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.
Pulmonic Stenosis, Ventricular Septal Defect, and Right Ventricular Pressure above Systemic Level