Interatrial Defect Sizing by Intracardiac and Transesophageal Echocardiography Compared With Fluoroscopic Measurements in Patients Undergoing Percutaneous Transcatheter Closure Fernando Boccalandro, 1 MD, Andreas Muench, 1 MD, Joseph Salloum, 1 MD, Hany Awadalla, 1 Catherine Carter, 1 Eddy Barasch, 2 MD, and Richard W. Smalling, 1 * MD, PhD The purpose of this study was to evaluate prospectively the feasibility and accuracy of using echocardiographic measurements by transesophageal and intracardiac echocar- diography (TEE and ICE, respectively) for interatrial septal defect sizing during percuta- neous transcatheter closure. Forty-two patients underwent balloon sizing of interatrial septal defects using TEE in 21 of them and ICE in the other half. These measurements were correlated with quantitative fluoroscopic analysis and evaluated for bias and agree- ment between methods using a Bland-Altman analysis. Echocardiographic measure- ments were obtained by ICE and TEE in all patients. An excellent correlation was found between TEE and quantitative fluoroscopy (r  0.898; P < 0.001) and between ICE and quantitative fluoroscopy (r  0.876; P < 0.001), with a significant agreement (P < 0.001) and minimal positive bias toward the echocardiographic measurements. Both TEE and ICE are excellent methods of interatrial defect sizing when compared with quantitative fluoroscopic measurements. Catheter Cardiovasc Interv 2004;62:415– 420. © 2004 Wiley-Liss, Inc. Key words: patent foramen ovale; atrial septal defect; interatrial shunt closure INTRODUCTION Percutaneous transcatheter closure of patent foramen ovale (PFO) and atrial septal defects (ASDs) is an effec- tive technique that allows closure of these communica- tions with a short recovery time and minimal complica- tions [1–3]. Echocardiography has become essential for diagnosis of these interatrial communications [4] and for the selection of an adequate closure device [5]. During the procedure, echocardiography plays an important role assisting in device positioning, device deployment, and assessment of immediate closure results. To determine the appropriate size of closure device, defect sizing is measured under fluoroscopy using the waist of a com- pliant balloon while stretching the defect and has become a requisite to choose the appropriate device needed for adequate closure, especially in patients with atrial septal defects. Transesophageal echocardiography (TEE) [6 –9] and, more recently, intracardiac echocardiography (ICE) [10 –12] have been successfully used as guiding methods during these procedures. However, the accuracy in defect sizing using both echocardiographic methods has not been investigated. Therefore, the purpose of this study is to analyze the feasibility and accuracy of TEE and ICE compared with quantitative fluoroscopic measurements during interatrial defect sizing before closure. MATERIALS AND METHODS Study Population Forty-two consecutive patients referred for percutane- ous interatrial closure were included in the study (37 PFOs with cryptogenic stroke and 5 ASDs with hemo- dynamically significant shunts). In the first 21 of them, the interatrial septal defect was closed using TEE guid- 1 Division of Cardiology, University of Texas Medical School Houston, Houston, Texas 2 Division of Cardiology, St. Francis Hospital, State University of New York at Stony Brook, Roslyn, New York *Correspondence to: Dr. Richard W. Smalling, Division of Cardiology, University of Texas Medical School Houston, 6431 Fannin Street, MSB 1.244, Houston, TX 77030. E-mail: richard.w.smalling@uth.tmc.edu Received 26 September 2003; Revision accepted 27 February 2004 DOI 10.1002/ccd.20082 Published online in Wiley InterScience (www.interscience.wiley.com). Catheterization and Cardiovascular Interventions 62:415– 420 (2004) © 2004 Wiley-Liss, Inc.