The role of real time 3D-transesophageal echocardiography for safe and successful atrial septal defect closure

Routine use of three-dimensional transesophageal echocardiography (3D-TEE) during percutaneous atrial septal defect (ASD) closure can deliver a more rapid and accurate morphologic assessment of the ASD, along with superior definition of spatial relationships compared with two-dimensional transthoracic echocardiography (2D-TTE). This case series highlights utilization of real-time 3D-TEE for percutaneous secundum ASD closure during the pre- and intra-operative period. Utilizing 3D-TEE, Case 1 revealed a 21×13 mm secundum ASD and a 20 mm occluder device was selected for closure, and TEE was instrumental in demonstrating adequate circumferential rim tissue purchase with the device. For case 2, 2D-TTE suggested a patent foramen ovale, but 3D-TEE revealed a 9 mm secundum ASD with bidirectional shunting closed percutaneously. Case 3 highlights a large secundum ASD estimated at a maximum diameter of 34 mm on 2D-TTE; however, pre-procedure 3D-TEE instead disclosed the true extent of this large secundum ASD, measuring 42×33 mm with inadequate rim tissue for device purchase and capture. The success of ASD percutaneous closures are greatly impacted by the improved accuracy of initial diagnostic assessment and minimized intra-operative complications. RT3D-TEE should serve as an essential imaging tool for guiding and assessing percutaneous ASD closure.