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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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451
Right ventricular systolic pressure tricuspid regurgitation gra= ddient right atrial pressure mmHg,+=+=46 10 56
Pulmonary arterial systolic pressure Right ventricular systolic= ppressure Pulmonary stenosis gradient mmHg.− =−=56 34 22
Diagnosis
The patient was diagnosed with Ebstein’s anomaly with severe
tricuspid regurgitation and mild valvular pulmonary stenosis.
Comment
The patient was asymptomatic and had mild right ventricular
systolic dysfunction, no atrial arrhythmia, and very good
growth at puberty. Consequently, prophylaxis for infective
endocarditis and follow-up were recommended.
Lesson
Valvular pulmonary stenosis is an occasional finding
with Ebstein’s anomaly [ 2 , 146 , 149 , 150 ]. Despite moderate septal displacement ratio, tricuspid regurgitation is
severe.
It is of notice that in the presence of pulmonary stenosis,
tricuspid regurgitation gradient is only a representative of
right ventricular systolic pressure. Systolic pulmonary arterial pressure is measured as follows:
Fig. 135.6 The right ventricular ejection fraction is 45 % by the multiplane modality of a four-dimensional probe
Case 135 Ebstein’s Anomaly with Valvular Pulmonary Stenosis
453
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_136, © Springer International Publishing Switzerland 2015
A 34-year-old pregnant woman (gravida 2, para 1) was
referred to our echocardiography laboratory for fetal heart
echocardiography. She had no history of congenital heart
disease either in herself or in her family, and her previous
child was normal. A previous sonographic examination had
demonstrated nothing abnormal, but lab screen tests were
suggestive of spina bifi da.
Fetal Heart Echocardiography
Focusing Ductal Arch
Case 136
ab
Fig. 136.1 The long-axis view of the aorta shows a normal left atrium.
The left atrium is connected to the left ventricle, and the left ventricle is
connected to the aorta. The right ventricle is also evident in the anterior
portion of the left ventricle ( a , b ). The sternum ( arrow ) and the verte-
bral column ( double arrows ) are also visualized. LA left atrium, LV left
ventricle, AO aorta, RV right ventricle
454
Diagnosis
The patient had a normal structural fetal heart echocardiography [ 151 , 152 ].
Fig. 136.2 The ductal arch view demonstrates the right ventricular
outfl ow tract and the pulmonary artery, as well as the ductus arteriosus,
which is connected to the descending aorta. RVOT right ventricular out-
fl ow tract, DAO descending aorta, DA ductus arteriosus
Case 136 Fetal Heart Echocardiography Focusing Ductal Arch
455
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_137, © Springer International Publishing Switzerland 2015
A 25-year-old pregnant woman (gestational age of 32 weeks)
was referred to our echocardiography laboratory for fetal heart
echocardiography because of gestational diabetes mellitus.
Fetal Heart Echocardiography:
Atrioventricular Septal Defect
and Common Atrium
Case 137
ab
Fig. 137.1 The subcostal four-chamber view shows a common atrio-
ventricular valve ( arrow ) in systole ( a ) and diastole ( b ) and a large atrial
septal defect (ASD) (ostium premium type), like a common atrium.
The stomach is also evident in this view ( double arrow ). SA single
atrium, LV left ventricle, RV right ventricle
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_137 ) contains supplementary material,
which is available to authorized users.
456
Diagnosis
The patient was diagnosed with an atrioventricular septal
defect, common atrium, and mitral valve cleft.
Comment
Because there is a 24–35 % association between the atrioventricular septal defect and Down’s syndrome, the patient
was referred for was amniocentesis [ 2 , 152 , 153 ].
Lesson:
Not all atrioventricular septal defects are associated with
Down’s syndrome. Therefore, if the fetus is genetically normal, the atrioventricular septal defect is a curable disease.
a
b
Fig. 137.3 The long-axis view
of the aorta reveals an anterior
mitral leafl et cleft ( a ) and the
fl ow through it ( arrow ) ( b ). LA
left atrium, LV left ventricle, AO
aorta, RV right ventricle
Fig. 137.2 A ventricular septal defect component of the atrioventricu-
lar septal defect is also evident in the subcostal four-chamber view
( arrow ). RV right ventricle, LV left ventricle
Case 137 Fetal Heart Echocardiography: Atrioventricular Septal Defect and Common Atrium
457
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_138, © Springer International Publishing Switzerland 2015
A 27-year-old pregnant woman (gravida 2) was referred to our
echocardiography laboratory for fetal heart echocardiography.
Her fi rst infant had died of unknown reason at 7 months.
Fetal Heart Echocardiography
Focusing Foramen Oval
Case 138
ab
Fig. 138.1 The subcostal four-chamber view of the fetus shows a
normal right atrium and a normal right ventricle, which are slightly
larger than the left atrium and the left ventricle [ 154 ]. The lower insertion of the tricuspid valve ( arrow ) is evident ( a ), and the membrane of
the Vieussens or fl ap valve of foramen ovale can be seen in the left
atrium ( curved arrow ) ( b ) [ 155 , 156 ]. 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_138 ) contains supplementary material,
which is available to authorized users.
458
Diagnosis
There was a normal structural fetal heart echocardiography.
Lesson
Fetal Circulation
In the fetus, there is a dominancy of the right atrium and
the right ventricle. The right system is slightly larger than the
left system. However, as the gestational age increases, this
dominancy decreases.
The left system takes about 30–35 % of the blood circulation, while the right system receives about 60–65 % of the
blood circulation. From the 35–40 % of the fl ow that the
left system receives, 8–10 % is from the pulmonary veins.
In the fetus, the lungs are inactive and do not participate in
ventilation, so the pulmonary circulation receives only
8–10 % of the fetal circulation.
The remaining 20–25 % of the blood fl ow that enters the
left system passes via the foramen ovale. In the fetus, the
interatrial septum has a defect which is about one third of
the total size of the interatrial septum. There is a membrane
in the orifi ce of this defect in the left atrium which is named
the Vieussens membrane. The orientation of the fl ow in the
fetal circulation is designed in a manner that the fl ow of the
inferior vena cava, which is oxygenated, passes through the
defect of the interatrial septum and enters the left atrium, left
ventricle, and aorta. About 5 % of the fl ow of the left system
goes toward the coronary arteries, 20–25 % to the branches
of the aortic arch, and 5–10 % to the isthmus.
ab
Fig. 138.2 The apical fi ve-chamber view demonstrates the rising of the aorta from the left ventricle via two-dimensional echocardiography
( a ) and the color Doppler fl ow study ( b ). LA left atrium, LV left ventricle, RA right atrium, RV right ventricle, AO aorta
Fig. 138.3 This is illustrative of a normal connection ( arrow ) between
the right and left atria (foramen ovale) in the subcostal four-chamber
view. This atrial communication occupies about one third of interatrial
septum [ 156 ]. LA left atrium, LV left ventricle, RA right atrium, RV right
ventricle
Fig. 138.4 The ductal arch ( arrow ) is evident in this ductal arch view.
RVOT right ventricular outfl ow tract, AO aorta
Case 138 Fetal Heart Echocardiography Focusing Foramen Oval
459
Consequently, the oxygenated blood enters the coronary
arteries and arch branches which supply the brain and the
upper extremities.
From 60 % to 65 % of the blood fl ow which enters the
right ventricle and then the pulmonary artery, 8–10 % goes
toward the lungs, and 50 % passes via the ductus arteriosus
toward the descending aorta. This is the reason why that duct
and the aortic arch receive nearly equal amounts of blood
(the duct about 50 % and the arch about 35 %) and so are
nearly equal in size.
Regarding the lungs, which are inactive in ventilation, the
pulmonary vascular resistance is high and is nearly equal to
the systemic vascular resistance. After birth with the fi rst cry,
the lungs become open and fi lled with air. The pulmonary
vascular resistance reduces suddenly to one third of its initial
value, and the O
2
saturation of the neonate rises. (The O 2
saturation of the fetus is about 75 %.) Within the fi rst 24 h,
the pulmonary vascular resistance decreases up to one half of
the systemic vascular resistance [ 101 , 152 ].
The increased O
2
saturation causes more vasoconstriction
in the systemic circulation and vasodilator effect in the pulmonary circulation. As a result, the systemic vascular resistance rises and the pulmonary vascular resistance falls
spontaneously; this will continue until 3 months after birth.
The cells of the ductus arteriosus are like the systemic
circulation cells, so they show a vasoconstrictive response to
increased O
2
saturation and diminished prostaglandins after
birth. The ductus arteriosus will be closed within the fi rst
hours after birth. The increased systemic vascular resistance
and pressure prohibits the passage of the fl ow through the
foramen ovale, and so the foramen ovale will functionally be
closed within the fi rst hours until anatomic closure occurs.
Case 138 Fetal Heart Echocardiography Focusing Foramen Oval
461
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_139, © Springer International Publishing Switzerland 2015
A 29-year-old woman was referred to our echocardiography
laboratory for fetal heart echocardiography. She was pregnant with twins.
The following is the echocardiographic examination of
the fi rst twin.
Fetal Heart Echocardiography
of Twins
Case 139
ab
Fig. 139.1 The short-axis view of the ventricles shows the left and
right ventricles. The stomach is also evident in this view ( arrow )
( a ). With some angulation toward the head of the fetus, the right
ventricular outfl ow tract appears in the long-axis view of the pulmonary
artery ( arrow ) ( b ). LV left ventricle, RV right ventricle
Electronic supplementary material The online version of this chapter
(doi:
10.1007/978-3-319-12934-1_139 ) contains supplementary material,
which is available to authorized users.
462
The following is the echocardiographic examination of
the second twin.
Fig. 139.2 The short-axis view demonstrates the left ventricle, right
ventricle, pulmonary artery, and ductus arteriosus. LV left ventricle, RV
right ventricle, PA pulmonary artery, DA ductus arteriosus
Fig. 139.3 The ductal arch view depicts the ductus arteriosus and the
descending aorta. AV aortic valve, DA ductus arteriosus, DAO descend-
ing aorta
Fig. 139.4 The long-axis view of the aorta shows the left atrium, left
ventricle, and aorta. The membrane of the Vieussens is evident in the
left atrium ( arrow ). The stomach is marked by the double arrow. LA left
atrium, LV left ventricle, RV right ventricle, AO aorta, ST stomach
Fig. 139.5 The short-axis view of the ventricles shows the left and
right ventricles. The position of the heart is in the left hemithorax. If we
draw a line between the vertebral column ( double curved arrow ) and
the sternum ( curved arrow ), the right ventricle lies on the right and the
left ventricle on the left of that line. LV left ventricle, RV right
ventricle
Case 139 Fetal Heart Echocardiography of Twins
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