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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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ab
Fig. 99.2 The systolic angulation of the anterior mitral leafl et ( arrow )
is due to the small attachment of the subvalvular aortic membrane to
this leafl et ( a ). The membrane is 3 mm in size and is about 12 mm away
from the aortic valve ( b ). LA left atrium, LV left ventricle, RV right
ventricle, AO aorta
a b
Fig. 99.3 The size of the membrane, which is attached to the interven-
tricular septum, is 6 mm on transesophageal echocardiography (TEE)
(0°) ( a ). The distance between this web and the aortic valve is also
2 mm on TEE (long-axis view) ( b ). LA left atrium, LV left ventricle, RV
right ventricle, AO aorta, RA right atrium
Case 99 Recurrence of Subvalvular Aortic Stenosis with Severe Obstruction
321
Fig. 99.5 The vena contracta of the tricuspid regurgitation is 5 mm in
the right ventricular infl ow tract. RA right atrium, RV right ventricle
Fig. 99.4 TEE (long-axis view) illustrates severe aortic regurgitation.
LA left atrium, LV left ventricle, RV right ventricle, AO aorta
Diagnosis
The patient was diagnosed with recurrence of the subvalvular membrane, signifi cant left ventricular outfl ow tract
obstruction, severe aortic regurgitation, and moderate
tricuspid regurgitation.
Comment
This membrane produced a systolic gradient of 60 mmHg
and severe aortic regurgitation. Consequently, redo surgery
was recommended for the patient. Additionally, the patient’s
tricuspid regurgitation was moderate and tricuspid annulus
was 35 mm; therefore, tricuspid annuloplasty, in conjunction
with subvalvular web resection and aortic valve replacement,
was recommended [ 23 ].
Case 99 Recurrence of Subvalvular Aortic Stenosis with Severe Obstruction
323
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_100, © Springer International Publishing Switzerland 2015
A 27-year-old athletic man presented with atypical chest pain
of 1-year duration. Transthoracic echocardiography revealed
mild left ventricular dilation with a normal systolic function.
Bicuspid Aortic Valve
and Severe Aortic Regurgitation
with Dilation of the Sinus
of Valsalva
Case 100
Fig. 100.1 The parasternal long-axis view shows severe eccentric aor-
tic insuffi ciency ( arrow ). LA left atrium, LV left ventricle, RV right ven-
tricle, AO aorta
Fig. 100.2 Transesophageal echocardiography (TEE) (short-axis view)
demonstrates a bicuspid aortic valve in systole. LA left atrium, AO aorta
a
b
Fig. 100.3 The origin of the left main ( arrow ) ( a ) and the right
coronary artery ( arrow ) ( b ) can be seen on TEE (short-axis view).
The bicuspid aortic valve is the result of the fusion of the left and right
coronary cusps. AO aorta
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_100 ) contains supplementary material,
which is available to authorized users.
Diagnosis
The patient was diagnosed with a bicuspid aortic valve,
severe aortic regurgitation, mild left ventricular dilation, and
normal systolic function.
Comment
The patient had a negative exercise tolerance test and a
left ventricular ejection fraction of greater than 50 %.
Accordingly, close follow-up and prophylaxis for infective
endocarditis were recommended for him.
Lesson
1. The most common form of the bicuspid aortic valve is
due to the fusion of the left and right coronary cusps
(70–80 %).
2. The diagnosis of the bicuspid aortic valve is made in
systole.
3. The bicuspid aortic valve is associated with aortopathy
and the dilation of the aortic root and the ascending aorta
[ 23 , 36 ].
Fig. 100.5 TEE (long-axis view) shows that the vena contracta of the
aortic insuffi ciency is 9 mm and that the width of the aortic insuffi ciency/left ventricular outfl ow tract is 13/32. LA left atrium, LV left ven-
tricle, AO aorta, RV right ventricle
Fig. 100.4 TEE (long-axis view) shows the dilation of the sinus of
Valsalva (up to 40 mm). The aortic annulus and sinotubular junction
measure 31 and 36 mm, respectively
Case 100 Bicuspid Aortic Valve and Severe Aortic Regurgitation with Dilation of the Sinus of Valsalva
325
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_101, © Springer International Publishing Switzerland 2015
A 20-year-old man presented with syncopal attack of
1-year duration. Physical examination revealed a systolic
ejection murmur and a holodiastolic murmur at the left
sternal border and the aortic area. Echocardiography
showed severe aortic insuffi ciency and the dilation of the
ascending aorta.
Bicuspid Aortic Valve
and Severe Aortic Regurgitation
with Dilation of the Sinus
of Valsalva
Case 101
a
b
Fig. 101.1 The eccentric closure of the aortic leafl ets ( arrow ) can be seen in the parasternal long-axis view ( a ). A schematic illustration of the
eccentric closure is presented in this view ( 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_101 ) contains supplementary material,
which is available to authorized users.
326
Fig. 101.4 The dilation of the ascending aorta and the sinus of Valsalva
is patent on TEE (long-axis view). The aortic annulus, sinus of Valsalva,
sinotubular junction, and ascending aorta measure 36, 42, 38, and
36 mm, respectively
ab
c
Fig. 101.2 Transesophageal echocardiography (TEE) (short-axis
view) demonstrates a bicuspid aortic valve ( a ). The raphe ( arrow ) may
be misdiagnosed as a marker of a third leafl et ( b ). This is a schematic
depiction of the bicuspid aortic valve and raphe on TEE (short-axis
view) ( c ). 1 fi rst aortic leafl et, 2 second aortic leafl et, LA left atrium, RA
right atrium, RV right ventricle, AO aorta
Fig. 101.3 Severe eccentric aortic insuffi ciency is seen on TEE
(long- axis view). LA left atrium, LV left ventricle, AO aorta
Case 101 Bicuspid Aortic Valve and Severe Aortic Regurgitation with Dilation of the Sinus of Valsalva
327
Diagnosis
The patient was diagnosed with a bicuspid aortic valve,
severe aortic regurgitation, and aortic root dilation. The
bicuspid aortic valve was due to the fusion of the left and
right coronary cusps.
Comment
The patient was referred for surgery. Because the sinus of
Valsalva was approximately 42–43 mm, a computed
tomography scan was recommended for a further evaluation of the ascending aorta. A sinus of greater than or
equal to 45 mm would have mandated the Bentall operation
[ 23 , 36 ].
Case 101 Bicuspid Aortic Valve and Severe Aortic Regurgitation with Dilation of the Sinus of Valsalva
329
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_102, © Springer International Publishing Switzerland 2015
A 46-year-old man presented with recent dyspnea on exer-
tion (functional class II). Physical examination showed a
systolic ejection murmur and a holodiastolic murmur at the
left sternal border. Transthoracic echocardiography revealed
that the aortic valve area was 1.1 cm
2
by direct planimetry
and 0.9 cm 2 by continuity equation.
Bicuspid Aortic Valve with Severe
Aortic Stenosis and Dilation
of the Ascending Aorta
Case 102
Fig. 102.1 The apical fi ve-chamber view shows severe aortic stenosis,
with a mean gradient of 38 mmHg
Fig. 102.2 A bicuspid aortic valve is patent on transesophageal
echocardiography (TEE) 1 fi rst aortic leafl et, 2 second aortic leafl e t
Fig. 102.3 TEE (long-axis view) demonstrates the dilation of the
ascending aorta (up to 50 mm)
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_102 ) contains supplementary material,
which is available to authorized users.
330
Diagnosis
The patient was diagnosed with bicuspid aortic valve, severe
aortic stenosis, dilation of the ascending aorta (up to 50 mm),
and mild mitral stenosis due to the extension of calcifi cation
to the anterior mitral leafl et.
Comment
With respect to the patient’s severe valvular aortic stenosis
and dilation of the ascending aorta up to 50 mm, the Bentall
operation was recommended.
Lesson
In the bicuspid aortic valve, aortic root replacement at the
time of aortic valve replacement is indicated with an aortic
dimension of greater than 45 mm. In the absence of the aortic
valve disease, aortic root replacement is recommended with
an aortic dimension of greater than 50 mm [ 23 , 36 ].
a
b
Fig. 102.4 The calcifi cation of the aortic valve extends to the anterior mitral leafl et base ( arrow ) ( a ) and produces mild mitral stenosis ( b ).
(The mitral valve area is 1.8 cm
2
by Doppler pressure half-time) LA left atrium, LV left ventricle, RA right atrium, RV right ventricle
Case 102 Bicuspid Aortic Valve with Severe Aortic Stenosis and Dilation of the Ascending Aorta
331
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_103, © Springer International Publishing Switzerland 2015
A 26-year-old woman presented with dyspnea on exertion
(functional class III) of recent duration. She was a known
case of aortic regurgitation since 13 years old and had delivered one child 2 years previously without complications.
Transthoracic echocardiography showed severe left ventricular dilation and normal systolic function. The left ventricular
ejection fraction was about 55 %.
Bicuspid Aortic Valve and Rupture
of the Chordae of the Posterior
Mitral Leaflet
Case 103
ab
Fig. 103.1 Severe aortic valve regurgitation is shown in the parasternal long-axis ( arrows ) ( a ) and apical fi ve-chamber ( b ) views. LA left atrium,
LV left ventricle, RV right ventricle, RA right atrium, AO aorta
Fig. 103.2 Transesophageal echocardiography ( TEE ) (long-axis
view) also reveals severe aortic valve regurgitation ( arrow ). LA left
atrium, LV left ventricle, AO aorta
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_103 ) contains supplementary material,
which is available to authorized users.
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