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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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308
Diagnosis
The patient was diagnosed with multiple ASDs (ostium
secundum type) and subvalvular aortic stenosis.
Comment
There are two different strategies for this patient: (1) surgical
closure of the ASDs and resection of the subvalvular web
and (2) device closure of the ASDs and follow-up for the
subvalvular membrane because the mean gradient in the left
ventricular outfl ow tract is 16 mmHg.
Lesson
The patient’s subvalvular stenosis precluded the estimation
of Qp/Qs.
ab
Fig. 95.3 TEE (93°) view illustrates two small atrial septal defects (ASDs): one is about 4 and the other one is about 7 mm in size ( a ). The dis-
tance between the two ASDs is about 10 mm ( b ). LA left atrium, RA right atrium, AO aorta
Case 95 Subvalvular Aortic Stenosis with Atrial Septal Defect (Ostium Secundum Type)
309
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_96, © Springer International Publishing Switzerland 2015
A 46-year-old woman presented with dyspnea on exertion
and frequent episodes of palpitations. Physical examination
revealed a systolic–diastolic murmur (grade III/VI) in the
aortic area. Echocardiography demonstrated a mild left
ventricular dilation with a good systolic function as well as
mild concentric left ventricular hypertrophy, normal aortic
valve thickness, and no evidence of doming and
calcifi cation.
Subvalvular Aortic Stenosis
(Membranous Type) with Severe
Left Ventricular Outflow Tract
Obstruction and Moderately
Severe Aortic Regurgitation
with Ascending Aorta Dilation
Case 96
Fig. 96.1 The apical fi ve-
chamber view shows a subaortic
membrane below the aortic valve
( arrow ) and systolic turbulency
in this area, in favor of subaortic
stenosis. LA left atrium, LV left
ventricle, AOV aortic valve
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_96 ) contains supplementary material,
which is available to authorized users.
310
Fig. 96.2 The subvalvular
membrane ( arrow ) is visible in
this four-dimensional
reconstruction in the apical
fi ve-chamber view. LA left
atrium, LV left ventricle, RA right
atrium, RV right ventricle, AOV
aortic valve
Fig. 96.3 Moderately severe aortic regurgitation ( arrow ) is evident in
the apical fi ve-chamber view. LA left atrium, LV left ventricle, RA right
atrium, RV right ventricle
Fig. 96.4 Color M-mode echocardiography (suprasternal long-axis
view) shows a pan-diastolic fl ow reversal ( arrow ) in the descending
aorta ( red color ), which is in favor of signifi cant aortic insuffi ciency
Case 96 Membranous Subvalvular Aortic Stenosis with Ascending Aorta Dilation
311
Fig. 96.5 The continuous wave study across the left ventricular out-
fl ow tract reveals that the peak and mean gradients across the left ventricular outfl ow tract are about 73 and 59 mmHg, respectively, in favor
of severe subvalvular aortic stenosis
Fig. 96.7 TEE (long-axis view) shows that the dilation of the ascend-
ing aorta is up to 50 mm. LA left atrium, AO aorta
Fig. 96.6 TEE (fi ve-chamber view) depicts two membranes: one is
attached to the base of the interventricular septum ( large arrow ), and
the other one is attached to the base of the anterior mitral valve leafl et
( small arrow ); this is in favor of a circumferential subvalvular
membrane. LA left atrium, LV left ventricle, AO aorta
Diagnosis
The patient was diagnosed with subvalvular aortic stenosis
(membranous type), severe left ventricular outfl ow tract
obstruction (peak gradient of 73 mmHg), circular web with
an attachment to the anterior mitral leafl et, moderately severe
aortic regurgitation, and dilation of the ascending aorta.
Comment
The Bentall operation and resection of the subvalvular
membrane was recommended. (This patient was a candidate for subvalvular web resection and aortic valve replacement
(AVR) in light of her signifi cant aortic regurgitation; however,
because her ascending aorta was 50 mm in diameter, the
Bentall operation became mandatory.)
Lesson
1. When a patient is a candidate for AVR, if the ascending
aorta is dilated and is equal to or greater than 50 mm in
diameter, there will be a risk for aortic dissection without
aortic root replacement. Accordingly, the Bentall
operation is indicated at the time of AVR [ 23 , 36 ].
2. Sometimes the web is circular with an attachment to the
anterior mitral leafl et. This attachment usually produces
an angulation on the anterior mitral leafl et. It is crucial to
diagnose this attachment before surgery [ 2 ].
Case 96 Membranous Subvalvular Aortic Stenosis with Ascending Aorta Dilation
313
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_97, © Springer International Publishing Switzerland 2015
A young woman presented with a history of atypical chest
pain and a systolic murmur (grade III/VI) in the aortic area
without ejection clicks. She had normal left and right
ventricular sizes and functions and mild concentric left
ventricular hypertrophy.
Valvular and Subvalvular
Aortic Stenosis with Bicuspid
Aortic Valve
Case 97
ab
c
Fig. 97.1 Two linear densities protrude from the left side of the
interventricular septal basal wall and the base of the anterior mitral
valve leafl et toward the left ventricular outfl ow tract, in favor of
subvalvular aortic stenosis (circumferential membranous type).
The arrows in ( a , b ) show this membrane, which is attached to the
interventricular septum and is about 4 mm in size ( c ). ( a ) Apical
fi ve-chamber view, ( b ) parasternal long-axis view by four-dimensional
reconstruction, and ( c ) parasternal long-axis view by two-dimensional
echocardiography. AV aortic valve, LA left atrium, LV left ventricle
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_97 ) contains supplementary material,
which is available to authorized users.
314
Fig. 97.2 The color-fl ow Doppler study in the parasternal long-axis
view shows systolic turbulency, which originates from the subvalvular
area ( two arrows ). LV left ventricle, AO aorta
Fig. 97.3 The peak and mean gradients across the left ventricular out-
fl ow tract are 102 and 71 mmHg, respectively, by the continuous wave
study (apical fi ve-chamber view)
Fig. 97.5 The color-fl ow Doppler study (parasternal long-axis view) in
diastole shows mild aortic insuffi ciency ( arrow ) despite a bicuspid aor-
tic valve and severe subvalvular aortic stenosis. LA left atrium, LV left
ventricle, AO aorta
a
b
Fig. 97.4 A thick aortic valve ( a ) and the fi shmouth appearance of the
aortic valve opening, suggestive of a bicuspid aortic valve, can be seen
here. A raphe ( arrow ) is visible between the right and left coronary
cusps. ( a , b) Short-axis views. LA left atrium, RA right atrium, RCC
right coronary cusp, LCC left coronary cusp, AO aortic valve, RV right
ventricle
Case 97 Valvular and Subvalvular Aortic Stenosis with Bicuspid Aortic Valve
315
Diagnosis
The patient was diagnosed with valvular and subvalvular
aortic stenosis (membranous type) with a severe left ventricular outfl ow tract gradient, bicuspid aortic valve, and mild
aortic insuffi ciency.
Comment
Since the patient had valvular and subvalvular aortic stenosis, TEE was recommended for a direct planimetry of the
aortic valve area and investigation for the need for aortic
valve replacement before surgery.
Lesson
When there is valvular and subvalvular aortic stenosis, it is
crucial to determine the degree of valvular aortic stenosis.
TEE by direct planimetry can help to measure the aortic
valve area.
Case 97 Valvular and Subvalvular Aortic Stenosis with Bicuspid Aortic Valve
317
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_98, © Springer International Publishing Switzerland 2015
A 22-year-old man, who had undergone surgery for
subvalvular aortic stenosis 3 years previously, presented with
atypical chest pain and was referred to our echocardiography
laboratory for echocardiography.
Recurrence of Subvalvular
Aortic Stenosis After Surgery
with Mild Left Ventricular
Outflow Tract Obstruction
and Moderate Aortic
Regurgitation
Case 98
ab
Fig. 98.1 The parasternal long-axis view shows a membrane below the aortic valve, which is attached to the anterior mitral leafl et ( arrow ) ( a ).
This membrane is 10 mm in size ( b ). LA left atrium, LV left ventricle, AO aorta, RV right ventricle
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_98 ) contains supplementary material,
which is available to authorized users.
318
Diagnosis
The patient was diagnosed with recurrence of the membrane
of subvalvular aortic stenosis after the fi rst surgery with a
mild obstruction in the left ventricular outfl ow tract and
moderate aortic regurgitation.
Comment
Prophylaxis for infective endocarditis and follow-up
echocardiography were recommended.
Lesson
Subvalvular aortic stenosis sometimes recurs following
surgery. The rate of recurrence is about 20–25 % [ 2 , 86 ,
118 ].
Fig. 98.3 There is moderate aortic regurgitation with a vena contracta
of 5 mm in the parasternal long-axis view. LA left atrium, LV left ven-
tricle, AO aorta, RV right ventricle
Fig. 98.2 This membrane produces a peak gradient of 17 mmHg in the
left ventricular outfl ow tract in the apical four-chamber view
Case 98 Recurrence of Subvalvular Aortic Stenosis with Mild Obstruction
319
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_99, © Springer International Publishing Switzerland 2015
A 39-year-old man, who had undergone subvalvular
web resection and aortic valve repair 8 years previously,
presented with dyspnea on exertion (functional class II) of
1-month duration.
Recurrence of Subvalvular
Aortic Stenosis After Surgery
with Severe Left Ventricular
Outflow Tract Obstruction
and Severe Aortic Regurgitation
Case 99
ab
Fig. 99.1 The parasternal long-axis view shows the narrowing of the
left ventricular outfl ow tract ( a ) with systolic turbulency, which begins
below the aortic valve ( arrow ) ( b ). It seems that there are two mem-
branes ( arrows ) below the aortic valve: one is attached to the interven-
tricular septum and the other one is attached 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_99 ) contains supplementary material,
which is available to authorized users.
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