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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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24
Diagnosis
The patient was diagnosed with a fenestrated IAS Swiss
cheese-like ASD [ 18 ].
Comment
Given the patient’s fenestrated IAS, surgery was recommended [ 19 , 20 ].
Lesson
Before the referral of a patient for the ASD device closure,
meticulous search for another defect(s) in the IAS is
recommended.
Fig. 8.5 TEE (bicaval view) shows multiple small ASDs ( arrows ) and
a fenestrated IAS. LA left atrium, RA right atrium
Fig. 8.4 TEE ( short-axis view ) demonstrates another small defect in
the IAS ( arrow ). AO aortic valve, LA left atrium, RA right atrium
Case 8 Fenestrated Interatrail Septum “Swiss Cheese-like Atrial Septal Defect”
25
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_9, © Springer International Publishing Switzerland 2015
A 36-year-old woman presented with dyspnea on exertion
(functional class II). Physical examination revealed a holosystolic murmur at the lower left sternal border.
Multiple Atrial Septal Defects (Ostium
Secundum Type)
Case 9
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_9 ) contains supplementary
material, which is available to authorized users.
26
a
c
e
b
d
Fig. 9.1 Transesophageal echocardiography (TEE) (0°) reveals at least
two atrial septal defects (ASDs) (ostium secundum type) by twodimensional echocardiography ( arrows ) ( a ) and color-fl ow Doppler
study ( b ). The defects are 5 mm in size ( c ) and 5 mm apart ( d ). This is
a schematic depiction of the defects ( arrow ) in this view ( e ). LA left
atrium, RA right atrium, AO aorta
Case 9 Multiple Atrial Septal Defects (Ostium Secundum Type)
27
a b
Fig. 9.3 Considering the three ASDs together, the total size of the defects is 32 mm on TEE (short-axis view) ( a ). This is a schematic illustration
of these defects in this view ( b ). LA left atrium, RA right atrium, AO aorta
a
c
b
Fig. 9.2 TEE (short- axis view) demonstrates another (third) defect in
the interatrial septum (6 mm) by two-dimensional echocardiography
( a ) and color-fl ow Doppler study ( b ). The distance between this defect
and the other ones is approximately 13 mm ( c ). 1 fi rst defect, 2 second
defect, 3 third defect LA left atrium, RA right atrium
Case 9 Multiple Atrial Septal Defects (Ostium Secundum Type)
28
ab
Fig. 9.4 TEE (bicaval view) illustrates the two ASDs ( arrows ) near the superior vena cava ( a ). There is another defect in the interatrial septum
( arrow ) in the proximity of the inferior vena cava in the same view by some rotation ( b )
Diagnosis
The patient had three ASD ostium secundum types.
Comment
Given the patient’s three ASDs (ostium secundum type),
relatively large size of the total defects together, Qp/Qs of 4,
and systolic pulmonary arterial pressure of 46 mmHg, surgery was recommended [ 19 ].
Case 9 Multiple Atrial Septal Defects (Ostium Secundum Type)
29
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_10, © Springer International Publishing Switzerland 2015
A 37-year-old woman presented with dyspnea on exertion
(functional class II).
Atrial Septal Defect (Ostium
Secundum Type) with an
Additional Defect in the
Interatrial Septum
Case 10
Fig. 10.1 The apical four-chamber view shows moderate right atrial
and ventricular dilation and a partially aneurysmal interatrial septum
(IAS) ( arrow )
a
b
Fig. 10.2 The modifi ed apical four-chamber view reveals an atrial sep-
tal defect (ASD) fl ow ( arrow ) ( a ). However, there seems to be another
defect in the IAS ( curved arrow ) ( b ). LA left atrium, RA right atrium
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_10 ) contains supplementary
material, which is available to authorized users.
30
Diagnosis
The patient was diagnosed with an ASD (ostium secundum
type) with another small defect in the IAS.
Comment
Considering the good size and rims of the larger ASD and
the symptoms of the patient, a decision was made to perform
the ASD device closure for the larger defect and not to intervene for the second smaller defect.
Lesson
Some types of multiple ASDs may be good candidates for
device closure [ 18 , 21 ]. If there is a large ASD (ostium
secundum type) together with a very small defect, the fi rst
defect can be closed and the patient should be followed up
for the smaller one because the defect is smaller than
5 mm. (It depends on the patient’s symptoms: if the patient
has a history of transient ischemic attack or paradoxical
emboli, it is advisable that even small defects be
closed) [ 2 ].
If two ASDs were close to each other, it is possible to
consider both ASDs as one ASD and use one large device for
both of them [ 18 ], and sometimes it is possible to use two
devices in one patient for ASD device closure [ 18 ]. Defects
separated more than 7 mm were categorized as widely separated [ 22 ].
a
c
b
Fig. 10.3 Transesophageal echocardiography (90°) detects another small defect ( curved arrow ) in the IAS in addition to the fi rst larger ASD
( arrow ) ( b ). This defect is 2 mm in size, and its distance from the fi rst defect ( arrow ) is 18 mm ( c ). LA left atrium, RA right atrium
Case 10 Atrial Septal Defect (Ostium Secundum Type) with an Additional Defect in the Interatrial Septum
31
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_11, © Springer International Publishing Switzerland 2015
A 57-year-old woman was referred to our center for decision-making regarding an atrial septal defect (ASD).
Transthoracic echocardiography (TTE) revealed moderate
tricuspid regurgitation (TR) with a gradient of about
40 mmHg.
Multiple Atrial Septal Defects
(Ostium Secundum Type)
Case 11
Fig. 11.1 Moderate right ventricular dilation is evident in the apical
four-chamber view. One ASD fl ow is shown in this view ( arrow ). LA
left atrium, RA right atrium
Fig. 11.2 The subcostal bicaval view shows two ASD fl ows ( arrows ),
one of which is in the proximity of the inferior vena cava ( curved
arrow ). LA left atrium, RA right atrium
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_11 ) contains supplementary
material, which is available to authorized users.
32
Fig. 11.3 The right ventricular
ejection fraction is about 37 % by
the multiplane modality of a
four-dimensional probe
a
b
Fig. 11.4 Two ASDs ( arrows ) are visualized on transesophageal echocardiography (TEE) (42°) by two-dimensional ( a ) and color Doppler study
( b ). LA left atrium, RA right atrium
a
b
Fig. 11.5 TEE (bicaval view) shows that there is an ASD ( arrow ) lying posteriorly to the septum and in the proximity of the inferior vena cava
by two-dimensional ( a ) and color Doppler study ( b ). LA left atrium, RA right atrium
Case 11 Multiple Atrial Septal Defects (Ostium Secundum Type)
33
Diagnosis
The patient was diagnosed with two ASDs (ostium secundum type): one of them was located anteriorly near the aorta,
and the other one was positioned posteriorly close to the
inferior vena cava.
Comment
The patient’s left-to-right shunt was approximately three.
She was referred for surgery for the closure of the two ASDs
(ostium secundum type) and tricuspid annuloplasty. (The tricuspid annulus was about 39 mm in the apical four-chamber
view.)
Lesson
In this case both of ASDs were large and one of them, near
inferior vena cava, so we have to refer the patient for surgery.
Tricuspid valve annuloplasty due to annulus dilation is also
recommended in the time of surgery [ 23 ].
Fig. 11.7 The fi rst ASD is about 19 mm in size on TEE (42°). LA left
atrium, RA right atrium, AO aorta
Fig. 11.6 This ASD is 16 mm in size, and there is nearly no rim to the
inferior vena cava. LA left atrium, RA right atrium
Case 11 Multiple Atrial Septal Defects (Ostium Secundum Type)
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