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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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487
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_149, © Springer International Publishing Switzerland 2015
A 14-day-old neonate was referred to our center due to
cyanosis.
Transposition of Great Arteries
Case 149
Fig. 149.1 The great artery, which is connected to the left ventricle, is
divided and is, therefore, the pulmonary artery ( arrow ). The peak gradi-
ent across the pulmonary valve is about 11 mmHg. LV left ventricle
Fig. 149.2 The great artery, which is connected to the right ventricle,
is not divided and is, therefore, the aorta ( arrow ). The peak gradient is
4 mmHg. RV right ventricle, AO aorta
Fig. 149.3 An atrial septal defect (ASD) (ostium secundum type),
measuring 5 mm, is seen in the subcostal view. LA left atrium, RA right
atrium
Fig. 149.4 There is continuity between the mitral valve and the great
artery, which is connected to the left ventricle and is divided ( arrows )
(pulmonary artery). LA left atrium, LV left ventricle, PA pulmonary
artery
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_149 ) contains supplementary
material, which is available to authorized users.
488
Diagnosis
A diagnosis of the transposition of the great arteries and an
ASD (ostium secundum type) was established.
Comment
The patient was referred for arterial switch.
Lesson
1. In a neonate with cyanosis, the most probable diagnosis is
the transposition of the great arteries. For the fi rst 48 h, if
the ductus arteriosus remains open, cyanosis may be
masked, but after the fi rst 48 h, cyanosis will appear.
Although there is some mixing of blood through the ASD,
the cyanosis progresses despite this shunt.
2. Cyanosis due to the tetralogy of Fallot usually appears
later in life (between 3 and 6 months).
3. One of the therapeutic strategies for the transposition of
the great arteries is to start prostaglandins. In this manner,
the duct will remain open.
4. If there is no ASD, VSD, or patent ductus arteriosus for
the mixing of blood, Rashkind’s procedure is logical. By
this method, interatrial septostomy is performed via a
venous catheter from the umbilical vein.
5. For arterial switch, the pulmonary artery and the aorta are
replaced with each other, and the coronary arteries are
reimplanted.
6. After arterial switch, the coronary arteries should be
reevaluated at 6 years old, and if there is no stenosis, the
patient can even participate in competitive sport.
7. After arterial switch, there may be some degrees of pulmonary stenosis (supravalvular type) or aortic regurgitation. The aortic regurgitation is trivial or mild, and there
is aortic root dilation. Supravalvular aortic stenosis is rare
[ 109 – 111 ].
Case 149 Transposition of Great Arteries
489
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_150, © Springer International Publishing Switzerland 2015
A 16-year-old pregnant woman was referred for fetal heart
echocardiography. It was her fi rst pregnancy (22 weeks of
gestation). There was no history of congenital heart disease
in the family and no mismatch blood groups.
Fetal Heart Echocardiography:
Pericardial Effusion
Case 150
a
b
Fig. 150.1 Pericardial effusion is seen around the left atrium, left ventricle, and right ventricle in the apical four-chamber view ( arrows ) ( a ). The
pericardial effusion measures 4 mm ( b ). LA left atrium, LV left ventricle, RV right ventricle
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_150 ) contains supplementary
material, which is available to authorized users.
490
Diagnosis
The patient was diagnosed with moderate pericardial effusion and mild to moderate tricuspid regurgitation.
Comment
Echocardiography after birth was recommended.
Lesson
1. The ductal arch has less curvature compared to the aortic
arch.
2. In the fetus, there is a normal inversion of the tricuspid
and mitral fl ows.
ab
Fig. 150.3 Mild to moderate tricuspid regurgitation is seen in this view ( arrow ) ( a ). The peak gradient across the tricuspid valve is 21 mmHg.
The normal inversion of the tricuspid fl ow is seen in this view ( b ) by the continuous wave Doppler study. RA right atrium, RV right ventricle
a
b
Fig. 150.2 The ductal arch is well visualized in this sagittal view ( arrow ) with color fl ow study ( a ) and two-dimensional echocardiography ( b ).
RV right ventricle, PA pulmonary artery, LPA left pulmonary artery, DAO descending aorta
Case 150 Fetal Heart Echocardiography: Pericardial Effusion
491
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_151, © Springer International Publishing Switzerland 2015
A 59-year-old woman presented with dyspnea on exertion of
recent duration. She was a known case of situs inversus dextrocardia. Electrocardiography showed superior axis deviation and a negative P wave in leads I and AVL.
All transthoracic echocardiographic images were obtained
from the right precordium, with the patient lying in the right decubitus position. The left ventricular ejection fraction was about
40 %, and there was inferior and anterior wall hypokinesia.
Situs Inversus Dextrocardia
Case 151
ab
Fig. 151.1 Moderate mitral regurgitation is seen in the apical four-
chamber view ( arrow ) ( a ). The tricuspid valve ( arrow ) has a lower
insertion compared to the mitral valve ( b ). Accordingly, corrected
transposition of the great arteries is ruled out. 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_151 ) contains supplementary
material, which is available to authorized users.
492
ab
Fig. 151.2 The subcostal view reveals that the aorta is located on the right side ( red fl ow ) ( arrow ) ( a ) and the inferior vena cava is located on the
left side ( blue fl ow ) ( curved arrow ) ( b )
a
b
Fig. 151.3 The pulse Doppler fl ow confi rms the right-sided position of the aorta ( a ) and the left-sided position of the inferior vena cava ( b )
Case 151 Situs Inversus Dextrocardia
493
Diagnosis
The patient was diagnosed to have situs inversus dextrocardia,
moderate left ventricular systolic dysfunction, wall motion
abnormality, and moderate ischemic mitral regurgitation.
Comment
Angiography was recommended for the patient.
Lesson
1. The chamber and vessel relationships are usually normal
in mirror image dextrocardia [ 157 ].
2. The cardiac situs often follows the abdominal situs.
The cardiac situs refers to the status of the atrial
appendages [ 2 ].
3. Moderate left ventricular systolic dysfunction and moderate mitral regurgitation should be differentiated from corrected transposition of the great arteries. In the latter, the
dysfunctional ventricle is the right ventricle, which has a
moderator band, coarse trabeculation, and septal insertion
of the papillary muscles. Also, there is an insuffi cient
atrioventricular valve (tricuspid), which has more apical
attachment compared to the mitral valve [ 114 , 115 , 157 ].
a
b
Fig. 151.5 Moderate mitral regurgitation ( arrow ) is seen on TEE (0°) ( a ). The mitral regurgitation vena contracta is about 5 mm ( b ). LA Left
atrium, LV left ventricle, AO aorta
a
b
Fig. 151.4 Transesophageal echocardiography (TEE) views are the mirror image of the usual TEE views: the 0° view is like the usual long-axis
view ( a ) and the long-axis view is like the usual 0° view ( b ). LA left atrium, LV left ventricle, RA right atrium, RV right ventricle, AO aorta
Case 151 Situs Inversus Dextrocardia
495
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_152, © Springer International Publishing Switzerland 2015
A 24-year-old man presented with newly diagnosed hypertension. Physical examination revealed an early diastolic
murmur (grade II/VI) on the aortic side. Echocardiography
showed mild concentric left ventricular hypertrophy, a bicuspid aortic valve with mild aortic insuffi ciency, and no aortic
stenosis.
Coarctation of Aortic Valve,
Bicuspid Aortic Valve,
and Patent Foramen Ovale
Case 152
Fig. 152.1 Transesophageal echocardiography ( TEE ) (short-axis
view) depicts the fi shmouth appearance ( arrow ) of the bicuspid aortic
valve, in systole. AO aorta
496
a
c
b
Fig. 152.2 The suprasternal long-axis view demonstrates the descending aorta narrowing with a systolodiastolic turbulency ( arrow ) ( a , b ). The
gradient in the ascending aorta is about 42 mmHg, and the velocity is 3.3 m/s ( c ). DAO descending aorta
a
b
Fig. 152.3 The narrowing of the descending aorta is more evident on TEE: about 40 cm from the dental arcade, the diameter is 27 mm ( a ), and
about 27 cm from dental arcade, it reaches to 16 mm ( b )
Case 152 Coarctation of Aortic Valve, Bicuspid Aortic Valve, and Patent Foramen Ovale
497
Diagnosis
The patient was diagnosed to have the coarctation of the
aorta, a bicuspid aortic valve with mild aortic regurgitation,
and a PFO.
Comment
Because the patient had mild aortic insuffi ciency, coarctoplasty was recommended.
Lesson
1. The bicuspid aortic valve and the coarctation of the aorta
are the anomalies that are highly associated [ 2 ].
2. The peak gradient, which is measured via Bernoulli’s
equation, overestimates the true gradient in aortic coarctation because the proximal velocity is not negligible in
this anomaly [ 158 ].
Fig. 152.6 This is a schematic illustration of the bicuspid aortic valve, left
main, and PFO fl ow. LA left atrium, RA right atrium, RV right ventricle
a
b
Fig. 152.4 This is a patent foramen ovale ( PFO ) fl ow at rest ( arrow ) ( a ). Agitated saline injection and Valsalva maneuver cause multiple bubbles
to pass through the PFO ( arrow ) ( b ). LA left atrium, RA right atrium, AO aorta
Fig. 152.5 TEE (short-axis view) reveals that the left main ( arrow )
originates from the left coronary cusp. AO aorta
Case 152 Coarctation of Aortic Valve, Bicuspid Aortic Valve, and Patent Foramen Ovale
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