ECHO - SImple Congenital Heart Diease

Question 1

TTE evaluation for ASD

Answer 1

see pic

Question 2

Types of ASD

Answer 2

• Secundum - most common
• Primum associated with cleft in the mitral valve
• Sinus venosus - posterior to the true atrial septum, associated with right sided pulmonary venous return
• Coronary sinus defect - unroofed CS - persistent left sided SVC

Question 2

Class I indication for ASD secundum closure (AHA)

transcatheter or surgical closure to reduce RV volume and improve exercise tolerance is recommended,

Answer 2

• causing impaired functional capacity (SYMPTOMATIC)
• right atrial and/or RV enlargement, and
• net left-to-right shunt sufficiently large to cause physiological sequelae (e.g., pulmonary–systemic blood flow ratio [Qp:Qs] ‡1.5:1)
• without cyanosis at rest or during exercise,
• provided that systolic PA pressure is less than 50% of systolic systemic pressure and
• pulmonary vascular resistance is less than one third of the systemic vascular resistance

***for primum, sinus venosus defect and coronary sinus defect -> surgical closure as Class I recommendation

***for ASYMPTOMATIC with same parameters, class IIa only

Question 2

defect in ASD Primum

Answer 2

defect in the AVS- atrioventricular septum

Question 3

Characteristics of ASD secundum

Answer 3

see pic

associated with Holt-Oram syndrome

Question 4

Bubble studies for PFO, positive result

Answer 4

bubbles in LA within 3-6 beats for intracardiac shunt

Question 4

characteristic of Patent Foramen Ovale

Answer 4

see pic

Question 5

CLASS III recommendation (AHA)

Answer 5

ASD closure should not be performed in adults with:
- PA systolic pressure greater than two thirds systemic, - pulmonary vascular resistance greater than two thirds systemic, and/or
- a net right-to-left shunt

Question 6

Class I indication for ASD secundum closure (ESC)

Answer 6

• evidence of RV volume overload and
• no PAH (no non-invasive signs of PAP elevation or invasive confirmation of PVR <3 WU in case of such signs) or
• LV disease,

ASD closure is recommended regardless of symptoms. - DEVICE closure is the method of choice

Question 7

Characteristic of Atrial septal aneurysm

Answer 7

see pic

Question 8

What is Chiari Network

Answer 8

see pic

Question 9

known as Partial type of Atrioventricular Septal Defect

Answer 9

see pic

Question 9

Mechanism of Chiari Network

Answer 9

see pic

Question 10

Types of AV septal Defect

Answer 10

• Complete
  -Partial
• Transitional
• Intermediate

Question 11

Associated Valve disorder with ASD Primum

Answer 11

Cleft Mitral valve

Question 11

Location of the defect of ASD primum

Answer 11

inferior portion of the atrial septum

Question 12

type of ASD that is associated with Left Axis Deviation

Answer 12

ASD Primum

Question 13

ASD type that is hard to detect in TTE

Answer 13

Sinus venosus ASD

Question 14

location of defect in sinus venosus ASD

Answer 14

superior and posterior aspects of the septum

Question 15

Mechanism of ASD: unroofed coronary sinus

Answer 15

absence of a portion of the common wall that separates the coronary sinus and the left atrium

Question 16

Associated anomaly with dilated coronary sinus
- most common

Answer 16

left SVC

Question 17

can cause dilated coronary sinus

Answer 17

• Elevated right atrial pressure
• Anomalous pulmonary connections to the coronary sinus

Question 17

T/F? VSD is a left to right shunt at ventricular level causes LEFT heart dilatation.

Answer 17

TRUE

Question 17

recommendation for ASD intervention

Answer 17

see pic

Question 18

What is the role of the ECHO in VSD?

Answer 18

- Define location of VSD - LV and LA size - Pulmonary pressures - Aortic Regurgitation - Tricuspid Regurgitation

Question 19

Locations of VSD?

Answer 19

- outlet - membranous - Inlet - trabecular or muscular

Question 20

different VSD terminology

Answer 20

see pic. depends on what terminology you will use

Question 21

Location of Echo based on standard imaging views

Answer 21

see pic

Question 22

Location of Echo based on PLAX view

Answer 22

- muscular - Perimembranous/outlet

Question 23

Location of Echo based on PSAX view (AV level)

Answer 23

between 9 to 12-1o clock - perimembranous type - between the tricuspid valve and aortic valve between 12 to 2 - 3 o clock - outlet/subarterial/subaortic -

Question 24

Location of Echo based on PSAX level (mid LV level)

Answer 24

- Inlet - Muscular/tracecular

Question 25

Location of Echo based on 4chamber view

Answer 25

- Inlet - Muscular/Trabecular

Question 26

Location of Echo based 5chamber view

Answer 26

- Perimembranous - muscular/trabecular

Question 27

type of VSD that is adjacent to TV and AV?

Answer 27

Membranous VSD

Question 28

type of VSD that is adjacent to the semilunar valves?

Answer 28

Subarterial VSD aka: outlet or supracristal

Question 29

What this be?

Answer 29

Pulmonic regurgitation. check the timing of the flow. this is a diastolic regurgitation

Question 30

Type of VSD that is remote from the valves

Answer 30

- Muscular VSD aka: Trabecular

Question 31

Associated trisomy with Inlet VSD?

Answer 31

trisomy 21

Question 32

Type of VSd that is usually occurs as part of AV septal defect

Answer 32

- Inlet VSD

Question 33

type of VSD that is immediately inferior to both AV boths

Answer 33

- Inlet VSD

Question 34

can you compute RVSP with VSD doppler evaluation?

Answer 34

yes. provided that SBP is obtain and there is no LVOT obstruction formula: RVSP = SBP - 4v^2

Question 34

Indication for VSD interventions

Answer 34

CLASS I Recommendation: - Left to right shunt with LV enlargement, - QpQs of >1.5:1 - PVR <1/3 of systemic - PASP <50% of systemic

Question 35

Indication for VSD interventions: Class IIa (ESC)

Answer 35

- in patient with no significant L-R shunt but history of repeated episodes of IE - associated with VSD-associated prolapse of an aortic valve cusp causing progressive AR - developed PAH and PVR 3-5WU

Question 35

Follow up for patients with VSD

Answer 35

Patients with more than small residual VSD, valvular lesions, or haemodynamic impairment (LV dysfunction or PAH) should be seen every year, including evaluation in specialized ACHD centres. In patients with a small VSD (native or residual, normal LV, normal PAP, asymptomatic) and no other lesion, 3-5 year intervals may be reasonable. After device closure, regular follow-up during the first 2 years and then, depending on the results, every 2-5 years is reasonable. After surgical closure without residual abnormality, 5-year intervals may be reasonable.

Question 36

Indication for closure for PDA

Answer 36

- LA and/or LV enlargement - net L-to-R shunt - PASP <50% of systemic - PVR <1/3 of systemic

Question 36

Indication for VSD interventions: Class IIa (AHA)

Answer 36

- associated with VSD-associated prolapse of an aortic valve cusp causing progressive AR CLASS IIb - history of repeated episodes of IE

Question 37

Echo views for the assessment of PDA

Answer 37

high left PSAX and Suprasternal Notch

Question 37

what Congenital heart disease is associated with Ebstein's anomaly?

Answer 37

- ASD or PFO (atrial level shunt)

Question 37

can you assess/estimate PASP in PDA?

Answer 37

yes Formula PASP = SBP-4v^2

Question 38

What is an Ebstein's anomaly?

Answer 38

it i a disorder of myocardial development ->valve disorder adn myopathy

Question 39

characteristic Echo features for Ebstein's anomaly?

Answer 39

- apical displacement of the the septal leaflet (TV) of >8mm/m^2 - Rotational displacement towards the RVOT - Anterior leaflet (TV) is large and sail-like - Atrialized RV - ASD or PFO in seen in majority of this patient