network
• Thebesian valve
HEART TUBE

SINUS VENOSUS VALVE

 EUSTACHIAN VALVE | PARTIAL VALVE OF IVC

LA

BARTOLOMEO EUSTACHI IVC

SVC
Latinized as Eustachius
(1514 -1574)
Italian anatomist

RA

NYU Leon H. Charney

Division of Cardiology
10/9/2016 19
 EUSTACHIAN VALVE | PARTIAL VALVE OF IVC

BARTOLOMEO EUSTACHI
Latinized as Eustachius
(1514 -1574)
Italian anatomist

NYU Leon H. Charney

Division of Cardiology
10/9/2016 20
 CHIARI NETWORK| REMNANT OF SINUS VENOSUS VALVE

HANS CHIARI
(1851 − 1916)
Austro-Hungarian
anatomist

LA LA

RA RA

NYU Leon H. Charney A Chiari network is present in 2%–3% of the general

population and is
Division of Cardiology
10/9/2016 21 the presence of PFO and ASA
associated with
 ATRIAL SEPTAL ANEURYSM

DEFINITION
• Redundancy or saccular
deformity of the atrial septum
• Increased mobility of the atrial
septal tissue. LA
• Excursion of the septal tissue
(typically the fossa ovalis) of
> 10 mm from the plane of the
atrial septum into the RA or
LA, or
• A combined total excursion RA
right and left of > 15 mm

PREVALENCE
• 2%–3% of humans

ASSOCIATIONS
• Increase prevalence of PFO
• Increased size of a PFO
• Increased prevalence of
cryptogenic stroke
• Multiple septal fenestrations
(fenestrated ASD)

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Division of Cardiology
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 ATRIAL SEPTAL ANEURYSM

NYU Leon H. Charney

Division of Cardiology
10/9/2016 23
 ATRIAL SEPTAL ANEURYSM | PFO SHUNT WITH SALINE
CONTRAST

NYU Leon H. Charney

Division of Cardiology
10/9/2016 24
 Contrast TTE Protocol

• Intravenous catheter, typically placed in antecubital vein, connected to a

three-way locking stopcock
• Combine in 10-mL syringe connected to the stopcock 8 mL of saline plus 1 mL
of blood from the patient plus 1 mL air; the addition of blood to the contrast
solution results in increased intensity of the microbubbles detected by
echocardiography
• Many laboratories prefer to avoid the use of the patient’s blood in the contrast
mixture preparation, and this can result in diagnostic quality opacification; in
such cases, approximately 9mL of saline and 1mL of air are used
• Rapidly mix back and forth with an empty 10-mL syringe attached to the
stopcock to manufacture bubbles
• Inject rapidly into the antecubital vein while acquiring a long clip length (i.e.,
10 seconds) with the echocardiography system; the echocardiographic images
are usually recorded from the four-chamber view for TTE, and the angle best
profiling the atrial septum is used for TEE, usually 30–100
• The use of biplane imaging might enhance detection of a small right-to-left
shunt
 INTRACARDIAC VS. INTRAPULMONARY SHUNT

• PROVOCATIVE MANEUVERS
Agitated saline injections should be performed at rest and provocative
maneuvers to increase the right atrial pressure, such as cough and the Valsalva
maneuver.

• PFO
Within 3-6 cardiac cycles
The presence of PFO is presumed when agitated saline contrast is noted in the left
atrium within 3-6 cardiac cycles after complete opacification of the right atrium.

• INTRAPULMONARY SHUNT
After 3-6 cardiac cycles
If the agitated saline contrast is noted after 6 cardiac cycles after complete
opacification of the right atrium, pulmonary arteriovenous malformations (AVMs)
must be considered.

• LARGE SHUNT
> 20 bubbles
Various classification schemes have been proposed to assess the sizes of shunts,
though none have been universally accepted yet. However, >20 bubbles crossing
the PFO from the right to left atrium is considered to be a large shunt

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Division of Cardiology
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 PFO VS. INTRAPULMONARY SHUNT

Intracardiac Intrapulmonary
Shunt Shunt
(PFO)

NYU Leon H. Charney

Division of Cardiology
10/9/2016 27
 ECHO IMAGING OF ATRIAL SEPTUM

Intrapulmonary shunt is present.

TTE | Apical 4-Chamber View with

with agitated saline injection
NYU Division of Cardiology 14 10/9/2016
 SHUNT FLOW QUANTIFICATION

• estimated by pulsed Doppler quantification of the pulmonary (Qp) to systemic

(Qs) blood flow ratio
• measurement of the systolic velocity time integrals (VTIs) of the RV and LV
outflow, and the maximal systolic diameters of the pulmonary and LV
outflow estimates the stroke volume for each ventricle
 INDICATIONS OF CLOSURE

The American College of Cardiology/American Heart Association guidelines have

recommended ASD closure for patients with RA and RV enlargement, regardless of
symptoms (class I).
Small ASDs (i.e., an ASD diameter of less than 5 mm) with no evidence of RV
enlargement or pulmonary hypertension do not require closure, because they are not
considered significant enough to affect the clinical course or hemodynamics of these
individuals.
THANK YOU
2 –D Echocardiography:
 direct visualization of any communication and their
shunting
excellent for localization of shunt
limited in the ability to quantify shunt

Indirect estimations
ASD with large shunting
 RA, RV dilated
 diastolic septal flattening
VSD with large shunting
 LA, LV dilatation
 Systolic and diastolic septal flattening
Methods:
1.Qp/Qs calculation from flow velocity (velocity
time integral) and cross sectional area
Qp/Qs = Area of Pa x VTI
Area of Aorta x VTI
Sanders et al used pulmonary flow with good
correlation , r=0.85.
Barron et al used Mitral flow with better
correlation , r= 0.9 vs 0.69.
2. Simplified method - the square of the pulmonary
to aortic diameter ratio was substituted for the
area ratio and the flow peak velocity ratio for the
velocity time integral.
 Qp/Qs = Vel. Pk PA x r2
Vel. Pk Ao x r2
r= radius / diameter
square of the ratio of the pulmonary to aortic
luminal diameter (or radius)is used instead of
vessel areas.
3. Qp/Qs = (pulm + mitral flow)/2
(tricuspid + aortic flow)/2
 Assumption that tricuspid and aortic flow
represent systemic flow and pulmonary & mitral
flows represent pulmonary flow.

 Maximal diameter of mitral and tricuspid valve

annulus is measured during diastole in an apical 4 –
chamber view & area calculated assuming the
annulus to be circular.
 Laborious & time taking.
 Combines measurements from all the 4 valves but
was not shown to be better than the previous 2.
4. Qp/Qs = Shunt flow + aortic flow
aortic flow
 Shunt (VSD) flow  as the product of the VTI
and color-derived cross-sectional area of VSD jet
measured at its narrowest point.
 This method does not use the pulmonary flow &
outflow diameter which are more variable.
Quantification of ASD
TTE estimation of ASD diameters & shunt
quantification by cath showed only fair correlation
(r=0.56).
• The size of the defect by transesophageal Doppler
color flow mapping correlated fairly well with the
size estimated at surgery (r = 0.73 ).

Other measurements by TTE for ASD are –

- RV/LV diameter (r=0.64)
- Area of PA (r=0.62)
- RV volume (r=o.71)
- PA/Ao (r=0.89)
R  L shunt quantification
Aortic flow + VSD flow = Input to RV
Pulmonary flow + R  L shunt = output from RV.
Hence R  L shunt = Aortic flow + VSD flow –
Pulmonary flow.
Only fair correlation found with Cath data (r =
0.61 –
0.77 )
Detection of left to right shunt
Level of Mean O2 sat % in Mean O2 Min Qp/Qs Possible causes
shunt distal chambers vol. % in reqd. for of step up
proximal detection at
(Highest value in
chambers 3L/min/m2
proximal
chambers) (Highest
value in
distal

c ha m b
≥ 1 .3 ( ≥
Atrial ≥7 (≥11) e rs ) 1.5 – 1.9 ASD, RSOV,
(SVC/IVC 2. 0) VSD with TR,
to RA) coronary fistula
to RA,
anomalous PV
drainage
Ventricular ≥5 (≥10) ≥1.0 (≥1.7) 1.3 – 1.5 VSD, PDA with
(RA to RV) PR, Primum
ASD, coronary
fistula to RV
Detection
Level of
of left
Mean O2 sat % in
to right
Mean O2
shunt
Min Qp/Qs Possible causes
shunt distal chambers vol. % in reqd. for of step up
(Highest value in proximal detection at
proximal chambers 3L/min/m2
chambers) (Highest
value in
distal
PDA, Aorta-
c ha m b
≥ 1 .0 ( ≥ pulmonic
Great ≥5 (≥5) ≥1.3
e rs )
1. 0) window,
vessel
Aberrant
(RV to coronary artery
PA)
All of the above
origin
Any level ≥7 (≥8) ≥1.3 (≥1.5) ≥1.5
(SVC to
PA)
Detection of left to right shunt
Chambers Single Multiple
sampled Sample samples
SVC – RA 7% 5%

RA – RV 5% 3%

RV – PA 4% 3%

PV/LA – -3% -2%

LV/SA