The Role of Trans-Oesophageal Echocardiography in the Interventional Cardiology of Adult Congenital Heart Diseases

Abstract

Advances in interventional cardiology have significantly broadened the range of congenital heart diseases (CHDs) amenable to trans-catheter interventions. Trans-oesophageal echocardiography (TOE) plays a pivotal role as a procedural guide in several percutaneous treatments. Enhanced imaging modalities and technological innovations in echocardiography have refined the precision and applicability of these approaches. This review explores the role, impact, and advancements of TOE in trans-catheter treatments for adult CHDs, including both common procedures (e.g., atrial septal defect closure, ventricular septal defect closure) and less frequent interventions (e.g., Mustard/Senning baffle leak closure, Fontan conduit fenestration, ruptured sinus of Valsalva embolization).

Keywords: adult congenital heart disease; catheterization; interventional cardiology; trans-oesophageal echocardiography.

Figure 1

Two-dimensional TOE. Mid-oesophageal view. Extracardiac mass (pseudo-aneurysm, probably) (#) with “ab-extriseco” right atrial compression.

Figure 2

Periorificial rim assessment. Anterior-superior and posterior rims (A) are evaluated in 45° mid−oesophageal view (B), anterior−inferior and posterior rims (C) in 0° mid−oesophageal view (D), and posterior−superior and posterior−inferior rims (E) in 90° mid−oesophageal view (F). Abbreviations: Ao, aorta; ASD-OS, atrial septal defect ostium secundum; IVC, inferior vena cava; RV, right ventricle; SVC, superior vena cava.

Figure 3

Two−dimensional TOE. Mid−oesophageal view. ASD with “octopus shape” [arrow] due to an associated double interatrial septum (right-side septum [*] and left-side septum [**]).

Figure 4

Three−dimensional TOE view of a circular-shape ASD (A), an oval−shape one (B), an irregular−shape (like a tennis racket) one (C), and a large ASD with an internal seeding (#) (D).

Figure 5

Two−dimensional TOE. Mid−oesophageal view highlights a large 17 mm ASD (A) with multiple accessory fenestration (B). A single occluder device was able to have complete closure of every interatrial shunt (C,D).

Figure 6

Two−dimensional TOE. Mid-oesophageal view of a hypermobile interatrial septum with a single ASD (A) and an aneurysmatic interatrial septum (base width 15 mm) with multiple interatrial shunts (B).

Figure 7

Graphic scheme of no-aneurysmatic ASD (#) (A) and different types of aneurysmatic interatrial septum: type 1R (B), type 2L (C), type 3RL (D), type 4LR (E), and type 5 (F). Abbreviations: LA, left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium; RV, right ventricle; TV, tricuspid valve.

Figure 8

Two-dimensional TOE. Mid-oesophageal view of a central ASD with a poor floppy posterior rim (*) and a well-represented anterior-superior rim (#). The septal malalignment may be highlighted extending the plane passing through the posterior rim (dotted red line) and measuring the distance of the latter from the anterior-superior rim (double arrow blue line).

Figure 9

Two−dimensional TOE. Mid-oesophageal view of a double interatrial septum (i.e., spiraliform septum). The distance (red double arrow) between the right septum (*) and the left one (**) defines the width of the double septum.

Figure 10

Two−dimensional TOE. Mid−oesophageal view of the following: an optimal static balloon interrogation without residual shunt (A), a residual shunt due to three accessory fenestrations (*) during a static balloon interrogation (B), a residual shunt due to under-inflation of the balloon (#) due to dynamic balloon sizing (C), a large ASD with internal seeding with a large residual shunt (arrow) due to the lack of seeding rupture during static balloon sizing (D).

Figure 11

Three-dimensional TOE. Left atrial view of two occluder devices in partial overlap.

Figure 12

Two−dimensional TOE. Mid−oesophageal view of a partial prolapse of the left disc of the device (d) with mild residual shunt (arrow) (A) and complete prolapse of the device (d) in the right atrium (B) during “push−and−pull” maneuver. In both cases, the device was substituted witha larger one.

Figure 13

Two−dimensional TOE. Mid−esophageal view of a peri-membranous VSD within a sub-aortic aneurysm (arrow) (A) that underwent device (red circle) closure without residual shunt (B).

Figure 14

Two−dimensional TOE. Trans−gastric view of an apical post−MI VSD (#) (A) that underwent device (red circle) closure without residual shunt (B).

Figure 15

Two-dimensional TOE. Trans-gastric view of static balloon sizing (#) of an apical post-MI VSD.

Figure 16

Two−dimensional TOE. Mid−oesophageal view of systemic baffle leak (#) with left−to−right shunt of a patient with TGA who has undergone a Mustard procedure (A). Three−dimensional TOE. Percutaneous closure of the baffle leak with an atrial septal defect occluder (circle) (B).

Figure 17

Two−dimensional TOE. Fenestration of an extracardiac Fontan conduit with right-to-left shunt (#) (A) that has undergone percutaneous closure with an atrial septal defect occluder (circle) (B).

Figure 18

Trans−catheter closure of ruptured SVA. Two−dimensional (A) and three−dimensional (B) views of a ruptured aneurysm of the right sinus of Valsalva (#) with the characteristic “windsock sign.” Two−dimensional (C) and three−dimensional (D) views of a single disc device closure (i.e., duct occluder device) without residual shunt and interference with aortic valve function.