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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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441
Fig. 132.4 The peak systolic
velocities of the base, mid-, and
apical segments of the right
ventricular free wall are
approximately 6.53, 4.45, and
1.85 cm/s, respectively, in favor
of mild right ventricular systolic
dysfunction [ 148 ]
Fig. 132.5 The peak systolic
strains in the base, mid-, and
apical segments of the right
ventricular free wall are 31.95,
12.84, and 17.6 %, respectively
Case 132 Ebstein’s Anomaly with Severe Tricuspid Regurgitation, Mild Septal Displacement Ratio
442
Diagnosis
The patient was diagnosed with Ebstein’s anomaly and
severe tricuspid regurgitation despite a mild degree of septal
displacement concomitant with mild right ventricular
dysfunction.
Comment
Given the patient’s severe tricuspid regurgitation and symptoms (uncontrolled supraventricular arrhythmia), surgery
was recommended.
Lesson
1. By measuring the peak systolic velocities by color-coded
tissue Doppler imaging, the peak velocities are considered
as the mean peak systolic velocities, and they are about
20 % less than the peak systolic velocities by pulse wave
Doppler [ 148 ].
2. The measurements of strain in the right ventricular
free wall decrease from the base to the midportion
and then slightly increase from the midportion to the
apex [ 148 ].
3. In our patient, despite a mild septal displacement of the
tricuspid leafl et, the cavity ratio indicated that the
Ebstein’s anomaly was severe (because there may be
severe tricuspid regurgitation in spite of the existing mild
septal leafl et apical displacement).
Case 132 Ebstein’s Anomaly with Severe Tricuspid Regurgitation, Mild Septal Displacement Ratio
443
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_133, © Springer International Publishing Switzerland 2015
A 26-year-old man presented with atypical chest pain.
Physical examination revealed a holosystolic murmur at the
left lower sternal border.
Ebstein’s Anomaly
with Moderate Tricuspid
Regurgitation and Moderate
Septal Displacement Ratio
Case 133
a
b
Fig. 133.2 The apical four-chamber view reveals the lower insertion of
the septal leafl et of the tricuspid valve ( arrow ) ( a ). This apical displace-
ment of the septal leafl et is about 49 mm from the mitral valve ( b ). The
ratio of septal leafl et displacement to the septal length is equal to
49/97 = 50 % indicative of moderate displacement ( b ). LA left atrium,
LV left ventricle, RA right atrium, RV right ventricle
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_133 ) contains supplementary material,
which is available to authorized users.
Fig. 133.1 The parasternal long-axis view depicts right ventricular
dilation. LA left atrium, LV left ventricle, RV right ventricle, AO aorta
444
Diagnosis
The patient had Ebstein’s anomaly, moderate apical
displacement of the septal leafl et, moderate tricuspid regurgitation, and normal right ventricular systolic function. The
right ventricular fractional area change = right ventricular
diastolic area-systolic area/diastolic area ( C ) × 100 = 36 %.
Comment
The patient was asymptomatic, and there was moderate tricuspid regurgitation and good right ventricular systolic function. Accordingly, follow-up was recommended.
Lesson
In this patient, septal displacement is of moderate severity
(a ratio less than 0.45 is mild, between 0.45 and 0.60 is moderate, and greater than 0.6 is representative of the severe
displacement of the tricuspid valve) [ 144 ], but there is a good
ratio of functional right ventricle to anatomic right
ventricle.
Fig. 133.3 The ratio of the functional right ventricle to the anatomic
right ventricle is about 20 cm
2
/31 cm 2 = 0.64. RA right atrium, RV right
ventricle
Fig. 133.4 There is moderate tricuspid regurgitation in the right ven-
tricular infl ow view ( arrow )
Case 133 Ebstein’s Anomaly with Moderate Tricuspid Regurgitation and Moderate Septal Displacement Ratio
445
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_134, © Springer International Publishing Switzerland 2015
A 32-year-old man was referred to our center for precise
echocardiography. He had dyspnea on exertion (functional
class III).
Ebstein’s Anomaly with Severe
Tricuspid Regurgitation
Case 134
Fig. 134.1 The parasternal long-axis view shows severe right ventricu-
lar dilation. LA left atrium, LV left ventricle, AO aorta, RV right
ventricle
Fig. 134.2 The right ventricular infl ow view shows the failure of the
coaptation of the tricuspid valve leafl ets in systole ( arrow ). RA right
atrium, RV right ventricle
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_134 ) contains supplementary material,
which is available to authorized users.
446
Fig. 134.3 The apical four-chamber view reveals the lower insertion of
the septal leafl et of the tricuspid valve ( arrow ). The tethering of the
anterior leafl et of the tricuspid valve is also evident ( curved arrow ). LA
left atrium, LV left ventricle, RA right atrium, RV right ventricle
Fig. 134.4 Severe free tricuspid regurgitation is visualized in the api-
cal four-chamber view ( arrow ). LA left atrium, LV left ventricle, RA
right atrium, RV right ventricle
Fig. 134.5 The right ventricular ejection fraction is reduced (about 39 %) according to the multiplane modality of a four-dimensional probe. The
right ventricular end-diastolic volume is about 119 CC, and the right ventricular end-systolic volume is about 72 CC
Case 134 Ebstein’s Anomaly with Severe Tricuspid Regurgitation
447
Fig. 134.6 The tethering of the septal ( arrow ), anterior ( curved arrow ),
and posterior leafl et ( arrowhead ) of the tricuspid valve is evident by the
multiplane modality of a four-dimensional probe. The septal and anterior
leafl ets are evident in apical four-chamber view, the anterior or septal and
posterior leafl ets are visible in apical two-chamber view, and the septal
and posterior leafl ets are visible in apical three-chamber view [ 145 ]
Fig. 134.7 The tethering of the
septal ( arrow ) and anterior
( curved arrow ) tricuspid leafl ets
is shown in a four-dimensional
reconstruction. RA right atrium
Case 134 Ebstein’s Anomaly with Severe Tricuspid Regurgitation
448
Diagnosis
The patient had Ebstein’s anomaly with severe tricuspid
regurgitation, severe right ventricular dilation, and moderate
right ventricular systolic dysfunction.
Comment
The patient was symptomatic with severe tricuspid regurgitation and moderate right ventricular systolic dysfunction.
Accordingly, surgery (tricuspid valve repair or replacement)
was recommended.
Lesson
1. The tricuspid valve repair whenever possible is preferable
to replacement.
2. Ebstein’s anomaly is an anomaly characterized by the
apical displacement and tethering of the septal leafl et of
the tricuspid valve. In some patients, the displacement is
more prominent. The posterior leafl et may also be
involved, although previously it was thought that the
anterior leafl et is never involved in this disease process
[ 2 ]. New modalities such as four-dimensional echocardiography can diagnose the involvement of the anterior
leafl et [ 145 ].
3. Right-sided failure is one of the indications for surgery.
Fig. 134.8 The parasternal short-axis view depicts the tethering of the
septal ( arrow ) and posterior ( curved arrow ) tricuspid leafl ets. LV left
ventricle, RA right atrium, RV right ventricle [ 145 ]
Fig. 134.9 The failure of the coaptation of the septal ( 1 ), posterior ( 2 ),
and anterior ( 3 ) tricuspid leafl ets ( arrow ) is shown in the parasternal
short-axis view
Case 134 Ebstein’s Anomaly with Severe Tricuspid Regurgitation
449
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_135, © Springer International Publishing Switzerland 2015
A 17-year-old female, who had been followed up in our
center for the previous 10 years, was referred to our echocardiography laboratory for follow-up echocardiography. She
was asymptomatic with normal growth and development.
Ebstein’s Anomaly with Valvular
Pulmonary Stenosis
Case 135
Fig. 135.1 The apical four-chamber view shows the apical displace-
ment of the septal leafl et of the tricuspid valve compared to the mitral
valve (about 39 mm). The ratio of septal displacement to septal length
is equal to 39/78 = 0.5 (moderate displacement). LA left atrium, LV left
ventricle, RA right atrium, RV right ventricle
Fig. 135.2 The parasternal short-axis view demonstrates mild valvular
pulmonic stenosis with a peak gradient of about 34 mmHg and a mean
gradient of 21 mmHg
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_135 ) contains supplementary material,
which is available to authorized users.
450
Fig. 135.3 There is severe tricuspid regurgitation in the apical four-
chamber view. The surface of the tricuspid regurgitation is approximately 9.5 cm
2
. LA left atrium, LV left ventricle, RA right atrium, RV
right ventricle
Fig. 135.4 The tricuspid regurgitation gradient is equal to 46 mmHg
a
b
Fig. 135.5 The three leafl ets of the tricuspid valve are evident in the parasternal short-axis view by two-dimensional echocardiography ( a ) and
four-dimensional reconstruction ( b ). 1 Septal leafl et, 2 posterior leafl et, 3 anterior leafl et of the tricuspid valve
Case 135 Ebstein’s Anomaly with Valvular Pulmonary Stenosis
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