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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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366
Three diagnoses were considered for the patient before
transesophageal echocardiography (TEE):
1. A ventricular septal defect of Gerbode type and a connection between the left ventricle and the right atrium
2. A coronary fi stula
3. The rupture of the sinus of Valsalva
Fig. 112.6 The right ventricle is moderately dilated in the apical four-
chamber view, and the apex is equally made from the right and left
ventricles. LA left atrium, LV left ventricle, RA right atrium, RV right
ventricle
Fig. 112.7 TEE (short-axis view) shows that the fl ow originates
( arrow ) behind the aortic leafl ets; it is, therefore, not aortic regurgita-
tion. LA left atrium, RA right atrium, RVOT right ventricular outfl ow
tract, AO aorta
Fig. 112.8 TEE (short-axis view) shows that the aortic valve has three
leafl ets and that there is a rupture in the noncoronary cusp ( arrow ). LA left
atrium, RA right atrium, RVOT right ventricular outfl ow tract, AO aorta
Case 112 Rupture of the Sinus of Valsalva: Noncoronary Cusp to the Right Atrium
367
a
c
d
b
Fig. 112.9 The site of the rupture ( arrow ), from the noncoronary cusp
to the right atrium, is visualized on TEE (short-axis view) ( arrow ) ( a ).
This site measures 7.4 mm ( b ). The fl ow from the noncoronary cusp to
the right atrium is visualized in diastole and systole ( arrows ) via the
color Doppler study ( c, d ). LA left atrium, RA right atrium, RV right
ventricle, AO aorta
Fig. 112.10 There is also a patent foramen ovale fl ow at rest from left
to right ( arrow ). LA left atrium, RA right atrium
Fig. 112.11 A four-dimensional reconstruction of this fi stula shows
that the aortic side measures 5.6 mm and the right atrial side is 8.5 mm.
RA right atrium, AO aorta
Case 112 Rupture of the Sinus of Valsalva: Noncoronary Cusp to the Right Atrium
368
Diagnosis
Rupture of the noncoronary cusp of the sinus of Valsalva to
the right atrium
Comment
The patient was referred for surgery, although transcatheter
closure of rupture of the sinus of Valsalva (noncoronary
cusp) to the right atrium has been reported [ 130 , 131 ].
Fig. 112.12 Four-dimensional transesophageal short-axis view shows
the fl ow of rupture of the noncoronary cusp of the sinus of Valsalva
toward the right atrium ( arrow ). RA right atrium, AO aorta
Case 112 Rupture of the Sinus of Valsalva: Noncoronary Cusp to the Right Atrium
369
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_113, © Springer International Publishing Switzerland 2015
A 24-year-old woman, who had a history of typical chest pain
and one episode of ventricular tachycardia as well as a continuous murmur (grade II/VI) in the second right intercostal
space, was referred to our clinic. Echocardiography revealed
normal left and right ventricular sizes and functions.
Coronary Arteriovenous Fistula:
Left Coronary Artery to the
Main Pulmonary Artery
Case 113
a
b
Fig. 113.1 The right coronary artery originates normally from the right coronary cusp and is about 3 mm in size ( a ). The left main originates normally
from the left coronary cusp but is dilated (diameter of about 9 mm) ( b ). AO aortic valve, LA left atrium, RA right atrium, ( a , b ) short-axis view
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_113 ) contains supplementary
material, which is available to authorized users.
370
Diagnosis
The patient was diagnosed with a coronary arteriovenous
fi stula between the left coronary system and the main pulmonary artery with a small left-to-right shunt.
Comment
The patient’s Qp/Qs was 1.2. Nevertheless, given her typical
chest pain and ventricular tachycardia, coronary angiography and the closure of the fi stula with coil embolization were
recommended.
Lesson
1. Fifty-fi ve percent of coronary arteriovenous fi stulae orig-
inate from the right coronary artery, and 35 % of them
originate from the left coronary artery [ 2 ].
2. Most of these fi stulae drain into the right atrium, right
ventricle, or coronary sinus. Drainage into the pulmonary
artery is an occasional fi nding [ 2 , 132 ].
3. The left-to-right shunt through the fi stula is usually small.
4. The hallmark of diagnosis is a dilated coronary system
and a continuous fl ow at the site of entry [ 2 ].
5. The left main coronary artery usually measures up to
5.5 mm in normal individuals [ 133 ].
Fig. 113.3 The Doppler fl ow study in the short-axis view depicts a
continuous systolic and diastolic fl ow with a systolic accentuation in
the main pulmonary artery
a
b
Fig. 113.2 The color-fl ow study in the short-axis view shows a continuous turbulent fl ow, systolic ( a ) and diastolic ( b ), in the main pulmonary
artery. AO aortic valve, LA left atrium, RA right atrium
Case 113 Coronary Arteriovenous Fistula: Left Coronary Artery to the Main Pulmonary Artery
371
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_114, © Springer International Publishing Switzerland 2015
A 24-year-old man, who had a history of exertional dyspnea
(functional class I), was referred to our clinic for cardiac
evaluation. Physical examination revealed a holosystolic
murmur (grade I/VI) in the mitral area and lower left sternal
border. Echocardiography demonstrated normal left and
right ventricular sizes and systolic functions. There was mild
tricuspid regurgitation, and the systolic pulmonary arterial
pressure was about 25 mmHg.
Cor Triatriatum
Case 114
a
b
c
Fig. 114.1 A thin membrane ( arrow ) divides the left atrium into two separated cavities, in favor of a cor triatriatum in the apical four-chamber view ( a ),
apical two-chamber view ( b ), and apical three-chamber view ( c ) by four-dimensional reconstruction. LV left ventricle, RV right ventricle, MV mitral valve
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_114 ) contains supplementary
material, which is available to authorized users.
372
a
b
Fig. 114.2 The anteroinferior chamber includes the left atrial append-
age ( a ) (the arrow points to the membrane), and the posterosuperior
chamber receives the left upper pulmonary vein ( b ). Transesophageal
echocardiography (TEE) (0°) ( a ) and midesophageal TEE (28°) ( b ).
LAA left atrial appendage, LUPV left upper pulmonary vein, LA , left
atrium
a
b
c
Fig. 114.3 The apical four-chamber view ( a ) and midesophageal TEE
(0°) ( b ) reveal that the membrane ( arrow ) is attached to the interatrial
septum in the foramen ovale site ( a ) and is attached between the left
atrial appendage and the left upper pulmonary vein on the opposite
side ( b ). This schematic illustration shows the attachment site of
the membrane of the cor triatriatum: the membrane is attached to the
interatrial septum in the foramen ovale site and is attached between the
left atrial appendage and the left upper pulmonary vein in the lateral
wall of the left atrium ( c ). FO foramen ovale, LAA left atrial appendage,
LUPV left upper pulmonary vein, PV pulmonary vein, LA left atrium,
LV left ventricle, RA right atrium, RV right ventricle
Case 114 Cor Triatriatum
373
a
b
c
Fig. 114.4 The membrane has large fenestrations: ( arrow ) ( a ) and ( b ).
The two arrows in this view ( c ) show two large defects in this membrane.
( a ) Apical two-chamber view by four-dimensional reconstruction,
( b ) apical three-chamber view by four-dimensional reconstruction, and
( c ) TEE (long-axis views). AOV aortic valve, LV left ventricle
a
b
Fig. 114.5 TEE ( long-axis view ) illustrates mild turbulency across this membrane ( a ). The continuous wave Doppler fl ow study demonstrates no
signifi cant gradients (maximum gradient of about 3.5 mmHg and mean gradient of 1 mmHg) at this site ( b ). AOV aortic valve
Case 114 Cor Triatriatum
374
Diagnosis
The patient was diagnosed with a cor triatriatum with mild
obstruction and a normal pulmonary arterial pressure.
Comment
The patient was referred for surgery [ 2 , 134 – 136 ].
Fig. 114.6 The pulse wave Doppler fl ow study of the pulmonary veins
reveals a normal fl ow pattern and gradients. This view shows the left
lower pulmonary vein fl ow study
Fig. 114.7 The contrast study shows no bubbles passing through the
interatrial septum. The arrow points to the cor triatriatum on TEE
(short-axis view). AOV aortic valve, LA left atrium, RA right atrium
Case 114 Cor Triatriatum
375
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_115, © Springer International Publishing Switzerland 2015
An 18-year-old old female, who had dyspnea on exertion
(functional class III) and cyanosis, was referred to our echocardiography laboratory.
Common Atrium, Atrioventricular
Septal Defect, and Subvalvular
Aortic Stenosis
Case 115
ab
Fig. 115.1 A single atrium by two-dimensional echocardiography, as
well as the left atrioventricularl valve ( double curved arrow ), right
atrioventricular valve ( curved arrow ), and atrial appendage ( arrow ),
can be seen in the apical four-chamber view in diastole ( a ) and systole
( b ). SA single atrium, LV left ventricle, RV right ventricle
Electronic supplementary material The online version of this chap-
ter (doi:
10.1007/978-3-319-12934-1_115 ) contains supplementary
material, which is available to authorized users.
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