Intelligent diagnosis of atrial septal defect in children using echocardiography with deep learning

Background Atrial septal defect(ASD)is one of the most common congenital heart diseases.The diagnosis of ASD via transthoracic echocardiography is subjective and time-consuming.Methods The objective of this study was to evaluate the feasibility and accuracy of automatic detection of ASD in children based on color Doppler echocardiographic static images using end-to-end convolutional neural networks.The proposed depthwise separable convolution model identifies ASDs with static color Doppler images in a standard view.Among the standard views,we selected two echocardiographic views,i.e.,the subcostal sagittal view of the atrium septum and the low parasternal four-chamber view.The developed ASD detection system was validated using a training set consisting of 396 echocardiographic images corresponding to 198 cases.Additionally,an independent test dataset of 112 images corresponding to 56 cases was used,including 101 cases with ASDs and 153 cases with normal hearts.Results The average area under the receiver operating characteristic curve,recall,precision,specificity,F1-score,and accuracy of the proposed ASD detection model were 91.99,80.00,82.22,87.50,79.57,and 83.04,respectively.Conclusions The proposed model can accurately and automatically identify ASD,providing a strong foundation for the intelligent diagnosis of congenital heart diseases.

The Role of Transesophageal Echocardiography for Transcatheter Closure of Atrial Septal Defects with the Amplatzer Septal Occluder

Objective: To evaluate of the role of transesophageal echocardiography (TEE)in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder. Methods:Sixty- two patients (10 to 55 years of age) were selected for percutaneous closure of ASD bytrans-esophageal echocardiography, which was also used to monitor the procedure, to select theappropriate size of the Amplatzer device, to verify its position, and to access the immediateresults of the procedure. During the follow-up, transthoracic echocardiography (TTE) or TEE was usedto evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiacchamber diameters. Results: The mean ASD diameter by TTE ([19. 1 +- 5. 8] mm) was significantlysmaller (P< 0. 001) than the stretched diameter of the ASD (25. 1 +- 6. 4) mm. There are nosignificant differences between the TEE -measured value (23. 5+_6. 2) mm and the stretched diameterof the ASD (P > 0. 05). Due to proper patient selection all procedures were successful. There wasimmediate and complete closure in 61/62 patients, only one patients had trivial residual shunt.Follow- up was performed using TTE or TEE right after operation, 1 d, 1 month, 3 months, 6 monthsand yearly thereafter. Ail, patients remain asymptomatic without any clinical or technical problems.Conclusion: With the aid of TEE, percutaneous closure of ASD can be performed successfully, safely,and effectively.

Misdiagnosis of unroofed coronary sinus syndrome as an ostium primum atrial septal defect by echocardiography:A case report

BACKGROUND Unroofed coronary sinus syndrome(UCSS)is a rare congenital heart disease,which has variable morphologic features and is strongly associated with persistent left superior vena cava(PLSVC).However,it is often difficult to visualize the left-to-right shunt pathway through the CS by transthoracic echocardiography(TTE).CASE SUMMARY A 37-year-old female was admitted to the hepatological surgery department of a hospital with complaint of subxiphoid pain that had started 1 wk prior.Physical examination revealed a grade 3/6 systolic murmur at the left margin of the sternum,between the 2nd and 3rd intercostal cartilage.The patient underwent echocardiography and was diagnosed with ostium primum atrial septal defect(ASD);thus,she was subsequently transferred to the cardiovascular surgery department.A second TTE evaluation before surgery showed type IV UCSS with secundum ASD.Right-heart contrast echocardiography(RHCE)showed that the right atrium and right ventricle were immediately filled with microbubbles,but no microbubble was observed in the CS.Meanwhile,negative filling was observed at the right atrium orifice of the CS and right atrium side of the secundum atrial septal.RHCE identified UCSS combined with secundum ASD but without PLSVC in this patient.CONCLUSION This rare case of UCSS highlights the value of TTE combined with RHCE in confirming UCSS with ASD or PLSVC.

Evaluation of Atrial Septal Defect Using Real-time Three-dimensional Echocardiography:Comparison with Surgical Findings

The present study evaluated the application of three dimensional echocardigraphy （3DE） in the diagnosis of atrial septal defect （ASD） and the measurement of its size by 3DE and compared the size with surgical findings. Two-dimensional and real-time three dimensional echocardiography （RT3DE） was performed in 26 patients with atrial septal defect, and the echocardiographic data were compared with the surgical findings. Significant correlation was found between defect diameter by RT3DE and that measured during surgery （r=0.77, P〈0.001）. The defect area changed significantly during cardiac cycle. Percentage change in defect size during cardiac cycle ranged from 6%-70%. Our study showed that the size and morphology of atrial septal defect obtained with RT3DE correlate well with surgical findings. Therefore, RT3DE is a feasible and accurate non-invasive imaging tool for assessment of atrial septal size and dynamic changes.

Clinical Value of Stereoscopic Three-dimensional Echocardiography in Assessment of Atrial Septal Defects: Feasibility and Efficiency

Stereoscopic three-dimensional echocardiography（S-3DE） is a novel displaying technol-ogy based on real-time 3-dimensional echocardiography （RT-3DE）. Our study was to evaluate the feasibility and efficiency of S-3DE in the diagnosis of atrial septal defect （ASD） and its use in the guidance for transcatheter ASD occlusion. Twelve patients with secundum ASD underwent RT-3DE examination and 9 of the 12 were subjected to transcatheter closure of ASD. Stereoscopic vision was generated with a high-performance volume renderer with red-green stereoscopic glasses. S-3DE was compared with standard RT-3D display for the assessment of the shape, size, and the surrounding tis-sues of ASD and for the guidance of ASD occlusion. The appearance rate of coronary sinus and the mean formation time of the IVC, SVC were compared. Our results showed that S-3DE could measure the diameter of ASD accurately and there was no significant difference in the measurements between S-3DE and standard 3D display （2.89±0.73 cm vs 2.85±0.72 cm, P〉0.05; r=0.96, P〈0.05）. The appearance of coronary sinus for S-3DE was higher as compared with the standard 3D display （93.3% vs 100%）. The mean time of the IVC, SVC for S-3DE monitor was slightly shorter than that of the standard 3D display （11.0±3.8 s vs 10.3±3.6 s, P〉0.05）. The mean completion time of interven-tional procedure was shortened with S-3DE display as compared with standard 3D display （17.3±3.1 min vs 23.0±3.9 min, P〈0.05）. Stereoscopic three-dimensional echocardiography could improve the visualization of three-dimensional echocardiography, facilitate the identification of the adjacent structures, decrease the time required for interventional manipulation. It may be a feasible, safe, and efficient tool for guiding transcatheter septal occlusion or the surgical interventions.

Reliability of Echocardiographic Pulmonary Vascular Resistance to Screen for the New Definition of Precapillary Pulmonary Hypertension in Uncorrected Secundum Atrial Septal Defect

Background and Objective:The most feared complication of uncorrected secundum Atrial Septal Defect(ASD)is pulmonary arterial hypertension(PAH).Pulmonary vascular resistance(PVR)is crucial in detecting precapil-lary pulmonary hypertension(PH)to guide the need for PAH-specific therapy.There is a change in the cut-off value of PVR according to the recently updated PH guideline.How echocardiographic PVR(PVRecho)correlates to PVR by right heart catheterization(RHC)(PVRcath)according to the new guidelines has not been known.The aim of this study is to determine the reliability of PVRecho in detecting PAH in Uncorrected Ostium Secundum ASD based on the current updated guideline and to help screen the high PVR group.Methods:429 ostium secun-dum ASD in the COngenital HeARt Disease in Adult and Pulmonary Hypertension(COHARD-PH)registry was divided into three groups according to the PVR.PVRecho was calculated using Abbas’Formula and compared the its gold standard,the PVRcath.The correlation between the two methods was analyzed.The Bland-Altman plot was used to analyze the agreement between the two methods.Receiver operating characteristics(ROC)analysis was used to determine the PVRecho cut-off value for high PVR.Results:The majority of the population(63.5%)had high PVR.Female gender dominated the study population(84%).PVR_(echo) was significantly correlated with PVRcath(r=0.6225,p<0.0001).Bland-Altman plot among all groups and in subgroups analysis showed a wide range of agreement.PVRecho underestimated PVRcath 5.124 WU.In subgroup analysis,PVRecho overestimated PVRcath 0.35 WU in those with PVR<2 WU.In the second and third groups,PVR_(echo) underestimated PVRcath 0.52 and 10.77 WU,respectively.Conclusion:PVRecho is reliable in predicting high PVR in uncorrected secun-dum ASD.However,there is a wide range of agreement.PVR_(echo) cut-off value of>1.62 WU showed good dis-criminatory power in determining high PVR.

Clinical Application of Three－dimensional Transesophageal Echocardiography in the Diagnosis of Atrial Septal Defect

This paper reports the use of three-dimensional (3-D) transesophageal echocardiography(TEE) in the diagnosis of atrial septal defect. The results displayed that the interatrial septum had integrity in normal persons. The size,shape and position of atrial septal defects could be showed clearly and the type of the defects could be identified. The reconstructed imaging of interatrial septum on 3-D TEE was clear and stereoscopic. The technique is helpful in defining spatial location and extent of atrial septal defects.

Completed atrioventricular block induced by atrial septal defect occluder unfolding:A case report

BACKGROUND An atrial septal defect is a common condition and accounts for 25%of adult congenital heart diseases.Transcatheter occlusion is a widely used technique for the treatment of secondary aperture-type atrial septal defects(ASDs).CASE SUMMARY A 30-year-old female patient was diagnosed with ASD by transthoracic echocardiography(TTE)1 year ago.The electrocardiogram showed a heart rate of 88 beats per minute,normal sinus rhythm,and no change in the ST-T wave.After admission,TTE showed an atrial septal defect with a left-to-right shunt,aortic root short-axis section with an ASD diameter of 8 mm,a parasternal four-chamber section with an ASD diameter of 9 mm,and subxiphoid biatrial section with a diameter of 13 mm.Percutaneous occlusion was proposed.The intraoperative TTE scan showed that the atrial septal defect was oval in shape,was located near the root of the aorta,and had a maximum diameter of 13 mm.A 10-F sheath was placed in the right femoral vein,and a 0.035°hard guidewire was used to establish the transport track between the left pulmonary vein and the inferior vena cava.A shape-memory alloy atrial septal occluder with a waist diameter of 20 mm was placed successfully and located correctly.TTE showed that the double disk unfolded well and that the clamping of the atrial septum was smooth.Immediately after the disc was revealed,electrocardiograph monitoring showed that the ST interval of the inferior leads was prolonged,the P waves and QRS waves were separated,a junctional escape rhythm maintained the heart rate,and the blood pressure began to decrease.After removing the occluder,the elevation in the ST segment returned to normal immediately,and the sinus rhythm returned to average approximately 10 min later.After consulting the patient’s family,we finally decided to withdraw from the operation.CONCLUSION Compression of the small coronary artery,which provides an alternative blood supply to the atrioventricular nodule during the operation,leads to the emergence of a complete atrioventricular block.

Reliability of transthoracic echocardiography in estimating the size of Amplatzer septal occluder and guiding percutaneous closure of atrial septal defects

Background In China, transthoracic echocardiography （TTE） is popularly used for pre-intervention examination for atrial septal defect （ASD） and for guiding ASD closure. However, the ability to determine ASD size and the safety and efficacy of l-rE for guiding ASD closure still has not been widely accepted. This study aimed to evaluate the efficacy and safety of l-rE used before, during and after transcatheter ASD closure with Amplatzer septal occluders （ASO）. Methods Sixty-eight subjects （15 men and 53 women; mean age （33.7±17.3） years） were enrolled. TTE was used to measure the diameters and guide transcatheter closure of ASD. The ASD was examined by long-axis view, basal short-axis view, apical four-chamber view and the subcostal view to observe position, diameter and relation with neighbouring structures. The largest diameter was selected as the reference diameter. Patients were divided into 3 groups according to the ASD reference diameter： 22 subjects with ASD diameter 4-14 mm （group A）; 21 subjects with ASD diameter 15-20 mm （group B）; and 25 subjects with ASD diameter 21-33 mm （group C）. Results ASD was occluded successfully in groups A and B. In group C, occlusion failed in 2 cases; 1 case remained with a 3-mm residual shunt sustained until 6-month follow-up. However, at 6-month follow-up, no case of thromboembolism, ASO dislocation or death occurred in the three groups. The diameter of ASD measured by l-rE could accurately predict the ASO size that could successfully occlude the ASD, especially in patients with ASD 〈20 mm. The ASD diameter measured by l-rE correlated well with ASO size （r= 0.925, P〈0.001 ; r=0.976, P〈0.001 ; r=0.929, P〈0.001 respectively）. Conclusions ASD diameter measured by l-rE can accurately estimate the size of the ASO needed for successful closure of ASD. The larger the ASD, the much larger the ASO needed. l-rE is a satisfactory guiding imaging tool for ASD closure.

Efficacy and Safety of the Atrial Septal Defect Closure for Patients with Absent or Malaligned Aortic Rim Using a Figulla Flex II Device Flared and Straddling Behind the Aorta

Background:Although transcatheter closure of atrial septal defect(ASD)is safe and effective for patients with sufficient rim,ASD patients with absent and/or malaligned aortic and/or superior rim have higher risks of device embolization and cardiac erosion.We have treated such high-risk patients using a Figulla Flex II(FFII)device shaped flared and straddling behind the aorta because this method would avoid such serious complications.However,its long-term efficacy and safety remain unclear.Therefore,the midterm efficacy and safety of this method were studied.Methods:We retrospectively evaluated the outcome of 47 consecutive patients with such rim(age 6–73 years,weight 17–75 kg,31 females)treated with this method at our hospital between February 2016 and September 2019.To make the flared and straddling shape,we selected a FFII 4–6 mm larger than the balloon sizing diameter by stop-flow technique.We also studied the device shape,the disc pressure to the Valsalva wall and their changes over 6 months by transesophageal echocardiography.Results:All procedures were successful,and leakage disappeared within 1 year.During a mean follow up of 37±12 months,complications included a transient sinus node dysfunction and one I°atrioventricular block within 3 months.Whole device shape changed from bulky to thin:the device waist and thickness significantly decreased by around 1.5 mm and 3.5 mm,respectively(p<0.05),but the two discs remained flared and straddling behind the aorta over 6 months;therefore,the disc edges seldom pressed the Valsalva wall perpendicularly,even though the inner plane of either disc often slightly pressed the wall.Conclusions:ASD closure using a FFII shaped flared and straddling behind the aorta is probably effective and safe for patients with absent and/or malaligned aortic and/or superior rim although requiring care for conduction disorders.

TRANSCATHETER CLOSURE OF LARGE SECUNDUM ATRIAL SEPTAL DEFECTS WITH AMPLATZER~ SEPTAL OCCLUDER

Objective To evaluate the safety and feasibility of transcatheter closure of large secundum atrial septal defects(ASDs)with Amplatzer~ septal occluder(ASO).Methods A total of 26 patients(age 16 to 67 years,median 43 years;body weight 52 to 102 kg,median 67 kg)with large ASDs underwent an attempted transcatheter closure using ASO.Large ASD was defined as those with a balloon-stretched diameter of ≥30 mm.Another 81 patients with small-to-moderate ASD during same period who underwent closure served as controls.Results In patients with large ASDs,the ASD dimension means were(22.1±3.2)mm(range from 16 to 30 mm)and(23.8±2.6)mm(range from 18 to 31mm)assessed by transesophageal echocardiography(TEE)and transthoracic echocardiography(TTE),respectively.The mean balloon-stretched diameter of the ASD was(31.9±2.1)mm(range from 30 to 37mm).The size of device was(32.0±1.9)mm(range from 30 to 36mm).The transcatheter procedure was successful in all patients(100%).Seventeen deployments were performed using the conventional left atrium approach,and remaining 9 patients required the right upper pulmonary vein approach.Immediately after deployment,TEE revealed that complete closure rate was 73%.Procedure-related complications were recorded in 3 patients(12%),including device embolization in one patient,pericardial effusion in one patient,and large hematoma at puncture site in one patient.During follow-up,the complete closure rate increased to 88% at 24h after procedure and 100% at 6 months.The procedural success rates,immediate TEE results and TTE results at 24h and 6 months after procedure,were not significantly different between patients with large ASDs and those with small-to-moderate ASDs.Conclusion Transcatheter closure of large ASDs using ASO is technical feasible and relatively safe.Proper care selection and specific technique modification such as the right upper pulmonary vein approach is vital for the implantation success.

The role of echocardiography in mini-invasive surgical device closure of ventricular septal defect

Objective To assess the application of echocardiography in mini-invasive surgical device closure of ventricular septal defect (VSD) . Methods 73 VSD patients including 35 with aneurysm formation and among them 21 with multi-defects in the aneurysm were treated by mini-invasive device closure. A closure device was positioned to the defect through parasternal mini-incision in all patients. TEE was used to monitor the whole procedure。

Percutaneous closure of secundum type atrial septal defects:More than 5-year follow-up

AIM: To investigate long-term efficacy of two different devices more than five years after percutaneous atrial septal defect(ASD) closure in adults.METHODS: All patients who underwent percutaneous closure of an ASD in the St. Antonius Hospital, Nieuwegein, The Netherlands, between February 1998 and December 2006 were included. Percutaneous closure took place under general anaesthesia and transesophageal echocardiographic moni toring. Transthoracic echocardiography(TTE) was performed 24 h post-procedure to visualize the device position and to look for residual shunting using color Doppler. All complications were registered. All patients were invited for an outpatient visit and contrast TTE more than 5-years after closure. Efficacy was based on the presence of a residual right-to-left shunt(RLS), graded as minimal, moderate or severe. The presence of a residual left-to-right shunt(LRS) was diagnosed using color Doppler, and was not graded. Descriptive statistics were used for patients' characteristics. Univariate analysis was used to identify predictors for residual shunting.RESULTS: In total, 104 patients(mean age 45.5 ± 17.1 years) underwent percutaneous ASD closure using an Amplatzer device(ASO) in 76 patients and a Cardioseal/Starflex device(CS/SF) in 28 patients. The mean follow-up was 6.4 ± 3.4 years. Device migration occurred in 4 patients of whom two cases occurred during the index hospitalization(1 ASO, 1 CS/SF). The other 2 cases of device migration occurred during the first 6 mo of follow-up(2 CS/SF). The recurrent thrombo-embolic event rate was similar in both groups: 0.4% per follow-up year. More than 12 mo post-ASD closure and latest follow-up, new-onset supraventricular tachyarrhythmia's occurred in 3.9% and 0% for the ASO and CS/SF group, respectively. The RLS rate at latest follow-up was 17.4%(minimal 10.9%, moderate 2.2%, severe 4.3%) and 45.5%(minimal 27.3%, moderate 18.2%, severe 0%) for the ASO- and CS/SF groups, respectively. There was no residual LRS in both groups.CONCLUSION: Percutaneous ASD closure has good long-term safety and efficacy profiles. The residual RLS rate seems to be high more than 5 years after closure, especially in the CS/SF. Residual LRS was not observed.

Device-related thrombosis on atrial septal defect occluder after simultaneous closure of left atrial appendage and atrial septal defect: a case report

An atrial septal defect (ASD) may cause right heart dysfunction, pulmonary hypertension and atrial fibrillation (AF), and atrial septal defect occlusion (ASDO) is the first choice for treating secundum defects when the morphology permits. ASD and AF frequently coexist, and the risk of AF and stroke persists after ASDO.[1] In recent years, left atrial appendage occlusion (LAAO) has been recognized as an effective treatment for stroke prevention in nonvalvular AF patients with a high risk of stroke, systemic embolism and bleeding who are unwilling to take oral anticoagulants or cannot tolerate them.

Should we consider patent foramen ovale and secundum atrial septal defect as different steps of a single anatomo-clinical continuum？

1 Introduction Isolated atrial septal defects （ASD） represent 7% of all cardiac anomalies and can present at any age. Adolescents and adults with simple congenital heart disease such as isolated atrial septal defects are more likely to reach adult age without being diagnosed. Secundum ASD （sASD） is by far the most common type, occurring in 1/1500 live births, with 65% to 75% involving females, On the other hand, patent foramen ovale （PFO） represents an endemic variant in the normal population with a prevalence of 25%-27%. These two entities appear so different that is difficult to fred a conjunction ring： nevertheless we use the same philosophy for the treatment, Indeed, device-based closure has been proved to be effective in both settings.

Transcatheter closure of secundum atrial septal defects using Amplatzer device

To evaluate the feasibility and short term results of transcatheter closure of secundum atrial septal defects (TCSASDs) using Amplatzer occluder device A new self centering device, the Amplatzer atrial septal occluder, has recently been evaluated in an animal model with excellent results This paper reports our clinical research with this device Methods 30 patients underwent an attempt at TCSASDs at an average age of 35 6±15 9?y (range, 5-62?y) and average weight of 63 6±14 5?kg (range, 17-78?kg) using the Amplatzer atrial septal occluder The average ASD diameter measured by transesophageal echocardiography (TEE) was 23 6±4 0?mm (range, 16-31?mm), and the average atrial septal defects (ASD) balloon stretched diameter was 25 2±5 8?mm (range, 9-34?mm) All patients had right atrial and ventricular volume overload with a Qp/Qs of 3 4±1 2 (1 4-5 2) A F8 12 catheter was used for delivery of the device in all patients Results The device was placed correctly in all patients There was immediate and complete closure in 30 patients The average device waist size used to close the defect was 25 6±5 9?mm (range, 9-34?mm) There was no episode of device embolization or any other complication Follow up was performed using transthoracic echocardiography (TTE) 1 day, 1 month, 3 months, 6 months and 1 year after the procedure The first day after operation; there was complete closure of the ASD in all patients; there have been no episodes of endocarditis, thromboembolism, or wire fracture Conclusion TCSASDs using the Amplatzer occluder device was an efficient nonsurgical method which had a very high technical success rate and satisfactoy short term and follow up results

Double Intervention in Single Sitting: Percutaneous Device Closure and Permanent Pacemaker Implantation in a Patient with Atrial Septal Defect

Context: Atrial septal defect may rarely be associated with other cardiac diseases such as arrhythmia, and may require additional intervention. Case report: A 16-year-old boy presented with effort dyspnea, tiredness, and fatigue. The electrocardiograph revealed right bundle branch block, atrioventricular block, and left axis deviation. Ostium secundum type of atrial septal defect was detected by transthoracic echocardiography and was confirmed by transesophageal echocardiography. The patient was advised to undergo percutaneous device closure. Permanent pacemaker implantation was also suggested considering the risk of fatal arrhythmias associated with atrioventricular block. Consequently, patient underwent percutaneous atrial septal defect closure and implantation of pacemaker in a single sitting. Both the procedures were successful, after which the patient showed remarkable symptomatic improvement. Conclusion: In atrial septal defect patients with unexplained atrioventricular block, closure of atrial septal defect and implantation of pacemaker in single sitting appear to be an attractive modality.

Occult anomalous origin of the left coronary artery from the pulmonary artery with atrial septal defect initially visualized by transthoracic echocardiography

Anomalous origin of left coronary artery from the pulmonary artery （ALCAPA） is a rare congenitalcardiac malformation. Here we report a case of ALCAPA with atrial septal defect （ASD） initially visualized by transthoracic echocardiography, subsequently confirmed by the coronary angiography.

Superior sinus venosus atrial septal defect

Atrial septal defect (ASD)is the third commonest congenital heart disease in adults.The most common type of ASD is the ostium secundum accounting for 75%-80%of all ASDs.Less common are the ostium primum (accounting for 15%of all ASDs),the sinus venosus defect (5%-10%) and the coronary sinus defect (less than 1%).[1,2]

Occlusion of atrial septal defect utilizing occluder devise via minimally invasive right chest approach

Objective To evaluate atrial septal defect(ASD) occlusion employing a small right anterior thoracotomy approach. Methods A total of 21 patients with ASD underwent general anesthesia and 2-3 cm incision was made in the fourth right intercostal space.Utilizing transesophageal or transthoracic echocardiography,the occluder was released using a monotube unit. Results All patients were occluded successfully.No patient required open surgery utilizing extracorporeal circulation.There were no major complications and no evidence of residual atrial shunt. Conclusion ASD occlusion via a minimal surgical incision is safe,less invasive,and has excellent outcomes.