Transthoracic echocardiography monitoring during ASD closure using an artificial hand system

Abstract

Aim: Continuous real-time echocardiographic monitoring is essential for guidance during ASD closure. However, transthoracic echocardiography (TTE) can only be implemented intermittently during fluoroscopy. We evaluate a novel approach to provide real-time imaging during the entire procedure.

Finding: We developed a custom-made TTE monitoring apparatus using artificial hand (AH-TTE) that enables real-time TTE images during atrial septal defect (ASD) closure. Thirty-two patients underwent successful device implantation using AH-TTE monitoring without complications. The median duration for real-time AH-TTE monitoring was 22 min and the median fluoroscopy time was 7.2 min. One case of pericardial effusion and one of transient bradycardia event due to air embolism was detected. All patients had uneventful recoveries.

Conclusions: Our simple and novel monitoring technique with AH-TTE provides TEE-like monitoring and may be a new alternative method for ASD closure. It gives real-time stable TTE images and minimizes radiation exposure for the interventional team during fluoroscopy.

Keywords: Artificial hand; Intracardiac echocardiography; Real-time transthoracic echocardiography monitoring; Transcatheter ASD closure; Transesophageal echocardiography.

Fig. 1

a The AH-TTE monitoring system consists of an artificial hand (AH) and a supporting device. The transthoracic transducer is held by the AH and secured in place at the subcostal area by locking the control button to obtain subcostal views and provide real-time TTE imaging during the entire procedure. b A 4-year-old girl during ASD closure using AH-TTE monitoring system. The AH grasping the transducer was placed in the subcostal area (arrow 1: AH; arrow 2: supporting device) and the procedure was performed after the area was covered with an aseptic cloth. c The correspondent real-time TTE imagings (arrow 3 in B) were demonstrated during ASD closure procedure. C1: An ASD (11.5 mm in size) with a left-to-right shunt. C2: The waist length of the ASD was 11.3 mm (denoted by the two-way arrow) as determined by balloon sizing. C3: The correct passing of the catheter through the defect. C4: The left disc (LD) was deployed in the LA. C5: The LD was pulled back against the atrial septum. C6: The RD was opened in the RA. C7: The RD was deployed in the RA. C8: An 11-mm Amplatzer™ Septal Occluder was successfully implanted and positioned in the atrial septum without requiring shunting. Abbreviations: AH, artificial hand; R, right; L, left; O, occluder; TTE, transthoracic echocardiography; RD, right disc; LD, left disc; RA, right atrium; LA, left atrium; T, transducer; S, septum

Fig. 2

Subcostal views of 3D TTE of MPR images using the AH technique in a 4-year-old boy during ASD closure. a The en face oblique atrial view shows a very thick atrial septum (S) and an ovoid-shaped defect measuring 4 × 8 mm in size. b The entire route of the delivery cable (C) passing correctly from the RA across the atrial septum to the LA. c The LD was deployed in the LA and pushed against the atrial septum (S). d The RD was deployed in the RA. e The occluder was deployed in the approximate position and its final position was confirmed by TEE images. Abbreviations: AH, artificial hand; TTE, transthoracic echocardiography; MPR, multiplanar reformatting; ASD, atrial septal defect; TV, tricuspid valve; C, delivery cable; PV, pulmonary vein; IVC, inferior vena cava; RD, right disc; LD, left disc