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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3612_Библиотеки_им_академика_М_И_Перельмана
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Key Questions in CONGENITAL CARDIAC SURGERY
calculated. The best views are the high right parasternal, the apical
five-chamber and the subcostal short-axis, as they provide the best
alignment with the cursor. If the outflow tract is not aligned with the
cursor, the estimation will be incorrect.
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Figure 15. Parasternal long-axis views of the aortic valve demonstrating a:
A) thickened aortic valve with; B) a turbulent narrow jet of flow across it on
the corresponding colour flow Doppler image; C) fibromuscular ridge (arrow)
causing subaortic stenosis; D) supravalvular aortic stenosis (arrow); and E)
turbulence starting above the level of the aortic valve on the corresponding
colour flow Doppler image. LA = left atrium; RV = right ventricle; LV = left
ventricle; Ao = aorta; AoV = aortic valve.
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4 Congenital echocardiography
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Figure 16. Parasternal short-axis view at the
level of the papillary muscles demonstrating
severe left ventricular hypertrophy. RV = right
ventricle; LV = left ventricle.
141
Figure 17. High right parasternal view with continuous wave
Doppler demonstrating a peak velocity of 4.5m/s across the
aortic valve, consistent with aortic stenosis.
142
Key Questions in CONGENITAL CARDIAC SURGERY
11 What are the principles of assessing mitral valve
disease on echocardiography?
In TTE, the parasternal long-axis, apical four-chamber (Figure 18)
•
and apical two-chamber views are best to visualise the mitral valve,
as well as subcostal views.
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Figure 18. Apical four-chamber view demonstrating
turbulent colour flow through a severely stenotic mitral
valve, an enlarged left atrium and bowing of the
interatrial septum into the right atrium. RA = right atrium;
LA = left atrium.
The praecordial short-axis views demonstrate the number and
•
arrangement of the papillary muscles, which are usually situated at
the 3 o’clock and 8 o’clock positions in this view. Absence,
hypoplasia or fusion of the papillary muscles (as in a parachute mitral
valve) may be demonstrated.
Isolated cleft of the mitral valve can be demonstrated in the subcostal
•
and parasternal short-axis views. The cleft ‘points’ towards the
outflow tract. The additional goal of imaging this lesion is to ensure
there is no evidence of outflow tract obstruction, as chordal
attachments to the septum may be seen.
4 Congenital echocardiography
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The short-axis view may also demonstrate an arcade mitral valve or
•
double-orifice mitral valve.
Supramitral rings may present with only subtle findings on
•
echocardiography, as the rings may be very close to and fused with
the valve leaflets. Additional valvular or subvalvular pathology is
usually present.
In a patient with isolated mitral regurgitation, the diagnosis of
•
anamolous left coronary artery from the pulmonary artery (ALCAPA)
should be diligently excluded.
Colour flow Doppler and continuous wave Doppler are used
•
extensively in the assessment of severity of regurgitation or stenosis.
3D echocardiography can be used to demonstrate both the mitral
•
valve leaflets and subvalvular apparatus and can be manipulated to
display the surgical view of the valve.
12 What are the principles of assessing cor triatriatum on
echocardiography?
Cor triatriatum is a condition where there is separation of blood flow
•
between the pulmonary veins and the mitral valve, secondary to a
membranous partition within the left atrium, which is seen best in the
apical or subcostal four-chamber views (Figure 19).
143
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Figure 19. Subcostal four-chamber view demonstrating: A) a cor
triatriatum membrane (green arrow) above the level of the mitral valve
leaflets (white arrows); with B) a narrow jet of flow passing through the
membrane on the corresponding colour flow Doppler image. RA = right
atrium; LA = left atrium; LV = left ventricle.
144
Key Questions in CONGENITAL CARDIAC SURGERY
In almost all cases, there is a communicating orifice within the
•
membrane that will allow varying degrees of blood flow.
Echocardiography should assess the position of the membrane and
any restriction to blood flow.
The atrial septum is most often intact but an ASD may be present in
•
some cases.
13 What are the principles of assessing total anomalous
pulmonary venous drainage on echocardiography?
In the normal heart, the best position to assess the pulmonary veins
•
is in the left subclavicular view. Reducing the Nyquist limit (colour
scale) will enable the pulmonary veins to be viewed in the
characteristic ‘crab view’, where the ‘legs’ of the crab are formed by
the pulmonary veins and the ‘claws’ by the right SVC and left atrial
appendage (Figure 20).
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Figure 20. Left subclavicular (‘crab’) view demonstrating the pulmonary
veins joining the left atrium. LUPV = left upper pulmonary vein; RUPV = right
upper pulmonary vein; LLPV = left lower pulmonary vein; RLPV = right lower
pulmonary vein.
Supracardiac total anomalous pulmonary venous connection
•
(TAPVC, Figure 21) is characterised by the pulmonary venous
confluence draining via a vertical vein that courses superiorly into the
left innominate vein, superior vena cava or azygos vein and thereafter
the right atrium. The left subclavicular view can be used to assess the
venous confluence and the suprasternal notch view to assess the
connections via the vertical vein and innominate vein. In younger
4 Congenital echocardiography
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Figure 21. Suprasternal view
demonstrating a supracardiac total
anomalous pulmonary venous
connection with a vertical vein (VV)
draining the confluence of the right
pulmonary veins (RPVs) and the left
pulmonary veins (LPVs). The blood
flow in the vertical vein ascends and
then connects to the innominate vein
draining into the superior vena cava
(SVC). Ao = aorta; PA = pulmonary
artery.
145
children, the subcostal views may also be used to identify the
pulmonary veins.
Cardiac TAPVC (Figure 22) is characterised by the pulmonary veins
•
joining via a confluence to the coronary sinus and thereafter draining
into the right atrium. The subcostal view best shows the pulmonary
veins draining into a severely dilated coronary sinus with a
characteristic ‘tail of the whale’ appearance. The associated ASD is
also best seen in the subcostal view with an obligate right-to-left
shunt (blue colour Doppler flow from the right atrium to the left
atrium).
Key Questions in CONGENITAL CARDIAC SURGERY
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Figure 22. Subcostal view demonstrating: A) an intracardiac total
anomalous pulmonary venous connection with the right pulmonary veins
(RPVs) and left pulmonary veins (LPVs) draining into the coronary sinus
(CS), creating a characteristic appearance resembling a ‘tail of a whale’
(outlined in green); and B) a small left atrium (LA) that fills with blood
passing from the right atrium (RA) via a secundum atrial septal defect
(blue flow with arrow), on the corresponding colour flow Doppler image.
LV = left ventricle; RV = right ventricle.
Infracardiac TAPVC (Figure 23) is characterised by the pulmonary
•
venous confluence draining into a vertical descending vein that
courses inferiorly to the portal vein or hepatic veins and thereafter the
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Figure 23. Echocardiographic images demonstrating: A) an infracardiac total
anomalous pulmonary venous connection with images taken from high on the
left chest show a descending vein (DV, outlined in green); and B) continuous
high-velocity flow due to obstruction on Doppler taken in the descending vein.
4 Congenital echocardiography
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inferior vena cava and right atrium. This type of anomalous pulmonary
venous connection is most prone to obstruction and requires
emergency lifesaving surgery.
Careful attention should be made in all cases of total anomalous
•
pulmonary venous connection to rule out obstruction, which is an
indication for immediate surgical intervention.
14 What are the principles of assessing an atrioventricular
septal defect on echocardiography?
A complete atrioventricular septal defect (cAVSD) can be assessed
•
in different echocardiographic views, including the:
a) apical view (Figure 24) — which will show an absence of
offsetting of the usual tricuspid and mitral valves, as instead of
the tricuspid valve septal attachment being slightly lower than
the mitral valve, in cAVSD the common atrioventricular (AV)
valve is at a single level, and shared across the two ventricles.
This view will also allow assessment of the size of the valve
annulus and chordal attachments. With a large VSD
component, it is important to assess valvular attachments and
whether there is any evidence of valve straddling;
b) subcostal short-axis view (Figure 25) — which can delineate
the common valve ‘en face’, so that the size and position of the
individual leaflets may be assessed. In this view, determination
of the Rastelli classification of the valve is visualised to aid
surgical planning, clefts may be seen, and colour flow Doppler
can demonstrate the location of the valvular regurgitation.
Tilting the probe delineates the papillary muscles.
147
In addition, the presence of any associated lesions should also be
•
identified, including:
a) patent ductus arteriosus;
b) coarctation of the aorta;
c) secundum ASD;
d) additional VSDs;
e) tetralogy of Fallot.
148
Key Questions in CONGENITAL CARDIAC SURGERY
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Figure 24. Apical views demonstrating atrioventricular septal defects
(AVSD): A) a primum septal defect (green asterisk) can be seen,
associated with the lack of the normal offset between the atrioventricular
valves (red line), as both the left and right are at the same level, which is
a diagnostic feature of AVSD; B) shunting of blood from the left atrium
(LA) to the right atrium (RA) across the defect (arrow) on the
corresponding colour flow Doppler image; C) a complete
atrioventricular septal defect with an atrial component (green arrow), just
above the common atrioventricular valve (CAVV), and a ventricular
component (red arrow), just below the CAVV, which has its valve tissue
at the same level on both sides on the septum. In addition, there is a
muscular ventricular septal defect (blue arrow). LV = left ventricle; RV =
right ventricle.
4 Congenital echocardiography
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Figure 25. Short-axis subcostal view demonstrating the
common atrioventricular junction.
15 What are the principles of assessing tetralogy of Fallot
on echocardiography?
The subcostal anterior oblique view (Figure 26) can demonstrate the
•
subpulmonary infundibulum, pulmonary valve, main pulmonary artery
and ventricular septum. It also gives excellent alignment for Doppler
assessment of the gradient across the right ventricular outflow tract.
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Figure 26. Echocardiographic images of tetralogy of Fallot: A) subcostal right
anterior oblique view demonstrating a ventricular septal defect (*) caused by
anterocephalad deviation of the outlet septum (OS); with B) right ventricular
outflow tract obstruction (turbulent yellow/cyan flow beginning in the
subpulmonary area) on the corresponding colour flow Doppler image; C)
parasternal long-axis view demonstrating the aorta overriding the ventricular
septal defect (red arrow). LPA = left pulmonary artery; RPA = right pulmonary
artery; PT = pulmonary trunk; LA = left atrium; RA = right atrium; RV = right
ventricle; TV = tricuspid valve; Ao = aorta.
149
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