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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5761_Библиотеки_им_академика_М_И_Перельмана
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144
Diagnosis
The patient was diagnosed with a perimembranous VSD,
which was partially closed by the septal leafl et of the tricuspid valve [ 75 ].
Comment
The patient’s Qp/Qs was about 1.4 and her systolic pulmonary arterial pressure was approximately 30 mmHg.
Consequently, follow-up and prophylaxis for infective endocarditis were recommended for her.
Lesson
One of the mechanisms for spontaneous VSD closure is by
the septal leafl et of the tricuspid valve, but a small residual
VSD may persist. Our patient was asymptomatic and had a
Qp/Qs of less than 1.5 and a normal systolic pulmonary arterial pressure; therefore, there was no need for intervention.
However, there was still the risk of infective endocarditis for
this small VSD, requiring prophylaxis.
Case 44 Perimembranous Ventricular Septal Defect Partially Closed with the Septal Leafl et of the Tricuspid Valve
145
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_45, © Springer International Publishing Switzerland 2015
An 8-year-old boy, who had been under observation since he
was 1, presented with a harsh systolic murmur at the lower
left sternal border and apex. He weighed about 30 kg, and he
had no respiratory infection.
Perimembranous Ventricular
Septal Defect Partially Closed by
the Septal Leaflet of the Tricuspid
Valve
Case 45
ab
Fig. 45.1 The parasternal short-axis view shows a turbulent fl ow ( arrow ) across the interventricular septum, in favor of a perimembranous ventricu-
lar septal defect (VSD) ( a ). The systolic peak gradient across the defect is about 90 mmHg ( b ). LV left ventricle, RVOT right ventricular outfl ow tract
Fig. 45.2 The VSD is not evident in the parasternal long-axis view. LA
left atrium, LV left ventricle, RV right ventricle, AO aorta
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_45 ) contains supplementary
material, which is available to authorized users.
146
Diagnosis
Perimembranous VSD partially closed by septal leafl et of
tricuspid valve
Comment
The patient’s Qp/Qs was 1.4 and his systolic pulmonary arterial pressure was approximately 30 mmHg. Prophylaxis for
infective endocarditis and follow-up were, therefore,
recommended.
Lesson
There are some mechanisms for the spontaneous (complete
or incomplete) closure of a perimembranousVSD:
1. By aneurysm formation of the interventricular septum
2. By the septal leafl et of the tricuspid valve
3. By the noncoronary or right coronary cusp of the aortic
valve
4. By fi bromuscular ridge or spur formation [ 76 ]
Sometimes, there are combinations of different mecha-
nisms. Spontaneous closure may be incomplete, and, for
example, there may be a defect at the center of the aneurysm.
The risk of infective endocarditis remains unchanged, however [ 75 ].
ab
Fig. 45.3 The VSD is 4 mm in size ( a ). The defect is partially closed by the septal leafl et of the tricuspid valve ( arrow ) ( b ) in the parasternal short
LA left atrium, RA right atrium, AO aortic valve, RVOT right ventricular outfl ow tract
Case 45 Perimembranous Ventricular Septal Defect Partially Closed by the Septal Leafl et of the Tricuspid Valve
147
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_46, © Springer International Publishing Switzerland 2015
A 12-year-old girl, weighing 45 kg, referred to our center.
Physical examination showed a holosystolic murmur at the
apex and left sternal border. She was asymptomatic.
Muscular Ventricular Septal Defect
in the Lower Part of the
Interventricular Septum
Case 46
Fig. 46.1 There is a turbulent fl ow toward the right ventricle ( arrow ) in the
right ventricular infl ow view, in favor of a muscular ventricular septal defect
(VSD). LA left atrium, LV left ventricle, RA right atrium, RV right ventricle
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_46 ) contains supplementary
material, which is available to authorized users.
148
Diagnosis
The patient was diagnosed with a muscular VSD, located in
the lower part of the septum.
Comment
The patient’s left-to-right shunt was approximately 1.2, and
her systolic pulmonary arterial pressure was approximately
20 mmHg. Accordingly, prophylaxis for bacterial endocarditis and follow-up were recommended.
Lesson
Muscular VSDs may be located in the lower part of the interventricular septum (below the moderator band). Muscular
types of VSDs account for about 20 % of all VSDs and are
more prone to spontaneous closure compared with the other
types of VSDs [ 7 , 75 , 76 ].
Fig. 46.3 The apical four-chamber view shows the turbulent fl ow of
the VSD ( arrow ) below the moderator band ( curved arrow ), in favor of
a lower muscular VSD. LA left atrium, LV left ventricle, RA right
atrium, RV right ventricle
a
b
Fig. 46.2 The parasternal short-axis view depicts the muscular VSD in the anteroseptal midportion ( arrow ) ( a ). The peak gradient across the
defect is 103 mmHg ( b ). LV left ventricle, RV right ventricle
Case 46 Muscular Ventricular Septal Defect in the Lower Part of the Interventricular Septum
149
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_47, © Springer International Publishing Switzerland 2015
A 23-year-old man presented with dyspnea on exertion
(functional class II). Physical examination revealed a harsh
systolic murmur at the lower left sternal border and apex.
The peak gradient across the VSD is 70 mmHg, and the
systolic pulmonary arterial pressure is about 30 mmHg.
Muscular Ventricular Septal
Defect Located High in
Interventricular Septum
Case 47
Fig. 47.1 The parasternal short-axis view shows a turbulent fl ow
across the interventricular septum, in favor of a muscular ventricular
septal defect (VSD) ( arrow ). LV left ventricle, RV right ventricle
Fig. 47.2 The muscular VSD is also evident in the apical four- chamber
view ( arrow ). LA left atrium, LV left ventricle, RA right atrium, RV right
ventricle
Fig. 47.3 The VSD is not visualized in the parasternal long-axis view.
LA left atrium, LV left ventricle, RV right ventricle, AO aorta
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_47 ) contains supplementary
material, which is available to authorized users.
150
Diagnosis
The patient was diagnosed with a muscular VSD, located
high in the interventricular septum.
Comment
The patient was symptomatic with a Qp/Qs of 1.5. There was
also a good distance between the VSD and the aortic valve.
As a result, VSD device closure was recommended for this
muscular VSD.
Lesson
VSD device closure is an alternate for surgery in muscular
types VSD. Now there is increasing experience for VSD
device closure in perimembranous type [ 2 , 7 ]. In early stages
of VSD device closure, when only the muscular devices is
available, the rim to aortic valve should be ≥5 mm; since the
membranous devices are available for VSD, device closure is
possible with the rim to aortic valve of only 2 mm [ 72 ].
Device size is chosen 1–2 mm greater than VSD size measured by echocardiography or angiography [ 72 ]. The available devices range between 4 and 18 mm [ 72 , 73 ].
Fig. 47.5 The right ventricular side of the VSD is 5 mm in size in the
parasternal short-axis view. LV left ventricle, RV right ventricle
ab
Fig. 47.4 The left ventricular side of the VSD is 9 mm in size in the parasternal short-axis ( a ) and apical four-chamber ( b ) views. LA left atrium,
LV left ventricle, RA right atrium, RV right ventricle
Case 47 Muscular Ventricular Septal Defect Located High in Interventricular Septum
151
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_48, © Springer International Publishing Switzerland 2015
A 28-year-old man presented with chest pain of 1-year duration. Physical examination revealed a harsh holosystolic
murmur at the apex and lower left sternal border.
Muscular Ventricular Septal Defect,
Intermediate Location in
Interventricular Septum
Case 48
ab
c
Fig. 48.1 The parasternal long-axis view demonstrates a turbulent
fl ow in the anteroseptal midportion, in favor of a muscular ventricular
septal defect (VSD) ( arrow ) ( a ). The peak gradient across the VSD is
approximately 109 mmHg ( b ). This is a schematic illustration of the
muscular VSD in the parasternal long-axis view ( c ). LA left atrium, LV
left ventricle, RV right ventricle, AO aorta
152
Diagnosis
The symptomatic patient was diagnosed with a muscular
VSD, in the intermediate location, and Qp/Qs = 1.7.
Comment
The patient had a suffi cient amount of rim to the aorta; as a
result, VSD device closure was recommended [ 2 , 7 , 72 , 77 ].
b
c
a
Fig. 48.2 Transesophageal echocardiography (TEE) (long-axis view)
shows that the left ventricular side of the defect is about 10 mm ( a ) and
the right ventricular side of the defect is 7 mm ( b ) in size. This is a
schematic depiction of this funnel-shaped muscular VSD on TEE
(long-axis view) ( c ). LA left atrium, LV left ventricle, RV right ventricle,
AO aorta
Case 48 Muscular Ventricular Septal Defect, Intermediate Location in Interventricular Septum
153
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_49, © Springer International Publishing Switzerland 2015
A 22-year-old woman presented with atypical chest pain of
2-year duration. Physical examination revealed a holosystolic murmur at the left sternal border.
Perimembranous Ventricular
Septal Defect with Fibromuscular
Ridge Formation in the Right
Ventricular Outflow Tract
Case 49
ab
Fig. 49.1 The parasternal long-axis view demonstrates a turbulent fl ow across the septum ( arrow ), in favor of a perimembranous ventricular septal
defect (VSD) ( a ). The peak gradient is approximately 130 mmHg ( b ). LA left atrium, LV left ventricle, RV right ventricle, AO aorta
ba
Fig. 49.2 The short-axis view shows a spur (fi bromuscular ridge) formation in the right ventricle in the site of the VSD closure ( arrow ) ( a ). This
is a schematic illustration of the spur formation ( b ). LA left atrium, RA right atrium, AO aorta, RV right ventricle, PA pulmonary artery
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