Incremental value of transesophageal echocardiography in the evaluation of patients before percutaneous closure of atrial septal defects

We have recently read with great interest the article by Chen et al. (1) entitled ‘‘Transcatheter device closure of atrial septal defects guided completely by transthoracic echocardiography: A single cardiac center experience with 152 cases’’ published in Anatol J Cardiol 2018; 20: 330-5. We recognize authors’ effort in the report describing the transcatheter device closure of atrial septal defects (ASDs) fully guided by transthoracic echocardiography (TTE), which was a single-cardiac-center experience including 152 cases. On the other hand, we believe that there are some major drawbacks that need to be addressed here. ASDs are one of the most common forms of congenital heart disease in adults. Although percutaneous closure of ASDs has gained more popularity in recent years as a repair technique, a morphological evaluation of the defect is necessary for an appropriate patient election due to a considerable variation in the size, morphology, and location of the defects (2). Traditional balloon sizing and/or two-dimensional (2D) transesophageal echocardiography (TEE) have been used for defect sizing and procedure monitoring. The evaluation of patients for percutaneous transcatheter closure of secundum ASDs requires accurate information regarding the anatomy of the defect, such as its maximal diameter and the length of the circumferential tissue rims (3). TTE has a limited ability in this regard. The use of TEE, on the other hand, provides useful information about the exact morphology of the ASD, such as the size, position in the interatrial septum, and adequacy of septal rims. Inadequate visualization may result in suboptimal device delivery and unfavorable outcomes. Various defects may cross multiple imaging planes, complicating and sometimes precluding accurate visualization by conventional 2D TEE. In such cases, real-time three-dimensional TEE allows an accurate assessment of the cardiac anatomy and an excellent spatial orientation, yielding detailed information about the shape and location of the defects (4, 5)