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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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221
a
b
c
d
Fig. 70.5 Trifurcation of the pulmonary artery is seen in this paraster-
nal short-axis view ( arrowhead ) ( a ). There is a large duct between the
pulmonary artery and the aorta ( arrowhead ) ( b ). A turbulent fl ow is
seen from the duct toward the pulmonary artery in systole ( arrowhead )
( c ), but this fl ow ( arrowhead ) in diastole is non-turbulent ( d ). AO aorta,
PA , pulmonary artery, RPA right pulmonary artery, LPA left pulmonary
artery, DAO descending aorta
Fig. 70.6 Contrast injection reveals the appearance of the contrast in
the descending aorta, which is in favor of a bidirectional fl ow
( arrowhead ). PA pulmonary artery, AO aorta
Case 70 Patent Ductus Arteriosus with Eisenmenger’s Syndrome
222
Diagnosis
The patient was diagnosed with a large PDA and pulmonary
arterial hypertension with a bidirectional fl ow across it. The
pulmonary vascular resistance and systemic vascular resistance were 10 and 28 units, respectively. The patient was
given oxygen for 10 min, and the mean pulmonary arterial
pressure reached 75 mmHg (the decrease was 10 % but the
absolute value not <40 mmHg) [ 29 , 30 , 75 , 90 , 100 , 101 ].
Comment
The patient was referred for catheterism and evaluation of
the pulmonary vascular resistance after the administration of
nitric oxide.
Lesson
1. In the atrial septal defect, there is right atrial and ventricular dilation because the two ventricles are fi lled with
the same pressure. In the normal heart, the left atrial
pressure is 5 mmHg greater than the right atrial pressure.
In the ventricular septal defect (VSD) and PDA, there is
left atrial and ventricular dilation. In the VSD, the blood
fl ow is from the left ventricle toward the right ventricle
and the pulmonary artery. Because the VSD fl ow is a systolic one, it goes to the pulmonary artery and then to the
left atrium and ventricle. In the PDA, the fl ow goes from
the aorta to the pulmonary artery and then to the left
atrium and ventricle. Right ventricular dilation in the
PDA and VSD is in favor of an increased pulmonary
arterial pressure.
2. A fl at interventricular septum in diastole is in favor of
right ventricular volume overload, whereas a fl at one in
systole is in favor of pulmonary arterial hypertension.
3. The appearance of the contrast material in the descending
aorta suggests a bidirectional shunt across the PDA.
a
c
b
Fig. 70.7 Transesophageal echocardiography (0°) shows the turbu-
lent fl ow in the descending aorta ( arrowhead ) ( a ). This fl ow is red in
systole ( arrowhead ) (from pulmonary artery to aorta) ( a ) and blue in
diastole ( arrowhead ) (from aorta to pulmonary artery) ( b ). There is a
large communication between the pulmonary artery and the aorta
( arrowhead ) ( c ). DAO descending aorta, PA pulmonary artery
Case 70 Patent Ductus Arteriosus with Eisenmenger’s Syndrome
223
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_71, © Springer International Publishing Switzerland 2015
A middle-aged man with a history of clubbing and cyanosis,
easy fatigability, and systolic and faint diastolic murmurs in the
second intercostal space was referred to our echocardiography
laboratory. Echocardiography revealed normal left ventricular
size and function with paradoxical septal motion and severely
dilated right ventricle with mild systolic dysfunction.
Large Patent Ductus Arteriosus
(Type A) with Eisenmenger’s
Syndrome
Case 71
Fig. 71.1 Two-dimensional echocardiography (short-axis view) shows
a severely dilated (about 58 mm) main pulmonary artery and a patent
ductus arteriosus (PDA) tunnel ( arrow ). DAO descending aorta, MPA
main pulmonary artery, RPA right pulmonary artery
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_71 ) contains supplementary
material, which is available to authorized users.
224
a
b
Fig. 71.2 There is a continuous fl ow from the pulmonary artery toward
the descending aorta in systole ( blue ) ( arrow ) ( a ) and from the descend-
ing aorta toward the pulmonary artery in diastole ( b ) ( arrow ), which is
in favor of a bidirectional PDA fl ow. The fl ow is still turbulent in systole
but is nonturbulent in diastole ( a , b ), short-axis view. AO aortic valve,
PA pulmonary artery, DAO descending aorta
Fig. 71.3 The short-axis view depicts moderate pulmonary insuffi -
ciency ( arrow ahead ) and right ventricular hypertrophy ( arrow ). PA
pulmonary artery
Fig. 71.4 Continuous wave Doppler fl ow across the pulmonary valve
in the short-axis view demonstrates that the early diastolic peak gradient of the pulmonary insuffi ciency is about 64 mmHg and that the mean
pulmonary arterial pressure is about 64 mmHg
Case 71 Large Patent Ductus Arteriosus (Type A) with Eisenmenger’s Syndrome
225
Diagnosis
The patient was diagnosed with a large PDA type A and
Eisenmenger’s syndrome.
Comment
Given the patient’s high pulmonary arterial systolic pressure,
sildenafi l and bosentan were prescribed. Additionally, catheterism and measurement of the pulmonary vascular resistance with nitric oxide and oxygen were recommended.
Lesson
If pulmonary vascular resistance is less than 8 units or if it is
between 8 and 12 units but there is pulmonary vascular reactivity to vasodilators (>10 % drop in the mean pulmonary
arterial pressure with vasodilators like nitric oxide and oxygen of an absolute value less than 40 mmHg or decrease in
pulmonary vascular resistance more than 33 %), the patient
can be referred for PDA closure [ 29 , 30 , 100 , 101 ].
Fig. 71.6 The parasternal short-axis view by two-dimensional echo-
cardiography reveals that the PDA tunnel is approximately 32 mm in
length. Also, the pulmonic side of the PDA is 19 mm, and its aortic side
is 22 mm. MPA main pulmonary artery, DAO descending aorta, AO
aorta
Fig. 71.5 The tricuspid regurgitation gradient is 95 mmHg in the api-
cal four-chamber view by the continuous wave Doppler fl ow study
Case 71 Large Patent Ductus Arteriosus (Type A) with Eisenmenger’s Syndrome
227
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_72, © Springer International Publishing Switzerland 2015
An 18-year-old female, who had undergone the device clo-
sure of a patent ductus arteriosus (PDA) a few months previously, was referred to us for control echocardiography.
Patent Ductus Arteriosus
Device Closure
Case 72
Fig. 72.1 The parasternal short-axis view, with some angulation,
shows the good position of the PDA device closure ( arrow ). PA pulmo-
nary artery, AO aorta
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_72 ) contains supplementary
material, which is available to authorized users.
228
Diagnosis
The patient had successful PDA device closure without complications and obstruction. There was no residual PDA.
Lesson
Sometimes the device closure of the PDA can produce turbulency and gradient in the descending aorta similar to a
coarctation, but signifi cant obstruction does not occur;
obstruction of the left pulmonary artery has been reported
with a rate of about 2 % [ 80 ].
a
b
c
Fig. 72.2 The suprasternal long-axis view demonstrates the bulging of the PDA device closure ( arrow ) toward the descending aorta ( a ) without
producing turbulency ( arrow ) ( b ) and gradient ( c ). DAO descending aorta, Arch aortic arch
Case 72 Patent Ductus Arteriosus Device Closure
229
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_73, © Springer International Publishing Switzerland 2015
A 38-year-old woman presented with a history of palpitation
and a systolic ejection murmur at the upper left sternal border. She had given birth to two children without symptoms,
and her body surface area was equal to 1.7/m
2
.
Echocardiography revealed normal left ventricular and right
ventricular sizes and systolic functions.
Tetralogy of Fallot with an
Additional VSD, Good Nakata Index,
and Abnormal Course of the
Coronary Artery
Case 73
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_73 ) contains supplementary
material, which is available to authorized users.
Fig. 73.1b The VSD is about 20 mm in size ( b ). LA left atrium, LV left
ventricle, RV right ventricle, AO aorta
b
a
Fig. 73.1a The parasternal long-axis view depicts the overriding of
the aorta, right ventricular hypertrophy ( double arrow ), ventricular
septal defect ( VSD ) ( arrow ), and malalignment of the interventricular
septum ( a )
230
a
b
Fig. 73.2 The modifi ed
apical four-chamber views
demonstrate a bidirectional
shunt fl ow across the VSD
( arrows ) ( a , b ), turbulent red
fl ow in systole, and
nonturbulent blue fl ow in
diastole ( a , b ). LA left atrium,
LV left ventricle, RV right
ventricle
Case 73 Tetralogy of Fallot with an Additional VSD, Good Nakata Index, and Abnormal Course of the Coronary Artery
231
Fig. 73.3 An additional small muscular VSD (about 4 mm) can be
seen near the apex in this apical four-chamber view. LA left atrium, LV
left ventricle, RA right atrium, RV right ventricle
a
b
Fig. 73.4 The abnormal course of the coronary artery is visible in the short-axis view: the green arrow shows the course of the coronary artery
( a ) and its fl ow ( b ). LA left atrium, RA right atrium, AO aorta
Case 73 Tetralogy of Fallot with an Additional VSD, Good Nakata Index, and Abnormal Course of the Coronary Artery
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