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Assessment of atrial septal defect size and residual rim using real-time 3D
transesophageal echocardiography

Article  in  Journal of Echocardiography · September 2009

DOI: 10.1007/s12574-009-0013-5

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J Echocardiogr (2009) 7:48–54
DOI 10.1007/s12574-009-0013-5
ORIGINAL INVESTIGATION
Assessment of atrial septal defect size and residual rim
using real-time 3D transesophageal echocardiography
Kyoko Kaku Æ Masaaki Takeuchi Æ Lissa Sugeng Æ Joseph A. Lodato Æ
Hiromi Nakai Æ Lynn Weinert Æ Kyoko Otani Æ Hidetoshi Yoshitani Æ
Nobuhiko Haruki Æ Ziyad M. Hijazi Æ Yutaka Otsuji Æ Roberto M. Lang
Received: 21 April 2009 / Revised: 19 May 2009 / Accepted: 26 May 2009 / Published online: 14 July 2009
Ó Japanese Society of Echocardiography 2009
Abstract
Background Accurate preoperative determination of
defect location and size is important for successful trans-
catheter closure of atrial septal defects (ASD). Real-time
3D transesophageal echocardiography (3DTEE) has the
potential to delineate the shape of ASD in 3D space.
Methods Full volume and 3D zoom datasets by 3DTEE
were acquired in 17 ASD patients. Using quantitative
software, maximal/minimal diameter, defect area and
residual rim length were measured and compared to the
standard 2D measurements.
Results Real-time 3DTEE allowed delineation of the
en-face view of the ASDs. The defect typically had an oval
shape, and its size changed dynamically, having its mini-
mal size at end-diastole and maximal at end-systole. A
good correlation was noted between the maximal defect
area by 3DTEE and 2DTEE (r = 0.93, p \ 0.001). Suc-
cessful delineation of rim length to the specific cardiac
structure was 100% by 3DTEE and 88% by 2DTEE. There
was a fair correlation of residual rim length between
3DTEE and 2DTEE (r = 0.69, p \ 0.001). Eight patients
K. Kaku
M. Takeuchi (&)
H. Nakai
K. Otani

H. Yoshitani
N. Haruki
Y. Otsuji
Second Department of Internal Medicine,
University of Occupational and Environmental Health,
School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku,
Kitakyushu 807-8555, Japan
e-mail: takeuchi@med.uoeh-u.ac.jp
L. Sugeng
J. A. Lodato
L. Weinert
R. M. Lang
Non-invasive Imaging Laboratory, University of Chicago
Medical Center, Chicago, IL, USA
Z. M. Hijazi
Rush Center for Congenital and Structural Heart Disease,
Rush University Medical Center, Chicago, IL, USA
123
underwent transcatheter closure of the ASD. Excellent
correlation was noted between 3D-derived maximal defect
diameter and device diameter (r = 0.97, p \ 0.001).
Conclusions Real-time 3DTEE allows measurements of
the temporal and spatial changes of ASD size and shape.
This methodology provides detailed information on defect
dynamics.
Keywords ASD
3D transesophageal echocardiography

Device closure
Introduction
Atrial septal defects (ASD) are one of the most common
congenital defects encountered in the adult population [1].
Successful transcatheter closure of ASD requires reliable
preoperative imaging of the location and size of the defects
as well as information on the relationship of the residual
rim length to the neighboring cardiac structures [2–4].
Although 2D transesophageal echocardiography (TEE) has
been widely used for the preoperative assessment of ASD,
it does not always provide reliable information on the
maximal defect size and minimal rim length due to imag-
ing of the defect in a single cross section at a time [5, 6].
3D echocardiography provides en-face views of atrial
septal defects and the relationship with adjacent structures,
thus eliminating some of the drawbacks of 2D imaging
[7, 8]. Previous 3D studies have described the dynamic nature
of the atrial defect size during the cardiac cycle [9–11].
Studies have also demonstrated that the defect size deter-
mined by 3DTEE correlates well with the balloon sizing
method [6, 12]. However, these studies have been per-
formed using gated-acquisition methods, which require
lengthy acquisitions and tedious off-line reconstructions.
J Echocardiogr (2009) 7:48–54
Consequently, these methods have not become part of
routine clinical practice [13]. The recent development of
3D fully sampled matrix array TEE transducers has
allowed real-time acquisition and on-line display of 3D
images, while providing superb imaging of specific cardiac
structures including the interatrial septum [14, 15]. Several
studies demonstrated the clinical utility of real-time
3DTEE for the guidance of device closure of atrial septal
defects and patent foramen ovale [16–20]. Thus, the aim of
this study was (1) to quantify the dynamic changes of ASD
size and shape using real-time 3DTEE, (2) to compare real-
time 3DTEE and standard 2DTEE methods for measuring
defect size and rim length, and (3) to investigate the ability
of 3D to measure the maximal diameter of the ASD defect
versus the deployed maximal device diameter in patients
who subsequently underwent percutaneous transcatheter
closure of the ASD.
Methods
Patient population
Seventeen patients with ostium secundum ASD referred for a
clinically indicated TEE were enrolled in this study. There
were 6 males. The mean age was 37 ± 15 years (range: 8–
73 years). Written informed consent was obtained from all
patients.
Real-time 3DTEE
3DTEE was performed using a commercially available
ultrasound machine (iE33, Philips Medical Systems, Ando-
ver, MA) and 3D matrix-array transesophageal echocardio-
graphic transducer (X7-2t). After intravenous sedation with
midazolam and fentanyl, The 3DTEE probe was advanced
into the esophagus. The interatrial septum was visualized
from a high to mid-esophageal transducer position. After
adjusting the transducer position for visualizing the ASD
defect in the center of the 2D sector, the 3D zoom mode was
activated. Using biplane imaging, the size of the pyramidal
box was adjusted to ensure that it encompassed the entire
defect and surrounding rim. Gain and compression as well as
time gain compensation were optimized to enhance image
quality. Real-time 3D zoom datasets with two consecutive
cardiac cycles were acquired and stored digitally. Subse-
quently, full pyramidal volume datasets were obtained. Care
was taken to include the entire interatrial septum within the
pyramidal scan volume. Full volume datasets were acquired
using a wide-angle (93° 9 80°) acquisition mode in which
four wedge-shaped sub-volumes (93° 9 20° each) were
obtained during four consecutive cardiac cycles. Acquisition
was triggered to the ECG R-wave.
49
Standard 2DTEE
Standard 2DTEE examinations using the same TEE probe
were also performed. At least three or more 2D cross-
sectional ASD images were obtained using the rotation of
multiplane angle of the TEE probe. Residual rim to the
aorta was measured between defect rim and the aortic wall
using the aortic short axis view at high-esophageal trans-
ducer position. Rim to the superior (inferior) vena cava was
determined from the bi-caval view at mid to high esopha-
geal transducer position. Residual rim to the mitral valve
was assessed using four-chamber view at mid-esophageal
transducer position.
Image analysis
Volumetric 3D datasets were transferred to a personal
computer for off-line analysis. From either full volume
or 3D zoom datasets, maximum and minimum diameters
of the ASD defect were measured using QLAB software
(Version 7.0, Philips Medical Systems, Andover, MA).
Also, the ASD defect area was traced in each frame
throughout one cardiac cycle (Fig. 1a). In order to adjust
for inter-subject differences in heart rate and frame rate,
time sequences were normalized to the percentage of
systolic (i.e, at end-systole, t was 100%) as well as
diastolic duration (i.e., at end-diastole, t was 100%)
using interpolation software. End-systole was defined as
the frame showing the onset of the closing motion of the
aortic valve in the 3D dataset. In order to measure the
residual rims of the ASD, full volume datasets were
sliced and cropped. The minimum diameter of the aortic
rim, superior vena cava (SVC) rim, inferior vena cava
(IVC) rim and mitral valve rim were all measured at end-
systole (Fig. 1b). For 2D ASD images, maximal and
minimal ASD defect diameters were measured during the
end-systolic frame, because the size of the ASD
dynamically changes throughout the cardiac cycle [10,
11]. Defect area was calculated as 0.785 9 maximum
diameter 9 minimum diameter. Residual rims lengths
were also measured.
Intra- and inter-observer variability
Intra-observer variability was determined by having one
observer repeat the 3D measurements of defect diameter
and area in ten randomly selected subjects 1 month after
completing the initial measurements. Inter-observer vari-
ability was determined by having a second observer repeat
these measurements in these same subjects. Intra- and
inter-observer variability values were calculated as the
absolute difference between the corresponding two mea-
surements in terms of percent of their mean.
123
50
Fig. 1 Measurements of defect size and its residual rim length. a The
left panel shows a cropped 3DTEE image of the ASD defect as
viewed from the left atrium in one patient. The two middle panels
show the maximal and minimal diameter of the defect. The right
panel depicts the defect area as well as maximal and minimal
Statistical analysis
Categorical data were expressed as percentages and con-
tinuous data as mean ± SD. Categorical data were ana-
lyzed using the chi-square test, whereas continuous data
were analyzed using t test. Linear regression analysis with
Pearson’s correlation coefficient was performed between
two techniques. Bland–Altman analysis was used to
determine the bias and limits of agreement between both
techniques. A p value of \0.05 was considered significant.
Results
Real-time 3DTEE allowed delineation of en-face view of
ASD from both the right and left atrial perspective in all
patients.
Dynamic change of defect size and shape during
the cardiac cycle
For determining frame-to-frame changes of defect size and
shape during one cardiac cycle, full volume datasets were
used for the analysis in 12 patients. In the other five patients,
3D zoom datasets were used, because stitch artifacts in the
full volume datasets precluded reliable measurement of
defect size and shape. Mean frame rates were 31 ± 10
frame/s for full volume datasets, and 6 ± 1 frame/s for 3D
zoom datasets. Figure 2 depicts an example of a represen-
tative case showing the dynamic changes of defect size and
123
J Echocardiogr (2009) 7:48–54
diameter of the defect. b The left panel shows a 3D cropped image as
viewed from the right atrium. Adjacent structures are labeled. The
three right panels show measurements of aortic, SVC, IVC and mitral
valve rim length. IVC inferior vena cava, SVC superior vena cava, MV
mitral valve
shape. Figure 3a depicts the change of defect size through-
out one cardiac cycle averaged for all patients. The ASD
defect size progressively increased during systole, reaching
its maximal value at end-systole. During diastole, the defect
size decreased, reaching its smallest size near end-diastole.
The relative area change, which was defined as maximum/
minimum area, ranged from 1.3 to 2.9 (mean: 1.8 ± 0.4).
Defect shape was not circular but ellipsoid in all patients.
The shape of the defect also changed dynamically
throughout the cardiac cycle, exhibiting a more ellipsoid
shape during mid-systole and a more circular shape from
end-systole to the early diastolic period (Fig. 3b).
Comparison of defect area and residual rim between
3DTEE and 2DTEE
A good correlation was noted between defect areas mea-
sured by 3DTEE and 2DTEE at end-systole (r = 0.93,
regression line slope 0.76 and intercept 1.20 cm2, Fig. 4,
upper left), with no statistically significant inter-method
differences. Bland–Altman analysis (Fig. 4, lower left)
showed a mean difference of -0.2 cm2 with 95% agree-
ment of ±2.8 cm2. For 12 patients, full volume datasets
acquired without significant stitch artifacts were used to
measure the residual defect rim length. Successful mea-
surements were accomplished for all aortic, SVC, IVC and
mitral valve rims. The ability to perform these measure-
ments using 2DTEE were 100, 92, 67 and 92%, respec-
tively. The mean value and range of individual residual rim
measured by 3DTTE and 2DTEE are shown in Table 1.
J Echocardiogr (2009) 7:48–54 51

Fig. 2 Representative case Frame 1 2 3 6 8 10 11

showing serial changes in defect
area and defect shape
throughout the cardiac cycle.
Note the ASD defect size
becomes largest at end-systole
and smallest at end-diastole
Defect area (cm 2) Maximal/ Minimal diameter ratio
4 4

AVC
AVO
3 3
MVO

2 2

1 1
1 2 3 4 5 6 7 8 9 10 11 (Frame)

Systolic duration Diastolic duration

Fig. 3 Dynamic change in (%)

e
he end-diastole

defect area (a) and defect shape a 2 b

mal diameter)
80
p<0.001 p<0.05
(b) during one cardiac cycle in
60
the study population 1.8
ea relative to th

ASD shape (maximal/minim

40
1.6
20
1.4
ange in ASD are

1.2
-20

-40 1
0 50 100 50 100 0 50 100 50 100
Cha

Time%, Systolic duration Time%, Diastolic duration Time%, Systolic duration Time%, Diastolic duration

There was a fair correlation of residual rim length mea- 2DTEE-derived maximum defect diameter and device size
surements using 3DTEE and 2DTEE (r = 0.69, regression (r = 0.91). Bland–Altman analysis showed a mean dif-
line slope 0.86 and intercept 0.30 cm, Fig. 4, upper right). ference of 0.2 cm with 95% agreement of ±1.49 cm.
Bland–Altman analysis (Fig. 4, lower right) showed a
mean difference of -0.14 cm with 95% agreement of Intra- and inter-observer variabilities
±1.20 cm.
Intra-observer variabilities for defect diameter and area
Accuracy of defect size assessed by 3DTEE versus were 3 and 7%, respectively, whereas inter-observer vari-
device size abilities were 8 and 9%, respectively.

A total of eight patients underwent transcatheter closure of

the ASD. The operator, who was blinded to the defect size Discussion
obtained using 3DTEE to determine device size, used the
balloon sizing method under the guidance of intracardiac The major findings in this study were (1) real-time 3DTEE
echocardiography to determine the device size. An excel- allows en-face delineation of ASD defects in all patients.
lent correlation was noted between 3DTEE measured (2) Defect size and shape change dynamically throughout
maximum defect diameter and the size of the deployed the cardiac cycle, a finding that is in agreement with pre-
device (r = 0.97, regression line slope 1.2 and intercept vious studies [9–11]. (3) Defect area and residual rim
-0.56 cm, p \ 0.001). Bland–Altman analysis showed a length, which were measured from 3D datasets, correlated
mean difference of 0 cm with 95% agreement of well with 2D measurements. (4) Maximal defect diameter
±0.63 cm. There was also good correlation between the by real-time 3DTEE showed excellent correlation with the

123
52 J Echocardiogr (2009) 7:48–54

Fig. 4 Relationship of defect (cm 2) (cm)

area and residual rim length 4

Defect area measured by 3DTEE

16
between 3DTEE and 2DTEE.

Rim mesured by 3DTEE

Upper panels show simple
linear regression analysis, and 12 3
lower panels show Bland–
Altman analysis between the 8 2
two techniques r=0.93 r=0.69
4 p<0.001 1 p<0.001

0 0
0 2 4 6 8 10 12 14 16 (cm 2) 0 1 2 3 4 (cm)
Defect area measured by 2DTEE Rim measured by 2DTEE

(cm 2) (cm)
10 3

Rim by 2DTEE – Rim by 3DTEE

Area by 2D – Area by 3D

2
5 +2SD 1.1
+2SD 2.6 1

0 mean -0.2 0 mean -0.1

-2SD -3.0 -1 -2SD -1.3
-5
-2

-10 -3
2
0 2 4 6 8 10 12 14 (cm ) 0 0.5 1 1.5 2 2.5 3 (cm)
(Area by 2D + Area by 3D) /2 (Rim by 3DTEE + Rim by 2DTEE) / 2

Table 1 Residual rim measured by 2DTEE and 3DTEE

Residual rim 2DTEE 3DTEE

Aorta 5.5 ± 2.4 (range: 2.5–8.9 mm) 4.7 ± 3.1 (range: 0–9.3 mm)
SVC 13.3 ± 4.6 (range: 7.7–19.4 mm) 12.9 ± 6.3 (range: 1.8–26 mm)
IVC 10.8 ± 8.4 (range: 0–23.3 mm) 10.7 ± 5.2 (range: 3.5–23.9 mm)
MV 16.5 ± 6.1 (range: 8.1–24.9 mm) 21.3 ± 6.3 (range: 12.8–35 mm)
Data are expressed as mean ± SD
SVC superior vena cava, IVC inferior vena cava, MV mitral valve

deployed device size in a subset of patients who underwent
transcatheter closure of ASD.
Preoperative accurate assessment of ASD location and
size is a key factor for successful transcatheter closure and
avoids short- and long-term complications [2–4, 21].
Although the previously used gated acquisition 3D tech-
niques have the advantage of superior imaging of the
anatomy of the ASD defects and the neighboring struc-
tures over conventional 2DTEE images, the lengthy
acquisition coupled with the tedious off-line reconstruc-
tion process made this technique not acceptable for routine
clinical use. The recent development of the matrix array
3DTEE transducer provides excellent real-time volume-
rendered images of the mitral valve apparatus, left atrial
appendage and interatrial septum [14, 15]. In addition, off-
line visualization of desired structures is relatively easy.
Commercially available quantitative software allows
measurements of the diameter and area on 2D images
extracted from the 3D datasets. Using the 3D zoom mode,
a high-quality real-time en-face view of the ASD defect
can be visualized from both the left atrial and right atrial
perspectives. These capabilities clearly enhance our
understanding of the dynamic morphology of the ASD. In
agreement with previous studies [9–11], we found
dynamic changes of the ASD defect size, demonstrating a
maximal area at end-systole and minimal area at end-
diastole. In contrast to conventional 2DTEE images, which
do not always delineate the maximal diameter because the
defect moves up and down, and back and forth during one
cardiac cycle, 3D datasets provide the spatial and temporal
change in defect size. We also observed that the ratio of
the maximal and minimal defect area varied among

123
J Echocardiogr (2009) 7:48–54
individual patients, ranging from 1.3 to 2.9. The ratio was
minimal at end-systole, suggesting a more circular shape
of the defect. Although the precise mechanism is not
known, expansion of the atrial wall during systole might
stretch whole rims of the defect, making their shape more
round. These results highlight the importance of using
end-systolic images for the measurement of ASD defect
size.
The excellent correlation noted between the 3D deter-
mined maximal defect diameter and the subsequently
deployed device size in a subset of patients who underwent
transcatheter closure of the ASD supports the accuracy of
3D measurements of the ASD defects. Although the bal-
loon sizing method has been regarded as the gold standard
for the selection of device size [2, 6], real-time visualiza-
tion of the en-face view of ASD defects provides reliable
measurements of ASD defect size, making this modality
useful for sizing these defects.
Because full-volume datasets encompassed both the
ASD defect and surrounding cardiac structures, cropping of
pyramidal datasets allowed measurements of rim length to
all specific cardiac structures quite easily compared to the
standard 2DTEE method. Cross-sectional views using
standard 2DTEE do not always cut the minimal distance
from the defect to the neighboring cardiac structures, and
thus, the rim measurements may not be accurate. This is
another advantage over standard 2DTEE measurement of
the residual rim.
Study limitations
The sample size of this study was relatively small. Further
studies with a greater number of patients are required to
validate our results. Although the 3D zoom mode allows
online assessment of defect dynamics, the lower frame rate
hindered more detailed descriptions of area changes when
using the zoom mode. To enhance frame rates, we also
acquired full volume datasets. However, stitch artifacts
derived from four consecutive subvolume acquisitions
were observed, precluding accurate assessment in a small
group of patients. Further technological advances and
refinement of this technology, including higher frame rates
and single beat acquisition of larger pyramidal volume,
could overcome these problems.
Conclusions
Real-time 3DTEE allows measurements of the temporal
and spatial changes of ASD size and shape. It also provides
accurate information regarding the rim length to neigh-
boring cardiac structures. This methodology has the
potential to provide detailed information regarding optimal
53
selection of patients who might benefit from transcatheter
closure of the ASDs.
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