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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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254
Fig. 79.2 Dextrocardia is demonstrated in the subcostal four-chamber
view. The cardiac apex ( arrow ) is located on the right side of the chest
a
b
Fig. 79.3 In the subcostal short-axis and four-chamber views, the infe-
rior vena cava is connected to the right atrial chamber ( a ), and the
Eustachian valve is placed in the right atrial chamber ( arrowhead ) ( b ).
Consequently, the right atrial chamber is the anatomical right atrium
(the atrial situs is solitus) ( a , b ). HV hepatic vein, IVC inferior vena
cava, RA right atrium
a
b
Fig. 79.4 In the apical four-chamber and subcostal four-chamber
views, there is a fi ngerlike appendage in the left-sided atrial chamber
( arrowhead a ), and the pulmonary veins are connected to this chamber
( b ). Accordingly, the left-sided chamber is the anatomical left atrium
( a , b ). LAA left atrial appendage, PV pulmonary vein
Case 79 Modifi ed Blalock–Taussig Shunt
255
Fig. 79.5 The subcostal four-chamber view demonstrates a large atrial
septal defect (secundum type) ( arrowhead )
Fig. 79.6 The subcostal four-chamber view shows that the two atrio-
ventricular valves ( 1 and 2 ) are on the same level ( arrowhead ) and that
there is no obvious interventricular septum
Fig. 79.7 The apical four-chamber view shows a ventricular septal
defect ( arrowhead ), which is functionally equivalent of a single
ventricle
Case 79 Modifi ed Blalock–Taussig Shunt
256
Fig. 79.9 The aorta is anterior and left-sided to the pulmonary artery,
which is in favor of the transposition of the great arteries. AO aorta,
PA pulmonary artery
a
b
c
Fig. 79.8 The two great arteries originate from a single ventricle, and the
aorta is in the anterior position relative to the pulmonary artery (bifurcated artery). The arrowheads show the left and right pulmonary artery
branches. The pulmonary valve annulus is signifi cantly smaller than the
aortic annuls ( a ). There is a turbulent fl ow in the pulmonary artery and its
branches ( arrowhead ), suggestive of pulmonary stenosis ( b ). The peak
gradient across the pulmonary valve is 76.9 mmHg ( c ). AO aorta, PA
pulmonary artery, PV pulmonary valve, Single V single ventricle
Case 79 Modifi ed Blalock–Taussig Shunt
257
a
c
e
d
b
Fig. 79.10 The color-fl ow Doppler study (suprasternal short-axis
view) reveals a turbulent continuous fl ow ( arrowhead ) from the right
subclavian artery into the right pulmonary artery ( a ). Two-dimensional
echocardiography demonstrates that a conduit ( * ) is located between
the aorta and the superior vena cava, which connects the right subclavian artery ( 1 ) to the right pulmonary artery; this is suggestive of a right
modifi ed Blalock–Taussig shunt ( b ). The peak gradient across this
shunt is approximately 54/22 mmHg ( c ). This is a schematic illustration
of the suprasternal short-axis view, depicting the connection between
the right subclavian artery via the Blalock–Taussig shunt ( pink color )
and the right pulmonary artery ( d ). The schematic illustration of the
heart of this patient depicts the connection between the right subclavian
artery and the right pulmonary artery via the Blalock–Taussig shunt ( e ).
AO aorta, AOV aortic valve, PV pulmonary vein, RPA right pulmonary
artery, SVC superior vena cava, BT shunt Blalock–Taussig shunt, LA
left atrium, LV left ventricle, RA right atrium, RV right ventricle
Case 79 Modifi ed Blalock–Taussig Shunt
258
Diagnosis
Dextrocardia, complex cardiac lesion equivocal to single
ventricle, pulmonary stenosis undergone modifi ed BT shunt
Lesson
For echocardiographic evaluation of the BT shunt, gradients
are not reliable and serial echocardiography is needed [ 108 ].
Modifi ed BT shunt seldom causes pulmonary hypertension
and is less likely to cause pulmonary distortion [ 2 ]. It is of
notice that like every prosthetic conduit, Gore-Tex of BT
shunt does not change with growth of child and so the patient
will develop cyanosis with time when the shunt is implanted
in early life.
a
c
b
Fig. 79.11 There is another turbulent fl ow near the right pulmonary
artery ( arrowhead ), indicating the main aortopulmonary collateral
artery in the suprasternal short-axis view ( a and b ) and the continuous
wave tissue Doppler study across the main aortopulmonary collateral
artery ( c ). MAPCA major aortopulmonary collateral artery
Case 79 Modifi ed Blalock–Taussig Shunt
259
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_80, © Springer International Publishing Switzerland 2015
A 12-year-old boy, who had undergone the Senning operation at 2 years old because of the transposition of the great
arteries, was referred to our center due to dyspnea on
exertion (functional class I). The systemic ventricle showed
a mildly reduced ejection fraction.
Senning Operation with Mild
Systemic Ventricular Dysfunction
Case 80
Fig. 80.1 The modifi ed parasternal long-axis view depicts the bifurca-
tion of the great artery ( arrow ), which is connected to the left ventricle,
left atrium, and indeed pulmonary artery. LA left atrium, PA pulmonary
artery
260
Diagnosis
The patient was diagnosed with the complete transposition
of the great arteries with an atrial switch operation (Senning)
and no obstruction in venous baffl es and mild systemic ventricular dysfunction (right ventricular ejection fraction of
about 45 %).
Comment
Medical therapy and follow-up were recommended for the
patient.
Lesson
Frequent cardiac abnormalities post atrial switch include:
1. Right ventricular dysfunction and tricuspid regurgitation
2. Atrial arrhythmia
3. Residual intra-atrial shunts
4. Caval and pulmonary pathway obstruction [ 109 – 112 ]
Residual intra-atrial baffl e shunts are readily detectable
by color Doppler study. They produce systemic-to- pulmonary
or pulmonary-to-venous shunting.
Fig. 80.3 The apical four-chamber view demonstrates that the sys-
temic venous fl ow is conducted toward the left atrium through a septal
fl ap just below the artifi cial defect ( arrow ). LA left atrium, LV left
ventricle, RA right atrium, RV tight ventricle
a
b
Fig. 80.2 The apical four-chamber view shows the baffl e, which con-
ducts the fl ow of the pulmonary veins through an artifi cial defect in the
interatrial septum ( arrow ) toward the right atrium, which is connected
to the right ventricle and aorta, in the color-fl ow study ( a ) and two-
dimensional echocardiography ( b ). LA left atrium, LV left ventricle, RA
right atrium, RV tight ventricle
Case 80 Senning Operation with Mild Systemic Ventricular Dysfunction
261
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_81, © Springer International Publishing Switzerland 2015
An 8-year-old girl, who had levo-transposition of the great
arteries and a history of the Senning operation performed
2 years previously, was referred to our echocardiography
laboratory.
Senning Operation with
Acceptable Intra-Baffle
Gradients
Case 81
Fig. 81.1 The apical four-chamber view identifi es the anatomical left
and right ventricles. The right-sided ventricle has hypertrabeculation,
and the right atrioventricular valve insertion into the septum is more
apical than the left atrioventricular valve. (The atrioventricular valves
are always associated with anatomical ventricles.) Accordingly, the
right-sided ventricle is the anatomical right ventricle. The left-sided
ventricle is smooth, and the papillary muscles are attached to the lateral
wall ( arrowhead ), which suggests that the left-sided ventricle is the
anatomical left ventricle (D loop)
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_81 ) contains supplementary
material, which is available to authorized users.
262
ab
Fig. 81.2 The modifi ed long-axis view and the pulse wave Doppler study across the aorta reveal that the aorta is connected to a hypertrabeculated
ventricle (anatomical right ventricle) ( a ) with mild aortic insuffi ciency ( b ). AO aorta, RV right ventricle, AI aortic insuffi ciency
Fig. 81.3 The modifi ed long-axis view depicts the anterior position of
the aorta and the posterior position of the pulmonary artery (bifurcated
artery). Arrows refer to branches of pulmonary artery. These two arter-
ies run parallel to each other, which is the opposite of the normal position. RV right ventricle, AO ascending aorta, PA pulmonary artery
Case 81 Senning Operation with Acceptable Intra-Baffl e Gradients
263
a
b
Fig. 81.4 The two-dimensional view and the schematic illustration of
the subcostal view of the great arteries demonstrate that the anterior
artery (the ascending aorta) is connected to the right ventricle and the
posterior artery (the pulmonary artery) is connected to the left ventricle,
suggestive of the transposition of the great arteries ( a , b ). AO ascending
aorta, PA pulmonary artery, LV left ventricle, RV right ventricle. The
pulmonary veins originated from the left atrium, inferior vena cava was
connected to the right atrium, left atrium was connected to the anatomical left ventricle, left ventricle was connected to the pulmonary artery,
right atrium was connected to the anatomical right ventricle, and right
ventricle was connected to the ascending aorta. The patient had atrioventricular concordance and ventriculoarterial discordance (levotransposition of the great arteries)
Fig. 81.5 The schematic illustration shows that the left atrium seems
to be divided into two cavities. The posterior cavity is the pulmonary
vein baffl e ( red color ), through which the pulmonary veins ( arrows )
drain into the right atrium and thence into the systemic ventricle (anatomical right ventricle). The anterior cavity is the systemic vein baffl e
( blue color ), through which the systemic venous fl ow drains into the
left atrium and thence into the pulmonary ventricle (anatomical left
ventricle)
Case 81 Senning Operation with Acceptable Intra-Baffl e Gradients
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