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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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165
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_53, © Springer International Publishing Switzerland 2015
A 32-year-old woman, who had been followed up in our center for the previous 8 years, developed atypical chest pain.
Physical examination showed a holosystolic murmur at the
left sternal border.
Echocardiography revealed normal left ventricular and
right ventricular sizes as well as systolic functions, Qp/Qs of
1.3, peak pulmonary arterial systolic pressure of 35 mmHg,
and trivial aortic insuffi ciency.
Doubly Committed Ventricular
Septal Defect
Case 53
ab
Fig. 53.1 The parasternal long-axis view demonstrates a turbulent
fl ow across the interventricular septum ( arrow ), in favor of a ventricular
septal defect (VSD) ( a ). The VSD is 6 mm in size ( b ). There is also
dilation of the ascending aorta. LA left atrium, LV left ventricle, RV
right ventricle, AO aorta
166
ab
c
Fig. 53.2 The short-axis view illustrates the position of the defect
below both pulmonary and aortic valves. A doubly committed VSD
( arrow ) ( a ) can also be seen here. The VSD is 5.4 mm in size in this
view ( b ). A schematic depiction of the doubly committed VSD
(short-axis view) is presented here ( c ). LA left atrium, RA right atrium,
RV right ventricle, RVOT right ventricular outfl ow tract, AO aorta, PA
pulmonary artery, VSD ventricular septal defect
Fig. 53.3 The peak gradient across the VSD is 91 mmHg in the
parasternal long-axis view
Case 53 Doubly Committed Ventricular Septal Defect
167
Diagnosis
The patient was diagnosed with a doubly committed VSD.
Comment
Considering that the patient was asymptomatic and had a
Qp/Qs of 1.3 and an upper limit of normal peak pulmonary
arterial systolic pressure (35 mmHg), prophylaxis for infective endocarditis and follow-up were recommended.
Fig. 53.4 This is the VSD in the apical fi ve-chamber view ( arrow ). LA
left atrium, LV left ventricle, RA right atrium, RV right ventricle, AO
aorta
Case 53 Doubly Committed Ventricular Septal Defect
169
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_54, © Springer International Publishing Switzerland 2015
A 24-year-old man, who had previously undergone device
closure for a ventricular septal defect (VSD) in our center,
was referred to our echocardiography laboratory for
follow-up echocardiography. He was totally asymptomatic.
Ventricular Septal Defect
Device Closure
Case 54
ab
c
Fig. 54.1 The VSD device closure is evident in the parasternal long-axis ( a ), parasternal short-axis ( b ), and apical four-chamber ( c ) views
( arrow ). LA left atrium, LV left ventricle, RA right atrium, RV right ventricle, AO aorta, RVOT right ventricular outfl ow tract
170
Diagnosis
The patient was diagnosed with a perimembranous VSD,
which was successfully closed by device. No residual shunt
or obstructive effect was seen on other organs.
Lesson
The perimembranous VSD can be closed by intervention. The
rim to the aortic valve must be more than 2 mm [ 72 ]. Amplatzer
VSD occluder membranous and muscular are available in
sizes between 4 and 18 mm. Membranous occluder type
extends 0.5 mm in the aortic end and 5.5 mm in the apical end
on the LV side. Right ventricular disk is symmetric and extends
4 mm, and the length is 1.5 mm. Muscular VSD occluder
extends 8 mm at the waist and the length is 7 mm [ 80 ]. Device
size is chosen 1–2 mm larger than VSD size measured by
echocardiography or angiography [ 72 ].
The possible complications of VSD device closure
include (1) complete atrioventricular block, (2) prolapse of
aortic leafl ets and aortic regurgitation, and (3) embolization
of device [ 72 ]. Tricuspid regurgitation severity improves following membranous VSD closure [ 81 ].
Fig. 54.2 The apical four-chamber view shows no obstruction or pres-
sure effect by the VSD device closure ( arrow ) on the other organs. LA
left atrium, LV left ventricle, RA right atrium, RV right ventricle
Case 54 Ventricular Septal Defect Device Closure
171
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_55, © Springer International Publishing Switzerland 2015
A 16-year-old male, completely asymptomatic with a history
of surgery for ventricular septal defect (VSD) closure 2 years
previously, was referred to us for follow-up echocardiography. Physical examination revealed a continuous murmur
(grade IV/VI) at the left sternal border.
Echocardiography showed a normal left ventricular size
and systolic function and a normal right ventricular size and
function.
Residual Ventricular Septal Defect
Post Surgery (Patch Closure)
Case 55
ba
Fig. 55.1 The parasternal long-axis view illustrates continuous systolic ( a ) and diastolic ( b ) turbulency toward the right ventricle ( arrow ) originat-
ing around the aortic valve. AOV aortic valve, AO aorta, RV right ventricle
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_55 ) contains supplementary
material, which is available to authorized users.
172
Comment
Given the continuous fl ow, the following differential diagnoses were considered for the patient:
1. Rupture of the sinus of Valsalva to the right ventricle
2. Fistula of the right coronary artery to the right ventricle
(although this anomaly has a diastolic accentuation of
fl ow, since the perfusion of the coronary arteries is dominated in diastole)
3. Low probability of the rupture of the VSD patch
Consequently, transesophageal echocardiography (TEE) was
conducted to make a defi nite diagnosis.
ab
c
Fig. 55.2 The short-axis view depicts the defect ( arrow ) at 10 o’clock ( a ) as well as systolic ( b ) and diastolic ( c ) turbulency ( arrow ) across it.
AOV aortic valve
Fig. 55.3 The color-fl ow Doppler study in the parasternal long-axis
view shows a continuous fl ow across this defect (systolic and diastolic)
with a peak velocity of about 4 ms
Case 55 Residual Ventricular Septal Defect Post Surgery (Patch Closure)
173
Diagnosis
The patient was diagnosed with a large VSD following the
fi rst surgery for VSD closure.
Comment
Given the pulmonary arterial systolic pressure of 50 mmHg
and the absence of rim to the aortic valve, the patient was
referred for VSD patch closure by surgery.
Lesson
The VSD fl ow is almost always systolic but there are rare
cases with systolic and diastolic fl ow [ 82 , 83 ].
Fig. 55.5 The size of the defect is 11 mm on TEE (short-axis view)
Fig. 55.4 TEE (long-axis view) shows that the site of the defect is in
the close proximity of the aortic valve without any rim to the aortic
valve. LVOT left ventricular outfl ow tract
Case 55 Residual Ventricular Septal Defect Post Surgery (Patch Closure)
175
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_56, © Springer International Publishing Switzerland 2015
A 33-year-old man presented with a seizure of recent onset.
He was a known case of a ventricular septal defect (VSD)
from childhood. Physical examination showed a harsh
systolic murmur at the lower sternal border and apex.
Ventricular Septal Defect
with Infective Endocarditis
Case 56
Fig. 56.1 There is a turbulent fl ow across the ventricular septum
toward the right ventricle, in favor of a VSD. LA left atrium, LV left
ventricle, RA right atrium, RV right ventricle
ab
Fig. 56.2 The VSD is not evident in the parasternal long-axis ( a ) and short-axis ( b ) views. LA left atrium, LV left ventricle, AO aorta, RV right
ventricle, AOV aortic valve
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_56 ) contains supplementary
material, which is available to authorized users.
176
Fig. 56.3 The VSD is partially closed by the aneurysm formation of
the interventricular septum and the septal leafl et of the tricuspid valve
( arrow ). LA left atrium, LV left ventricle, RA right atrium, RV right
ventricle
Fig. 56.4 The tricuspid regurgitation gradient is about 18 mmHg in the
apical four-chamber view
ab
Fig. 56.5 The VSD cannot be visualized on transesophageal echocardiography (TEE) short-axis ( a ) and long-axis ( b ) views. LA left atrium,
LV left ventricle, AO aorta, RV right ventricle, AOV aortic valve
Case 56 Ventricular Septal Defect with Infective Endocarditis
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