Suprasternal View Image For Subclavian Bifurcation

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TEE-RVOT views (see Chapter 23).

A4C, apical four-chamber; A5C, apical five-chamber; AV, atrioventricular; PLAX, parasternal long-axis; PSAX, parasternal short-axis; RVOT, right ventricular outflow tract; TEE, transesophageal echocardiography.

A4C, apical four-chamber; A5C, apical five-chamber; AV, atrioventricular; PLAX, parasternal long-axis; PSAX, parasternal short-axis; RVOT, right ventricular outflow tract; TEE, transesophageal echocardiography.

Role of Echocardiography in VSDs

• Define anatomical site/type and size (Figs. 11-17; please see companion DVD for corresponding video for Figs. 12 and 14); less than 1 cm (small).

Levocardia Heart

Fig. 7. Position of the cardiac apex. (A) Following ventricular looping, the apex normally points toward the left (levocardia). (B) Mediastinal shifts can displace the entire heart to the right (dextroposition), but heart chambers are otherwise normal. (C) Isolated dextrocardia results from incomplete pivoting, but chambers are situs solitus and concordant. (D) Mirror image dextrocardia involves both situs inversus and discordant cardiac chambers.

Fig. 7. Position of the cardiac apex. (A) Following ventricular looping, the apex normally points toward the left (levocardia). (B) Mediastinal shifts can displace the entire heart to the right (dextroposition), but heart chambers are otherwise normal. (C) Isolated dextrocardia results from incomplete pivoting, but chambers are situs solitus and concordant. (D) Mirror image dextrocardia involves both situs inversus and discordant cardiac chambers.

• Assess hemodynamic impact on global cardiac indices, especially ventricular function, signs of volume and pressure overload, pulmonary artery pressures, pulmonary vascular resistance (Fig. 11).

• Assess shunt size (restrictive vs nonrestrictive); Qp/Qs measurement by 2D and PW at RVOT and left ventricular outflow tract (see Chapter 21).

• Detection and adjunct to management of related conditions, (e.g., aortic valve prolapse with supracristal and paramembraneous VSDs; Fig. 15).

• Detection and adjunct to management of unrelated attendant conditions (e.g., coronary or valvular heart disease).

• Intraprocedural/intraoperative TEE or 2D for trans-catheter or surgical closure.

• Follow-up, including postintervention.

Patent Ductus Arteriosus

A patent ductus arteriosus (PDA) is a residual communication between the pulmonary artery and aorta, necessary during gestation. Normally, this communication closes at birth. Most PDAs are diagnosed in infancy and childhood (5-10% of pediatric CHD), but may be incidental finding during echocardiography in the adult (Fig. 18; please see companion DVD for corresponding video).

Anatomical Site

• Ductus connects the aorta to the left pulmonary artery (LPA) (Fig. 19).

• A patent ductus arteriosus (PDA) is mainly an isolated defect, usually small and hemodynamically insignificant when seen in the adult.

Physiological Categories

Restrictive or nonrestrictve PDA with or without

Eisenmenger's syndrome.

Best Echo Windows

• Suprasternal view—angulate toward the LPA (Fig. 20).

• Color flow Doppler, PW and CW Doppler examining typical anatomic location of PDA with presence of systolic and diastolic flow, but patterns vary (Figs. 21 and 22). Reversal of flow may be seen in the rare Eisenmenger PDA in an adult.

Role of Echocardiography

• Identification of PDA.

• Assessment of size and Qp/Qs ratio.

• Detect changes within the ductus (e.g., aneurysm, atheroma, calcification, infective endocarditis). Aortic dissection involving ductus are rare, but known to occur.

Pda Echocardiography Images

Fig. 8. A 48-yr-old male with a single syncopal episode. Right apical four-chamber (A4C) view shown in A was accidentally inverted, with index mark at 9 o'clock instead of the 3 o'clock position (novice sonographer). Note the normal leaflet relationship (arrows) at cardiac crux (A; see Fig. 5). Subcostal imaging showed the liver and inferior vena cava (IVC) in their normal situs (B). Parasternal short axis (PSAX) view showing normal situs of the great arteries. Right A4C view by an experienced sonographer (D) shows normal atrial situs (pulmonary veins—right and left upper pulmonary veins [LUPV, RUPV] flowing into left atrium), atrioventricular concordance, and normal cardiac crux (arrows). This man's segmental nomenclature is therefore dextrocardia (S,D,S).

Fig. 8. A 48-yr-old male with a single syncopal episode. Right apical four-chamber (A4C) view shown in A was accidentally inverted, with index mark at 9 o'clock instead of the 3 o'clock position (novice sonographer). Note the normal leaflet relationship (arrows) at cardiac crux (A; see Fig. 5). Subcostal imaging showed the liver and inferior vena cava (IVC) in their normal situs (B). Parasternal short axis (PSAX) view showing normal situs of the great arteries. Right A4C view by an experienced sonographer (D) shows normal atrial situs (pulmonary veins—right and left upper pulmonary veins [LUPV, RUPV] flowing into left atrium), atrioventricular concordance, and normal cardiac crux (arrows). This man's segmental nomenclature is therefore dextrocardia (S,D,S).

Short Axis Echo Septal Defects Types

Fig. 9. Ventricular septal defects (continued).

Ventricular Septal Defects

Fig. 9. Ventricular septal defects (continued).

Pulmonic Leaflets Psax
Fig. 9. (Continued) Ventricular septal defects.

• TEE role limited because of interposed left bronchus between esophagus and aorta.

• TTE can guide transcatheter closure and establish the diagnosis/differentiate from aortico-pulmonary window (Fig. 23).

Coarctation of the Aorta

Stenotic lesion of the descending thoracic aorta, just distal to the origin of the left subclavian artery.

Anatomical Site

• Narrowing (stenosis) most commonly near the liga-mentum arteriosum—preductal and postductal types (Fig. 24).

• Degree of stenosis variable—may be discrete or long and tubular.

• Can be an isolated lesion ("simple" coarctation) or with associated lesions ("complex" coarctation).

Associated Cardiac Lesions

• Aortic stenosis secondary to BAV.

• Collateral circulation involving the internal mammary and intercostal arteries.

• Ventricular septal defect.

• Aortic medial disease with increased risk of aortic dissection.

• Anomalous right subclavian artery.

Best Echo Modalities, Windows

• Suprasternal notch (optimal neck extension).

• TEE (aortic arch, descending aortic long and short axes—see Chapter 23).

Role of Echocardiography

• Diagnosis of coarctation.

• Evaluation for associated lesions.

• Assess ventricular function for hypertensive heart disease (concentric hypertrophy), coronary artery disease (premature), secondary heart failure, aortic rupture/dissection, and infective endocarditis.

• Left ventricular function and the presence (or absence) of left ventricular hypertrophy.

• The presence (or absence) of other extracardiac cardiovascular anomalies such as collateral circulation, involvement of other vessels (subclavian/carotid stenoses) and associated aneurysms.

Doppler Assessment in PDA

Doppler echocardiography is crucial in the assessment of coarctation. The descending aorta should be interrogated with PW and CW Doppler in patients with suspected coarctation to assess velocities and calculate pressures. Color flow Doppler can also be helpful in looking for turbulence in the region of a coarcta-tion, and can often be the first clue of a stenosis.

Fig. 10. Recommended echocardiography windows for visualization of ventricular septal defects. The relative positions of ventricular septal defects on 2D echocardiography using the color scheme used in Figs. 9 and 10.

Pda Echocardiography Images

Fig. 10. Recommended echocardiography windows for visualization of ventricular septal defects. The relative positions of ventricular septal defects on 2D echocardiography using the color scheme used in Figs. 9 and 10.

Tetralogy of Fallot

Category

Cyanotic CHD with RVOT obstruction and shunt. Anatomy

• One primary defect leads to the tetrad—antero-cephalad displacement of the infundibular septum narrows the pulmonary artery, widens the aorta, and leaves a defect (Fig. 26). Right ventricular hypertrophy is secondary to RVOT obstruction.

• May be accompanied by PFO or ASD.

Pathophysiology

Pulmonary blood flow is obstructed to varying degrees—ranging from mild to severe. Right to left shunting of "blue" blood leading to cyanosis.

Natural History

• Almost all repaired in childhood (industrialized countries).

• Few unoperated patients seen in adulthood (Figs. 27 and 28; please see companion DVD for corresponding video for Fig. 27).

Palliative Surgery to Increase Pulmonary

Blood Flow

A number of potential repairs have been utilized in patients with Tetralogy of Fallot. These include the Blalock-Taussig shunt (Fig. 29) and a full corrective repair (Fig. 30).

Role of Echocardiography

• Look for residual pulmonary stenosis, pulmonary regurgitation, or residual VSD.

• Assess pulmonary pressures—for signs of pulmonary hypertension.

• Assess aortic root—look for dilatation and aortic regurgitation.

• Assess right and left ventricular size and function (including myocardial performance index).

Hemodynamics Pulmonary Regurgitation

Fig. 11. Ventricular septal defects: physiological categories. Schema illustrating the physiological varieties of ventricular septal defects. Shunt size can be assessed by the pulmonary-to-system flow ratio (Qp/Qs). Smaller shunts (restrictive VSDs) generally have Qp/Qs<1.1, Nonrestrictive or open shunts have Qp/Qs >2.2, indicating significant hemodynamic impact. PASP, pulmonary artery systolic pressure; AP, aortic pressure.

Fig. 11. Ventricular septal defects: physiological categories. Schema illustrating the physiological varieties of ventricular septal defects. Shunt size can be assessed by the pulmonary-to-system flow ratio (Qp/Qs). Smaller shunts (restrictive VSDs) generally have Qp/Qs<1.1, Nonrestrictive or open shunts have Qp/Qs >2.2, indicating significant hemodynamic impact. PASP, pulmonary artery systolic pressure; AP, aortic pressure.

Hemodynamic Restrictive Cardiomyopathy

Fig. 12. Ventricular septal defects: small membranous (restrictive). Parasternal long-axis view (PLAX) of a small perimembranous ventricular septal defect in 62-yr-old male. Left ventricular dilation, secondary to ischemic cardiomyopathy, was also present. (Please see companion DVD for corresponding video.)

Fig. 12. Ventricular septal defects: small membranous (restrictive). Parasternal long-axis view (PLAX) of a small perimembranous ventricular septal defect in 62-yr-old male. Left ventricular dilation, secondary to ischemic cardiomyopathy, was also present. (Please see companion DVD for corresponding video.)

Short Paresternal Long Axis

Fig. 13. Ventricular septal defects: small perimembranous (restrictive). (A) Classic perimembranous VSD at the 10 o'clock position in parasternal short axis (PSAX) views. (B) Peak instantaneous velocity measured 4 m/s (peak instantaneous gradient 65 mmHg), but no increased pulmonary artery pressures or chamber dilatation was present.

Fig. 13. Ventricular septal defects: small perimembranous (restrictive). (A) Classic perimembranous VSD at the 10 o'clock position in parasternal short axis (PSAX) views. (B) Peak instantaneous velocity measured 4 m/s (peak instantaneous gradient 65 mmHg), but no increased pulmonary artery pressures or chamber dilatation was present.

• In patients with palliative shunts—assess flow velocities and direction for evidence of shunt stenosis, occlusion, thrombosis, infection, or aneurysm.

Ebstein Malformation

Ebstein's anomaly or malformation is a condition in which the septal leaflet of the tricuspid valve is apically displaced, sometimes dramatically, and the anterior leaflet becomes "sail-like," extending deeply into the RV. Many patients survive into adulthood without surgical intervention (Figs. 31-33; please see companion DVD for corresponding video for Fig. 31).

Anatomy/Physiology

• Anatomic and functional anomalies of the TV.

• Apical displacement of the septal and posterior leaflets of the TV.

• "Atrialization" of right ventricular inflow tract (large right atrium) at the expense of the RV.

• Tricuspid regurgitation.

• Echodiagnosis: apical displacement of septal TV leaflet more than 8 mm/m2 with elongated "sail-like" TV leaflet.

Associated Cardiac Lesions

PFO, ASD, VSD, pulmonary stenosis.

Role of Echocardiography

• Establish the diagnosis.

• Define anatomic lesion—severity (degree of apical displacement).

Pisa Echocardiography

Fig. 14. Ventricular septal defects: moderately restrictive. Parasternal long axis views (PLAX, A,B) of 32-yr-old female with a loud systolic murmur and increasing shortness of breath. Note the easily visible perimembraneous VSD with marked shunting (large PISA) on color flow Doppler. Peak instantaneous velocity measured 5.3 m/s (peak gradient 114 mmHg). Her Qp/Qs was 1.4 (C). Note systolic flattening (D-shaped) of the interventricular septum consistent with right ventricular pressure and volume overload. (Please see companion DVD for corresponding video.)

Fig. 14. Ventricular septal defects: moderately restrictive. Parasternal long axis views (PLAX, A,B) of 32-yr-old female with a loud systolic murmur and increasing shortness of breath. Note the easily visible perimembraneous VSD with marked shunting (large PISA) on color flow Doppler. Peak instantaneous velocity measured 5.3 m/s (peak gradient 114 mmHg). Her Qp/Qs was 1.4 (C). Note systolic flattening (D-shaped) of the interventricular septum consistent with right ventricular pressure and volume overload. (Please see companion DVD for corresponding video.)

Pisa Aortic Regurgitation

Fig. 15. Transesophageal views of a 58-yr-old male with a ventricular septal defect and worsening aortic regurgitation. Note the marked prolapse of the right cusp in the ME Aortic valve long axis view (A). Flow acceleration was noted on color Doppler and CW Doppler evaluation showed peak velocities exceeding 1.8 m/s (B,C). Transgastric view shows prolapse extending into the ventricular outflow tract.

Fig. 15. Transesophageal views of a 58-yr-old male with a ventricular septal defect and worsening aortic regurgitation. Note the marked prolapse of the right cusp in the ME Aortic valve long axis view (A). Flow acceleration was noted on color Doppler and CW Doppler evaluation showed peak velocities exceeding 1.8 m/s (B,C). Transgastric view shows prolapse extending into the ventricular outflow tract.

Echocardiography Supersternal Image

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Responses

  • INES
    Are the pulmonary veins are visible on suprasternal sonographic view?
    6 years ago
  • Onni
    What echo views show the rupv?
    5 years ago
  • louise
    What types of septum in apical view in echo?
    2 years ago

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