Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3677_Библиотеки_им_академика_М_И_Перельмана
.pdf
40
https://t.me/medicina_free
3 Septal Defects
a
c
b
d
Fig. 3.6 An 8-year-old boy with a history of an atrial septal defect underwent surgical repair. The
preoperative TEE ME AV LAX view (a) depicted a defect located in the terminal portion of the
coronary sinus (CS), indicated by an arrow, as well as the lack of the left superior vena cava
(LSVC), also known as an isolated coronary sinus atrial septal defect (ASD). The preoperative
bicaval view (b) showed a dilated right atrium (RA) and wide-opened ostium of the CS (OS CS)
with an unroof part (dots line) connecting directly to the LA.The postoperative TEE ME fourchamber view (c) showed the surgical repair with a patch closure of the ostium of the CS.The
postoperative bicaval view (d) showed the surgical closure of the ostium of the CS with a patch
3.1 Atrial Septal Defect (ASD)
https://t.me/medicina_free
41
a
d
Fig. 3.7 A 5-year-old boy presenting with symptoms of exertional dyspnea underwent surgical
repair for a totally unroofed coronary sinus (CS) atrial septal defect. Preoperative double-obliquesagittal CT (a) showed blood in the persistent left superior vena cava (PLSVC) draining directly
into the left atrium (LA) instead of the right atrium (RA). Intraoperative TEE (b) revealed an
interatrial defect (ASD) and complete absence of the roof of CS.The intraoperative color Doppler
TEE (c) demonstrated a small LA and large RA, with a left-to-right shunt clearly visible across the
atrial septal defect (arrow). Bubble study (d) demonstrated bubbles (small yellow arrows) in the
LA via PLSVC and a patent foramen ovale (PFO) defect between the RA and LA.Postoperative
TEE (e, f) showed successful atrial septal defect repair with patch by closure of the opening of the
native coronary sinus. And rerouted coronary venous return to the RA.The four-chamber view (f)
showed the spiral repair with patch and reconnection of the LSVC to the right atrial appendage
(RAA). However, the reconnection of the LSVC to the RAA is not visible in this gure
(Abbreviation: CV, Coronary vein)
b
e
c
f
42
https://t.me/medicina_free
3 Septal Defects
ab
c
Fig. 3.8 A 4-year-old boy experienced hypoxemia after TOF repair, which was caused by an
undiagnosed coronary sinus (CS) atrial septal defect (ASD). This was revealed through: (a) TEE
with a ME four-chamber view displaying the repaired VSD patch (p, yellow arrows), (b) TEE with
contrast injection showing a partial CS ASD, by identing some bright echogenity bubbles (arrowheads) in LA and (c) ME four-chamber view demonstrating a large CS, right-to-left shunt, and
elevated RA pressure. As a result, the partial CS ASD was repaired again
3.1 Atrial Septal Defect (ASD)
https://t.me/medicina_free
43
ab
d
Fig. 3.9 A girl underwent surgical repair for ASD and persistent Eustachian valve. (a) The cardiac
CT scan revealed an inferior sinus venous atrial septal defect (ASD), indicated by a red dotted line,
in which all the right pulmonary veins open into the RA. (b) Preop TEE showed large interatrial
defect (green dotted line) and a giant Eustachian valve (EV). (c) Color Doppler showed a 2.2cm
diameter ASD with left-to-right shunt and discontinuity of IVC-IAS. (d) Intraoperative photo
showed an inferior sinus venous ASD, with the suction tube pointing toward it. (e) Postoperative
TEE showed removal of Eustachian valve and surgical repair of inferior sinus venous defect
by a patch
e
c
44
https://t.me/medicina_free
3 Septal Defects
ab
Fig. 3.10 A 12-year-old boy with an atrial septal aneurysm (ASA) during routine follow-up. (a)
TEE with ME four-chamber view showed two localized saccular deformities in the atrial septum
(eye glass appearance). (b) LAX view showed the ASA without shunting ow or septal defect
References
1. Naqvi N, McCarthy KP, Ho SY.Anatomy of the atrial septum and interatrial
communications. J Thorac Dis. 2018;10:S2837–47.
2. McCarthy K, Ho S, Anderson R.Dening the morphologic phenotypes of atrial
septal defects and interatrial communications. Images Paediatr Cardiol.
2003;5:1–24.
3. Murphy JG, Gersh BJ, McGoon, etal. Long-term outcome after surgical repair
of isolated atrial septal defect. Follow-up at 27 to 32 years. N Engl Med.
1990;323:1645–50.
4. Cho YH, Jun TG, Yang JH, etal. Surgical strategy in patients with atrial septal
defect and severe pulmonary hypertension. Heart Surg Forum. 2012;15:E111–5.
3.2 Ventricular Septal Defect (VSD)
Ventricular septal defect (VSD) is a common congenital heart defect that involves a
hole or holes in the septum between the two ventricles.
There are four types of VSD based on the location of the defect within the septum [1, 2] (Fig.3.11).
• Perimembranous (Pm) VSD, accounting for approximately 80% of cases, occurs
in the region of the membranous septum, which is located near the aortic and
tricuspid valves (Fig.3.12).
• Muscular VSD, also known as trabecular VSD, accounts for approximately
5–20% of cases. This type of VSD primarily affects the muscular septum, which
will be further explained in Figs. 8.35, 8.36, and 8.37 in the context of catheter
interventions.
3.2 Ventricular Septal Defect (VSD)
https://t.me/medicina_free
45
• Inlet VSD, also known as AV canal type VSD, accounts for approximately 5–8%
of cases. It occurs in the inlet muscular septum. Inlet septum defects often involve
abnormalities in the tricuspid and mitral valves, collectively known as common
atrioventricular canal defect (Figs.3.18 and 3.20).
• Outlet VSD occurs in the infundibular region of the ventricular septum and can
be classied into two subtypes: muscular outlet VSD or doubly committed jux-
taarterial (subarterial) VSD.It accounts for approximately 5–7% of cases. Please
refer to Figs.3.13 and 3.15 for visual representations of these subtypes of VSDs.
a b
Fig. 3.11 Describes the various types of ventricular septal defect (VSD) based on their location.
(a) This schematic illustration shows the various segments of the ventricular septum as viewed
from the unroofed right ventricle. It displays the length of the interventricular septum, including
the membranous septum (yellow), outlet septum (green), inlet septum (blue), and trabecular septum (brown). (b) This 3D virtual image model displays various types of VSDs in a baby’s heart.
The image shows different types of VSDs, including the muscular VSD indicated by the white
arrow. Other types of VSDs depicted in the image include the outlet type (green) with a red dot
indicating a doubly committed subarterial (juxtaarterial) VSD and a brown dot indicating a muscular outlet VSD.Additionally, the perimembranous (pm) type is shown in yellow, the inlet type
(also known as atrioventricular septal defect or AVSD) is shown in blue, and the muscular type is
depicted in red-brown. (c–e) Show schematics of different types of VSDs in TEE images: (c) displays the ME ve-chamber view with a pmVSD in membranous septum (yellow) and a muscular
VSD in trabecular septum (brown), (d) ME AV SAX view shows the presence of a pmVSD (yellow) and an outlet VSD (green), with a brown arrowhead indicating muscular outlet and a red
arrowhead indicating doubly committed subarterial (juxtaarterial) VSD along ventricular septum,
(e) AV LAX view shows the presence of a pmVSD (yellow) and an outlet VSD (green) along ventricular septum. (f–h) TEE images corresponding to the VSD diagrams (c–e). In (f), the ME fourchamber view shows a muscular VSD (arrow) with left-to-right shunt conrmed by color Doppler.
In (g), ME AV SAX view displays a perimembranous (pm) VSD (arrow) with turbulent ow
toward the tricuspid valve (TV) also demonstrated by color Doppler. (h) The same view as (d)
displays an outlet VSD (arrow) with a turbulent ow toward the pulmonary valve (PV) conrmed
by color Doppler
46
ab
de
gh
https://t.me/medicina_free
3 Septal Defects
c
f
Fig. 3.11 (continued)
Fig. 3.12 Depicts a signicant perimembranous ventricular septal defect (VSD) in children, as
observed through intraoperative transesophageal echocardiography (TEE) with the mid- esophageal
aortic valve short-axis (ME AV SAX) view (a) and the mid-esophageal aortic valve long-axis (ME
AV LAX) view (b). The TEE images illustrate a VSD with a diameter of 1.3cm (indicated by the
yellow dotted line), and the color Doppler TEE demonstrates the ow of blood from the left to the
right heart chamber and toward the tricuspid valve (TV)
3.2 Ventricular Septal Defect (VSD)
https://t.me/medicina_free
47
ab
Fig. 3.13 Shows outlet VSD in children as seen on: (a) Intraoperative TEE with ME AV SAX
view displays a 1cm outlet ventricular defect (yellow dotted line) and VSD jet ow from left to
right heart chamber toward PV as seen in color Doppler TEE (right diagram). (b) TEE with ME
AV LAX shows a partial prolapse of the aortic valve (white arrow) with outlet ventricular defect
and VSD jet ow from left to right heart chamber (RV) as seen in color Doppler TEE (right
diagram)
The clinical course for pediatric patients with VSD depends on the size and location of the defect, as well as the age and overall presence of any other heart
conditions.
Small VSDs may not require any treatment and may close on their own over
time. However, large symptomatic VSDs (calculated pulmonary to systemic shunt
larger than 1.5 or increased pulmonary vascular resistance, poor weight gain, exercise intolerance, associated aortic valve prolapse, associated double-chambered
right ventricle, infective endocarditis) usually require catheter-based intervention
(will be discussed in Sect. 8.4) or surgical repair under the TEE monitoring (as
shown in Figs.3.11, 3.12, 3.13, 3.14, 3.15, 3.16, 3.17, 3.18, 3.19, and 3.20).
The complication of residual VSD following surgical repair:
Following the repair procedure, it was found that the majority of children exhibited a small, asymptomatic residual ventricular septal defect (VSD) [3–5]. In cases
where the diameter of the residual VSD was less than 3mm, spontaneous healing
was observed (Fig.3.16). However, certain children presented with larger VSDs,
which resulted in volume overload, heart failure, and reduced cardiac output. These
cases necessitated further surgical or catheter intervention (Please refer to Chap. 10,
Sect. 10.2).
48
ab
https://t.me/medicina_free
3 Septal Defects
c
Fig. 3.14 A 3-month-old baby with heart failure due to a large VSD underwent surgery. (a)
Intraoperative photo of open-heart surgery. (b) Preop color Doppler TEE shows a large perimembranous VSD with a L-R shunt. (c) VSD repaired with patch during surgery. (d) Postop TEE displays a successful patch repair without any residual shunt
d
aa
3.2 Ventricular Septal Defect (VSD)
https://t.me/medicina_free
49
1
b1b
Fig. 3.15 A 7-year-old boy with an outlet-type ventricular septal defect (VSD) and aortic valve
prolapse underwent surgical repair. (a) Preop TEE image with ME AV LAX view displays a 5mm
VSD partially obstructed by prolapsed right coronary cup (yellow arrow). The defect has a diameter of 10.5mm from the RV side and there is a left-to-right shunt visible on color Doppler image.
(a1) ME AV SAX color TEE image displays a VSD (red dotted circle) with a small jet ow of
left-to-right shunt (yellow arrowhead) obstructed by right coronary cup prolapse, and mild aortic
regurgitation (white arrow) during diastole. (b) Postop TEE image with ME AV LAX view displays surgical closure of VSD using a 1.5cm patch (double-head red line) and without any residual
shunt is visible on the right diagram. (b1) ME AV SAX color TEE image shows trivial aortic
regurgitation during diastole after VSD closure with patch
Соседние файлы в папке Библиотека им академика М.И. Перельмана