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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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297
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_92, © Springer International Publishing Switzerland 2015
A 31-year-old man presented with dyspnea on exertion
(functional class II).
Subvalvular Aortic Stenosis
(Membranous Type with Circular
Web) with Severe Left
Ventricular Outflow Tract
and Moderate Aortic
Regurgitation
Case 92
Fig. 92.1 The parasternal long-axis view shows a subvalvular mem-
brane, which is attached to the interventriular septum ( arrow ). LA left
atrium, LV left ventricle, RV right ventricle, AO aorta
Fig. 92.2 The parasternal long-axis view illustrates moderate aortic
regurgitation ( arrow ). LA left atrium, LV left ventricle, RV right
ventricle, AO aorta
Electronic supplementary material The online version of this chap-
ter (doi:
10.1007/978-3-319-12934-1_92 ) contains supplementary
material, which is available to authorized users.
298
Fig. 92.3 This membrane produces a severe left ventricular outfl ow
tract obstruction, with a peak gradient of 72 mmHg and a mean gradient
of 41 mmHg
Fig. 92.4 The membrane ( arrow ) is also evident in the apical four-
chamber view. LA left atrium, LV left ventricle, RA right atrium, RV
right ventricle
Fig. 92.5 Transesophageal echocardiography (TEE) (long-axis view)
depicts this membrane. The membrane is about 6 mm in size and is
about 8 mm away from the aortic valve. LA left atrium, LV left ventricle,
AO aorta
Fig. 92.6 There is also another attachment of this anterior mitral leaf-
let, 2 mm in size and 12 mm from the aortic valve. LA left atrium, LV
left ventricle, AO aorta
Case 92 Circular Membranous Subvalvular Aortic Stenosis with Severe Obstruction
299
ab
Fig. 92.7 The vena contracta of the aortic regurgitation is about 4 mm ( a ), and the width of the aortic regurgitation to the left ventricular outfl ow
tract is about 8/19 mm ( b ). LA left atrium, LV left ventricle, AO aorta
Fig. 92.8 A circular web is also evident on TEE (long-axis view).
There is a septal attachment ( arrow ) as well as an anterior mitral leafl et
attachment ( arrow ahead ), producing an angulation on this leafl et
( curved arrow ). LA left atrium, LV left ventricle, AO aorta
Case 92 Circular Membranous Subvalvular Aortic Stenosis with Severe Obstruction
300
Diagnosis
The patient was diagnosed with subvalvular aortic stenosis
(membranous type), severe left ventricular outfl ow tract
obstruction, attachment of the membrane to the anterior
mitral leafl et, and moderate aortic regurgitation.
Comment
Given the patient’s peak gradient of greater than 50 mmHg,
mean gradient of greater than 30 mmHg, and moderate aortic
regurgitation, surgery (subaortic web resection and aortic
valve replacement) was recommended.
Lesson
Although some authors recommend aortic valve replacement
in moderate aortic regurgitation at the time of surgery of subaortic stenosis [ 7 , 23 ], decision-making about aortic valve
replacement when there is moderate aortic regurgitation is a
matter of debate [ 36 ].
Whether there is any association between left ventricular
outfl ow tract gradient and the degree of aortic regurgitation
is a matter of debate. While some authors believe that there
is an association between the severity of left ventricular outfl ow tract obstruction and damage to aortic valve [ 118 ],
another study could not prove it [ 86 ].
ab
Fig. 92.9 TEE (short-axis view) shows the coaptation failure of the aortic leafl ets ( arrow ) ( a ) and moderate aortic regurgitation ( arrow ) ( b ). LA left
atrium, AO aorta
Case 92 Circular Membranous Subvalvular Aortic Stenosis with Severe Obstruction
301
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_93, © Springer International Publishing Switzerland 2015
A young man with a history of atypical chest pain was
referred to our echocardiography laboratory. Physical examination revealed a systolic ejection murmur (grade III/VI) in
the aortic area. Echocardiography showed normal left and
right ventricular sizes and functions as well as mild concentric left ventricular hypertrophy.
Subvalvular AS Membranous
Type with Mild Left Ventricular
Outflow Tract Obstruction
and No Aortic Regurgitation
Case 93
Fig. 93.1 The parasternal long-axis view depicts a linear density
( arrow ) in the close proximity of the aortic valve (below it), which is
attached to the septum. LA left atrium, LV left ventricle, RV right ven-
tricle, AO aorta
Fig. 93.2 No systolic angulation is visible at the base of the anterior
mitral valve leafl et, and this is in favor of a non-circumferential membrane with no attachment to the anterior mitral leafl et. LA left atrium,
LV left ventricle, RV right ventricle, AO aorta
302
Diagnosis
The patient was diagnosed with subvalvular aortic stenosis
(AS) (membranous type), with an approximate gradient of
36 mmHg, and no aortic insuffi ciency.
Comment
The patient’s peak systolic gradient was less than 50 mmHg,
and there was no aortic insuffi ciency. Accordingly, follow up echocardiography and prophylaxis for infective endocarditis were recommended.
Fig. 93.3 The continuous wave Doppler study in the apical fi ve-
chamber view demonstrates that the peak gradient across the aortic
valve is approximately 35.7 mmHg
Case 93 Subvalvular AS Membranous Type with Mild Left Ventricular Outfl ow Tract Obstruction and No Aortic Regurgitation
303
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_94, © Springer International Publishing Switzerland 2015
A middle-aged man presented with a history of dizziness
during exercise and atypical chest pain. Physical examination revealed a systolic ejection murmur (grade III/VI) at the
apex and at the left sternal border.
The size of the base of the interventricular septum is about
21 mm.
Subvalvular Aortic Stenosis:
Fibromuscular Type with Severe
Left Ventricular Outflow Tract
Obstruction
Case 94
a
b
Fig. 94.1 The apical four-chamber view depicts asymmetrical septal
hypertrophy ( arrow ) ( a ) and systolic turbulency in the left ventricular
outfl ow tract ( arrow ) ( b ). There is also a linear density ( double arrow )
attached to the interventricular septum. LA left atrium, LV left ventricle,
RA right atrium, RV right ventricle
Fig. 94.2 The peak gradient across the left ventricular outfl ow tract is
about 57 mmHg
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_94 ) contains supplementary material,
which is available to authorized users.
304
Fig. 94.7 TEE (long-axis view) shows that the aortic insuffi ciency
vena contracta is approximately 5 mm, and the width of the aortic insuffi ciency/left ventricular outfl ow tract is about 8/14; this is indicative of
moderate aortic insuffi ciency. LA left atrium, LV left ventricle, AO
aorta, RV right ventricle
b
a
Fig. 94.3 Transesophageal echocardiography (0° and long-axis view)
demonstrates the systolic anterior motion of the anterior mitral leafl et
( arrow ) ( a ), moderately severe mitral regurgitation ( a ), and vena con-
tracta of the mitral regurgitation (about 5 mm) ( b ). There is also systolic
turbulency in the left ventricular outfl ow tract ( double arrow ). LA left
atrium
Fig. 94.4 TEE (long-axis view) depicts the systolic anterior motion of
both mitral leafl ets ( arrow ). LA left atrium, LV left ventricle, AO aorta,
RV right ventricle
Fig. 94.5 TEE (0°) illustrates a linear density ( arrow ) at the base of the
interventricular septum. LA left atrium, LV left ventricle, RV right
ventricle
Fig. 94.6 The subvalvular membrane is 12 mm in size. LA left atrium,
LV left ventricle, RA right atrium, RV right ventricle
Case 94 Subvalvular Aortic Stenosis: Fibromuscular Type with Severe Left Ventricular Outfl ow Tract Obstruction
305
Diagnosis
The patient was diagnosed with subvalvular aortic stenosis
(fi bromuscular or tunnel type) with an interventricular septum of 21 mm at the base, 57-mmHg gradient in the left ventricular outfl ow tract, moderate aortic regurgitation and
moderately severe mitral regurgitation due to the prolapse of
the mitral valve leafl ets and annulus dilation.
Comment
The patient was referred for myectomy, in conjunction with
subvalvular web resection, mitral valve repair, and aortic
valve replacement.
Lesson
In some forms of subvalvular aortic stenosis, there is a
tunnel- shaped left ventricular obstruction due to the muscular hypertrophy of the interventricular septum in association
with a membrane (fi bromuscular type). Consequently, the
resection of the membrane alone is not suffi cient for the
relief of the obstruction, and more extensive resection or a
Konno–Rastan procedure is needed [ 2 , 7 , 118 , 119 ].
Case 94 Subvalvular Aortic Stenosis: Fibromuscular Type with Severe Left Ventricular Outfl ow Tract Obstruction
307
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_95, © Springer International Publishing Switzerland 2015
A 26-year-old obese man presented with a history of multiple episodes of respiratory infections. Physical examination
revealed a systolic ejection murmur in the aortic area.
Echocardiography showed normal left and right ventricular
sizes and functions.
Subvalvular Aortic Stenosis
with Atrial Septal Defect
(Ostium Secundum Type)
Case 95
ab
Fig. 95.1 Transesophageal echocardiography (TEE) (long-axis view) shows a small subaortic membrane ( arrowhead ) at the base of the interven-
tricular septum ( a ). This membrane is about 12 mm in size ( b ). LA left atrium, LV left ventricle, RV right ventricle, AO aorta
Fig. 95.2 The apical fi ve-chamber view reveals that the peak and
mean gradients across the left ventricular outfl ow tract are about
21 mmHg and 16 mmHg, respectively
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_95 ) contains supplementary material,
which is available to authorized users.
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