Abstract
Evaluating complex cardiac defects in small children preoperatively
requires multiple diagnostic procedures including echocardiography, and
also invasive methods such as cardiac catheterisation, computer-tomography
and magnetic resonance imaging. We assessed the complex anatomy of the
atrioventricular valves in atrioventricular septal defect using bedside
real-time three-dimensional echocardiography and comparing these results
to the anatomic findings at the time of operative intervention.
MeSH
| Echocardiography, Three-Dimensional |
Heart defects, congenital |
|
Article
We report the case of a 5 month old boy in whom an atrioventricular
septal defect had been diagnosed postnatally associated with the clinical
signs of Down’s Syndrome. Two-dimensional-echocardiography revealed an
atrial septal defect of ostium primum type (ASD I), an inlet-ventricular
septal defect (VSD) together with moderate tricuspid and mitral valve regurgitation.
The child was gaining weight well and was presented for elective corrective
surgery at the age of five months. In order to achieve more detailed information
about the anatomy of the atrioventricular valves we used Real-Time Three-Dimensional-Echocardiography
on a Phillips Sonos 7500 System operating a 4 MHZ-Transducer. The images
obtained were suggestive of an atrioventricular septal defect of Rastelli
Type A. An incompletely separated AV-valve was seen formed from a left
and right ventricular part with a small posterior bridging leaflet and
a relatively prominent anterior bridging leaflet. The "cleft" between the
two leaflets could be demonstrated as well as the atrial septal defect
(Fig.1). The surgeon’s view through the right atrium during the corrective
operation confirmed our diagnosis by revealing an atrioventricular connection
through an incompletely separated AV-valve (Fig. 2).
Figure 1: Three-Dimensional Echocardiographic view on the Atrioventricular
Valves in Atrioventricular Septal Defect from above: a prominent anterior
bridging leaflet (AL), a small posterior bridging leaflet (PL) with
the typical “cleft” in between is shown, R = right ventricular side, L
= left ventricular side, A = aortic root, C = “cleft”.
|
Figure 2: Intraoperative view on the Atrioventricular valves:
the right atrium is open and the small anterior bridging leaflet (AL) as
well as the prominent posterior bridging leaflet (PL) and the cleft is
seen. R = right ventricular side, L = left ventricular side, C = “cleft”.
|
Although two-dimensional echocardiographic assessment is a useful tool
for gaining information about the anatomy of congenital heart defects it
fails whenever detailed information about the three-dimensional relationship
of intracardiac structures is necessary. 1 The new techniques
of transcatheter closure of atrial and ventricular septal defects for example
make it more difficult deciding about surgical or interventional closure
of the defect. More precise information about size and location of these
defects is strongly needed in order to plan the best procedure for the
individual patient.
Evaluating cardiac defects in newborns and infants by MRI, CT or cardiac
catheterisation on the other hand requires general anaesthesia or sedation
with their associated risks. Therefore three-dimensional-echocardiography
is an attractive alternative imaging system, but in past it was available
only offline; the images being reconstructed after scanning the patient
without the possibility of assembling new scans.2
Realtime-three-dimensional-echocardiography now offers the same advantages
at the bedside.3-4 The three-dimensional scan is shown on the
display during the examination, every angulation in every plane is possible
and allows clear demonstration of all cardiac structures in their real-time
setting. In atrioventricular septal defects, a precise demonstration of
the morphology of the AV-valves and clear visibility of potential straddling
chordae will help substantially in planning the surgeon`s procedures.2
Three dimensional echocardiography will assist when transcatheter closure
of an atrial septal defect is planned by delineating the size of the defect
and its rims, allowing choice of appropriate size and type of device.5
In ventricular septal defect the 3-D view will permit assessment of feasibility
of transcatheter closure by determining the precise location and maximum
diameter.1
The real-time 3-D-modality will also be useful in the examination of
complex congenital heart defects such as double-outlet-right ventricle
or univentricular heart. Preoperative planning will be based on very different,
important new aspects of these defects otherwise available only by MRI
or CT. The real-time 3-D-modality will be useful in the evaluation of aortic
arch anomalies, of peripheral arteries, of pulmonary arteries and of ventricular
size and performance. When 3-D-echo-color-doppler becomes available it
will be possible to classify regurgitant jets with respect to their true
extension in a three-dimensional image of the beating heart. So we are
convinced that by real-time-3-D-echocardiography, preoperative planning
of procedures will be substantially changed and facilitated.
References:
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Assessment of muscular ventricular septal defect closure by transcatheter
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