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The non-surgical treatment of congenital heart malformations or iatrogenic lesions following cardiac surgery by interventional cardiac catheterisation is so well established that up to 40% of cases can be treated in this way. The most frequent procedures undertaken are balloon valvotomy or angioplasty, stenting of arterial or venous stenoses, closure of intracardiac or extracardiac communications, and balloon atrial septostomy or blade atrial septectomy. While most of these are carried out with the assistance of radiographic screening, in some circumstances transoesophageal echocardiography greatly improves the success and safety. Transoesophageal ultrasonography is an important part of imaging for closure of oval fossa atrial septal defects, occlusion of baffle fenestrations following total caval pulmonary connection, closure of congenital (or ischaemic) muscular ventricular septal defects, blade atrial septectomy, balloon mitral valvotomy, and non-surgical reduction of the ventricular septum in hypertrophic cardiomyopathy. Intracardiac ultrasound, however, may become an alternative imaging technique during device closure of atrial septal defects in older patients, avoiding the need for general anaesthesia.
Atrial septal defects
The initial selection of patients for transcatheter closure of an atrial septal defect is based on precordial echocardiography, which allows the various types to be distinguished. The final arbiter of suitability is transoesophageal echocardiography, usually performed immediately before the procedure, except in adolescents and adults with a poor echo window in whom confirmation of the diagnosis will be based on prior transoesophageal echocardiography.
The true interatrial septum is the oval fossa, the majority of the remaining of tissue separating the atrial chambers being composed of an infolding of the atrial wall.1 Defects within the oval fossa are “secundum” defects (fig 1), which may extend outside the true limits of the oval fossa when there is a deficiency of the infolding (fig 2). These defects may extend therefore posteriorly to the mouth of the coronary sinus, inferiorly to …