© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12606
Echocardiography
Three-Dimensional Transesophageal Echocardiography for Guiding Percutaneous Fontan Fenestration Closure George Giannakoulas, M.D.,* and Vasilios Thanopoulos, M.D.† *Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece; and †Department of Interventional Pediatric Cardiology, Iatrikon Medical Centre, Athens, Greece
(Echocardiography 2014;31:E230-E231) Key words: congenital heart disease, three-dimensional transesophageal echo, Fontan, fenestration, device A 17-year-old male with a history of hypoplastic left heart syndrome and several surgical procedures that resulted in a Fontan circulation was referred because of significant desaturation during exercise. Two-dimensional transesophageal echo (TEE) demonstrated a fenestration in the lateral tunnel of the Fontan circuit (Fig. 1), which resulted in significant right-to-left shunting in a bubble study. A 3DTEE study demonstrated the 5-mm fenestration (Figs. 2,3; movie clips S1 and S2). Right heart catheterization calculated a central venous pressure of 11 mmHg, which permitted percutaneous closure of the small communication. Procedure was performed under general anesthesia. Due to the posterolateral position of the fenestration in the baffle and its slit-like anatomy, it was extremely difficult to guide the procedure with fluoroscopy and
Figure 2. Small fenestration consisted of a single 5-mm communication (white arrow) between the Fontan channel and the pulmonary venous atrium acquired in 3D zoom mode.
Figure 1. Two-dimensional transesophageal echo (TEE) (color compare mode) showing the right-to-left shunt through a small defect in the Fontan pathway. Address for correspondence and reprint requests: George Giannakoulas, M.D., First Cardiology Department, AHEPA University Hospital, St. Kyriakidi str 1, 54636, Thessaloniki, Greece. Fax: +302310994673; E-mail: [email protected]
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Figure 3. Live 3D color transesophageal echo (TEE) (baffle view) demonstrating the shunt through the fenestration (black arrow).
3DTEE in Fontan Fenestration Closure
Figure 6. Cine fluoroscopy image of the fully deployed ASD closure device (white arrows).
Figure 4. 4F Cobra catheter crossing the fenestration (black arrow) acquired in 3D zoom mode.
3D visualization of any given device may be potentially superior to 2D echocardiography in the assessment of intra- and postprocedural complications, such as presence and severity of residual shunt and device malposition, embolization, and fracture.3 References 1. Simpson JM, Miller O: Three-dimensional echocardiography in congenital heart disease. Arch Cardiovasc Dis 2011;104:45–56. 2. Baker GH, Shirali G, Ringewald JM, et al: Usefulness of live three-dimensional transesophageal echocardiography in a congenital heart disease center. Am J Cardiol 2009;103:1025–1028. 3. Shirali GS: Three-dimensional echocardiography in congenital heart disease. Echocardiography 2012;29:242–248.
Figure 5. Three-dimensional zoom mode TEE showing the well-seated ASD device (arrows) between the baffle and pulmonary venous (systemic) atrium.
2DTEE. Real time 3DTEE was used to guide a 4F Cobra catheter to cross the defect in preparation for device closure (Fig. 4; movie clips S3 and S4), which was accomplished with an 8-mm Cocoon R ASD device (Vascular Innovations, Nonthaburi, Thailand) (Figs. 5 and 6; movie clip S5). The patient experienced an increase in his oxygen saturation at rest and minimal desaturation during exercise. All images and videos depicted in this manuscript were obtained using the Philips iE33 Ultrasound system (Philips Medical Systems, Andover, MA, USA). Real time 3DTEE plays an important complementary role in the guidance of catheter closure of atrial septal defects that are located in nontypical anatomical positions.1,2 Moreover,
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. Small fenestration between the Fontan channel and the pulmonary venous atrium acquired in 3D zoom mode (baffle view). Movie clip S2. Three-dimensional zoom color mode en face baffle view showing the right-to-left shunting through the fenestration. Movie clip S3. Three-dimensional zoom mode (baffle view) showing a 4F Cobra catheter trying to cross the fenestration (depicted with white arrow). Movie clip S4. Three-dimensional zoom mode (baffle view) showing a 4F Cobra catheter after crossing the fenestration. Movie clip S5. Three-dimensional zoom mode TEE showing the well-seated ASD device between the baffle and pulmonary venous (systemic) atrium.
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Echocardiography
Three-Dimensional Transesophageal Echocardiography for Guiding Percutaneous Fontan Fenestration Closure George Giannakoulas, M.D.,* and Vasilios Thanopoulos, M.D.† *Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece; and †Department of Interventional Pediatric Cardiology, Iatrikon Medical Centre, Athens, Greece
(Echocardiography 2014;31:E230-E231) Key words: congenital heart disease, three-dimensional transesophageal echo, Fontan, fenestration, device A 17-year-old male with a history of hypoplastic left heart syndrome and several surgical procedures that resulted in a Fontan circulation was referred because of significant desaturation during exercise. Two-dimensional transesophageal echo (TEE) demonstrated a fenestration in the lateral tunnel of the Fontan circuit (Fig. 1), which resulted in significant right-to-left shunting in a bubble study. A 3DTEE study demonstrated the 5-mm fenestration (Figs. 2,3; movie clips S1 and S2). Right heart catheterization calculated a central venous pressure of 11 mmHg, which permitted percutaneous closure of the small communication. Procedure was performed under general anesthesia. Due to the posterolateral position of the fenestration in the baffle and its slit-like anatomy, it was extremely difficult to guide the procedure with fluoroscopy and
Figure 2. Small fenestration consisted of a single 5-mm communication (white arrow) between the Fontan channel and the pulmonary venous atrium acquired in 3D zoom mode.
Figure 1. Two-dimensional transesophageal echo (TEE) (color compare mode) showing the right-to-left shunt through a small defect in the Fontan pathway. Address for correspondence and reprint requests: George Giannakoulas, M.D., First Cardiology Department, AHEPA University Hospital, St. Kyriakidi str 1, 54636, Thessaloniki, Greece. Fax: +302310994673; E-mail: [email protected]
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Figure 3. Live 3D color transesophageal echo (TEE) (baffle view) demonstrating the shunt through the fenestration (black arrow).
3DTEE in Fontan Fenestration Closure
Figure 6. Cine fluoroscopy image of the fully deployed ASD closure device (white arrows).
Figure 4. 4F Cobra catheter crossing the fenestration (black arrow) acquired in 3D zoom mode.
3D visualization of any given device may be potentially superior to 2D echocardiography in the assessment of intra- and postprocedural complications, such as presence and severity of residual shunt and device malposition, embolization, and fracture.3 References 1. Simpson JM, Miller O: Three-dimensional echocardiography in congenital heart disease. Arch Cardiovasc Dis 2011;104:45–56. 2. Baker GH, Shirali G, Ringewald JM, et al: Usefulness of live three-dimensional transesophageal echocardiography in a congenital heart disease center. Am J Cardiol 2009;103:1025–1028. 3. Shirali GS: Three-dimensional echocardiography in congenital heart disease. Echocardiography 2012;29:242–248.
Figure 5. Three-dimensional zoom mode TEE showing the well-seated ASD device (arrows) between the baffle and pulmonary venous (systemic) atrium.
2DTEE. Real time 3DTEE was used to guide a 4F Cobra catheter to cross the defect in preparation for device closure (Fig. 4; movie clips S3 and S4), which was accomplished with an 8-mm Cocoon R ASD device (Vascular Innovations, Nonthaburi, Thailand) (Figs. 5 and 6; movie clip S5). The patient experienced an increase in his oxygen saturation at rest and minimal desaturation during exercise. All images and videos depicted in this manuscript were obtained using the Philips iE33 Ultrasound system (Philips Medical Systems, Andover, MA, USA). Real time 3DTEE plays an important complementary role in the guidance of catheter closure of atrial septal defects that are located in nontypical anatomical positions.1,2 Moreover,
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. Small fenestration between the Fontan channel and the pulmonary venous atrium acquired in 3D zoom mode (baffle view). Movie clip S2. Three-dimensional zoom color mode en face baffle view showing the right-to-left shunting through the fenestration. Movie clip S3. Three-dimensional zoom mode (baffle view) showing a 4F Cobra catheter trying to cross the fenestration (depicted with white arrow). Movie clip S4. Three-dimensional zoom mode (baffle view) showing a 4F Cobra catheter after crossing the fenestration. Movie clip S5. Three-dimensional zoom mode TEE showing the well-seated ASD device between the baffle and pulmonary venous (systemic) atrium.
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