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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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a
b
c
Fig. 1.4 The ASD cannot be seen in the standard view of TEE (0°) ( a ). With some rotation, the defect is visualized ( b ). The ASD/interatrial
septum (IAS) is 21/30 ( b ), and the posterior rim is 8 mm ( c ). LA left atrium, RA right atrium
ab
Fig. 1.5 TEE ( short-axis view ) shows that the ASD/IAS is 17/37 ( a ), the rim to the aorta is 9 mm, and the atrial depth is 38 mm ( b ) [ 1 ]. LA left
atrium, RA right atrium, AO aorta
Case 1 Atrial Septal Defect (ASD) Ostium Secundum Type
4
Diagnosis
The patient was symptomatic with an ASD (ostium secundum type). The maximum size of the ASD was 21 mm by
TEE, and all the rims were greater than 5 mm.
Recommendation
Given the suitable rims and size of the ASD (ostium secundum type) and QP/QS of 2.5, the ASD device closure was
recommended.
Lesson
1. Severe right ventricular dilation indicates that a left-toright shunt in an ASD is signifi cant, especially in the
absence of other causes of right ventricular dilation such
as severe tricuspid regurgitation.
2. Qp/Qs >1.5 in an ASD (ostium secundum type) is an indication for intervention [ 2 ].
3. For measuring the ASD rims to the neighboring vital
organs, the posterior and anterior rims should be measured.
The posterior-superior and the posterior-inferior rims are
the superior and inferior vena cava rims, respectively. The
anterior-superior and the anterior- inferior rims are the rims
to aorta and the tricuspid valve, respectively. The absence
of rim to the aorta is not a contraindication for the ASD
device closure [ 3 – 5 ].
4. What is the possible diagnosis of a dilated right
ventricle?
4.1. ASD
4.2. Abnormal pulmonary venous return
4.3. Cor pulmonale and pulmonary thromboemboli
4.4. Severe tricuspid regurgitation
4.5. Pulmonary hypertension
4.6. Ebstein’s anomaly
4.7. Right ventricular dysplasia
4.8. Right ventricular dysfunction, e.g., due to right ven-
tricular infarction
5. In this patient, ASD was not visualized in classic 0° view,
so measurement of the rim to mitral or tricuspid valve was
not possible.
a
b
Fig. 1.6 TEE ( bicaval view ) shows that the ASD/IAS is 19/58 ( a ), the rim to the superior vena cava is 27 mm, and the rim to the inferior vena
cava is 14 mm ( b ). LA left atrium, RA right atrium
Case 1 Atrial Septal Defect (ASD) Ostium Secundum Type
5
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_2, © Springer International Publishing Switzerland 2015
A 17-year-old male presented with dyspnea on exertion
(functional class I) and a systolic murmur at the lower sternal border. Transthoracic echocardiography revealed an
atrial septal defect (ASD) (ostium secundum type) with the
Qp/Qs of 2 and the systolic peak arterial pressure of
40 mmHg.
Atrial Septal Defect (Ostium
Secundum Type) Attached
to the Coronary Sinus
Case 2
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_2 ) contains supplementary material,
which is available to authorized users.
Fig. 2.1 The apical four-chamber view shows severe right atrial and
ventricular enlargement, an ASD (ostium secundum type) ( arrow ), and
a prominent Eustachian valve ( curved arrow ). RA right atrium, LA left
atrium, RV right ventricle, LV left ventricle
a b
Fig. 2.2 The ASD is attached to the coronary sinus ( arrow head ), and
there is no rim to the coronary sinus on transesophageal echocardiography
(TEE) (0°) in the lower esophageal level ( arrow ) ( a ). This is a schematic
illustration of the ASD (ostium secundum type), which is attached to the
coronary sinus on TEE (0°) ( b ). LA left atrium, RA right atrium, LV left
ventricle, RV right ventricle, ASD atrial septal defect, CS coronary sinus
6
Diagnosis
There was an ASD (ostium secundum type) attached to the
coronary sinus.
Comment
Given the patient’s Qp/Qs of 2, mildly elevated systolic pulmonary arterial pressure, and absence of rim to the coronary
sinus, surgery was recommended.
Lesson
In case of an ASD (ostium secundum type), TEE (0°) in the
lower esophageal level is used for the visualization of the
coronary sinus. If the rim of the ASD to the coronary sinus is
not enough, surgery is recommended [ 3 – 5 ]. The rim to the
coronary sinus is not always measurable. Sometimes on TEE
(0°) in the lower esophageal level, where the coronary sinus
can be visualized, the ASD is not detectable.
Case 2 Atrial Septal Defect (Ostium Secundum Type) Attached to the Coronary Sinus
7
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_3, © Springer International Publishing Switzerland 2015
A 30-year-old woman presented with recent dyspnea on
exertion (functional class II). Physical examination revealed
an ejection systolic murmur at the second left intercostal
space and fi xed S2 splitting. Electrocardiography showed
normal sinus rhythm, right axis deviation, and rsr’ in leads
V1 and V2.
Atrial Septal Defect (Ostium
Secundum Type) with a Small Rim
to the Inferior Vena Cava
Case 3
Fig. 3.1 The parasternal long-axis view demonstrates right ventricular
dilation. LA left atrium, RV right ventricle, LV left ventricle, AO aorta
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_3 ) contains supplementary
material, which is available to authorized users.
8
ab
c
Fig. 3.3 Transesophageal echocardiography (TEE) (0°) demonstrates
that the ASD/interatrial septum (IAS) is 20/42 ( a ), the posterior rim is
11 mm, and the rim to the mitral valve is 14 mm ( b ). This is a schematic
illustration of the ASD (ostium secundum type) in this view ( c ). RA
right atrium, RV right ventricle, LA left atrium, ASDOS atrial septal
defect ostium secondum type
a b
Fig. 3.2 The apical four-chamber view demonstrates moderate right
ventricular dilation and the passage of the fl ow through the ASD
(ostium secundum type) ( arrow ) ( a ) from the left atrium toward the
right atrium. This is a schematic illustration of the ASD (ostium secundum type) ( b ). RA right atrium, RV right ventricle, LA left atrium, LV
left ventricle
Case 3 Atrial Septal Defect (Ostium Secundum Type) with a Small Rim to the Inferior Vena Cava
9
ab
d
c
Fig. 3.4 TEE ( short-axis view ) demonstrates that the ASD/IAS is
29/45 ( a ), the rim to the aorta is 8 mm and the opposite rim is 11mm
( b ), and the atrial depth is 30 mm ( c ). This is a schematic illustration of
the atrial depth and the rim to the aorta on TEE ( short-axis view ) ( d ). RA
right atrium, RV right ventricle, LA left atrium, AO aorta
Case 3 Atrial Septal Defect (Ostium Secundum Type) with a Small Rim to the Inferior Vena Cava
10
Diagnosis
The patient was symptomatic and was diagnosed with an
ASD (ostium secundum type) with moderate right ventricular enlargement and inadequate rim to the inferior vena cava.
Recommendation
Given the patient’s relatively small rim to the inferior vena
cava (5 mm), surgical ASD closure was recommended.
Lesson
It is important that the rims of an ASD (ostium secundum
type) to the superior and inferior venae cavae, mitral and
tricuspid valves, and coronary sinus be measured before the
ASD device closure. (These rims should be greater than
5 mm.) Moreover, the ASD should not be too large (stretched
balloon diameter <38–41 mm), and it should have suitable
anatomy [ 2 , 6 , 7 ].
Rims:
1. Posterosuperior rim: rim to the superior vena cava
2. Posteroinferior rim: rim to the inferior vena cava
3. Anterosuperior rim: rim to the aorta
4. Anteroinferior rim: rim to the tricuspid valve
5. Posterior rim on TEE (0°): rim to the right upper pulmonary vein [ 8 ]
a
c
b
Fig. 3.5 TEE ( bicaval view ) shows that the size of the ASD is 31 mm
( a ), the rim to the inferior vena cava is 5 mm, and the rim to the superior
vena cava is 25 mm ( b ). A schematic illustration of the ASD (ostium
secundum type) and its rims is presented in this view ( c ). RA right
atrium, LA left atrium, SVC superior vena cava, IVC inferior vena cava
Case 3 Atrial Septal Defect (Ostium Secundum Type) with a Small Rim to the Inferior Vena Cava
11
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_4, © Springer International Publishing Switzerland 2015
A 26-year-old pregnant woman, who had undergone surgical atrial septal defect (ASD) closure 2 years previously,
referred to our clinic for checkup. This was her second
pregnancy. During her fi rst pregnancy, she was diagnosed
with an ASD (ostium secundum type) with pulmonary arterial hypertension. The fi rst transthoracic echocardiography
and transesophageal echocardiography (TEE) demonstrated
that the size of the ostium secundum ASD was 36 mm; the
systolic and mean pulmonary arterial pressures were 110
and 55 mmHg, respectively; and the pulmonary and systemic vascular resistance was 7 and 20 units, respectively.
The mean pulmonary arterial pressure reached to 45 mmHg
with 10 minutes of oxygen, although it decreased up to
10 mmHg but mean pulmonary arterial pressure was still
more than 40 mmHg. Therefore, she underwent termination of her fi rst pregnancy before referral for cardiac surgery.
Follow-up echocardiography after cardiac surgery revealed
the following:
Atrial Septal Defect (Ostium
Secundum Type) with Pulmonary
Arterial Hypertension Subjected
to Patch Closure with a Valve
Case 4
Fig. 4.2 TEE (90°) shows the ASD, which is 7 mm in size. LA left
atrium, RA right atrium
Fig. 4.1 An ASD (ostium secundum type) ( arrow ) can be seen on
transthoracic echocardiography (four-chamber view). RA right atrium,
RV right ventricle, LV left ventricle
12
Comment
Because of the patient’s pulmonary arterial hypertension at
the time of surgery, the surgeon performed ASD double
patch closure with a check valve. Accordingly, only follow up was recommended for the patient. The fi rst postoperative
transthoracic echocardiography revealed a pulmonary arterial pressure (PAP) of 60 mmHg.
Lesson
1. This ASD (ASD double patch closure with a check valve)
should not be confused with a residual postoperative
ASD.
2. Before operation, despite the patient’s elevated pulmonary vascular resistance (7 unit), the left-to-right shunt
was still more than 1.5, and the pulmonary arterial systolic pressure was still subsystemic. The systolic pulmo-
nary artery pressure was 110 mmHg by catheterism, the
pulmonary arterial diastolic pressure was 40 mmHg, and
the aortic systolic pressure was 140 mmHg. Although
the ratio of pulmonary vascular resistance to systemic
vascular resistance was 7/20 (is equal to 0.35 < 2/3) and
the ratio of systolic pulmonary arterial pressure to systemic was 0.78 (more than 2/3), the left-to-right shunt
was more than 1.5 (1.85), so closure of atrial septal
defect seemed logic [ 2 , 7 , 9 ]. Use of fenestrated ASD
occluder has also been reported for ASD with pulmonary arterial hypertension [ 10 , 11 ]. In another study,
ASD occluder used with ASD and pulmonary vascular
resistance more than six units, if during 1 h of occlusion
mean pulmonary arterial pressure falls ≥20 %, no fall in
systemic pressure and no worsening of sign or symptom
occur [ 9 ].
Case 4 Atrial Septal Defect (Ostium Secundum Type) with Pulmonary Arterial Hypertension Subjected to Patch Closure with a Valve
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