TEE is Standard of Care for Intraprocedural Guidance During Percutaneous ASD Closure
Transesophageal echocardiography (TEE) is considered standard of care for guiding percutaneous atrial septal defect closure, providing real-time visualization of defect morphology, sizing, device deployment, and immediate assessment of complications 1.
Role of TEE in Percutaneous ASD Closure
Preprocedural Assessment
TEE excels at visualizing the entire atrial septum and is particularly valuable for:
- Defect characterization: Measuring maximum defect diameter, area, and morphology with superior accuracy compared to transthoracic echocardiography (TTE) 1
- Rim assessment: Evaluating adequacy of tissue rims around the defect, which is critical for device selection and stability 1
- Pulmonary venous anatomy: Identifying anomalous pulmonary venous connections, especially right upper and middle lobe veins associated with sinus venosus defects 1
- Exclusion of left atrial appendage thrombus: Essential safety check before device deployment 1
Important caveat: While TEE is excellent for superior sinus venosus defects and associated anomalous pulmonary veins, cross-sectional imaging (CMR or CCT) may be superior for other anomalous pulmonary venous connections that are difficult to visualize echocardiographically 1.
Intraprocedural Guidance
TEE provides real-time imaging throughout the procedure for:
- Device sizing: Either by direct visualization or confirming balloon "stop-flow" diameter 1
- Deployment monitoring: Ensuring proper device position and configuration across the septum
- Immediate complication detection: Identifying pericardial effusion, thrombi on wires/devices, or device malposition 1
- Residual shunt assessment: Using color Doppler to evaluate for persistent flow across the defect
Clinical evidence demonstrates that TEE-guided closure is highly effective, with studies showing 100% successful closure rates for defects <25mm, shorter intracardiac manipulation times, and no radiation exposure compared to fluoroscopy-guided approaches 2, 3.
Alternative: Intracardiac Echocardiography
Intracardiac echocardiography is an alternative to TEE that provides similar guidance capabilities without requiring general anesthesia 1. The choice between TEE and intracardiac echo depends on institutional expertise and patient factors.
Three-Dimensional TEE Enhancement
3D TEE offers additional advantages:
- En face visualization of the defect and surrounding structures 4, 5
- More accurate measurement of defect dimensions and area
- Better assessment of spatial relationships between the device and adjacent structures (particularly the aorta)
- Identification of patients at higher risk for aortic erosion by measuring contact length between the left atrial disk and aorta 4
Post-Procedural Surveillance
Following device closure, TTE (not TEE) is appropriate for routine surveillance 6:
- Within 1 week, at 1 month, 3-6 months, and 1 year post-procedure
- Every 2-5 years thereafter in asymptomatic patients without complications
- TEE is rarely appropriate for routine surveillance 6
TEE should be reserved for evaluation of suspected complications such as device migration, thrombosis, erosion, or significant residual shunt 6.
Common Pitfalls to Avoid
Don't rely solely on TTE for preprocedural assessment in adults: TTE has limited visualization of the superior and posterior atrial septum and may miss important anatomical details 1
Don't attempt percutaneous closure of non-secundum defects: Primum, sinus venosus, and coronary sinus ASDs require surgical closure due to inadequate rims and proximity to critical structures 1
Don't use TEE for routine post-procedure surveillance: This is rarely appropriate and TTE is sufficient for uncomplicated cases 6
Assess for aortic rim deficiency: Patients with deficient aortic rims may be at higher risk for erosion, particularly when the left atrial disk contacts the aorta throughout the cardiac cycle 4