Echogenicity and echocardiographic guidance

We have read with great interest the article 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 by Chen et al. (1). In their study, they reported that lone echocardiographic guidance with transcatheter device closure of atrial septal defects is safe and effective as fluoroscopic and echocardiographic guidance together. I have made the following comments and concerns. When we compare the groups, the ages ranged from 3 to 75 years for group I and from 4 to 60 years for group II. Echogenicity is the major concern in both echocardiographic assessment and guidance especially in the older patient population.