septal defects

sternal scar indicates

open heart surgery that required cardiopulm bypass

lateral scar at 4th/5th ribs indicate

shunt replacement, coarc repair, PDA ligation

what is the order of identification if you suspect CHD?

establish situs

identify chambers and great vessels that connect to them

then begin looking for defects

what is situs solitus?

ao stomach spleen on left side

liver and IVC on right side

RA is identified by

right atrial appendige (triangular)

lots of pectinate muscle

rv is identified by

coarsely trabeculations (more than LV)

la is identified by

LAA (finger shaped pouch)

less pectinate muscle

lv is identified by

smooth walls that are thicker than the rv

differentiate between ao and pulm

ao has 2 branches and pulm has 3

what kind of murmurs for VSD?

holosystolic

what are small vs large VSDs?

small : less than 1/3 diameter of ao annulus → restrictive flow

large : greater than ½ size of ao annulus → non restrictive flow

what are rv and lv pressures when there is non restrictive flow

relatively equal

normal qp/qs vaules should be

around 1:1

signficant shunt defect is Qp/Qs of

2 or higher

what is Qp and how do you get it

pulmonary cardiac output

• pulmonic SV : CSA x VTI x 100

  • csa : rvot diameter at base of pulm leaflets

    • CSA =.785 x D²

  • vti : pw doppler tracing of rvot flow

• pulm CO : SV x HR

what is Qs and how do you get it

systemic cardiac output

• systemic SV : CSA x VTI x 100

  • csa : lvot diameter at base of pulm leaflets

    • csa = .785 xD²

  • vti : pw doppler tracing of lvot flow

• systemic CO : SV x HR

what are the types of vsds?

perimembranous

muscular/trabecular

outlet/supracristal/subpulmonic/doubly committed

inlet

what is the most common vsd?

perimembranous

where are perimembranous VSDs found?

in LVOT near aortic valve

• inferior to right coronary cusp and adjacent to septal leaflet of tricuspid valve

perimembranous VSDs are best evaluated in

PLAX

(any view where ao is in view)

perimembranous VSDs are commonly associated with

aortic insufficiency

ventricular septal aneurysm

where are perimembrnous VSDs seen in PSAX?

10-12 oclock position

what is the second most common type of VSD?

muscular/trabecular

muscular VSDs are best evaluated in

subcostal views

where is the outlet VSD located?

in RVOT near pulmonic valve

• inferior to left coronary leaflet of ao valve and adjacent to pulmonic valve

outlet VSDs are aka (3)

supracristal

subpulmonic

doubly committed

where are outlet VSDs best seen?

high parasternal short

PLAX

where are outlets VSDs seen in PSAX?

12-2 oclock

what is commonly associated with outlet VSDs?

60-70% have right ao cusp prolapse

ao insufficiency

where are inlet VSDs located?

in posterior septum, near posterior leaflet of tricuspid valve

inlet VSDs are associated with

AVSD

inlet VSDs are best evaluated in

high parasternal short

PLAX

A4ch

large VSDs can lead to

eisenmenger syndrome with right to left shunting

shunt flow is normally

left to right

the higher the gradient the - the defect

smaller

how do you calculate RVSP with VSD?

systolic BP - VSD gradient = RVSP

what is the second most common form of CHD identified in adults?

ASD

what is the most common form of CHD identified in adults?

bicuspid AV

large ASDs will cause

right heart volume overload and reduced ventricular compliance

what are the types of ASDs?

septum primum

septum secundum

sinus venosus

coronary sinus defects

common atrium

what is the most common type of ASD?

septum secundum

where are septum secundum asds located?

mid septal area

septum secundum asds are associated with

MVP

what is the second most common ASD?

septum primum

where are septum primum asds located?

close to av valves

septum primum asds are associated with

cleft mitral valve

where are sinus venosus ASDs located?

near SVC entrance

what are sinus venosus ASDs associated with

persistent LSVC

common atriums are associated with

ellis van creveld syndrome : bone growth disorder

what are the signs and symptoms of asds?

murmur

dyspnea

orthopnea

jugular vein distention

peripheral edema

what views are optimal for evaluating atrial septum?

subcostal

normal ASD shunt flow should be

left to right atrium with small flow reversal at early systole

if pressures in both atria are normal what will the avg peak velocity/peak pressure gradient be?

avg peak velocity : 1 m/s

peak pressure gradient : 5 mmHg

(because normal difference in pressure between right and left atrium is 5mmHg)

bidirectional flow in ASD indicates

increased right atrial pressure equivalent to left atrial pressure

ASDs are associated with

interatrial septal aneurysms

• defect of septumprimum layer

ASD will cause - heart dilation bc -

right bc of shunting of flow across septum to right atrium

saline bubble study is positive if

there is presence of bubbles in LA and ventricle

how can secundum ASDs be treated?

percutaneous transcatheter device closure

• called amplatzer

• implanted through balloon catheter

how are septum primum/sinus venosus defects treated?

surgical intervention

what is endocardial cushion defect? aka

incomplete development of endocardial cushions

aka atrioventricular septal defect (AVSD) or AV canal defect

endocardial cushion defects are associated with

trisomy 21

partial endocardial cushion defects have

septum primum ASD

cleft mitral valve

complete endocardial cushion defects have

septum primum ASD

inlet VSD

common av valve with 5 leaflets

how do common av valves appear

as a single linear structure between ventricles and atria

(lack of normal offest of TV toward apex)

what will you see with AVSD?

right heart volume overload

dilated RV w paradoxical ventricular septal motion

in the embryonic development of the cardiac vessels there are - total arches that form and - of these arches develop into normal structures

a 6 6

b 12 6

c 4 8

d 8 4

b

which of the following is primary difference between a standard adult echo and an adult echo performed for congenital heart defects

a pt history is reviewed for prior surgery

b protocol includes a complete evaluation of abd organs

c 10-20 second clips are stored of sweeps through cardiac anatomy

d image display is inverted during the exam

c

a lateral scar on a patients chest is most suggestive of what type of surgery

a cardiac bypass

b pericardiocentesis

c valve replacement

d cardiac shunt replacement

d

which of the following describes how to document situs on an echo pt

a parasternal approach with transducer notch at 10

b apical approach w transducer at 9

c subcostal approach with transducer at 3

d suprasternal approach w transducer notch at 2

c

what is the best way to differentiate the pulm artery from the aorta on an echo

a location

b size

c number of valve leaflets

d number of branches

d

the size of a VSD is compared to the size of what cardiac structure to estimate severity

a ao

b pulm

c foramen ovale

d la

a

the qp/qs ration is used to compare

a peak systolic velocities in pulm art and ao

b pulm and systemic cardiac output

c end diastolic velocity in pulm artery and ao

d right and left ventricle diameters

b

in psax view, perimembranous VSD are identified

a near apex of heart

b at 12-2 position in septum

c at 10-12 position in septum

d inferior to left coronary leaflet of ao valve

c

which type of VSD is located in the posterior septum, near the posterior leaflet of tricuspid valve

a outlet

b perimembranous

c inlet

d muscular

c

which type of VSD is most commonly associated with right ao cusp prolapse

a outlet

b perimembranous

c inlet

d muscular

a

describe hemodynamic changes associated with small and large VSDs

small

• dilated LV with hyperkinesis and LA dilated = left heart overload

large

• can lead to eisenmenger syndrome w right to left shunting

when evaluating flow through VSD, smaller defects will demonstrate

a low peak velocity flow

b bidirectional shunting

c right to left shunting

d high peak velocity flow

d

which of the following is used to correct a VSD?

a stitches

b piece of pericardium

c occlusive devise

d all of the above

d

list the 5 asds and associated defects

septum primum : cleft MV

septum secundum : MV prolapse

sinus venosus : PAPVR

coronary sinus defects : persistent LSVC

common atrium : ellis van crevald syndrome

which of the following is a common symptom of ASD?

a diastolic murmur

b jugular vein distention

c systemic HTN

d premature ventricular contractions

b

what echo view is preferred to evalute the integrity of the atrial septum?

a parasternal

b apical

c subcostal

d suprasternal

c

which of the following findings is associated with an ASD in an adult

A qp/qs >1.5 : 1

b d shaped lv

c t artifact

d all

d

what type of defect can be repaired with amplatzer?

a sept primum

b sept secundum

c sinus venosus

d all

b