Assessment of Muscular Ventricular Septal Defect Closure by Transcatheter or Surgical Approach: A Three-Dimensional Echocardiographic Study

Three-dimensional Echocardiography in Congenital Heart Disease: An Expert Consensus Document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Three-dimensional echocardiography (3DE) has become important in the management of patients with congenital heart disease (CHD), particularly with pre-surgical planning, guidance of catheter intervention, and functional assessment of the heart. 3DE is increasingly used in children because of good acoustic windows and the non-invasive nature of the technique. The aim of this paper is to provide a review of the optimal application of 3DE in CHD including technical considerations, image orientation, application to different lesions, procedural guidance, and functional assessment.

Three-Dimensional Echocardiographic En Face Views of Ventricular Septal Defects: Feasibility, Accuracy, Imaging Protocols and Reference Image Collection

BACKGROUND

Ventricular septal defect (VSD) is the most common congenital cardiac anomaly. Accurate assessment is critical for planning treatment. Recent advances in three-dimensional (3D) echocardiography have improved image quality and ease of use.

METHODS

The feasibility and accuracy of three specific 3D echocardiographic protocols to demonstrate en face views of VSDs were analyzed in a retrospective review of 100 consecutive patients. Sixty-four patients underwent transthoracic echocardiography and 36 transesophageal echocardiography. Types of VSDs included 34 muscular, 32 perimembranous, 18 malaligned, 11 inlet, four outlet, and one acquired. Ages ranged from 1 day to 77 years, and body weights from 3 to 92 kg. Three-dimensional echocardiographic full-volume mode with standard XYZ and adjustable plane cropping, 3D full-volume mode with iCrop, and narrow-sector live 3D protocols were compared for feasibility and accuracy to obtain a diagnostic-quality en face view of a VSD.

RESULTS

The success rate for obtaining a high-quality en face image for the three protocols was 100% for full-volume mode with iCrop, 97% for full-volume standard mode, and 94% for narrow-sector live 3D mode. The ability of both full-volume mode with iCrop and full-volume standard mode to demonstrate a VSD was slightly better than that of narrow-sector live 3D mode (P < .001 for both vs narrow-sector live 3D mode). In all patients, the type, size, and location of the VSD were demonstrated accurately by two or more of the protocols.

CONCLUSIONS

Three-dimensional echocardiography of VSDs is feasible and accurate in most patients using defined protocols. The protocols are described and illustrated in detail, and a reference 3D image collection is presented.

3D transesophageal echocardiography is a decision-making tool for the management of cardiogenic shock following a large postinfarction ventricular defect

Postinfarction ventricular septal defect (PIVSD) is a devastating mechanical complication following acute myocardial infarction. The management of this pathology is quite challenging, especially in case of complicated cardiogenic shock. The difficulties lie in the timing and type of intervention. Debates exist with regard to immediate versus deferring repair, as well as open repair versus percutaneous closure. The anatomic characteristics and hemodynamic consequence of PIVSD are important elements determining which strategy to adopt, since large septal defect (>15 mm) cannot be appropriately treated by percutaneous occluder devices limiting by their available size, while compromised hemodynamics usually require emergent repair or mechanical support “bridging to surgery”. Herein, we report our experience of successful management of a case of cardiogenic shock complicating large PIVSD (38 mm) by delayed surgical repair bridged with Extracorporeal Membrane Oxygenation (ECMO) during 7 days. We emphasize the importance of 3-dimensional transesophageal echocardiography as a decision-making tool.

Percutaneous closure of a residual ventricular septal defect in a challenging patient

Percutaneous transcatheter closure of congenital or acquired cardiac ventricular septal defects has emerged as a valid alternative to surgical closure in selected cases. It avoids the considerable morbidity and mortality related to open heart surgical procedures. The choice of the device is determined by the particular VSD morphology and thanks to considerable material and technical improvements procedural success rates of over 90% are nowadays achievable. We discuss the case of a young woman who required VSD closure, and in whom re-open-heart surgery was avoided by a successful percutaneous closure using an Amplatzer Patent Ductus Arteriosus Occluder.

Three-Dimensional Echocardiography

Over the past 3 decades, echocardiography has become a major diagnostic tool in the arsenal of clinical cardiology for real-time imaging of cardiac dynamics. More and more, cardiologists' decisions are based on images created from ultrasound wave reflections. From the time ultrasound imaging technology provided the first insight into the human heart, our diagnostic capabilities have increased exponentially as a result of our growing knowledge and developing technology. One of the most significant developments of the last decades was the introduction of 3-dimensional (3D) imaging and its evolution from slow and labor-intense off-line reconstruction to real-time volumetric imaging. While continuing its meteoric rise instigated by constant technological refinements and continuing increase in computing power, this tool is guaranteed to be integrated in routine clinical practice. The major proven advantage of this technique is the improvement in the accuracy of the echocardiographic evaluation of cardiac chamber volumes, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened views. Another benefit of 3D imaging is the realistic and unique comprehensive views of cardiac valves and congenital abnormalities. In addition, 3D imaging is extremely useful in the intraoperative and postoperative settings because it allows immediate feedback on the effectiveness of surgical interventions. In this article, we review the published reports that have provided the scientific basis for the clinical use of 3D ultrasound imaging of the heart and discuss its potential future applications.

[Three-dimensional echocardiography in congenital heart disease]

The introduction of real time three-dimensional (3D) echocardiography has led to its use in everyday clinical practice. The 3D matrix probe enables the instantaneous acquisition of transthoracic volumes. Several modes of 3D are available: 3D volume, biplan and 3D color Doppler. Real time 3D echocardiography gave more accurate description of various congenital heart diseases as well as valvulopathy, shunt and aorta pathology. Fetal 3D echocardiography is available. Quantitative measurement of ventricular volumes could be obtain by 3D echocardiography. The facility of utilisation of the matrix probe should lead to routine usage of 3D echocardiography as with 2D and Doppler method. Its values should be decisive in many congenital cardiac lesions requiring surgery or interventional catheterisation.

Interventional approach to congenital heart disease

PURPOSE OF REVIEW

This review summarizes important publications and advances in the field of interventional pediatric cardiology. The article focuses on new interventional techniques, devices, and catheter equipment and reviews modifications and advances made in already well-established techniques such as atrial septal defect device closure. Some interventions that reflect mainly the adult population, such as patent foramen ovale device closure and closure of postinfarct ventricular septal defects, are also discussed.

RECENT FINDINGS

The recent results of device closure of perimembranous ventricular septal defects using the Amplatzer membranous ventricular septal defect device have been encouraging. We discuss a modification of the delivery system for the membranous ventricular septal defect device that is aimed to overcome the difficulty in correctly positioning the device and delivery sheath. Important device modifications discussed in this article include the angled Amplatzer Ductal Occluder, the cribriform atrial septal defect device for use in multifenestrated atrial septal defects and the fenestrated atrial septal defect device. The hybrid approach to congenital heart disease is discussed in this article.

SUMMARY

Interventional pediatric cardiology is a constantly evolving specialty. Surgical procedures are being partially replaced by percutaneous interventions or hybrid approaches. We believe that the primary treatment for coarctation beyond the neonatal period as well as for muscular ventricular septal defects should be the transcatheter approach.