Three-Dimensional Transthoracic Echocardiography as a Tool for Patient Selection for Percutaneous Atrial Septal Defect Closure

Planning for percutaneous closure of large atrial septal defects presents a challenge for pediatric cardiologists. Transcatheter repair is preferred to open heart surgery however in borderline cases, it may be difficult to assess whether the tissue rims around the atrial septal defect are sufficient for closure in the cath lab. In these cases, three-dimensional echocardiography in the outpatient clinic may assist decision making. All patients referred for atrial septal defect closure at our center, specializing in minimally-invasive surgery, over a three-year period were reviewed. At the start of the study period three-dimensional transthoracic echocardiography was introduced to the outpatient clinic work-up for patients whose two-dimensional echo imaging was insufficient for direct referral to surgical or percutaneous closure. Overall, 36 patients were included in the study. Following two-dimensional imaging 15 patients were referred for surgical closure and 8 patients were referred for percutaneous closure. After three-dimensional echocardiography 12 of 13 patients (age 4-44, median 8 years) were deemed suitable for percutaneous closure. 11 of these patients (weight 15.5-59.8, median 33 kg) underwent successful percutaneous device closure (device size 14-30 mm, median 24 mm). In four patients previously assessed at another tertiary center, surgical repair was recommended. In these, and other borderline cases, adequate rims for transcatheter closure were visualized clearly on three-dimensional echocardiogram. Two patients underwent surgical repair, one at the recommendation of the team, and one at the request of the parents. Three-dimensional transthoracic echocardiography is a useful decision making aid in percutaneous closure of large atrial septal defects. This may be especially useful to less experienced or more conservative interventionalists.