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Congenital heart disease part 1.pptx
- 1. CONGENITAL HEART DISEASE ECHO FINDINGS - Part 1
- 2. • Segmental approach • Abnormalities of RV inflow • Abnormalities of LV inflow • Abnormalities of RV outflow • Abnormalities of LV outflow • Coarctation of Aorta • Abnormalities of cardiac septations (ASD, VSD, ECC) • Abnormalities of vascular connections and structure • Abnormalities of systemic venous connection • Abnormal coronary circulation • TOF, TGA, Truncus arteriosus, Fontan circulation
- 3. A SEGMENTAL APROACH TO ANATOMY 1. Determine atrial situs and assess venous inflow 2. AV connections are defined 3. Ventricular morphology 4. Ventriculo-arterial relationship
- 4. ATRIAL SITUS • FIGURE 19.2 AND 19.1
- 9. ECHOCARDIOGRAPHIC CHARACTERISTICS OF RIGHT AND LEFT VENTRICLES RIGHT VENTRICLE LEFT VENTRICLE Trabeculated endocardial surface Smooth endocardial surface Three papillary muscles Two papillary muscles Chordae inserted into ventricular septum Chordae inserted into papillary muscle Moderator band - - - - - - - - - Triangular cavity Ellipsoidal geometry Tricuspid valve with relative apical insertion
- 10. ECHOCARDIOGRAPHIC CHARACTERISTICS OF RIGHT AND LEFT VENTRICLES RIGHT VENTRICLE LEFT VENTRICLE Trabeculated endocardial surface Smooth endocardial surface Three papillary muscles Two papillary muscles Chordae inserted into ventricular septum Chordae inserted into papillary muscle Moderator band - - - - - - - - - Triangular cavity Ellipsoidal geometry Tricuspid valve with relative apical insertion
- 11. • PICTURE OF VENTRICLES
- 12. GREAT ARTERIES CONNECTIONS • LA -------> AORTA • RA -------> PULMONARY ARTERY • In normal orientation it is A L P and P R A with a “sausage and circle” appearance
- 15. ABNORMALITIES OF RV INFLOW • APICAL, SUBCOSTAL 4C, SAX at base, medially angulated PLAX. • Most important are – Tricuspid atresia and Ebstein
- 17. • Ebstein anomaly is a spectrum of abnormalities – - Extent of apical displacement of the valve - Distal attachments of the leaflets - Size and function of the remaining right ventricle - Degree of tricuspid regurgitation - Presence of right ventricular outflow tract mobstruction (usually from the redundant anterior mtricuspid valve leaflet).
- 18. • Severity of Ebstein anomaly – - degree of atrialization of ventricle - extent of leaflet tethering - magnitude of deformity / dysplasia
- 22. ABNORMALITIES OF LV INFLOW LEVELS OF OBSTRUCTION OF LEFT VENTRICULAR INFLOW PULMONARY VEINS - Pulmonary vein stenosis - Hypoplastic pulmonary vein - Extrinsic compression LEFT ATRIUM - Cor triatriatum - Supravalvular stenosing ring MITRAL VALVE - Hypoplastic mitral valve - Congenital mitral stenosis - Parachute mitral valve - Anomalous mitral arcades - Double orifice mitral valve
- 23. PULMONARY VEINS • Stenosis at or near junction • Views used are - apical - subcostal 4 chamber - “crab view”
- 27. LEFT ATRIUM • Fibrous membrane ; cor triatriatum - superior chamber - inferior chamber • At or near mitral annulus ; supra valvular stenotic ring
- 30. MITRAL VALVE • Parachute mitral valve
- 31. • Anomalous mitral arcade
- 32. • Double orifice mitral valve
- 33. ABNORMALITIES OF RV OUTFLOW • In the Right ventricle - Sub-valvular pulmonary stenosis - infundibular area - either fibromuscular narrowing or muscle ……..hypertrophy - Best seen in PSAX and Subcostal 4 C - Dynamic obstruction
- 35. • In Pulmonary Valve - Stenosis - Fairly common - mc is fusion of cusps & incomplete raphe - dome like structure with narrow orifice - Post stenotic dilation but…….. - Dysplasia - myxomatous thickening of leaflet
- 39. • In Pulmonary artery - Stenosis - aka peripheral or supra valvular PS - various morphologies - proximal lesion in PSAX - distal lesion in supra sternal view
- 41. ABNORMALITIES OF LV OUTFLOW CONGENITAL FORM OF LEFT VENTRICLE OUTFLOW OBSTRUCTION SUBVALVULAR - Discrete membranous stenosis - Fibromuscular tunnel - HOCM VALVULAR - Unicuspid - Bicuspid - Dysplastic SUPRAVALVULAR - Discrete (membranous or “hourglass”) - Aortic hypoplasia or atresia - Interrupted Aortic Arch - Coarctation of Aorta
- 42. Subvalvular Obstruction • Discrete subaortic stenosis- - thin fibrous membrane - crescentric barrier - Anterior septum to Anterior mitral leaflet - 50% asso. with AR - best in Apical view - on M-mode …….. • Fibromuscular type
- 46. Valvular Aortic stenosis • May be at birth • May develop overtime in an abnormal valve • Valve may be – - acommisural - Unicuspid unicommisural - Bicuspid - Tricuspid • Best view – PSAX (as far as anatomy is concerned) • But for Congenital AS PLAX is best
- 49. Supravalvular Aortic Stenosis • Least common among the three - Fibromuscular - Discrete fibrous membrane - Diffuse hypoplasia of Asc. Aorta • Two important additional features - dilation of coronary artery - thickening and fibrosis of aortic cusp • Normal aorta v/s S-AS aorta
- 51. Coarctation of Aorta • Ridge like indentation on the posterolateral wall of aorta • Three types • Best view is Suprasternal • False positive and negative
- 54. THANK YOU
Editor's Notes
- Imaging in children has both advantage and disadvantage. In future there will be more adults with CHD than children
- Tell how to differentiate RAA and LAA Tell how to visualize pulmonary vein and WHY it is not used to determine the LA ASK MAM about the statement “Although venous inflow doesn’t define the atrial morphology the pattern of systemic and pulmonary venous return help in determining situs”
- PULMONARY ARTERY THEN COURSES POSTERIORLY AND BIFURCATES, WITH RIGHT PUL. ARTERY PASSING JUST BELOW THE AORTIC ARCH
- Apical displacement of this insertion site is optimally assessed in 4C view and is the key to diagnosis. Measuring the distance between insertion sites of the two atrioventricular valves, when normalized for body surface area >8 mm/M2 is indicative of Ebstein anomaly. Other investigators have advocated a maximal displacement of more than 20 mm as the diagnostic criterion in adults.
- If tethering significant ----> Replacement rather than repair More atrialization, worse prognosis Area of functional RV <1/3rd of Total RV area worse prognosis LV dysfunction etiology unknown but if present then prognosis
- Crab view – Posteriorly angulated supra sternal short axis view Turbulent flow in posterior left atrium may be the only echocardiographic abnormality s/o stenotic pulmo. vein. Normally it is biphasic
- Antero-superior to postero-lateral wall What do the chambers receive……?
- Perforation may be single or multiple Best is apical 4C
- NO doming Turbulence at the level of annulus and not the tip Explain how MR may develop
- Diagnosis mostly relies on presence of single papillary muscle
- Short chordae inserted into multiple small papillary muscle
- Occurs due to duplication of mitral orifice All chordae inserted into same papillary muscle like parachute mitral valve but then the mitral valve has two orifice
- BUT annulus is always normal in size
- Degree of septal flattening and RV enlargement correlates with the severity of stenosis BUT quantitative measure is by doppler
- Membrane like lesion, long tubular stenosis, tubular hypoplasia Remember that PDA also shows turbulance DISTAL LESION should be suspected in children with unexplained RVH
- Normally, they appear as thin, delicate structures that appear to open completely in systole and are aligned parallel to and against the aortic walls. With congenital aortic stenosis, the cusps are thickened and appear to dome during systole, the result of restricted motion of the tips relative to the more mobile bodies of the cusps
- Tell opening is eccentric….