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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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286
Diagnosis
The patient was diagnosed with severe valvular and
subvalvular pulmonary stenosis.
Comment
The patient was referred for pulmonary valvuloplasty and
underwent a successful valvuloplasty.
Lesson
Infundibular hypertrophy with a dynamic gradient tends to
regress over the subsequent months following valvuloplasty
or surgery. Propranolol will help this regression [ 116 ]. Mild
valvular pulmonary stenosis is not usually a progressive
lesion, but moderate valvular pulmonary stenosis is a progressive disease due to calcifi cation of the valve and infundibular reactive myocardial hypertrophy [ 7 ].
ab
Fig. 87.3 There is also severe narrowing of the subpulmonic area ( arrow ) ( a ). The turbulency begins below the pulmonary valve with a velocity
of about 3 (m/s) in the right ventricular outfl ow tract view
ab
Fig 87.2 The right ventricular outfl ow tract view demonstrates turbulency across the pulmonary valve ( arrow ) ( a ). The velocity is about 6 (m/s),
and the peak gradient is 139 mmHg in the parasternal short-axis view ( b ). RVOT right ventricular outfl ow tract, PA pulmonary artery
Case 87 Severe Valvular and Subvalvular Pulmonary Stenosis
287
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_88, © Springer International Publishing Switzerland 2015
A 36-year-old woman presented with lower extremity edema
and dyspnea on exertion (functional class II) of 2-year duration. She had given birth to fi ve children and had mild symptoms during the pregnancies. Physical examination revealed
a systolic ejection murmur in the pulmonic area.
Electrocardiography showed right-axis deviation and right
ventricular hypertrophy.
Severe Valvular Pulmonary
Stenosis and Bicuspid
Pulmonary Valve
Case 88
Fig. 88.1 The parasternal short-axis view shows systolic turbulency in
the pulmonary artery, which is in favor of pulmonic stenosis. RVOT
right ventricular outfl ow tract, PA pulmonary artery, AO aorta
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_88 ) contains supplementary
material, which is available to authorized users.
288
ab
cd
Fig. 88.2 Two -dimensional ( a ) and even four-dimensional reconstruc-
tion ( b ) suggest a membrane below the pulmonary valve in the paraster-
nal short-axis view ( arrow ). Transesophageal echocardiography (TEE)
(short-axis view) in the upper esophageal area reveals only a severe
valvular pulmonary stenosis without a membrane ( c ) and a gradient of
about 136 mmHg across the pulmonary valve ( d ). RVOT right ventricu-
lar outfl ow tract, PA pulmonary artery, AO aorta, PV pulmonary valve
Case 88 Severe Valvular Pulmonary Stenosis and Bicuspid Pulmonary Valve
289
Diagnosis
The patient was diagnosed with severe valvular pulmonary
stenosis and severe right ventricular systolic dysfunction.
Comment
The patient was referred for surgery. However, due to severe
pulmonary stenosis, there was a risk of right ventricular suicide. (Fatal right ventricular failure occurs immediately postoperatively in rare cases [ 116 ]).
After cardiac surgery (pulmonary valvuloplasty), the
patient underwent transthoracic echocardiography.
Lesson
Right ventricular dilation is not a common fi nding in pulmonary stenosis. When there is right ventricular dilation,
accompanied by pulmonary stenosis, two diagnoses are possible: (1) an accompanying atrial septal defect and (2) right
ventricular systolic dysfunction.
Fig. 88.4 The high parasternal short-axis view reveals a bicuspid pul-
monary valve after surgery (commissurotomy). AO aorta, PV pulmo-
nary valve
Fig. 88.3 A severe right atrial and right ventricular enlargement can be
seen on TEE (0°). There was severe right ventricular systolic
dysfunction. RA right atrium, RV right ventricle
Case 88 Severe Valvular Pulmonary Stenosis and Bicuspid Pulmonary Valve
291
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_89, © Springer International Publishing Switzerland 2015
A 20-year-old woman with a history of atypical chest pain
was referred to our echocardiography laboratory for more
precise evaluation. Physical examination showed a systolic
ejection murmur (grade III/VI) and a diastolic murmur
(grade II/VI) in the second left intercostal space.
Echocardiography revealed normal left and right ventricular
sizes and functions, together with mild right ventricular
hypertrophy.
Moderate Valvular Pulmonary
Stenosis with Moderate
Pulmonary Regurgitation
Case 89
Fig. 89.1 The arrow in this short-axis view shows a thick pulmonic
valve in diastole. AO aortic valve, RPA right pulmonary artery, PV pul-
monary valve
Fig. 89.2 The parasternal short-axis view shows systolic turbulency in
the main pulmonary artery by the color-fl ow Doppler study, indicative
of pulmonary stenosis. AO aortic valve, PA pulmonary artery
Fig. 89.3 Transesophageal echocardiography (TEE) (short-axis view)
depicts a dilated main pulmonary artery (about 51 mm). LA left atrium,
RA right atrium, AO aortic valve, PA pulmonary artery
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_89 ) contains supplementary
material, which is available to authorized users.
292
The peak and mean gradients across the pulmonary valve
were 50 and 25 mmHg, respectively.
Diagnosis
The patient was diagnosed with moderate valvular pulmonary stenosis and moderate pulmonary regurgitation.
Comment
Because the patient had moderate valvular pulmonary stenosis and moderate pulmonary insuffi ciency, follow-up echocardiography was recommended.
Fig. 89.5 The vena contracta of the pulmonary insuffi ciency is 3 mm,
and the width of the pulmonary insuffi ciency/right ventricular outfl ow
tract is approximately 5/15 on TEE (short-axis view)
ab
Fig. 89.4 A diastolic fl ow ( arrows ) is seen across the pulmonic valve, suggestive of moderate pulmonary insuffi ciency. ( a , b ) Transthoracic
echocardiography and TEE (short-axis views). AO aorta
Case 89 Moderate Valvular Pulmonary Stenosis with Moderate Pulmonary Regurgitation
Peripheral Pulmonary Stenosis:
ab
()()
()
()
Moderate Restenosis of Right
Pulmonary Artery Stenting
A 12-year-old boy with a history of balloon dilation and
stenting of the right pulmonary artery branch stenosis was
referred to our echocardiography laboratory. Physical
examination showed an ejection systolic murmur (grade II/
VI) at the first and second left intercostal spaces.
Case 90
Fig. 90.1 The modified short-axis view shows the pulmonary artery
stenting (arrow) and a turbulent flow within. R VOT right ventricular
outflow tract, PA pulmonary artery
Fig. 90.2 The velocity of the proximal portion of the right pulmonary artery stent is measured at 205 cm/s (about 2.05 m/s, peak gradient
of 16.8 mmHg) (a). The velocity of the distal portion of the right pulmonary artery stent is measured at 399 cm/s (3.99 m/s, peak gradient
of 63.3 mmHg) (b). According to the Bernoulli equation, the gradient across the device is estimated as follows:
42 243992×− =× −
velocity of distal velocityof proximal.22052 40.
pulmonary artery was 90 mmHg
Electronic supplementary material The online version of this
chapter (doi:10.1007/978-3-319-12934-1_90) contains supplementary
material, which is available to authorized users.
= mmHg
. Before stenting, the peak gradient across the right
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_90, © Springer International Publishing Switzerland 2015
293
294
Case 90 Peripheral Pulmonary Stenosis: Moderate Restenosis of Right Pulmonary Artery Stenting
Diagnosis
The patient was diagnosed with moderate stenosis of the
right pulmonary artery stenting.
Comment
Given that the patient was asymptomatic, follow-up was recommended. An indication for intervention in peripheral pulmonary artery stenosis is pulmonary in-stent restenosis. Stent
restenosis for peripheral pulmonary artery stenosis is not very
uncommon and 24 % in a recently published article [117].
295
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_91, © Springer International Publishing Switzerland 2015
A 46-year-old woman presented with dyspnea on exertion
(functional class II) and palpitation. Physical examination
showed a systolic ejection murmur at the left sternal border
and an early diastolic murmur in the aortic area.
Subvalvular Aortic Stenosis
(Membranous Type Without
Attachment to Anterior Mitral
Leaflet) with Severe Left
Ventricular Outflow Tract
Obstruction and Severe Aortic
Regurgitation
Case 91
ab
Fig. 91.1 The apical long-axis view shows a membrane ( curved
arrow ) below the aortic valve ( arrow ) ( a ), which is thick and calcifi ed.
The membrane is 12 mm in size and is situated 18 mm below the aortic
valve ( b ), with no attachment to the anterior mitral leafl et. LA left
atrium, LV left ventricle, RV right ventricle, AO aorta
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_91 ) contains supplementary material,
which is available to authorized users.
296
Diagnosis
The patient was diagnosed with membranous subvalvular
aortic stenosis, severe left ventricular outfl ow tract gradient,
severe aortic regurgitation, and no attachment of the
membrane to the anterior mitral leafl et.
Comment
Given the patient’s peak gradient of 67 mmHg and severe
aortic insuffi ciency, she was referred for surgery for the
resection of the subvalvular membrane and aortic valve
replacement.
Lesson
1. In subvalvular aortic stenosis (membranous type), there
may be an attachment to the anterior mitral leafl et [ 2 , 86 ].
2. A mean gradient greater than 30 mmHg is an indication
for surgery [ 2 , 118 ]. Nevertheless, some authors regard
a peak gradient greater than 50 mmHg as an indication
for surgery and more than mild aortic regurgitation
[ 119 ]. Guidelines of the European society regard mean
gradient ≥50 mmHg as an indication for surgery; progressive aortic regurgitation to more than mild is of
class IIb [ 7 ].
3. Although aortic regurgitation regresses in a large number
of cases after subaortic web resection, aortic valve
replacement is preferable when there is severe aortic
regurgitation [ 7 ].
Fig. 91.3 The parasternal long-axis view reveals severe aortic insuffi -
ciency ( arrow ). LA left atrium, LV left ventricle, RV right ventricle, AO
aorta
Fig. 91.2 This membrane produces a peak gradient of 67 mmHg and a
mean gradient of 42 mmHg in the left ventricular outfl ow tract
Case 91 Membranous Subvalvular Aortic Stenosis with Severe Obstruction
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