Application Of Real-time Three-dimensional Transesophageal Echocardiography In Treatment Of Secundum Atrial Septal Defect By Minimally Invasive Occlusion

ObjectiveAtrial septal defect(ASD) is one of the most common congenital heart disease. There are three kinds of operation mode commonly used in the treatment of ASD at present, which are conventional surgery, transcatheter intervention closure and transthoracic minimally invasive occlusion. In this paper, we use real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) as intraoperative monitoring tool, to evaluate the role of RT-3D-TEE in treatment of secundum atrial septal defect by minimally invasive occlusion.Methods108patients who were diagnosed with secundum ASD by transthoracic echocardiography (TTE) before the operation were going through the minimally invasive occlusion by the guidance of RT-3D-TEE. Among the108patients, there are17patients with double ASD,8patients with porous ASD,16patients with ventricular septal defect (VSD) membranous aneurysm and9patients with arterial ductus arteriosus (PDA). During the surgery, RT-3D-TEE was used to observe the shape, size, position and the surrounding anatomical structures, help choosing appropriate occluder models, selecting the right atrial puncture point, monitoring the whole process of occlusion, and evaluating the therapeutic effect immediately.Patients with VSD membranous aneurysm or PDA were also using minimally invasive transthoracic occlusion to treatment VSD or PDA. During the surgery,2D-TEE was used to observe the shape, size and the edges of VSD or PDA, help selecting appropriate puncture point, choosing suitable occluder models, monitoring the whole process of occlusion, and evaluating the therapeutic effect immediately.All the patients were examined again by TTE3days,1week and1month after surgery.Results①Among108secundum ASD patients, there were6patients chooseing conventional surgery, and the others, including the patients with VSD membranous aneurysm and PDA, choosing transcatheter intervention closure surgery successfully.②There are11patients showed that the first umbrella was not firm and we selected relative large occluder instead, and then we place the occluder successfully at the second time.1patient showed the occluder a little large the first time and we changed a smaller one instead, then we placed the occluder successfully. And the others were one-time place of occluder successfully.③We observed the occluder immediately after the operation, found that all the occluder had normal position and good morphology.84patients presented no residual shunt,3patients presented minimal residual shunt at the edge of the occluder,15patients showed of minimal residual shunt between the two umbrellas. The patients who were using conventional surgery showed no residual shunt between the two umbrellas at the edge of the patch. We saw all the occluders in good position and morphology with no residual shunt by transthoracic echocardiography3days and1week after surgery.2patients showed minimal residual shunt at the edge of the occluder. But all the patients showed no residual shunt one month after surgery. The occluder size was11～42mm (28.7±5.4) mm.④During the operation, RT-3D-TEE showed:27cases were round or round-like defects,32cases were oval defects,24cases were irregular defect,17cases were double defects and8cases were porous defects.⑤After3days after the operation,1patient was found occluder detachment. The other patients did not appear complications such as perforation of esophagus, upper gastrointestinal bleeding, transient arrhythmia, occluder shift and occluder shedding and so on. ConclusionTransthoracic minimally invasive occlusion of ASD which was applied in this article is a new technology merged by conventional surgery and transcatheter intervention closure. This technology has great advantages without cardiopulmonary bypass and X-ray monitoring. As the intraoperative monitoring tool, RT-3D-TEE can stereoscopic display the position, shape, size and surrounding structures of ASD. It has important clinical value on choosing the occluder type, selecting right atrial puncture point during the opration, guiding occluder placement comprehensively and evaluating therapeutic effect immediately after the operation. By monitoring108secundum ASD patients with RT-3D-TEE, this article confirmed that RT-3D-TEE is safe, effective and feasible in guiding transthoracic minimally invasive occlusion of secundum ASD. RT-3D-TEE has good prospect and clinical value.