PEDIATRIC CARDIOLOGY and CARDIAC SURGERY VOL. 26 NO. 2 ( ) 心室中隔欠損心エコー診断について Key words: ventricular septal defect, Soto s classification, echoca

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1 PEDIATRIC CARDIOLOGY and CARDIAC SURGERY VOL. 26 NO. 2 ( ) 心室中隔欠損心エコー診断について Key words: ventricular septal defect, Soto s classification, echocardiographic diagnosis Ventricular Septal Defect Echocardiographic Diagnosis of Ventricular Septal Defect Hirofumi Tomimatsu Department of Pediatric Cardiology, Tokyo Women s Medical University, Tokyo, Japan Ventricular septal defects (VSDs) are the most common form of congenital heart disease when the bicuspid aortic valve is excluded. Many ways to classify VSDs have been proposed. According to the report by Soto et al., the ventricular septum is regarded as having four components: an inlet septum separating the mitral and tricuspid valves; a trabecular septum, which extends from the attachments of the tricuspid leaflets outward to the apex and upward to the crista supraventricularis; the smooth-walled outlet or infundibular septum, which extends from the crista to the pulmonary valve; and the membranous septum, which is relatively small and is usually divided into two parts by the septal leaflet of the tricuspid valve. The anatomic localization of all VSDs is facilitated by using 2-dimensional (2D) echocardiographic images with a Doppler system and by superimposing the color-coded direction and velocity of blood flow on the real-time images. However, to be diagnosed without taking into account the limitations of echocardiography leads to misdiagnosis, resulting in more instances of adopting the wrong method and timing of treatment. This paper mainly discusses echo diagnosis for the simple perforation type of VSD only. 要旨 ventricular septal defect VSD VSD はじめに ventricular septal defect VSD 60 1 Fallot 解剖, 分類 3 Fig. 1 trabecular septmarginalis TSM 2 anterior limb of TSM

2 6 133 Fig. 1 Ventricular septum viewed from right ventricular side. Fig. 2 Soto s classification. posterior limb of TSM 2 medially papillary muscle Lancisi TSM moderator band TSM anterior papillary muscle VSD 1 Kirklin Soto 4 Fig. 2 Soto VSD VSD Soto

3 VSD 4 血行動態 6 1 Pp/Ps<0.3 Qp/Qs<1.4 2 Pp/Ps>0.3 Qp/Qs Pp/Ps>0.3 Qp/Qs>2.2 4 Eisenmenger Pp/Ps>0.9 Qp/Qs<1.5 Pp/Ps Qp/Qs 心エコー診断 VSD X VIII Fig. 3 Fig

4 6 135 Fig. 3 Illustration of scheme by which the location of a ventricular septal defect is determined by analyzing the imaging planes in which the defect is visualized. The location of a defect, as seen from the right side of the septum. Patterns indicate where lesions are visualized on LV short-axis (papillary muscle level), GAs short-axis, apical four-chamber, apical five-chamber, LV long-axis, and RV long-axis images. RV: right ventricle, LV: left ventricle, GAs: great arteries, TV: tricuspid valve, RVOT: right ventricular outflow tract, LA: left atrium, RA: right atrium, MV: mitral valve, Ao: aorta Fig. 4 The relations with the extension direction of ventricular septal defect and attachment position of medial papillary muscle. a: Defects extending into the inlet septum: The medial papillary muscle was usually found above the defect. b: Defects extending into the trabecular septum: The medial papillary muscle tended to originate from the midpoint of the right side of the defect. c: Defects extending into the infundibulum: The medial papillary muscle was below the defect

5 136 6 a LA/Ao M LAD AoD Qp/Qs LAD AoD 8 9 b velocity time integral VTI Qp/Qs VTI Qp Qs 2 Qp/Qs 2 a V m/sec Bernoulli mmhg =4 V mmhg 5 15 mmhg VSD VSD VSD b VSD VSD mmhg = 4 VSD m/sec 2 VSD 10 c 0 mmhg Bernoulli d ejection time ET acceleration time ACT ACT/ET mmhg 11 e 12 VSD f M pre ejection period PEP ET PEP/ET A-dip notch 3 1 Valsalva

6 6 137 Fig. 5 Two-dimensional images from the left parasternal projection (LV long-axis view) of an infundibular ventricular septal defect. Note the prolapse of the right coronary cusp of the aortic valve at systole (solid arrow). Diastole: The dotted arrow indicates the right coronary cusp of the aortic valve. Systole: The solid arrow indicates a prolapse of the right coronary cusp of the aortic valve. LA: left atrium, LV: left ventricle, RV: right ventricle a VSD VSD VSD prolapse Venturi Fig. 5 M b Valsalva VSD 16 Valsalva 16 Valsalva VSD 17 Valsalva Valsalva Valsalva Fig. 6 Valsalva

7 Two-dimensional image from the left parasternal projection (LV short-axis view, papillary muscle level).

7 138 6 Fig. 6 Two-dimensional images from left parasternal projection (LV long-axis view) of an infundibular ventricular septal defect. Note the protrusion of the sinus of Valsalva (arrows). Fig. 7 Two-dimensional image from the left parasternal projection (LV short-axis view, papillary muscle level). Note the sharp bend in the interventricular septum (arrow). The right ventricle is divided into two chambers, the highand low-pressure chambers, by the anomalous muscle band and the hypertrophic moderator band. 2 Fig. 7 VSD おわりに VSD VSD

8 6 139 参考文献 Kirklin JW, Harshbarger HG, Donald DE, et al: Surgical correction of the ventricular septal defect: Anatomic and technical considerations. J Thoracic Surg 1957; 33: Soto B, Becker AE, Moulaert AJ, et al: Classification of ventricular septal defects. Br Heart J 1980; 43: pp Connelly MA, Webb GD, Somerville J, et al: Canadian Consensus Conference on Adult Congenital Heart Disease Can J Cardiol 1998; 14: X VIII Circ J Suppl VI Lester LA, Vitullo D, Sodt P, et al: An evaluation of the left atrial/aortic root ratio in children with ventricular septal defect. Circulation 1979; 60: Lewis AB, Takahashi M: Echocardiographic assessment of left-to-right shunt volume in children with ventricular septal defect. Circulation 1976; 54: Schamberger MS, Farrell AG, Darragh RK, et al: Use of peak Doppler gradient across ventricular septal defects leads to underestimation of right-sided pressures in patients with sloped Doppler signals. J Am Soc Echocardiogr 2001: 14: Kitabatake A, Inoue M, Asano M, et al: Noninvasive evaluation of pulmonary hypertension by a pulsed Doppler technique. Circulation 1983; 68: King ME, Braun H, Goldblatt A, et al: Interventricular septal configuration as a predictor of right ventricular systolic hypertension in children: A cross-sectional echocardiographic study. Circulation 1983; 68: Meyer RA: Pediatric Echocardiography. Philadelphia, Lea & Febiger, 1977, pp Riggs T, Hirschfeld S, Borkat G, et al: Assessment of the pulmonary vascular bed by echocardiographic right ventricular systolic time intervals. Circulation 1978; 57: Lue H, Takao A: Subpulmonic ventricular septal defect. Tokyo, Springer-Verlag, 1986, pp pp Nicholas T, Kouchoukos, et al (eds): Congenital sinus of Valsalva aneurysm and aortico-left ventricular tunnel, in Kirklin/Barratt-Boyes Cardiac Surgery: Morphology, Diagnostic criteria, Natural History, Techniques, Results, and Indications 3rd edition. Philadelphia, Churchill Livingstone, 2003, pp Chu SH, Hung CR, How SS, et al: Ruptured aneurysms of the sinus of Valsalva in oriental patients. J Thorac Cardiovasc Surg 1990; 99: Sakakibara S, Konno S: Congenital aneurysma of the sinus of Valsalva: anatomy and classification. Am Heart J 1962; 63 : guideline/pdf/jcs2008_miyatake_h.pdf

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PEDIATRIC CARDIOLOGY and CARDIAC SURGERY VOL. 26 NO. 2 ( ) 心室中隔欠損 心エコー診断について Key words: ventricular septal defect, Soto s classification, echoca

PEDIATRIC CARDIOLOGY and CARDIAC SURGERY VOL. 26 NO. 2 ( ) 心室中隔欠損心エコー診断について Key words: ventricular septal defect, Soto s classification, echoca