Aortico Pulmonary Window

Echocardiography

Fig. 17. Pulmonary artery banding was also performed to reduce volume and pressure effects of a previous unrestricted VSD. Note the increased echodensity (A). Flow acceleration indicating band stenosis was noted on color flow Doppler evaluation (B), and stenosis gradient was quantified by CW Doppler (C) revealing a peak velocity of 2.8 m/s (peak gradient of = mmHg).

Fig. 17. Pulmonary artery banding was also performed to reduce volume and pressure effects of a previous unrestricted VSD. Note the increased echodensity (A). Flow acceleration indicating band stenosis was noted on color flow Doppler evaluation (B), and stenosis gradient was quantified by CW Doppler (C) revealing a peak velocity of 2.8 m/s (peak gradient of = mmHg).

Fig. 18. Patent ductus arteriosus. Parasternal short-axis (PSAX) diastolic frame showing typical jet (arrow) of a patent ductus arteriosus with left-to-right shunt. (Please see companion DVD for corresponding video.)

Patent Ductus Arteriosus Echo Images

Fig. 18. Patent ductus arteriosus. Parasternal short-axis (PSAX) diastolic frame showing typical jet (arrow) of a patent ductus arteriosus with left-to-right shunt. (Please see companion DVD for corresponding video.)

Patent ductus arteriosus

Proximal Ductal Arteriosus
Fig. 19. Patent ductus arteriosus. A patent arterial duct connects the anterior surface of the proximal descending thoracic aorta to the roof of the left pulmonary artery.

• Assess biventricular dimensions and function—often impaired.

• Assess degree of tricuspid regurgitation.

• Pulmonary artery pressures.

• Look for/assess shunts and related lesions (ASDs are commonly associated).

• TEE if inadequate windows on TTE.

Complete Transposition of the Great Arteries (D-TGA)

In transposition of the great arteries, the atrioventricular connections are concordant (correct anatomically), whereas the ventriculo-arterial connections are discordant.

Anatomy

• AV connections concordant.

• Ventriculoarterial connections discordant.

• Most patients have simple TGA, but additional lesions common—"complex" transposition is common, e.g., with VSD and pulmonary/subpulmonic stenosis.

Surgical Correction

Almost all adults have had surgical intervention. A variety of corrective surgical repairs have been used in patients with transposition, the details of which are beyond the scope of this book (Fig. 34).

CHD: MISCELLANEOUS TOPICS

Persistent Left Superior Vena Cava

This is the commonest form of anomalous venous drainage involving the superior vena cava (Fig. 35).

It represents a persistence of the left horn of the embryonic sinus venosus that normally involutes to become the coronary, and therefore, almost always drains into the coronary sinus and manifests as a markedly dilated coronary sinus. This anomaly is of no clinical significance.

Pda Echocardiography Images
Fig. 20. Patent ductus arteriosus. Tiny jet (arrow) of left-to-right shunt from a small PDA can be seen entering the roof of the left pulmonary artery in relation to the aorta.
Patent Ductus Arterio
Fig. 21. Patent ductus arteriosus. Pulsed Doppler interrogation at the site (same patient, Fig. 20) shows continuous low velocity flow with systolic accentuation.
Patent Ductus Arterio
Fig. 22. Patent ductus arteriosus. Continuous-wave Doppler evaluation of PDA flow in the main pulmonary artery of patient (Fig. 18), confirms continuous flow pattern.
Patent Ductus Arterio

Fig. 23. Another arterio-venous fistula that causes continuous flow is the aortico-pulmonary window—usually an acquired defect that connects walls of the ascending thoracic aorta and the main pulmonary trunk. It can behave similarly to a large PDA with large left-to-right shunt and sequelae may be associated with a PDA, Coarctation, VSD, interrupted aortic arch.

Aortico-Pulmonary Window

Fig. 23. Another arterio-venous fistula that causes continuous flow is the aortico-pulmonary window—usually an acquired defect that connects walls of the ascending thoracic aorta and the main pulmonary trunk. It can behave similarly to a large PDA with large left-to-right shunt and sequelae may be associated with a PDA, Coarctation, VSD, interrupted aortic arch.

Interrupted Aortic Arch

Interrupted Aortic Arch

Fig. 24. Coarctation of the aorta (CoA) and interrupted aortic arch (IAA). On echocardiography, CoA can be distinguished from interrupted aortic arch by CW Doppler evaluation: significant CoA shows peak gradient more than 30 mmHg. No significant gradient is seen with IAA. The classic pattern of high peak velocity, delayed upstroke, and antegrade diastolic flow. TEE examination can establish the diagnosis, but CT, MRI, or angiography may be needed for confirmation.

Interrupted Aortic Arch

Fig. 24. Coarctation of the aorta (CoA) and interrupted aortic arch (IAA). On echocardiography, CoA can be distinguished from interrupted aortic arch by CW Doppler evaluation: significant CoA shows peak gradient more than 30 mmHg. No significant gradient is seen with IAA. The classic pattern of high peak velocity, delayed upstroke, and antegrade diastolic flow. TEE examination can establish the diagnosis, but CT, MRI, or angiography may be needed for confirmation.

Echocardiography

Fig. 25. Coarctation of the aorta. Suprasternal view showing distal aortic arch and descending thoracic aorta shows echodensity (arrow) in the proximal descending thoracic aorta (A). PW Doppler evaluation of flow proximal to the echodensity showed peak instantaneous velocities less than 1.2 m/s (B). Color flow Doppler of the same region shows no diastolic flow distal to the echodense region (C), but peak instantaneous velocities reached 3.7 m/s (peak instantaneous gradient = 54 mmHg) (D).

Fig. 25. Coarctation of the aorta. Suprasternal view showing distal aortic arch and descending thoracic aorta shows echodensity (arrow) in the proximal descending thoracic aorta (A). PW Doppler evaluation of flow proximal to the echodensity showed peak instantaneous velocities less than 1.2 m/s (B). Color flow Doppler of the same region shows no diastolic flow distal to the echodense region (C), but peak instantaneous velocities reached 3.7 m/s (peak instantaneous gradient = 54 mmHg) (D).

Aortic Coarctation Nursing
Fig. 26. The basis of the tetralogy of Fallot—one defect—the anterocephalad displacement of the infundibular septum—explains the tetrad.
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