3D TEE in Interatrial Septum Imaging: Insights from a Rare Anatomical Anomaly

Imaging the interatrial septum (IAS) is a fundamental part of transesophageal echocardiography (TEE), especially in:

• Transseptal puncture
• Structural heart interventions
• Congenital and acquired septal abnormalities

While 2D TEE provides useful information, it is often limited in fully characterizing complex septal anatomy.

With the advancement of real-time 3D transesophageal echocardiography (3D TEE), we now have the ability to visualize the IAS in its true anatomical form.

📄 Original Image Case Publication

Read the original case here:
👉 https://pubmed.ncbi.nlm.nih.gov/25411253/

🎥 Watch: How to Image the Interatrial Septum (RATLe-90 Maneuver)

To master IAS imaging using 3D TEE, watch this open-access CIC lecture:

👉 https://ciceg.net/courses/online-advanced-echocardiography-course/lessons/how-to-image-the-inter-atrial-septum-using-3d-tee-ratle-90-maneuver/

🎯 This lecture covers:

• Standard IAS imaging views
• 3D TEE acquisition
• RATLe-90 maneuver
• Practical tips for clinical use

Case Overview: A Rare Interatrial Septal Anomaly

A 51-year-old female with severe mitral regurgitation underwent TEE evaluation.

🔍 Findings:

• On 2D TEE:
  • A ridge-like structure was seen on the left atrial side of the IAS
• On 3D TEE:
  • The structure was clearly visualized as:
    • A longitudinal ridge from the left atrial perspective
    • A corresponding depression on the right atrial side

📌 As demonstrated in the images of the article, 3D TEE provided a complete spatial understanding of this structure that was not fully appreciated in 2D

Understanding the Anatomy

This rare anomaly is thought to result from:

👉 Abnormal fusion between:

• Septum primum
• Septum secundum

This leads to:

• Prominent enfolding toward the left atrium
• Corresponding depression on the right atrium

Why 3D TEE Was Critical

❌ Limitations of 2D TEE:

• Shows only slices
• Cannot fully represent spatial relationships
• May miss complex morphology

✅ Advantages of 3D TEE:

• En face visualization of IAS
• True anatomical orientation
• Simultaneous visualization of both atrial aspects

This is clearly illustrated in the multi-panel images of the publication, where 3D imaging reveals the full geometry of the septum

Clinical Implications

Understanding such anatomical variations is crucial for:

🔹 1. Transseptal Procedures

• Avoid incorrect puncture sites
• Prevent complications

🔹 2. Structural Heart Interventions

• MitraClip
• LAA closure
• ASD/PFO procedures

🔹 3. Accurate Diagnosis

• Avoid misinterpretation of unusual structures

The Role of Standardized 3D Imaging (RATLe-90)

To consistently visualize the IAS:

👉 The RATLe-90 maneuver provides:

• Anatomically oriented en face view
• Better spatial understanding
• Standardized imaging approach

🎥 (Explained step-by-step in the lecture above)

From Rare Cases to Daily Practice

Although this is a rare anomaly, the key message is broader:

💡 3D TEE should be routinely used for IAS assessment

Because:

• Many subtle anatomical variations exist
• These variations can affect procedural outcomes
• 3D imaging reduces uncertainty

🎓 Learn Advanced 3D TEE & Structural Echo

If you want to master:

• Interatrial septum imaging
• 3D TEE acquisition
• Transseptal guidance
• Structural heart procedures

👉 Explore CIC Online Echocardiography Courses:
🔗 https://ciceg.net/cic-courses/

✔️ Real clinical cases
✔️ Practical step-by-step teaching
✔️ On-demand access
✔️ Designed for cardiologists worldwide

Conclusion

This case highlights the incremental value of 3D TEE in understanding complex interatrial septal anatomy.

By providing true anatomical visualization, 3D TEE:

• Enhances diagnostic accuracy
• Improves procedural planning
• Reduces complications

It reinforces a key concept:

👉 “If you want to understand anatomy… think in 3D, not 2D.”