Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5761_Библиотеки_им_академика_М_И_Перельмана
.pdf
190
Diagnosis
The patient was diagnosed with sustained VT, left ventricular hypertrophy, moderately severe mitral regurgitation, and
a perimembranous VSD, which was completely closed by
the aneurysm formation of the interventricular septum and
the septal leafl et of the tricuspid valve.
Lesson
Can a closed VSD produce sustained VT or is this VT due to
left ventricular hypertrophy or mitral regurgitation?
It has already been reported that in long-term follow-up of
patients undergoing surgical VSD closure, ventricular tachycardia occurs in 40 % of patients with ventricular approach
and 35 % with transarterial approach, while small residual
VSD was found only in 6 % of cases [ 93 ].
Fig. 60.2 Moderately severe mitral regurgitation is seen in the apical
four-chamber view. The mitral regurgitation is about 10 cm
2
in surface.
LA left atrium, LV left ventricle, RV right ventricle
Case 60 Ventricular Septal Defect Completely Closed
191
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_61, © Springer International Publishing Switzerland 2015
A 40-year-old woman presented with dyspnea on exertion
(functional class I). She had had two event-free child deliveries
before. Physical examination revealed an ejection systolic
murmur at the upper left sternal border.
Ventricular Septal Defect
with Subvalvular Pulmonary
Stenosis
Case 61
Fig. 61.1 The parasternal long-axis view shows a turbulent fl ow across
the interventricular septum, which is in favor of a perimembranous
ventricular septal defect (VSD). The VSD is below the aortic valve
( arrow ). LA left atrium, LV left ventricle, RV right ventricle, AO aorta
Fig. 61.2 The peak gradient across the VSD is 100 mmHg in the
parasternal long-axis view
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_61 ) contains supplementary
material, which is available to authorized users.
192
Diagnosis
Perimembranous VSD with subvalvular pulmonary stenosis.
Comment
Because there was no aortic insuffi ciency, prophylaxis for
infective endocarditis and follow-up were recommended.
Lesson
1. There are two relative indications for VSD closure: (a)
more than mild aortic regurgitation in the perimembranous and outlet type and (b) recurrent endocarditis.
2. One of the mechanisms for the prevention of pulmonary
hypertension is the hypertrophy of the right ventricular
outfl ow tract, which produces subvalvular pulmonary
stenosis.
3. The association between the VSD and valvular pulmonary stenosis is rare. If there is a gradient across pulmonary valve with VSD, it is most probably subvalvular
dynamic pulmonary stenosis due to a compensatory
mechanism or Tetralogy of Fallot [ 94 – 97 ].
a
b
Fig. 61.3 The parasternal short-axis view illustrates the turbulency below the pulmonary valve ( arrow ) ( a ), in favor of subvalvular pulmonary
stenosis. The peak gradient is 40 mmHg ( b ) and is dynamic type. RVOT right ventricular outfl ow tract, AO aorta, PA pulmonary artery
Case 61 Ventricular Septal Defect with Subvalvular Pulmonary Stenosis
193
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_62, © Springer International Publishing Switzerland 2015
A 22-year-old man with dyspnea on exertion (functional
class I) of recent duration referred to our echocardiography
laboratory. He had an ejection-type systolic murmur at the
pulmonic area. The electrocardiogram showed a tall R in the
right precordial leads.
Perimembranous Ventricular
Septal Defect and Subvalvular
Pulmonary Stenosis
with an Additional Apical VSD
Case 62
a
b
Fig. 62.1 The parasternal long-axis view reveals a systolic turbulent fl ow ( arrow ) in the right ventricle by the color-fl ow study ( a ). The right
ventricular wall is thick (about 9 mm) ( b ). LA left atrium, LV left ventricle, RV right ventricle, AO aorta
Fig. 62.2 The parasternal short-axis view demonstrates
a systolic turbulent fl ow ( arrow ) across the interventricular septum,
in favor of a perimembranous ventricular septal defect (VSD).
RVOT right ventricular outfl ow tract
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_62 ) contains supplementary
material, which is available to authorized users.
194 Case 62 Perimembranous Ventricular Septal Defect and Subvalvular Pulmonary Stenosis with an Additional Apical VSD
a
b
c
Fig. 62.3 There is a 104-mmHg gradient across the pulmonary valve
( a ). A careful evaluation demonstrates that there are two instances of
systolic turbulency in the right ventricular outfl ow tract: one ( arrow ) is
from the VSD and the other one ( curved arrow ) is the origin of the right
ventricular outfl ow tract obstruction ( b ), in the parasternal short-axis
view by the continuous wave Doppler ( a ) and color-fl ow ( b ) studies.
The pulmonary valve is not thick in the parasternal short-axis view ( c ).
PA pulmonary artery, AO aorta, RVOT right ventricular outfl ow tract
Fig. 62.4 There is another apical VSD ( arrow ) in the apex by the
apical four-chamber view. LV left ventricle, RV right ventricle
195Case 62 Perimembranous Ventricular Septal Defect and Subvalvular Pulmonary Stenosis with an Additional Apical VSD
Diagnosis
The patient was diagnosed with a perimembranous VSD, in
addition to a muscular VSD and subvalvular pulmonary
stenosis.
Comment
The patient was referred for surgical closure of the VSDs and
the reconstruction of the right ventricular outfl ow tract.
a
b
Fig. 62.5 Transesophageal echocardiography (long-axis view) reveals that there is a VSD (about 11 mm in size) ( a ) and that the rim of the VSD
to the aortic valve is 9 mm ( b ). LA left atrium, LV left ventricle, RV right ventricle, AO aorta
197
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_63, © Springer International Publishing Switzerland 2015
A 35-year-old woman presented with dyspnea on exertion
(functional class II) of recent accentuation. Physical examination showed a systolic ejection murmur at the pulmonic
area. Electrocardiography revealed a prominent R in the
right precordial leads.
Ventricular Septal Defect
and Subvalvular Pulmonary
Stenosis
Case 63
a
a b
b
RVOT
Fig. 63.1 The parasternal long-axis view illustrates a turbulent systolic
fl ow across the ventricular septum, in favor of a perimembranous ventricular septal defect (VSD) ( arrow ) by the color Doppler fl ow study
( a ). The peak gradient across this defect is about 113 mmHg ( b ). LA left
atrium, LV left ventricle, AO aorta, RVOT right ventricular outfl ow tract
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_63 ) contains supplementary
material, which is available to authorized users.
198
a
c
b
Fig. 63.2 The perimembranous VSD is also evident in the parasternal
short-axis view by two-dimensional echocardiography ( a ) and the color
Doppler fl ow study ( arrows ) ( b ). The defect is about 11 mm in size in
this view ( c ). The narrowing of the right ventricular outfl ow tract is
evident in the short-axis view by two-dimensional echocardiography
( arrow head ) ( a ). PA pulmonary artery, RVOT right ventricular outfl ow
tract, AO aorta
Case 63 Ventricular Septal Defect and Subvalvular Pulmonary Stenosis
199
a
c
b
Fig. 63.3 There is also another systolic turbulent fl ow ( arrowhead ) in the right ventricular outfl ow tract ( a , b ) with a 72-mmHg peak gradient ( c )
in the parasternal short-axis view. PA pulmonary artery, PV pulmonary valve, AOV aortic valve, RVOT right ventricular outfl ow tract
Fig. 63.4 Transesophageal echocardiography (TEE) (short-axis view)
also confi rms that there are two instances of systolic turbulency in this
view: one ( arrow ) from the aortic valve (7 o’clock) toward the right
ventricle and the other one ( curved arrow ) below the pulmonary valve
in the right ventricular outfl ow tract
Case 63 Ventricular Septal Defect and Subvalvular Pulmonary Stenosis
200
Diagnosis
The patient was diagnosed with a perimembranous VSD and
subvalvular pulmonary stenosis.
Comment
The patient was referred for surgery.
a
b
Fig. 63.5 TEE (long-axis view) demonstrates the perimembranous VSD ( arrow ) ( a ), which measures 4 mm ( b ) with no rim to the aortic valve.
LA left atrium, LV left ventricle, AO aorta, RV right ventricle
Case 63 Ventricular Septal Defect and Subvalvular Pulmonary Stenosis
Соседние файлы в папке Библиотека им академика М.И. Перельмана