How to assess an adult with a Ventricular Septal Defect. When it should be closed and how?

Transcription

1 TTE AND TEE VDS ASSESSMENT. WHAT S S THE SIZE, WHERE ARE THE MARGINS? How to assess an adult with a Ventricular Septal Defect. When it should be closed and how? Dr Gianfranco Butera, MD, PhD Dr Gianfranco Butera, MD, PhD Departement Departement of Pediatric of Pediatric Cardiology Cardiology and GUCH and GUCH unit unit IRCCS IRCCS Policlinico Policlinico S. Donato, S. Donato, S.Donato S.Donato Milanese Milanese - Italy - Italy

2 Gianfranco Butera TTE AND TEE VDS ASSESSMENT. WHAT S S THE SIZE, WHERE ARE THE MARGINS? DISCLOSURE INFORMATION: AB Medica- AGA division: Proctorship in Italy

3 Patients selection Hemodynamically significant VSD clinical signs left atrial enlargement, defined as a left atrial-to-aortic ratio >1.5; left ventricular enlargement (left ventricular overload), defined as a left ventricular end-diastolic diameter > +2 SD above the mean for the patient s age. Hystory of bacterial endocarditis

4 Which patients with congenital VSD are not suitable to percutaneous closure? Exclusion criteria: Supracrystal VSD Malalignement VSD Associated significant aortic regurgitation Prolapse of aortic cusp Sub-aortic stenosis Sub-pulmonary stenosis (RV mid ventricular stenosis) Eisenmenger syndrome High pulmonary pressures (PAR > 2/3 SAR)

5 VSD

6 VSD

7 Muscular VSD

8 Muscular VSD Echocardiographic evaluation (TTE/TEE) Size (measure in different views) Number (single/multiple) Location (apical/mid muscular/high muscular) Associated defects (ASD/pulmonary stenosis/aortic coarctation/others) Contra-indication to percutaneous closure

9 Muscular VSD Echocardiographic evaluation (TTE/TEE) TTE Views Apical 4 chamber view Parasternal long and short axis views Subcostal views

10 Muscular VSD Echocardiographic evaluation (TTE/TEE) TEE Views Mid-esophageal 0 Trans-gastric views Mid-low esophageal 30-35

11 Muscular VSD WHAT S S THE SIZE, WHERE ARE THE MARGINS? Usually it is quite easy to analyse the margins and measure the size of the defect Margins are usually well seen Measure of the defect in 2D and with color (measure at the PISA )

12 Muscular VSD

13 Muscular VSD

14 Muscular VSD Procedural Echocardiographic evaluation (TEE)

15 Muscular VSD Echocardiographic evaluation

16 Muscular VSD Echocardiographic evaluation

17 High-Muscular VSD Echocardiographic evaluation

18 High-Muscular VSD

19 Muscular VSD

20 Perimembranous VSD

21 Perimembranous VSD

22 Perimembranous VSD Size (measure in different views) Number (single/multiple) Extension (inlet/trabecular/outlet) Echocardiographic evaluation (TTE/TEE) Aneurysm/Pouches from the TV/ septal L of the TV Associated defects (ASD/pulmonary stenosis/aortic coarctation/others) Contra-indication to percutaneous closure

23 Perimembranous VSD Echocardiographic evaluation TTE Views Apical 4 chamber view Parasternal long and short axis views Subcostal views

24 Primembranous VSD Echocardiographic evaluation TEE Views Mid-esophageal 0 (four-chamber view) Mid-esophageal 130 (long-axis view) Mid-low esophageal (short axis view)

25 Perimembranous VSD WHAT S S THE SIZE, WHERE ARE THE MARGINS? Sometimes it is difficult to analyse the margins and measure the size of the defect Measure of the defect in 2D and with color (measure at the PISA )

26 Perimembranous VSD Echocardiographic evaluation

27 Perimembranous VSD Echocardiographic evaluation

28 Perimembranous VSD Echocardiographic evaluation

29 Perimembranous VSD Echocardiographic evaluation

30 Perimembranous VSD Echocardiographic evaluation

31 Perimembranous VSD Echocardiographic evaluation

32 Perimembranous VSD Echocardiographic evaluation Associated aneurysm

33 Perimembranous VSD Echocardiographic evaluation Associated aneurysm

34 Perimembranous VSD Echocardiographic evaluation Associated aneurysm Defect closure on the LV side at the exit(s) of the aneurysm (on the RV side)

35 Perimembranous VSD with septal aneurysm

36 Multiple Perimembranous VSD with septal aneurysm

37 Multiple Perimembranous VSD with septal aneurysm

38 Multiple Perimembranous VSD with septal aneurysm

39 Perimembranous VSD with septal aneurysm Closure with Muscular VSD occluder

40 Conclusions Echocardiographic evaluation is mandatory in patients with VSDs Integration of echocardiographic data with data from angiography is mandatory to perform successfully percutaneous closure

41 Thank you for your attention Thank you for your attention