Echocardiography is well established as an essential tool for the assessment of atrial septal defects (ASD). These defects comprise up to one-third of congenital heart disease detected in adults. 1 The morbidity and mortality benefits of closing large ASDs with significant left to right shunting are well established. 2 Over the past decade, several devices have been engineered to allow for a less invasive transcatheter approach to closing these defects. The optimal device for closure is still under investigation and multiple trials are currently ongoing to further analyze the benefits this approach. A recent case-control study comparing surgical with percutaneous catheter closure revealed fewer major (1.6% vs. 6%) and minor (5.2% vs. 19%) complications with catheter closure versus surgery. 3 Due to findings such as these, an increasing number of ASDs are being closed by this less invasive method.With recent technological advances, real time 3D echocardiography has emerged allowing for greater spatial resolution. The utility of 3D echocardiography has been demonstrated in several areas. 4 3D echocardiography provides a more detailed and accurate characterization of true ASD geometry and morphology. Variability of ASD shape is well known and can First two authors contributed equally to the manuscript. be identified by 2D echocardiography by using several orthogonal planes. Assuming a round shape may lead to a significant miscalculation of the defect size and shunt flow. The greater spatial resolution of real time 3D echocardiography and its ability to directly visualize the true defect shape and area allow for a superior assessment of ASDs. An example illustrating the superior accuracy of real time 3D echocardiography in ASD assessment is presented.A 9-year-old girl with a body surface area of 1.2 m 2 presented for evaluation of an ASD. She underwent a 2D transthoracic echocardiogram, which demonstrated a large secundum ASD. The following data were obtained. The right ventricular outflow tract (RVOT) flow (using the velocity-time integral (VTI) and crosssectional area (CSA) of the RVOT) was calculated to be 5.6 l/min. The left ventricular outflow tract (LVOT) flow was calculated to be 2 l/min via the same method. Thus, the pulmonic to systemic flow ratio (Qp:Qs) was 2.8:1 and the ASD flow was calculated to be 3.6 l/min. 3D transthoracic echocardiography was attempted, but did not provide adequate defect images.To better assess the secundum ASD, a 2D transesophageal echocardiogram was then performed. The VTI and the diameter of the ASD were measured at 0 degrees. The diameter was measured to be 1.9 cm (Fig. 1). Using this diameter, the CSA of the ASD was calculated to be 2.8 cm 2 . Given the patient's heart rate (75 bpm) and the VTI of the ASD (31 cm), the ASD flow was calculated to be 6.5 l/min and the Vol. 26, No. 2, 2009 ECHOCARDIOGRAPHY: A Jrnl. of CV Ultrasound & Allied Tech. 233
Significant advances in medical treatment, medical technology, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, coronary artery disease (CAD) is the leading cause of cardiovascular death of women in the Western world. In the past 2 decades, the focused research on women at risk for CAD has helped to clarify our understanding of some of the sex-specific factors that are important in the detection of CAD. In women, the detection and evaluation of physiologically significant CAD can be challenging. Many of the traditional tests that are designed to detect focal areas of coronary artery stenosis are less sensitive and specific in female patients, who have a greater burden of symptoms, higher atherosclerotic burden, and lower prevalence of obstructive coronary disease. In this article, we review the available evidence on the role of contemporary noninvasive diagnostic techniques in the evaluation of women with symptoms of CAD.
Evolving knowledge regarding sex differences in coronary heart disease has demonstrated that the prevalence, symptomatology, and pathophysiology of coronary atherosclerosis vary between genders. Women experience higher mortality rates and more adverse outcomes after acute myocardial infarction than men, despite a lower prevalence of obstructive coronary artery disease. Based on recent insights into the complex pathophysiology of coronary heart disease which includes a spectrum of obstructive coronary artery disease and dysfunction of the coronary microvasculature and endothelium, the term ischemic heart disease is a more accurate term for discussion of coronary atherosclerosis specific to women. In women, with clinical features and risk factors for ischemic heart disease, the detection and evaluation of ischemic heart disease is challenging due to the diverse pathogenic mechanisms of ischemic heart diseases in women. In this article, we discuss noninvasive imaging tests, provocative tests, including exercise testing in women with suspected ischemic heart disease.
An unusual case of total anomalous pulmonary venous connection surviving to adulthood without surgical correction is presented. Transthoracic echocardiography first led to this diagnosis and magnetic resonance imaging refined the anatomic diagnosis leading to successful surgical correction.
Article Title: Optimization of ASD Assessment Using Real Time Three‐Dimensional Transesophageal Echocardiography
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