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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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264
ab
Fig. 81.7 ( a , b ) The two-dimensional echocardiography and the color-
fl ow Doppler study (subcostal views) show the connection of the inferior vena cava to the right atrium (atrial situs solitus) and the systemic
venous baffl e ( green arrow ), which drains the systemic venous fl ow
( orange arrows ) into the pulmonary ventricle. IVC inferior vena cava,
IAS interatrial septum, RA right atrium
a
b
Fig. 81.6 ( a , b ) The apical four-chamber view and the schematic illus-
tration of the four-chamber view show that there is a linear density in
the left atrium (interatrial baffl e, green arrow ), which seems to have
divided the left atrium into two cavities. The posterior cavity is the pulmonary vein baffl e, through which ( orange arrow ) the pulmonary veins
drain into the systemic ventricle, and the anterior cavity is the systemic
venous baffl e, which drains the systemic venous fl ow into the pulmonary ventricle. 1 pulmonic baffl e (PVB), 2 right atrium, 3 systemic ven-
tricle (anatomical right ventricle), 4 systemic vein pathway, 5 pulmonary
ventricle (anatomical left ventricle). PV pulmonary vein, MV mitral
valve, TV tricuspid valve
Case 81 Senning Operation with Acceptable Intra-Baffl e Gradients
265
Fig. 81.8 The suprasternal short-axis view demonstrates the systemic
venous baffl e (Crab view). SVC superior vena cava
a
c
b
Fig. 81.9 The apical four-chamber view shows that the systemic ven-
tricle (anatomical right ventricle) is dilated and the size of the pulmonary ventricle (anatomical left ventricle) is relatively small ( a ). Also,
there is moderate atrioventricular valve regurgitation from the systemic
ventricle ( a ) with a peak gradient of about 56 mmHg across it ( b ). The
systemic ventricular function is severely impaired, S’ is about 7 cm/s
( c ), and the fractional area change is 13 % (not shown in this view)
Case 81 Senning Operation with Acceptable Intra-Baffl e Gradients
266
Diagnosis
The patient was diagnosed with the complete transposition
of the great arteries with an atrial switch operation (Senning)
and good function of the two baffl es [ 112 ].
Comment
It seemed that the patient’s symptoms were in consequence
of severe systemic ventricular dysfunction. Therefore,
medical treatment and follow-up were recommended.
Lesson
Although the intra-baffl e mean gradient of 14–15 mmHg is
reported high and of 4 mmHg is acceptable [ 112 ], the exact
mean gradient that needs intervention remains to be
identifi ed.
ab
Fig. 81.10 The pulse wave tissue Doppler study across the systemic venous baffl e ( a ) and pulmonary valve baffl e ( b ) shows a blunted S wave
(S<D), in favor of a reduced fl ow across the baffl e s
Fig. 81.11 The gradients across the systemic venous baffl e are accept-
able. (The peak and mean gradients are 8.8 and 2.4 mmHg, respectively.) The peak gradient across the pulmonary vein baffl e is 6 mmHg
(not shown in this view)
Case 81 Senning Operation with Acceptable Intra-Baffl e Gradients
267
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_82, © Springer International Publishing Switzerland 2015
A 35-year-old man presented with dyspnea on exertion
(functional class II–III) of recent duration. Physical
examination showed a systolic murmur at the apex and the
lower left sternal border.
Corrected Transposition
of the Great Arteries
Case 82
c
ab
Fig. 82.1 The parasternal long-axis view shows that there is no fl ow
from the left atrium and the systemic ventricle toward the great artery
(which indeed is the pulmonary artery) by two-dimensional echocardiography and the color-fl ow study ( a , b ). Also, there is severe systemic atrio-
ventricular valve regurgitation ( arrow ). This is a schematic illustration of
the connection between the left atrium and the right ventricle and the
absence of a connection between the right ventricle and the pulmonary
artery ( c ). LA left atrium, RV right ventricle, PA pulmonary artery
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_82 ) contains supplementary
material, which is available to authorized users.
268
a
b
c
Fig. 82.2 The parasternal short-axis view reveals that the great artery, which is positioned posteriorly, is divided, and so is the pulmonary artery
( a – c ). RA right atrium, LV left ventricle, PA pulmonary artery, RPA right pulmonary artery, LPA left pulmonary artery
Case 82 Corrected Transposition of the Great Arteries
269
a
b
c
Fig. 82.3 The left atrium, which is connected to the left atrial append-
age and receives the pulmonary veins ( curved arrows ) ( a ), is also con-
nected to the right ventricle. The Eustachian valve at the entrance of the
inferior vena cava is a marker of the right atrium ( arrow ) ( a ). The mod-
erator band is also a marker of the right ventricle ( arrowhead ) ( a ). The
lower insertion of the tricuspid valve, which is always attached to the
right ventricle as opposed to the mitral valve, is evident ( arrow ) ( b ).
A schematic depiction of the congenitally corrected transposition of the
great arteries in the apical four-chamber view is presented here ( c ).
LA left atrium, RV right ventricle, RA right atrium, LV left ventricle,
LAA left atrial appandage
Case 82 Corrected Transposition of the Great Arteries
270
b
a
Fig. 82.4 Transesophageal echocardiography (TEE) (0°) shows the
lower insertion of the atrioventricular valve, which is connected to the
left atrium (posterior atrium); this is in favor of the tricuspid valve,
which is almost always attached to the right ventricle ( a ). This is a sche-
matic presentation of the congenitally corrected transposition of the
great arteries on TEE (0°) ( b ). LA left atrium, RV right ventricle, RA
right atrium, LV left ventricle, TV tricuspid valve, MV mitral valve
Fig. 82.5 Severe systemic atrioventricular valve regurgitation (indeed
tricuspid regurgitation) is patent on TEE (short-axis view). LA left
atrium, RV right ventricle
b
a
Fig. 82.6 TEE (long-axis view) demonstrates the connection of the left
atrium (posterior atrium) to the ventricle, which is connected to the
aorta. Also, the conus can be seen below the aortic valve ( arrow ) ( a ),
between the tricuspid valve and the aortic valve. This is a schematic
illustration of the congenitally corrected transposition of the great arteries on TEE (long-axis view) ( b ). LA left atrium, RV right ventricle, PA
pulmonary artery, AO aorta
Case 82 Corrected Transposition of the Great Arteries
271
a
b
Fig. 82.7 TEE (89°) shows the connection of the anterior atrium (right
atrium) to the ventricle, which is connected to the pulmonary artery ( a ).
A schematic presentation of this connection is presented in this view
( b ). LA left atrium, RA right atrium, LV left ventricle, PA pulmonary
artery
b
a
Fig. 82.8 These are the pulmonary artery and the aorta, side by side
( a ), on TEE (short-axis view). A schematic depiction of this side-by-
side position on TEE (short-axis view) is presented ( b ). LA left atrium,
RA right atrium, LV left ventricle, AO aorta, PA pulmonary artery
Case 82 Corrected Transposition of the Great Arteries
272
Diagnosis
The patient was diagnosed with congenitally corrected
transposition of the great arteries, severe tricuspid (systemic
atrioventricular valve) regurgitation, and mild systemic
ventricular dysfunction (right ventricular ejection fraction of
about 45 %).
Comment
The patient was referred for surgery, i.e., systemic atrioventricular valve replacement.
Lesson
Congenitally corrected transposition of the great arteries is a
congenital anomaly whose symptoms usually appear in the
third or fourth decade of life. In this anomaly, there is a ventricular inversion. The left atrium connects to the right ventricle, which connects to the aorta. The right atrium connects
to the left ventricle, which connects to the pulmonary artery.
And fi nally, the aorta is positioned anteriorly to the pulmonary artery. Consequently, the desaturated blood from the
right atrium enters the pulmonary artery and the oxygenated
blood from the pulmonary veins enters the aorta. However,
the problem is that the right ventricle and the tricuspid valve
are not designed for systemic ventricular pressure, so the
symptoms and signs of systemic ventricular failure and systemic atrioventricular valve incompetence gradually appear.
The typical presentation is usually a 30–40-year-old patient
with dyspnea on exertion, and it is diagnosed as mitral regurgitation with left ventricular systolic dysfunction. Exact
echocardiography reveals that there is a ventricular inversion
and tricuspid regurgitation [ 2 , 113 ].
Fig. 82.9 A patent foramen ovale with a left-to-right shunt ( arrow ) is
patent on TEE (short-axis view). LA left atrium, RA right atrium, LV left
ventricle
Case 82 Corrected Transposition of the Great Arteries
273
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_83, © Springer International Publishing Switzerland 2015
A 34-year-old woman presenting with dyspnea on exertion
(functional class III) was referred to our echocardiography
laboratory for a precise evaluation of her severe mitral
regurgitation and left ventricular systolic dysfunction prior
to surgery.
Congenitally Corrected
Transposition of the Great
Arteries with Subaortic Stenosis
Case 83
Fig. 83.1 The apical four-chamber view depicts a ventricular inver-
sion. The lower insertion of the tricuspid valve is connected to the left
atrium and the systemic atrioventricular valve. LA left atrium, RV right
ventricle, RA right atrium, LV left ventricle
Fig. 83.2 The left ventricle is connected to the mitral valve (higher
insertion), reaching a great artery, which is divided (the pulmonary
artery) (arrow) , in the modifi ed apical four-chamber view. LV left ven-
tricle, RV right ventricle, PA pulmonary artery, RPA right pulmonary
artery, LPA left pulmonary artery
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_83 ) contains supplementary
material, which is available to authorized users.
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