Atrial Abnormalities and Atrial Septal Defects

  • Louis I. BezoldEmail author


Transesophageal echocardiography (TEE) allows for a comprehensive assessment of atrial chamber and interatrial septal anatomy. Due to the posterior position of the probe and its proximity to atrial structures, high resolution imaging of the atria and atrial septum represent a particular strength of this modality. Combined with color flow mapping and spectral Doppler interrogation, TEE is able to characterize communications at the atrial level, anatomic variants of the atria, and pathologic conditions that may affect these structures. This chapter focuses on the role of TEE in the characterization of atrial septal defects and atrial abnormalities such as juxtaposition of the atrial appendages and cor triatriatum.


Transesophageal echocardiography Atrial septal defects Atrial communications Patent foramen ovale Atrial abnormalities Juxtaposition of the atrial appendages Cor triatriatum 

Supplementary material

Video 7.1

Two-dimensional image of a mid esophageal four-chamber view. This cross section represents a starting point in the evaluation of atrial septal defects as it adequately displays both atria, the interatrial septum, atrioventricular valves and ventricular inflows. Right and left probe shaft rotation in this window optimizes structures of interest (MOV 3327 kb)

Video 7.2

A centrally located secundum atrial septal defect is displayed in the mid esophageal four-chamber view with rightwards probe rotation. Color flow Doppler interrogation demonstrates a moderate amount of left-to right shunting across the defect (blue signal) (MOV 3738 kb)

Video 7.3

Four-chamber view in the mid esophagus (with slight rightwards probe rotation) demonstrates aliasing of color flow Doppler consistent with restrictive flow across a small secundum atrial communication. The interatrial septum bulges towards the right suggesting elevated left atrial pressures (MOV 2345 kb)

Video 7.4

Sweep of the interatrial septum in a mid esophageal four-chamber view with slight rightwards probe rotation. Note that the deficiency in the central aspect of the interatrial septum and the rims around the secundum defect are only seen in portions of this video. This emphasizes the importance of full sweeps when assessing communications at the atrial septum as well as many other defects (MOV 8959 kb)

Video 7.5

Superior sinus venosus atrial septal defect as seen by withdrawal of the imaging probe above the level of the fossa ovalis from a mid esophageal position. Color Doppler interrogation demonstrates flow across the defect (MOV 5512 kb)

Video 7.6

Color Doppler image displaying left to right shunting across a primum atrial septal defect in the mid esophageal four-chamber view. Note the trivial-mild amount of associated right and left atrioventricular valve regurgitation (MOV 3208 kb)

Video 7.7

Transesophageal view displaying the characteristic broad-based nature of the right atrial appendage (RAA). There is also a moderate to large secundum atrial septal defect present (MOV 1837 kb)

Video 7.8

Cross-sections obtained by turning the imaging probe from the mid esophageal four-chamber view clockwise to visualize right-sided structures. Color Doppler demonstrates an intact atrial septum and laminar tricuspid inflow in this video (MOV 3568 kb)

Video 7.9

Mid esophageal view with clockwise probe shaft rotation to examine the right pulmonary venous connections into the left atrium (MOV 4725 kb)

Video 7.10

Color flow Doppler in a similar plane as shown in Video 7.9 to assess drainage of the right upper pulmonary vein (red color flow) into the left atrium (MOV 2353 kb) (628 kb)
Video 7.11 Mid esophageal four-chamber view obtained with counterclockwise rotation of the imaging probe demonstrates a markedly dilated left atrium, in this case due to mitral regurgitation. Note the abnormal configuration of the interatrial septum from a volume loaded left atrium (MOV 627 kb)
Video 7.12

The courses of two left sided pulmonary veins into the left atrium are demonstrated in this sweep. Note the two different orientations of the pulmonary veins as they enter the left atrium (MOV 2631 kb)

Video 7.13

Color Doppler interrogation as it assists in the characterization of pulmonary venous flow (MOV 1703 kb)

Video 7.14

Video displays color Doppler imaging of the left upper pulmonary vein as it courses towards the left atrium. A concern for pulmonary vein stenosis was raised from the color information superimposed on the two-dimensional images and the disturbed color flow signal. This finding should prompt further evaluation that includes pulsed-Doppler interrogation (MOV 1271 kb)

Video 7.15

Video displays a dilated coronary sinus (seen in cross-section) below the left pulmonary venous inflow. This finding may indicate the presence of a persistent left superior vena cava (MOV 693 kb)

Video 7.16

Video obtained with transducer anteflexion as the imaging probe is withdrawn from a mid esophageal four-chamber view. The left atrial appendage is seen just anterior to the left upper pulmonary vein (MOV 2378 kb)

Video 7.17

Mid esophageal two-chamber view demonstrating the anterior orientation of the left atrial appendage. A mildly dilated coronary sinus is seen posteriorly in cross-section (MOV 1207 kb) (686 kb)
Video 7.18 Mid esophageal long-axis view (multiplane angle 114°) corresponding to the same patient displayed in Video 7.11. This image confirms the large dimensions of the left atrium related to severe mitral regurgitation and displays the left ventricle and aortic root. A mild amount of prolapse of the anterior mitral leaflet is seen (MOV 685 kb)
Video 7.19

Video obtained after advancing the probe from the mid esophagus to a lower esophageal window. The coronary sinus in seen in long-axis as it courses in the atrioventricular groove to drain into the right atrium. This is not to be confused with a primum atrial septal defect (MOV 4446 kb)

Video 7.20

Contrast echocardiogram obtained following injection of agitated saline into the left arm in a patient with a persistent left superior vena cava to coronary sinus connection. Contrast is seen along the dilated coronary sinus as this empties into the right atrium (MOV 1721 kb) (696 kb)
Video 7.21 Mid esophageal bicaval view displaying the entire atrial septum. The flap valve of the foramen is well seen in this video (MOV 695 kb) (790 kb)
Video 7.22 Video of a mid esophageal bicaval view displaying a dilated left atrium with bulging of the interatrial septum towards the right atrium. This image was obtained in a patient with pulmonary hypertension. The inferior vena cava is well seen as the transducer is advanced (MOV 789 kb)
Video 7.23

Two-dimensional image of a superior sinus venosus defect as demonstrated in the mid esophageal bicaval plane. The superior vena cava is seen straddling the interatrial septum. Color flow Doppler confirms atrial level left-to-right shunting (MOV 7867 kb)

Video 7.24

Small secundum atrial septal defect as shown in the mid esophageal bicaval view (MOV 3839 kb)

Video 7.25

Image demonstrates a high secundum atrial septal defect in the mid esophageal bicaval view by two-dimensional imaging and color flow Doppler (MOV 2957 kb)

Video 7.26

Large secundum atrial septal defect with associated left to right shunting. Note the slightly more inferior location of this defect as compared to the atrial communication illustrated in the same imaging plane in Video 7.25 (MOV 6087 kb)

Video 7.27

Color flow mapping in the mid esophageal bicaval view demonstrating flow (red) near the superior vena cava to right atrial junction suggestive of the presence of anomalous pulmonary venous drainage in a patient with a superior sinus venosus atrial septal defect (MOV 4746 kb)

Video 7.28

Video of a mid esophageal right ventricular inflow-outflow view. This cross-section is useful in the comprehensive assessment of atrial septal defects as it displays the tricuspid valve, left atrium, right atrial and right ventricular sizes, right ventricular inflow and outflow tract, pulmonary valve, and proximal main pulmonary artery. In this example there is also a large secundum atrial septal defect. Mild tricuspid valve septal leaflet prolapse is also noted (MOV 2476 kb)

Video 7.29

Transgastric mid short-axis view demonstrating a large, volume loaded right ventricle in a patient with a large atrial septal defect (MOV 2476 kb)

Video 7.30

Deep transgastric sagittal images of the atrial septum displaying two-dimensional and color information. The interatrial septum appears to be intact in this case (MOV 5753 kb)

Video 7.31

Images obtained in the same cross-sections as shown in Video 7.30. In this example, the presence of a secundum atrial septal defect is demonstrated (MOV 3467 kb)

Video 7.32

The video displays a modified plane in the deep transgastric window that also allows for echocardiographic assessment of the interatrial septum (MOV 4042 kb)

Video 7.33

Video of an inferior sinus venosus defect as obtained from a modified deep transgastric sagittal view (same view as shown in Videos 7.30 and 7.31). Note the deficiency in the lower aspect of the interatrial septum and the presence of left to right shunting across the defect. The Eustachian valve is also seen. Additional planes in this window may provide information regarding associated anomalies of pulmonary venous drainage (MOV 1244 kb)

Video 7.34

Mid esophageal images in orthogonal planes obtained to assess right ventricular size and function. The images demonstrate right ventricular dilation with low normal systolic function (MOV 4008 kb) (8.3 mb)
Video 7.35 Images demonstrate an aneurysm of the interatrial septum as shown by two-dimensional imaging (left panel), color flow mapping (middle panel), and contrast echocardiography (right panel). Injection of agitated saline into a lower extremity vein was performed to assess for the presence of a patent foramen ovale in a child with a history of multiple strokes (MOV 8523 kb)
Video 7.36

Transesophageal imaging sequence capturing the steps involved during radiofrequency perforation of the interatrial septum in a critically ill infant with hypoplastic left heart syndrome and an intact atrial septum. The images were acquired in the mid esophageal bicaval view and modified cross-sections that allowed for transesophageal monitoring during the procedure as follows: (1) intact atrial septum with hypertensive left atrium and bulging of the interatrial septum towards the right atrium; (2) catheter advanced across inferior vena cava and positioned against atrial septum; (3) catheter perforation of interatrial septum (note image artifact during radiofrequency perforation and microbubbles in the left atrium once chamber is entered); (4) an exchange wire is advanced well into the left atrium; (5) a stent is positioned across the septum over a balloon and deployed straddling the interatrial septum; (6) color and spectral interrogation is performed to document flow thought the stent and confirm adequacy of the intervention (MOV 43428 kb)

Video 7.37

Mid esophageal imaging with color flow interrogation to assess the results of the surgical intervention following patch closure of a secundum atrial septal defect. A trivial signal of tricuspid regurgitation (physiologic) is seen (MOV 1845 kb)

Video 7.38

Video displays the post surgical evaluation of a secundum atrial septal defect in the mid esophageal bicaval plane. No residual shunting is detected across the patch (MOV 1475 kb)

Video 7.39

Video depicts the abnormal orientation of the interatrial septum in the mid esophageal four-chamber view in a patient with juxtaposed left atrial appendages (MOV 5247 kb)

Video 7.40

Video displays the abnormal position of the right atrial appendage in the mid esophageal four-chamber view as it extends to lie next to the left atrial appendage in left juxtaposition of the atrial appendages. The abnormal orientation of the interatrial septum is also appreciated in these images (MOV 4938 kb)

Video 7.41

Deep transgastric sweep performed to further assess the anatomy/orientation of the atrial appendages in the infant shown in Videos 7.39 and 7.40 with juxtaposition of the atrial appendages. Note that as the imaging plane moves posteriorly the left-deviated right atrial appendage is seen as it courses behind the great arteries to lie next to the left atrial appendage (left juxtaposition). Associated defects in this patient included double outlet right ventricle-malposed great arteries (Taussig Bing Anomaly). Note the prominent left coronary artery anterior to the right atrial appendage (MOV 21006 kb)

Video 7.42

Cor triatriatum membrane as seen in the mid esophageal four- and two-chamber views with color flow imaging. Although the membrane appears rather thick, the relatively laminar nature of the color Doppler signal does not suggest significant obstruction across this region(MOV 8590 kb)

Video 7.43

In contrast to the images shown in Video 7.42, the cor triatriatum membrane in this patient was of an obstructive nature. Note the division of the left atrium by the membrane into proximal and distal portions. Color Doppler displays aliased flow across a small orifice for the egress of blood across the proximal atrial chamber. Spectral Doppler demonstrates lack of the normal phasic flow pattern across venous structures(MOV 6317 kb)

Video 7.44

In this mid esophageal sweep it is seen that the left atrial appendage (LAA) lies below the level of the membrane in cor triatriatum. This is in contrast to a supravalvar mitral ring where the appendage lies above (MOV 12244 kb)

Video 7.45

Sweep across several planes at the mid esophageal level displaying a severely dilated left atrial chamber proximal to a cor triatriatum membrane. A small eccentric posteriorly located orifice is seen measuring 5.7 mm. Note the aliased color flow consistent with severe obstruction across this area (MOV 26307 kb)


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Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  1. 1.Department of PediatricsKentucky Children’s Hospital, University of Kentucky College of MedicineLexingtonUSA

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