Echocardiographic evaluation of ventricular septal defects

Ventricular septal defects (VSDs) are the most common forms of acyanotic congenital heart disease accounting for 37% of congenital heart disease in children. A VSD is defined by parts of the ventricular septum involved. There are four major types of VSDs: perimembranous, muscular, outlet, and inlet VSDs. Echocardiography is the most important clinical tool to help diagnose and characterize a VSD. Although most VSDs are clinically nonsignificant or close on their own, echocardiography with Doppler and color flow mapping can be used to provide accurate anatomic and hemodynamic evaluation of VSDs in order to determine if surgical or transcatheter-based intervention is needed. Hence, understanding how to use echocardiography to characterize VSDs is of crucial importance when caring for patients with adult congenital heart disease.     

Echocardiographic manifestations of postinfarction ventricular septal rupture.

The echocardiographic features of three patients with postinfarction ventricular spectal rupture are described. All patients showed a decreased or paradoxical motion on the ventricular septum, and two of the patients demonstrated an unusual motion of the tricuspid valve. There were no abnormalities in mitral valve motion. The echocardiogram can be helpful in the diagnosis of postinfarction ventricular septal rupture and can assist in distinguishing this condition from acute disruption of the mitral valve complex.     

Echocardiographic evaluation of left-to-right shunt in ventricular septal defect and persistent ductus arteriosus.

Forty-five patients with either a ventricular septal defect or a persistent ductus arteriosus were assessed by echocardiography and cardiac catheterisation. Left atrial dimension was expressed either as a function of the body surface area (LAD cm per m2 BSA), or as a multiple of the aortic root dimension (LAD/AR), and was compared with the shunt size as determined by oximetry. A highly significant (P less than 0-001) regression relation was found for the group as a whole. A significant relation also existed for each individual group: ventricular septal defect, ventricular septal defect with pulmonary hypertension, and persistent ductus arteriosus. Regression equations were derived for the whole group. The value of echocardiography is in separating large from small shunts and in adding a dimension to the follow-up of the individual patient.     

Echocardiographic evaluation of aortic cusp prolapse in children with ventricular septal defect

Echocardiograms were obtained from 48 Japanese children with ventricular septal defect (16 having aortic cusp prolapse, Group I, and 32 without it, Group II). In the case of right coronary cusp prolapse, the right coronary sinus protrudes anteriorly into the right ventricular outflow tract, and thus, the anteroposterior diameter of the aortic root increases. In the case of non-coronary cusp prolapse, the non-coronary sinus bulges posteriorly into the right ventricle, and thus, the aortic root increases in size. For evaluating the degree of these prolapses quantitatively, we measured the aortic root diameter echocardiographically and expressed them as a percent of a normal one. In Group I the aortic root diameter was 131 +/- 9% (mean +/- SD) and in Group II it was 105 +/- 7%, and the difference between the 2 groups was statistically significant (p less than 0.001). In Group I 14 of the 16 patients had a value greater than 120%, while all 32 patients of Group II had a value smaller than 120%. Thus, in children with ventricular septal defect, an aortic root diameter greater than 120% of normal suggests the presence of aortic cusp prolapse. Systolic semiclosure of the aortic valve was found in 8 patients of Group I (50.0%) and in 2 of Group II (8.7%). Coarse systolic fluttering of the pulmonary valve with an amplitude of greater than 3 mm was detected in 6 of Group I (40.0%) and in 3 of Group II (10.0%). Therefore, semiclosure of the aortic valve and fluttering of the pulmonary valve are considered to be also useful for evaluating aortic cusp prolapse qualitatively.     

Echocardiographic findings in left ventricular septal aneurysm

The unusual echocardiographic findings are described in a case of congenital interventricular septal aneurysm. The aneurysm involved the middle part of the interventricular septum and was associated with a cleft of the mitral valve and an atrial septal defect but with no evidence of an atrioventricular septal defect. There was extensive fibroelastosis of the right ventricle. The patient presented with brief runs of ventricular tachycardia.     

Echocardiographic findings of ventricular septal rupture in acute myocardial infarction.

Echocardiograms were recorded both before and after the clinical appearance of an autopsy-confirmed interventricular septal rupture in a patient with an acute myocardial infarction. The major findings were related to the upper portion of the interventricular septum. Before rupture, this portion of the septum was relatively akinetic with a slight anterior motion during systole, whereas after rupture there was a marked increase in the amplitude of septal motion with abrupt posterior motion occurring with the onset of ventricular diastole.     

Echocardiographic detection of aneurysms of the interventricular septum associated with ventricular septal defect. A method of noninvasive diagnosis and follow-up.

Spontaneous closure of a ventricular septal defect is frequently accompanied by the formation of an aneurysm of the membranous septum. The exact anatomic basis for such an aneurysm varies. Some arise from redundant tissue from the endocardial cushions or from adherence of the tricuspid septal leaflet to the defect; the origin of others cannot be determined. Echocardiographic studies in 17 patients with the diagnosis of ventricular septal defect revealed in 7 an aneurysm of the membranous septum that was later confirmed by angiography. In no patient was an aneurysm missed or erroneously diagnosed in the echocardiographic study. Echocardiography can be a useful diagnostic and prognostic tool in the long-term management of patients with ventricular septal defect.     

Echocardiographic evaluation of left ventricular function, mass and wall stress in children with isolated ventricular septal defect

M-Mode echocardiography was performed in 22 normal children and 22 children with ventricular septal defects. Left ventricular and left atrial chamber dimensions and wall thicknesses were measured in all patients. Utilizing these data, indices of left ventricular function were derived: shortening fraction, velocity of fiber shortening, peak diastolic fiber lengthening, end-systolic wall stress, radius thickness ratio, and ventricular mass. The results showed that ventricular septal defect was associated with enlarged left ventricular and atrial dimensions and increased shortening fraction, but that velocity of shortening and early diastolic lengthening remained normal. Left ventricular mass was increased, thus maintaining normal wall stress and radius/thickness ratio. Cardiac failure complicating ventricular septal defect was associated with enlarged left ventricular and atrial dimensions (indexed for weight). Ventricular mass, wall stress and function, however, were similar in subjects with ventricular septal defect, with or without cardiac failure. Since left ventricular mass was adequate to maintain wall stress and function in subjects with heart failure, other factors were presumably responsible for heart failure complicating ventricular septal defect.     

Aortic regurgitation associated with ventricular septal defect. Echocardiographic and hemodynamic observations.

Ventricular septal defect is sometimes associated with aortic regurgitation. In this report, an echocardiogram demonstrating dramatic prolapse of the noncoronary cusp into the left ventricular outflow tract and ventricular septal defect in a patient with Down's syndrome and ventricular septal defect, confirmed by angiographic studies, is presented. The echocardiogram supports the concept of anatomic lack of support of the aortic ring due to a deficient septum and hemodynamically significant flow of blood to the right ventricle through the ventricular septal defect, resulting in trauma to aortic cusps and prolapse.     

Assessment of left-to-right shunt and left ventricular function in isolated ventricular septal defect. Echocardiographic study.

This echocardiographic study was designed to assess left ventricular function and pulmonary blood flow in ventricular septal defect. Fifty-one patients aged 2 weeks to 21 years were investigated (group 2). Five of 10 operated patients were studied one week after surgical closure of the defect (group 3) and seven 3 to 6 weeks postoperatively (group 4). The control group consisted of 45 normal subjects aged 2 weeks to 21 (group 1). Left atrium/aortic root dimension ratio (LA/Ao) was used to express the pulmonary systemic flow ratio. Left ventricular chamber size was assessed by measurement of left ventricular end-diastolic dimension and volume. The left ventricular mass and the ratio of end-diastolic volume to left ventricular mass were determined to relate the degree of left ventricular hypertrophy to volume overload. Myocardial function was evaluated using ejection phase indices. Ventricular septal thickness, posterior wall thickness, and echocardiographic patterns of septal motion were also studied. The left atrium/aortic root dimension, end-diastolic volume, and left ventricular mass were significantly greater in group 2 patients (P less than 0.05) than in the normal controls. There was a very good correlation between LA/Ao and pulmonary/systemic flow ratio (r = 0.83). Eleven of the group 2 patients showed asymmetric septal hypertrophy (unrelated to shunt size) but left ventricular function as assessed by ejection phase indices appeared unimpaired. Immediately after operation (group 3) there was a deterioration in left ventricular function in 5 patients as shown by reduced ejection fraction, mean velocity of circumferential shortening, and relative changes in minor axis with systole. Septal motion was impaired but returned to normal in 3 to 6 weeks in 7 patients (group 4). Left atrial/aortic root dimension, end-diastolic volume, and left ventricular mass decreased significantly immediately after operation (group 3) but were still raised at 3 to 6 weeks (group 4).     

Assessment of left-to-right shunt and left ventricular function in isolated ventricular septal defect. Echocardiographic study.

This echocardiographic study was designed to assess left ventricular function and pulmonary blood flow in ventricular septal defect. Fifty-one patients aged 2 weeks to 21 years were investigated (group 2). Five of 10 operated patients were studied one week after surgical closure of the defect (group 3) and seven 3 to 6 weeks postoperatively (group 4). The control group consisted of 45 normal subjects aged 2 weeks to 21 (group 1). Left atrium/aortic root dimension ratio (LA/Ao) was used to express the pulmonary systemic flow ratio. Left ventricular chamber size was assessed by measurement of left ventricular end-diastolic dimension and volume. The left ventricular mass and the ratio of end-diastolic volume to left ventricular mass were determined to relate the degree of left ventricular hypertrophy to volume overload. Myocardial function was evaluated using ejection phase indices. Ventricular septal thickness, posterior wall thickness, and echocardiographic patterns of septal motion were also studied. The left atrium/aortic root dimension, end-diastolic volume, and left ventricular mass were significantly greater in group 2 patients (P less than 0.05) than in the normal controls. There was a very good correlation between LA/Ao and pulmonary/systemic flow ratio (r = 0.83). Eleven of the group 2 patients showed asymmetric septal hypertrophy (unrelated to shunt size) but left ventricular function as assessed by ejection phase indices appeared unimpaired. Immediately after operation (group 3) there was a deterioration in left ventricular function in 5 patients as shown by reduced ejection fraction, mean velocity of circumferential shortening, and relative changes in minor axis with systole. Septal motion was impaired but returned to normal in 3 to 6 weeks in 7 patients (group 4). Left atrial/aortic root dimension, end-diastolic volume, and left ventricular mass decreased significantly immediately after operation (group 3) but were still raised at 3 to 6 weeks (group 4).     

Echocardiographic demonstration of pulmonary valve endocarditis associated with congenital ventricular septal defect.

A 38 year old woman previously known to have a heart murmur presented with malaise and bloodstained sputum. Echocardiographic examination showed a subpulmonary ventricular septal defect and probable vegetations on the pulmonary valve, and blood cultures grew Escherichia coli. She made a full recovery after 6 weeks' antibiotic treatment.     

Echocardiographic features of supracristal ventricular septal defect with prolapsed aortic valve leaflet.

Anatomically diagnostic echocardiographic features of a supracristal ventricular septal defect with prolapsed right coronary aortic leaflet are described in four children aged 2 to 10 years. Both single crystal M mode as well as 80 ° phased array sector scan techniques were used. The echographic features in the M mode scan from the aorta to the left ventricle in three of four patients included (1) the position of the ventricular septal defect as a clear space between the interrupted septal echoes below the aortic root, and (2) the prolapsed right coronary aortic leaflet as anomalous linear echoes in the right ventricular outflow tract. Angiographic, intraoperative and echocardiographic contrast studies were used to establish the diagnosis.On sector scanning using the long axis view, the supracristal ventricular septal defect was recognized as a clear space between the top of the ventricular septum and the anterior segment of the aortic root in three of four patients. The right coronary aortic leaflet was seen to prolapse into the right ventricular outflow tract through this defect, and its motion could be clearly followed during systole and diastole. It is concluded that echocardiography provides anatomic diagnosis of this lesion. Furthermore, the severity and progression of this lesion can be assessed by quantitation of the left ventricular size and performance.