Adult Congenital

Adult Congenital Heart Disease cases

CASE 1. SVC (arm) injection

Eusthachian Valve serves as a "barrier"for the agitated saline contrast to reach the area of the Fossa Ovalis. Where as it directs flow from IVC to the fossa Ovalis.

Illustration of IVC and SVC flow

This explains why injection of agitated saline contrast through lower extremity large bore access would be superior to arm injections to detect a PFO. The IVC flow is directed towards the fossa ovals by the Eustachian valve. This same valve may end up partially blocking to SVC flow towards the region.

RLE injection

A much more obvious PFO is present

CASE 1. SVC (arm) injection

Eusthachian Valve serves as a "barrier"for the agitated saline contrast to reach the area of the Fossa Ovalis. Where as it directs flow from IVC to the fossa Ovalis.

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ASA

ASA

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ASD 3D

ASD Area = 1.24cm2

ASD area calculated from 3-D images

ASD 3D

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ASD, secundum

3-d guided ASD area measurement

PFO

Rt-to-Lt shunting is better identified with injectiong through IVC than SVC (leg better than arm)

Bicaval view on TEE shows why it is more difficult to demonstrate a PFO with agitated saline contrast study through arm injection than, in theory, thorugh leg injection as IVC bubbled are directed to the fossa Ovalis/PFO whereas SVC venous flow is not. In this case the Eustachian valve obstructs to some degree the bubbled from reaching the area of the fossa ovalis. In the second injection, more forceful and with slight different angle we can see the PFO with right to left shunting. The pt also has an interatrial aneurysm.

Atrial Septal aneurysm

3-d TEE

Septum primum and secundum with aneurysm of the septum primum over the fossa ovalis

Echocardiography

ASD, secundum

3-d guided ASD area measurement

Man in his 50's with h/o DM, HTN, DLP, CAD with coronary ectasia and heavy tobacco use. S/p NSTEMI with multivessel CAD. CMR for assessement of culprit vessel also identified possible shunt at atrial level. He had RVE with Qp:Qs not done. TEE showed ASD Qp:Qs 1.5. It was closed by one one of my interventional partners w/o complications. F/u TEE 6 months latter showed small throombus on LA side of the 20 mm Amplatzer device. Anticoaglation performed for 6 months, f/u TEE pending.

This would have raised some questions was the deviced placed for a cryptogenic TIA/CVA.

ASD on TEE (L to R shunt)

3-d view from RA

3-D LA view - Thrombus resolved

ASD on TEE (L to R shunt)

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Cor Triatriatum

2-d and 3-d TEE

Incidentally found Cor Triatriatum in patient with atrial fibrillation. The impression from the 3-d images was that the defect was not obstructing flow in the LA, this was confirmed by catheterization.