Physiology of Ventricular Septal Defect Shunt Flow in the Fetus Examined by Color Doppler M-Mode

Abstract Introduction Patients with small restrictive ventricular septal defect are usually asymptomatic. This case report presented a case of shortness of breath in a patient with known restrictive ventricular septal defect. Case report A 51 years old woman was diagnosed to have a small supra-cristal ventricular septal defect in early twenties. She enjoyed good functional state since the diagnosis. Routine echocardiogram assessment one year ago found normal left ventricular size and systolic function. However, she presented with exertional shortness of breath and severe bilateral lower limbs edema for two weeks. Transthoracic echocardiogram found both left and right ventricles were dilated. Left ventricular ejection fraction was 50%. The right ventricular systolic pressure(RVSP) was 70mmHg from tricuspid regurgitation peak velocity estimation. It was significantly raised compared with the RVSP 35mmHg measured last year. This caused right ventricular pressure overload with systolic flattening of interventricular septum. On color doppler examination, apart from the known ventricular septal defect flow, there was an abnormal turbulent flow at the right ventricular outflow tract. The two jets was close to each other and the nature of the abnormal jet could not be clearly identified. During trans-esophageal echocardiogram, in order to differentiate the two different jets, the baseline of the color doppler was shifted towards the directions of the jets to look for the proximal isovelocity surface area (PISA). Finally there were two PISA could be clearly seen. One was the PISA of the ventricular septal defect while the other one was due to ruptured right coronary sinus with shunting from aorta to right ventricular outflow tract. The findings was supported by continuous wave doppler examination. The ventricular septal defect flow was predominantly systolic whereas the aorto-right ventricular shunting was a continuous flow. Moreover, three dimension echocardiogram also showed the two closely related holes. Finally the patient underwent percutaneous closure of the ruptured sinus of valsalva. And the patient recovered well afterwards. Discussion Small ventricular septal defect with restrictive physiology usually will not lead to heart failure. When patient presented with heart failure while having a small ventricular septal defect, other pathology should be carefully looked for. Ruptured sinus of valsalva was known to associate with ventricular septal defect. However, the jet of ruptured sinus of valsalva may be missed in view of the close proximity with the ventricular septal defect jet as in this case. Methods to better delineate the different jets including demonstration of double PSIA, continuous flow on continuous wave doppler and three dimension echocardiogram. Nowadays, ruptured sinus of valsalva could also be closed percutaneously with success. Abstract 507 Figure.

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Two-Dimensional and Color Doppler Assessment of Ventricular Septal Defect of Congenital Origin

Journal of Diagnostic Medical Sonography ◽

10.1177/875647938900500639 ◽

1989 ◽

Vol 5 (6) ◽

pp. 356-356

Keyword(s):

Ventricular Septal Defect ◽

Septal Defect ◽

Color Doppler ◽

Two Dimensional ◽

Congenital Origin

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P22.08: Characteristics of interventricular shunt flow in fetuses with isolated ventricular septal defect assessed by dual Doppler imaging

Ultrasound in Obstetrics and Gynecology ◽

10.1002/uog.18226 ◽

2017 ◽

Vol 50 ◽

pp. 227-227

Author(s):

T. Kaji ◽

Y. Hayabuchi ◽

K. Maeda ◽

A. Hichijo ◽

N. Yonetani ◽

...

Keyword(s):

Ventricular Septal Defect ◽

Septal Defect ◽

Doppler Imaging ◽

Shunt Flow

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A new method for noninvasive estimation of ventricular septal defect shunt flow by Doppler color flow mapping: Imaging of the laminar flow convergence region on the left septal surface

Journal of the American College of Cardiology ◽

10.1016/0735-1097(91)90808-m ◽

1991 ◽

Vol 18 (3) ◽

pp. 824-832 ◽

Cited By ~ 50

Author(s):

Valdir A. Moises ◽

Benedito C. Maciel ◽

Lisa K. Hornberger ◽

Azucena Murillo-Olivas ◽

Lilliam M. Valdes-Cruz ◽

...

Keyword(s):

Laminar Flow ◽

Ventricular Septal Defect ◽

Septal Defect ◽

Convergence Region ◽

Flow Mapping ◽

Color Flow ◽

Shunt Flow ◽

Noninvasive Estimation ◽

Flow Convergence ◽

Doppler Color

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Quantitative assessment of ventricular septal defect shunt flow by three-dimensional reconstruction of color Doppler imaged vena contracta and flow convergence region

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(98)81937-2 ◽

1998 ◽

Vol 31 ◽

pp. 298

Author(s):

M. Ishii ◽

G. Eto ◽

T. Tautsumi ◽

H. Kato

Keyword(s):

Ventricular Septal Defect ◽

Quantitative Assessment ◽

Septal Defect ◽

Color Doppler ◽

Three Dimensional ◽

Three Dimensional Reconstruction ◽

Convergence Region ◽

Vena Contracta ◽

Dimensional Reconstruction ◽

Flow Convergence

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A case report of unexpected right-to-left shunt under mechanical support for post-infarction ventricular septal defect: evaluation with haemodynamic simulator

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab209 ◽

2021 ◽

Vol 5 (8) ◽

Author(s):

Arudo Hiraoka ◽

Keita Saku ◽

Takuya Nishikawa ◽

Kenji Sunagawa

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Ventricular Septal Defect ◽

Cardiac Function ◽

Septal Defect ◽

Left Ventricular ◽

Haemodynamic Instability ◽

Shunt Flow ◽

Oxygenation Level ◽

The Right

Abstract Background Post-myocardial infarction ventricular septal defect (PIVSD) is a complication of acute myocardial infarction with high mortality. A percutaneous left ventricular assist device, Impella, is currently used in maintaining haemodynamic stability in PIVSD. Case summary A 65-year-old man was transferred to our hospital for treatment of acute myocardial infarction of the proximal right coronary artery. Percutaneous intervention was performed but haemodynamic instability continued. At 10 days after onset, the patient was diagnosed with PIVSD by echocardiogram. To stabilize haemodynamics, we initiated venoarterial extracorporeal membrane oxygenation (ECMO). Three days after ECMO initiation, pulmonary congestion increased and an echocardiogram revealed closed aortic valve and spontaneous echo contrast at the aortic root. After an Impella 2.5 was inserted for unloading of the left ventricle, the oxygenation level and cardiac function rapidly declined. Unexpectedly, an echocardiogram showed a right-to-left shunt (to-and-fro pattern) via PIVSD. By increasing the ECMO and decreasing Impella flow, the shunt flow changed to left-to-right, and oxygenation level and cardiac function improved. Ten days after ECMO was started, elective surgical repair was successfully performed. Conclusion ECPELLA (ECMO + Impella) can offset the adverse effects of isolated ECMO support and reduce the PIVSD shunt flow. However, the risk of right-to-left shunt has not been reported, and ECPELLA caused a right-to-left shunt with deoxygenated systemic perfusion in the present case. A simulation study indicated that the right ventricular failure in PIVSD may pose a risk for right-to-left PIVSD shunt under Impella support.

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