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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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154
Fig. 49.3 The apical fi ve-chamber view illustrates a left-to-right shunt
fl ow through the VSD across the septum ( arrow ). LA left atrium, LV left
ventricle, RV right ventricle, AO aorta
Fig. 49.4 This is a four-dimensional reconstruction of the VSD
( arrow ) on transthoracic echocardiography (parasternal long-axis
view). LA left atrium, LV left ventricle, RV right ventricle
Case 49 Perimembranous Ventricular Septal Defect Partially Closed by Fibromuscular Ridge Formation
155
ab
c
d
e
Fig. 49.5 Transesophageal echocardiography (TEE) (long-axis view)
shows that the VSD is 6 mm in size on the left ventricular side ( a ),
3 mm on the right ventricular side ( b ), and 8 mm in length ( c ). The rim
to the aorta is approximately 11 mm ( d ). A schematic illustration of the
funnel- shaped VSD and its rim to the aorta is presented ( e ). LA left
atrium, LV left ventricle, RV right ventricle, AO aorta
Case 49 Perimembranous Ventricular Septal Defect Partially Closed by Fibromuscular Ridge Formation
156
Diagnosis
The patient was diagnosed with a perimembranous VSD,
which was partially closed by spur formation in right ventricular outfl ow tract.
Comment
The patient had a Qp/Qs of 1.1 and a systolic peak arterial
pressure of 22 mmHg. Therefore, VSD closure was recom-
mended on condition that the patient was truly symptomatic
[ 7 , 75 ].
Lesson
Fibromuscular ridge or spur formation with or without subaortic obstruction is seen in 3–6 % of perimembranous VSDs
[ 76 ], but it is rare in the right ventricular outfl ow tract.
ab
Fig. 49.6 The spur formation or fi bromuscular ridge is visible in the right ventricle near the VSD on TEE (long-axis view) ( a , b ) ( arrows ). LA left
atrium, LV left ventricle, RV right ventricle, AO aorta
Case 49 Perimembranous Ventricular Septal Defect Partially Closed by Fibromuscular Ridge Formation
157
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_50, © Springer International Publishing Switzerland 2015
A 70-year-old man presented with chest pain and new recent
inferior myocardial infarction. Physical examination revealed
S1, S2, and S4 together with a normal jugular venous pressure. There was no cyanosis or clubbing.
Echocardiography showed normal left ventricular size,
moderate left ventricular systolic dysfunction, left ventricular ejection fraction of about 40 %, and normal right ventricular size with mild right ventricular systolic dysfunction.
Ventricular Septal Defect Almost
Closed by the Aneurysm Formation
of the Septum
Case 50
ab
Fig. 50.1 There is an aneurysm formation in the base of the interven-
tricular septum ( arrow ) in the apical four-chamber view ( a ). The color
Doppler study shows a faint red nonturbulent fl ow ( arrow ) ( b ), in favor
of a small ventricular septal defect (VSD), which is almost closed by an
aneurysmal formation at the base of the interventricular septum. LA left
atrium, LV left ventricle
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_50 ) contains supplementary
material, which is available to authorized users.
158
Diagnosis
The patient was diagnosed with a VSD, which was almost
closed by an aneurysm formation of the interventricular
septum.
Lesson
The spontaneous closure of a VSD occurs until adulthood
and is more common in the perimembranous type of VSDs.
The aneurysm formation of the interventricular septum is
one of the common mechanisms for the closure of perimem-
branous VSDs, and it is fairly common that a small defect
remains open in its center or around the center. In such cases,
prophylaxis for infective endocarditis should be given to the
patient [ 75 ].
Inferior myocardial infarction may produce aneurysm
formation in the septal basal and the inferior basal. In this
patient, although VSD post myocardial infarction is a differential diagnosis, but usually VSD post myocardial infarction produces more symptoms and hemodynamic instability,
so it is a less probable diagnosis.
ab
c
Fig. 50.2 The apical four-chamber view illustrates the tricuspid valve
leafl et in systole ( a ) and diastole ( b ), which is completely independent
of the septal basal aneurysm and does not participate in the closing of
the VSD. The yellow arrow ( a ) shows the septal tricuspid valve leaf-
let, and the green arrow points to the aneurysmal formation at the
base of the septum. This is a schematic illustration of the VSD, which
is partially closed by the aneurysm formation at the base of the interventricular septum ( c ). LA left atrium, LV left ventricle, RA right
atrium, RV right ventricle, PV pulmonary vein, VSD ventricular septal
defect
Case 50 Ventricular Septal Defect Almost Closed by the Aneurysm Formation of the Septum
159
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_51, © Springer International Publishing Switzerland 2015
A young woman with a history of harsh systolic murmur on
physical examination was referred to our echocardiography
laboratory for an evaluation of the systolic murmur. She had
a holosystolic murmur (grade III/VI) at the left sternal border, and there was no clubbing and cyanosis.
Echocardiography revealed a normal left ventricular size
and global systolic function as well as a normal right ventricular size and systolic function.
Ventricular Septal Defect Partially
Closed by the Aneurysm Formation
of the Septal Basal Segment and
Septal Leaflet of Tricuspid Valve
Case 51
Fig. 51.1 The apical fi ve-chamber view shows a perimembranous
ventricular septal defect (VSD) ( arrow ) just below the aortic valve in
the color-fl ow Doppler study. LA left atrium, LV left ventricle, RA right
atrium, RV right ventricle, AO aortic valve
Fig. 51.2 The VSD ( arrow ) is partially closed by the septal leafl et of
the tricuspid valve and the aneurysmal formation of the basal segment
of the interventricular septum. LA left atrium, LV left ventricle, RA right
atrium, RV right ventricle, AO aorta
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_51 ) contains supplementary
material, which is available to authorized users.
160
Diagnosis
The patient was diagnosed with a perimembranous VSD,
which was partially closed by the septal leafl et of the tricuspid valve and the aneurysm formation of the septum.
Comment
Given the small size of the VSD, Qp/Qs of 1.3, and normal
pulmonary arterial systolic pressure, the patient was not candidated for VSD closure. Only prophylaxis for subacute bacterial endocarditis was, therefore, recommended [ 2 , 75 ].
b
a
Fig. 51.5 The VSD ( green arrow ) is almost closed by the aneurysmal
formation at the base of the interventricular septum ( curved arrow ) and
the septal leafl et of the tricuspid valve ( straight yellow arrow ) on TEE
(four-chamber view) ( a ). This is a schematic illustration of the VSD,
which is partially closed by the septal leafl et of the tricuspid valve and
the aneurysm formation of the basal segment of the interventricular
septum ( b ). LA left atrium, LV left ventricle, RA right atrium, RV right
ventricle, VSD ventricular septal defect
Fig. 51.3 The apical fi ve-chamber view demonstrates a very small
remnant of the VSD ( arrow ), about 2 mm in size. LA left atrium, LV left
ventricle, RA right atrium, RV right ventricle, AO aorta
Fig. 51.4 Transesophageal echocardiography (TEE) (long-axis view)
depicts the perimembranous VSD ( arrow ). LA left atrium, LV left ven-
tricle, AO aorta
Case 51 Ventricular Septal Defect Partially Closed by the Aneurysm Formation of the Septal Basal Segment
161
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_52, © Springer International Publishing Switzerland 2015
A 25-year-old man presented with palpitation and dyspnea
on exertion (functional class II) of recent duration. Physical
examination revealed a harsh systolic murmur at the fourth
and third left sternal borders. The left ventricle was
moderately dilated (64 mm), and there was mild left ventricular systolic dysfunction. Also, there was mild tricuspid
regurgitation, and the pulmonary arterial systolic pressure
was about 40 mmHg.
Doubly Committed Ventricular
Septal Defect with No Aortic
Regurgitation
Case 52
b
c
a
Fig. 52.1 The parasternal long-axis view reveals a turbulent fl ow
( arrow ) across the interventricular septum, in favor of a ventricular sep-
tal defect (VSD) ( a ). The peak gradient across the VSD is about
115 mmHg ( b ). The VSD measures 4 mm in this view ( c ). 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_52 ) contains supplementary
material, which is available to authorized users.
162
Fig. 52.2 The parasternal short-axis view demonstrates that the fl ow
of the VSD ( arrow ) enters the right ventricle near the pulmonary valve.
Accordingly, the VSD is doubly committed or is an outlet type.
PV pulmonary valve, AOV aortic valve
c
ab
Fig. 52.3 Transesophageal echocardiography (TEE) (short-axis view)
confi rms the entrance of the fl ow into the right ventricle near the pulmonary valve ( arrow ) ( a ) by the color-fl ow study. Two-dimensional
echocardiography shows the defect ( arrow ) ( b ). The defect measures
5 mm in this view and is located at 5 o’clock ( c ). AOV aortic valve,
PA pulmonary artery, PV pulmonary valve
Case 52 Doubly Committed Ventricular Septal Defect with No Aortic Regurgitation
163
Diagnosis
The patient was diagnosed with a doubly committed VSD.
Comment
The patient was symptomatic and had moderate left ventricular dilation, Qp/Qs of 1.6, and pulmonary arterial systolic
pressure of 40 mmHg (mildly elevated). Consequently, surgery was recommended.
Lesson
1. The VSD device closure is used for muscular and perimembranous defects and not for doubly committed or
outlet-type ones.
2. The doubly committed VSD is believed to be more common in the Asian population, although in our experience
it is rare.
3. The doubly committed VSD may be associated with aortic regurgitation [ 7 , 76 ].
4. One of the relative indications for surgery in the doubly
committed VSD and the perimembranous VSD is more
than mild aortic regurgitation [ 2 , 78 , 79 ].
5. The doubly committed VSD means that the defect is
related to both aorta and pulmonic valves. It is also called
“the outlet type,” “supracristal VSD,” “subarterial VSD,”
“subpulmonic VSD,” and “infundibular [ 7 ] VSD” in some
references.
c
ab
Fig. 52.4 TEE (long-axis view) reveals that the VSD is nearly attached
to the aortic valve without any rim ( arrows ) by the color Doppler study
( a ) and two-dimensional echocardiography ( b ). There is no aortic
regurgitation ( arrow ) in this view ( c ). LA left atrium, LV left ventricle,
RV right ventricle, AO aorta
Case 52 Doubly Committed Ventricular Septal Defect with No Aortic Regurgitation
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