Cross sectional echocardiography for recognition of ventricular topology in atrioventricular septal defect.

The cross sectional echocardiograms of 150 children with atrioventricular septal defects were reviewed to determine the spatial orientation of the ventricles. In 125 cases with usual atrial arrangement (situs solitus), ventricular topology showed the right hand pattern. Of the 25 patients with atrial isomerism, 13 had similar right hand topology but 12 (48%) had the left hand pattern. This finding was more common in hearts in the right side of the chest (dextrocardia), but there was no significant correlation between ventricular topology and number of atrioventricular valves or the ventriculoarterial connection. In part because of inferences for disposition of the conducting tissue, knowledge of ventricular topology is important when operation for atrioventricular septal defects is considered. Ventricular topology can be promptly recognised by cross sectional echocardiography.     

Cross sectional subcostal echocardiography: atrioventricular septal defects and the short axis cut

A short axis echocardiographic cut of the heart from the subcostal approach was used to study the atrioventricular junction in 47 infants and children with congenital heart disease and 20 with normal hearts. Examination of the diastolic openings of both atrioventricular valves was able to establish normal developments of the valves and annuli even when this was found in cases of complex congenital heart disease. In 30 patients with atrioventricular septal defects the technique distinguished between a partial defect (when the two atrioventricular valves were linked transseptally) and a complete defect (when there was only one atrioventricular valve). A range of atrioventricular attachments was seen in these patients. Short axis echocardiography from the subcostal approach reliably identifies different forms of atrioventricular septal defects by defining the anatomy of the atrioventricular valves during maximal diastolic expansion.     

Cross sectional subcostal echocardiography: atrioventricular septal defects and the short axis cut.

A short axis echocardiographic cut of the heart from the subcostal approach was used to study the atrioventricular junction in 47 infants and children with congenital heart disease and 20 with normal hearts. Examination of the diastolic openings of both atrioventricular valves was able to establish normal developments of the valves and annuli even when this was found in cases of complex congenital heart disease. In 30 patients with atrioventricular septal defects the technique distinguished between a partial defect (when the two atrioventricular valves were linked transseptally) and a complete defect (when there was only one atrioventricular valve). A range of atrioventricular attachments was seen in these patients. Short axis echocardiography from the subcostal approach reliably identifies different forms of atrioventricular septal defects by defining the anatomy of the atrioventricular valves during maximal diastolic expansion.     

Cross sectional echocardiographic assessment of the extent of the atrial septum relative to the atrioventricular junction in atrioventricular septal defect

Objective—To study patients with atrioventricular septal defect to determine the pathognomonic morphological features of the lesion and the relation between the septal structures and the atrioventricular junction.
Setting —Tertiary level paediatric cardiology centre.
Methods—Cross sectional echocardiograms from 60 patients were reviewed using qualitative and quantitative analysis. The unifying feature was the presence of a common atrioventricular junction. The overall dimensions of the septal defect were determined and related to the plane of the common junction; the extent of both the atrial and the ventricular septal components was then measured according to the site of closure of the bridging leaflets.
Results—In 48 cases, the common junction was guarded by a common valvar orifice, but in 12 cases there were separate right and left valvar orifices. Irrespective of the valvar morphology, no significant difference was found between the groups in terms of the dimensions of the atrial and ventricular septal components. In all patients, the hole permitting shunting at atrial level extended below the plane of the atrioventricular junction, with a variable position of the leading edge of the atrial septum itself.
Conclusions—The atrioventricular junction is a common structure irrespective of valvar morphology. In spite of the presence of unequivocal shunting at atrial level, the atrial septum is usually a well formed structure, even extending in some below the level of the common atrioventricular junction.

Keywords: atrioventricular canal malformation; endocardial cushion defects; level of shunting; morphology     

Cross-sectional echocardiography in the diagnosis of atrioventricular septal defect

Between 1983-1988 cross-sectional echocardiography was performed in 63 patients having an atrioventricular septal defect with common atrioventricular orifice. We excluded from this study all those patients with separate right and left orifices ("ostium primum" defects), those with isomerism of the right and left atrial appendages, those with univentricular atrioventricular connexions and those with discordant atrioventricular and ventriculo-arterial connexions. Parasternal long- and short-axis views, apical 4-chamber views and subcostal long-axis views were employed in all patients. In the last 26 cases, we also obtained the subcostal short-axis view. Nineteen patients showed ventricular dominance, with the right ventricle being dominant in 15. Ten patients had an associated defect in the oval fossa, while the atrial septum was partially or completely absent in the other 53. A ventricular septal defect was observed in all, but it was small in 10 and multiple in 2. Attachments of the superior and inferior bridging leaflets to the crest or the right side of the ventricular septum were seen in 32 cases. The inferior leaflet was hypoplastic in 19 patients. There was narrowing of the left ventricular outflow tract in 8 patients, and obstruction of the right ventricular outflow tract in 3. Abnormal attachment of the right portion of the common valvar orifice was present in 2 cases. A solitary papillary muscle supporting the left ventricular component of the common valve was seen in 6 cases producing a parachute-like arrangement. Our study shows that cross-sectional echocardiography is an excellent technique for the analysis of this anomaly.     

Intraoperative transesophageal echocardiography of ventricular septal defect

The accuracy and limitations of intraoperative two-dimensional (2-D) and color Doppler flow mapping transesophageal echocardiography (TEE) of ventricular septal defect (VSD), before and after cardiopulmonary bypass, were analyzed in 62 children. Twenty-one patients had an isolated VSD, and 41 had a VSD plus additional cardiac anomalies. Two-dimensional and color Doppler flow mapping TEE were performed with a miniaturized 5-MHz single (transverse) plane transducer in the 51 of 62 patients weighing less than 20 kg. The remaining 11 were monitored using a single plane adult probe (n = 4) and a biplane (transverse plus longitudinal) probe (N = 7). Prebypass TEE provided a correct diagnosis in 57 of 62 cases (92%) and corrected an erroneous preoperative transthoracic echocardiographic diagnosis in three of 62 cases (5%). Single plane TEE diagnosis was erroneous in five patients: four with doubly-committed subarterial VSD and one with multiple small apical muscular defects and pulmonary hypertension. Biplane TEE (transverse longitudinal) provided clear and complete imaging of the right ventricular outflow tract in all seven cases in whom it was used. Postbypass TEE showed absence of a hemodynamically significant residual VSD in 30 of 40 patients (95%) who underwent VSD patch closure, prospectively identified two of 40 with significant residual VSD, and accurately measured the color Doppler jet width of all residual VSDs. We conclude that hemodynamically significant VSDs can be identified immediately after cardiopulmonary bypass based on the width of the residual VSD color Doppler flow map jet. Therefore, 2-D and color Doppler flow mapping TEE provide an accurate diagnosis in most cases of VSD but may miss doubly-committed subarterial and apical muscular VSD unless biplane TEE is used.     

Doppler echocardiography of double orifice of the left atrioventricular valve in atrioventricular septal defect

A left atrioventricular valve having a double orifice is a rare congenital abnormality, and is most commonly described in association with atrioventricular septal defect. We report the Doppler echocardiographic findings of this abnormality and present a case where limited surgical repair has resulted in a favourable outcome.     

Doppler echocardiography in adults with isolated ventricular septal defect

Doppler echocardiography and cardiac catheterization were undertakenin 70 consecutive patients, 31-68 years of age (mean 39), whohad isolated congenital ventricular septal defects (VSD), 28of whom had been operated upon. In 50 patients with invasivelyproven VSD, 37 had a correct Doppler diagnosis of VSD (group1) and in 13 a false negative result was obtained (group 2);i.e. a sensitivity of 74%. No false positive Doppler diagnosiswas made in the 20 patients without evidence of shunt. Leftto right ventricular systolic pressure difference (P) rangedbetween 55 and 142 mm Hg, with a mean value of 103 mm Hg ingroup 1 and 99 mm Hg in group 2. There was good correlationbetween P obtained by continuous wave Dopier and catheterisationin 17 group 1 patients with moderate and large shunts (r=0.81,P<0.001). There was no correlation in the remaining 20 patientsin group 1 with small shunts (r=0.20, P>0.l). Doppler echocardiography in the adult with isolated VSD hasgood sensitivity and excellent specificity. Doppler predictionof P is reasonably correct in patients with moderate and largeshunts, but of no value in patients with small shunts.     

Risk factors for atrioventricular block after occlusion for perimembranous ventricular septal defect

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Outcomes of hospitalization in adults in the United States with atrial septal defect, ventricular septal defect, and atrioventricular septal defect

Atrial septal defect, ventricular septal defect (VSD), and atrioventricular septal defect (AVSD) are among the most common congenital heart lesions, with most children surviving to adulthood. However, the clinical course of these patients is largely unknown, particularly pertaining to inpatient care. The purpose of this study was to assess hospitalizations for septal defects in adults with congenital heart disease (CHD) and risk factors associated with significant morbidity and mortality. The 2007 Nationwide Inpatient Sample was used to assess national prevalence of hospitalizations in adults with CHD with septal defects. Co-morbidities and risk factors for mortality were also determined. There were 84,308 adult CHD admissions in the United States in 2007. Fifty-four percent of adult CHD admissions had diagnoses of septal defects, with 48% having atrial septal defect, 7% having VSD, and 0.4% having AVSD. Overall in-hospital mortality was 2.1%. Common co-morbidities included arrhythmias (31%), heart failure (20%), and diabetes mellitus (18%). On multivariable analysis, independent risk factors for mortality included presence of VSD (odds ratio 3.1, 95% confidence interval [CI] 1.5 to 6.5), trisomy 21 (odds ratio 2.9, 95% CI 1.1 to 7.5), and pulmonary hypertension (odds ratio 1.5, 95% CI 1.0 to 2.4). In conclusion, this study of hospitalizations in adults with septal defects found that admissions are common and associated with significant co-morbidities. Overall mortality is low but is increased in patients with VSD. Cardiac and noncardiac co-morbidities are commonly encountered. Many noncardiac conditions, including trisomy 21 and the youngest and oldest groups, are associated with an increased risk of death.     

室问隔缺损介入术后并发三度房室阻滞

目的分析国内室间隔缺损患者介入封堵术后三度房室阻滞的发生特点和原因。方法通过中国生物医学文献数据库和清华同方医学期刊数据库文献检索系统,以“室间隔缺损”和“传导”为任意字段进行检索,在纳入的文献中,重点对患者年龄、性别、术后三度房室阻滞的发生时间、恢复时间、处理措施等进行总结分析。结果总计纳入23篇文献,共报道了73例术后出现三度房室阻滞的患者,女性和儿童多见。88％的三度房室阻滞发生于术后3～7d。80％的病例均在症状出现后的7—15d恢复窦性心律。有3例患者植入了永久起搏器。结论室间隔缺损介入术后的三度房室阻滞有其发生发展的规律,多数为一过性,需植入永久性起搏器的患者极少。     

超声心动图在嵴内型室间隔缺损封堵中的作用

目的:研究超声心动图在嵴内型室间隔缺损（VSD）封堵中的作用,并与X线左室造影结果比较。方法:入选病例包括嵴内型VSD患者13例。二维超声心动图及彩色多普勒血流图于胸骨旁左室长轴、大血管短轴及心尖五腔观测量缺损大小及其距主动脉右冠瓣、肺动脉瓣及三尖瓣的距离;术中行X线左室造影观测缺损口大小、距主动脉右冠瓣距离。封堵器释放后测量其腰部的直径。结果:二维超声心动图与彩色多普勒血流图除2例部分切面难以判断缺损口大小外,其余病例均显示缺损口大小及距各瓣的距离,大部分病例超声术前测量的缺损口大小与释放后封堵器的腰径相似。X线左室造影5例因造影角度不佳无法显示分流口大小,仅显示右室内存在分流;显示分流口的病例中部分明显小于释放后封堵器腰径。本组病例中1例封堵后出现少量主动脉瓣返流,1例术后出现封堵器移位,并出现残余分流。结论:超声心动图对嵴内型VSD封堵的术前选择优于X线左室造影。适合于嵴内型VSD封堵的患者缺损口不宜大于8mm,并无主动脉瓣脱垂。如缺损口过大可能出现术后主动脉瓣返流或封堵器移位。     

Recognition of residual ventricular septal defect by intraoperative contrast echocardiography

Intraoperative two-dimensional contrast echocardiography wasused to detect a residual shunt in 50 patients after surgicalrepair of ventricular septal defect. Contrast injections wereperformed following termination of the extracorporeal circulation.In the presence of a shunt the intensity of opacification ofboth left and right ventricular cavities was compared. In 40patients no ventricular shunting was observed; insignificantshunting was noted in five patients. Follow-up of these 45 patientsproved uneventful. Significant opacification of the right ventricle was noted infive patients. This finding, however, does not necessarily indicatea residual shunt of significant volume. In two patients theresidual shunt was confirmed postoperatively by pulsed Dopplerechocardiography but clinically there was no need for surgery.Three other patients subsequently required reoperation and partialpatch dehiscence was confirmed in all. Thus, intraoperativetwo-dimensional contrast echocardiography is a sensitive techniqueto detect a residual ventricular septal defect, an observationwhich may warrant reoperation before chest closure.     

Importance of spontaneous closure of the ventricular part in atrioventricular septal defect.

The clinical features, hemodynamic changes and prognosis of 21 children with simple atrioventricular septal defect (3 associated with patent ductus arteriosus) were studied during a follow-up period of 1 month to 13 3/12 years (median 3 years). Six patients had spontaneous closure of the ventricular part of the defect within 22.2 +/- 27.7 months (Group I). The symptoms and signs of failure to thrive, frequent respiratory tract infections and congestive heart failure were more common in patients without spontaneous closure of the ventricular part of atrioventricular septal defect (Group II) than in patients in Group I. The Qp/Qs ratio, pulmonary vascular resistance and pulmonary to systemic resistance ratio were also higher in Group II than in Group I. In spite of a higher postoperative mortality rate and a higher incidence of transient complete heart block, the children in Group II also had a significantly higher (p less than 0.005) preoperative mortality rate than those in Group I. In conclusion, if the ventricular part of the atrioventricular septal defect closed or was closing spontaneously, symptoms and signs were less severe and there was a better prognosis.