See Figure 49-3A.
See Figure 49-3B, right panel.
See Figure 49-3B, left panel.
See Figure 49-6C.
See Figure 49-6A.
See Figure 49-6D.
See Figure 49-6B.
It shows the sequence of steps used for the voltage mapping technique to predict the slow AV node location. The same equipment, type of catheters and steps were used as described in Figure 21.25 A-D. The total recording time was 20 minutes but the video was shortened to 7.5 minutes for optimal viewing. The first 3 min. 45 sec are shown at 4x speed at the end of which the reference was changed briefly from the 20-pole catheter to the His catheter to enable more voltage mapping beneath the His catheter area. Then 2x speed and normal speed are intermittently used at end of voltage data point collection. The propagation map at normal speed starts at 4 minutes and the wave front collision at site of predicted slow pathway during the propagation map is shown at 5 min 17 sec. The added hand written black circle predicts the cryo ablation target. At 5 min 50 seconds, the cryoablation applications are displayed followed by individual placement. Cryo-applications 1-6 (blue circles) were 1-1.5 min in duration and were unsuccessful (inducible AVNRT during application). These applications were placed anteriorly towards the tricuspid valve annulus and slightly outside the voltage mapping-predicted slow pathway bridge area because the atrial electrograms appeared more ideal (low voltage, high frequency). Therefore, the electrograms (using conventional anatomic / electrogram approach) were thought to be inconsistent with the voltage map. However, despite the less than optimal slightly greater amplitude electrograms, when cryo-application 7 was applied closer to the voltage mapping-predicted slow pathway, immediate block in the slow pathway was recorded (using the S1-S2 atrial stimulation technique) at less than one minute. This application and subsequent “bonus” ones 8-12 (orange) were placed during 4 minute applications. No inducible AVNRT was evident after cryo 7. (Courtesy of Christopher C. Erickson, MD Children's Hospital & Medical Center, Professor of Pediatrics, University of Nebraska Medical Center; and John Prusmack, St. Jude Medical S.C., Inc.who assisted in the data acquisition, refinement and display.)
Interventional 3D transesophageal echocardiography (TEE) imaging. A: 3D TEE guidance of transseptal atrial septal puncture. The transeptal needle (arrow) punctures the septum primum (SP) just below the limbus (L) of the fossa ovalis. Live images seen in Video 37.5. B: 3D TEE reconstruction of the left atrial view of a mechanical mitral valve prosthesis with a large paravalvular leak present delimited by the arrows. It is elliptical and located in the posterior and medial aspect of the valve. The valve discs (D) are identified. Live images are seen in Video 37.6. C: 3D color flow image of the paravalvar regurgitant jet (arrow).
Real time zoom mode 3D imaging of the mitral valve. Note small sector and high spatial resolution of the image which allows good visualization of the mitral valve.
Live 3D transesophageal echocardiography (TEE) image of the tricuspid valve in a patient with Ebstein anomaly. The tricuspid valve anterior leaflet is thickened (arrowhead) and several fenestrations are noted (arrow). Ao, aorta; RA, right atrium; RV, right ventricle.
Anomalous insertion of the left main coronary artery into the posterior aspect of the proximal main pulmonary artery (PA) from a parasternal short-axis view in a 4-month- old infant with anomalous left coronary artery from the PA. The left anterior descending (LAD) and circumflex (Cx) arteries are both seen entering the PA through a short left main coronary segment, clearly a long distance from the normal entrance into the aortic root (Ao).
NC/C ratio in systole is >2.8.
RV compromise is highly suspected.
As we sweep cephalad, the branching pulmonary artery is seen arising from the left ventricle, and the non-branching aorta is seen arising from the right ventricle, which lies anterior and rightward of the pulmonary artery. Of note, three vessels appear to branch from the pulmonary artery; these are the right and left pulmonary arteries and the ductus arteriosus.
This patient had hypertrophic obstructive cardiomyopathy with significant left ventricular outflow tract obstruction.
Parasternal long-axis view in diastole showing mild aortic regurgitation.
2D and color Doppler parasternal long-axis clip showing a posteriorly directed jet of mitral regurgitation extending >2 cm behind the mitral valve and a small jet of aortic regurgitation.
Cineangiogram through a pigtail catheter advanced retrograde to the descending thoracic aorta following PDA closure with a 6-6 Amplatzer Duct Occluder II demonstrates a well-seated device with no residual shunting. There is no evidence of aortic obstruction. Courtesy of Renelle George, MD (AngioAtlas.org)
Contrast is seen appearing in the left atrium after 3 cardiac cycles consistent with a positive contrast study.
The mital valve chordae and papillary muscles appear echobright secondary to ischemia.
There is a severely dilated left ventricle with severely depressed systolic function. The mitral valve chordae and papillary muscles appear echobright secondary to ischemia.
The left coronary artery (seen branching into the left anterior descending and circumflex coronary arteries) is seen arising from the pulmonary artery with retrograde flow into the pulmonary artery (blue color Doppler flow)
The left ventricle appears severley dilated with severely depressed systolic function. The mitral valve papillary muscles appear echobright secondary to ischemia.
Moderately depressed global ventricular function. Contrast was negative to rule out apical thrombosis.
Matching apical 4-chamber.
Ultrasound transducer transmitting a plane of ultrasound through a heart in a parasternal, sagittal, or long-axis plane. The myocardial and valvar structures reflect the ultrasound energy back to the transducer. The crystals within the transducer detect the returning energy, and the processors within the ultrasound system quantitate the intensity of the reflected waves and the time required for the ultrasound energy to travel from the transducer to the reflector and back. The intensity of the returning signal determines the brightness of the display, and the time defines the depth at which the signal is displayed. The central processing unit filters and then converts this information into a video display , which corresponds to the anatomy encountered by the plane of sound as it traversed the chest. AV, aortic valve; LA, left atrium; LV, left ventricle; RV, right ventricle.
Multiple segments to the right and left lungs were supplied by aortopulmonary collaterals not demonstrated on this angiogram. Note the tubular hypoplasia centrally with mild discrete stenosis in both main branch pulmonary arteries.
Preservation of left ventricular function in an older child
Short-axis image using color Doppler to identify retrograde flow in the left anterior descending (LAD) coronary artery in the same 4-month- old infant with anomalous left coronary artery from the pulmonary artery shown in Figure 27.4. Flow in the LAD is blue as it moves away from the transducer toward the pulmonary artery (PA), which is abnormal because it should be flowing away from the aortic root (red Doppler signal) rather than toward it. A turbulent flow signal (arrows) is also seen in the pulmonary artery as the anomalous left coronary artery empties into the low-pressure pulmonary artery.
Short-axis image of color Doppler interrogation of the ventricular septum shows septal coronary collateral flow in the same 10-year- old child as Figure 27.5. The child was initially referred for evaluation of a heart murmur and was found to have anomalous origin of the left coronary from the pulmonary artery. A low-velocity linear diastolic flow signal is seen in the ventricular septum. The color Doppler and spectral Doppler timing of flow in diastole help differentiate this septal collateral from a ventricular septal defect, which is generally characterized by a high-velocity systolic flow signal. The identification of this septal flow signal was the initial echo finding that led to the diagnosis of ALCAPA in this boy.
The left superior pulmonary vein is also seen.
A pigtail catheter is positioned in the aortic root retrograde from the femoral artery. With injection, the aortic valve is doming and while the aortic valve annulus is normal, there is a narrow jet of negative contrast washout through the effective orifice of the aortic valve. The ascending aorta is also dilated. There is no aortic insufficiency.
Cases of significant valvar AS are often associated with severe LV dysfunction, which in turn results in decreased cardiac output, decreased transvalvar flow, and a decreased maximum instantaneous gradient across the AoV despite the severity of the obstruction
Parasternal long-axis view of aortic valve prolapse into a ventricular septal defect. Shows distortion of the aortic valve in the area of the defect and mild aortic regurgitation.
The left-sided AV valve appears more apically displaced consistent with a left-sided tricuspid valve. The septal leaflet appears tethered and shortened. The left atrium appears severely dilated. The (left-sided) right ventricle appears hypertrophied and trabeculated in appearance
There is a large vegetation noted on the septal leaflet of the tricuspid valve. Echo image courtesy of www.pedecho.org
The tricuspid valve appears atretic with a plate-like oriface.
Echo image courtesy of www.pedecho.org
The common AV valve appears largely committed to the left ventricle. The right ventricle appears moderately hypoplastic.
The common AV valve appears largely committed to the right ventricle. The left ventricle appears moderately hypoplastic.
Mild to moderate tricuspid regurgitation is noted secondary to elevated right ventricular pressures in the setting of pulmonary venous obstruction
There is severe hypertrophy of the ventricular septum with systolic anterior motion of the mitral valve causing severe dynamic left ventricular outflow tract obstruction
The leaflets demonstrate restricted excusion.
There is end systolic right atrial collapse and diastolic right ventricle collapse consistent with tamponade physiology.
The left ventricle and mitral valve are severely hypoplastic.
Note the swinging heart and the prominent right atrial wall collapse in late diastole.
The atrioventricular valves remain on the same plane.
The myocardium has a sparkling appearance. There is also similar thickening of the interatrial septum. Mild generalized thickening of the valves is present.
Commonly, contrast is needed to visualize the spade-like appearance of the LV in these patients.
Note the presence of the native apically displaced tricuspid valve.
There is atrialization of the basal to mid-right ventricle.
The apical position of the tricuspid valve identifies the hypertrophied systemic ventricle as the morphologic right ventricle.
An echodensity can be seen prolapsing across the tricuspid valve. The right ventricle is dilated with McConnell's sign suggestive of acute pulmonary embolism.
McConnell's sign present in the setting of acute pulmonary embolism.
Marked left atrial dilatation is seen.
A large chronic (echogenic) laminar apical thrombus is seen when the image is tilted to provide a “non-foreshortened” view illustrating the importance of probe position to adequately evaluate the left ventricular apex especially in dilated hearts.
There is a large proportion of the right ventricle that is "atrialized."
Note the gross malcoaptation of the tricuspid valve leaflets secondary to annular dilatation.
Marked right heart dilatation with severe right ventricular hypokinesis. A small underfilled left ventricle with evidence of compression from pericardial effusion is seen.
These findings are consistent with pericardial tamponade.
There is also right ventricular (RV) dilation.
Note the large pericardial effusion and thrombus in the pericardial space.
The left atrial and left ventricular cavities are small in comparison.
This patient was found to have septic emboli seen on a subsequent chest computed tomography scan.
Note marked displacement of the mitral annulus during diastole.
Asterisks illustrate deep inter-recess spaces.
Notice significant shadowing from the bioprosthesis struts affecting assessment of color Doppler in the left atrium. There is systolic turbulence consistent with mitral regurgitation seen in the center-posterior left atrium where the beam is unaffected by shadowing.
The mass appears to originate from the anterior mitral valve leaflet. Note no significant mitral valve regurgitation is seen.
Overall mass is increased consistent with concentric left ventricular hypertrophy.
Marked mitral valve calcification with relative sparing of the leaflet tips.
Overall mass is markedly increased consistent with eccentric left ventricular hypertrophy.
Notice the apical focus position to destroy the bubbles in the apex and decrease contrast attenuation.
These two-dimensional features are associated with ischemic mitral valve regurgitation.
Unlike organized laminar left ventricular thrombus, this thrombus is protuberant.
Note the “spade”-shaped left ventricular cavity.
An echodensity is noted in the left ventricular apex concerning for thrombus.
Stored fluoroscopy during deployment of a 20 mm Amplatzer Septal Occluder across the atrial septum. The left atrial disc is deployed first, followed by the center waist and right atrial disc.Courtesy of Renelle George, MD (AngioAtlas.org)
Stored fluoroscopy during release of a 20 mm Amplatzer Septal Occluder positioned across the atrial septum. The device is in good position following release. Courtesy of Renelle George, MD (AngioAtlas.org)
Balance steady state free precession (b-SSFP) cine magnetic resonance imaging showing the left ventricular inflow and outflow tracts, the muscular and perimembranous interventricular septum, the ascending aorta and the right ventricular inflow. Note the high blood to myocardium contrast that allows visualization of intracardiac structures such as the papillary muscles and redundant and elongated mitral valve chordal tissue.
In the patient described in Figure 6.27, with balloon occlusion of the innominate vein and subsequent angiographic dye injection a small levoatrial cardinal vein connecting to the left atrium is demonstrated.
In the same patient described in Figure 6.27, 16 years later, cephalad (red) flow is demonstrated in the levoatrial cardinal vein.
Stored fluoroscopy during balloon aortic valvuloplasty with a 7 mm x 3 cm Tyshak II balloon. The waist disappears completely at maximal inflation. A pacing catheter is positioned in the right ventricle to increase balloon stability during the inflation. Courtesy of Renelle George, MD (AngioAtlas.org)
Cineangiogram via a pigtail catheter in the ascending aorta of a seven week-old male with a thickened, unicommissural aortic valve and severe aortic stenosis. There is no significant aortic valve regurgitation at baseline. Courtesy of Renelle George, MD (AngioAtlas.org)
Cineangiogram through a pigtail catheter in the ascending aorta following balloon aortic valvuloplasty demonstrates trivial aortic valve regurgitation. Courtesy of Renelle George, MD (AngioAtlas.org)
Parasternal short-axis view of a bicuspid aortic valve with fusion or underdevelopment of the commissure between the right coronary and noncoronary leaflets
Stored fluoroscopy during inflation of a 11 mm x 3 cm Tyshak II balloon across the pulmonary valve. There is near-complete resolution of the waist at maximal inflation. Courtesy of Renelle George, MD (AngioAtlas.org)
Cineangiogram via a Berman catheter in the right ventricle of a 5-month-old female with moderate-to-severe valvar pulmonary stenosis demonstrates a hypertrophied right ventricle with qualitatively normal systolic function. The pulmonary valve is thickened and domes in systole. There is post-stenotic dilatation of the main pulmonary artery. Courtesy of Renelle George, MD (AngioAtlas.org)
Cineangiogram via the Berman catheter in the main pulmonary artery following balloon pulmonary valvuloplasty demonstrates improved leaflet excursion. The dilated main pulmonary artery with confluent, good-sized branch pulmonary arteries are again visualized. There is no significant pulmonary regurgitation. Courtesy of Renelle George, MD (AngioAtlas.org)
There is a right aortic arch with an aberrant left subclavian artery arising from a bulbous Kommerell diverticulum. There is fixed mild tracheal narrowing at the level of the vascular ring. The aorta is labeled in red, the trachea in orange, and the pulmonary artery in blue.
There is a right dominant double aortic arch with mild to moderate extrinsizc compression of the mid to lower trachea at the level of the double arch.
The left pulmonary artery arises from the right pulmonary artery and extends leftward and posteriorly.
The anomalous muscle bundle is seen dividing the inflow and outflow RV chambers, similar to the angiographic findings.
There is late gadolinium enhancement in the same area on LGE imaging.
Modified subcostal view of a central venous line in the right atrium. The use of B-color allows easy identification of the dense vegetation, giving a thickened, irregular appearance to the catheter.
Subcostal images in a patient with a pronounced Chiari network. The Chiari network can be seen as multiple small mobile echogenic areas in the right atrium.
Child with anomalous aortic origin of the left coronary from the right sinus of Valsalva and an interarterial course.
Short-axis view through the aortic root in a child with Kawasaki disease and aneurysms in both the proximal left and right coronary arteries
Apical view in the same child with Kawasaki disease, identifying multiple aneurysms in the posterior descending branch of the right coronary artery (arrows). The scanning plane has been angled posteriorly through the right heart to visualize the atrioventricular groove behind the tricuspid valve to image this distal coronary branch, which was important in characterizing the extent of the disease. The left atrium (LA) and left ventricle (LV) are also imaged, with a pericardial effusion posteriorly as well.
2D echocardiographic apical four-chamber clip demonstrating thickened leaflets, restricted diastolic excursion, left atrial (LA) enlargement.
2D echocardiographic parasternal long-axis clip demonstrating thickened mitral valve leaflets with restricted diastolic motion and a ‘hockey-stick’ deformity of the anterior leaflet.
This series can be used for analysis of right ventricular function. This is the case of a patient after arterial switch for transposition of the great arteries. The right ventricle is dilated and hypertrophic and shows preserved global systolic function. A large jet of tricuspid regurgitation is seen. Note the central pulmonary artery.
Cineangiogram via a pigtail catheter in the transverse arch of an adult male with recurrent coarctation of the aorta following end-to-end anastomosis in infancy demonstrates discrete coarctation just distal to the origin of the left subclavian artery. Courtesy of Renelle George, MD (AngioAtlas.org)
Cineangiogram via a pigtail catheter in the transverse arch following balloon angioplasty with a 5 mm x 2 cm Tyshak mini balloon demonstrates significant improvement in the coarcted segment. There is no evidence of vascular injury. Courtesy of Renelle George, MD (AngioAtlas.org)
Cineangiogram via a pigtail catheter in the transverse arch of a 7-week-old premature male demonstrates a severe, discrete coarctation of the aorta distal to the origin of the left subclavian artery. Courtesy of Renelle George, MD (AngioAtlas.org)
Cineangiogram via pigtail catheter in the transverse arch following implantation of a 26 mm Max LD stent on an 18 mm BiB and post-dilation with an Atlas Gold balloon demonstrates a well-apposed stent with no evidence of vascular injury. Flow to the head and neck vessels is unobstructed. Courtesy of Renelle George, MD (AngioAtlas.org)
Cineangiogram through a pigtail catheter advanced retrograde to the descending aorta following PDA closure with a 5mm x 4mm Nit-Occlud PDA coil demonstrates a well-seated device with no residual shunting. There is no evidence of aortic obstruction. Courtesy of Renelle George, MD (AngioAtlas.org)
The arch is hypoplastic, and arch flow is completely retrograde.
Color Doppler in a long- axis transgastric view of a prosthetic aortic valve showing normal trivial intravalvular regurgitation (asterisk) that is not localized outside the prosthetic valve ring.
Color flow Doppler demonstrating antegrade flow in the right-sided aortic arch (R Ao arch) as it passes to the right of the trachea. It joins a left-sided arterial duct (L duct) to form the characteristic “U” shape. The R Ao arch traverses to the right of the trachea (Tr). Bilateral SVC (RSVC and LSVC) lie on either side of the aortic arch and arterial duct. SVC, superior vena cava.
Color flow will demonstrate blood flowing cranially, in the opposite direction to the descending aorta
Some atrial septal tissue is seen bowing into the left atrium. There is mild right ventricular hypertrophy.
Techniques used for Cone reconstruction of the tricuspid valve in a 21-year-old patient with Ebstein malformation.
Apical 4-chamber image focused on the right atrium in a patient with cor triatriatum dexter. Membrane can be seen superior to the tricuspid valve (TV).
Critical aortic stenosis with hypoplasia of the ascending aorta and a large patent ductus arteriosus.
Image courtesy of J. Chris Wilkinson, Texas Children's Hospital.
The images in these video clips illustrate the imaging technique used to determine cardiac position and sidedness, both in patients with normal anatomy and in those with complex male positions. Video 2.1A, 2.1D display the anatomy of the upper abdominal organs and great vessels. Normal abdominal sidedness is shown in the Video 2.1A, with the liver (L) positioned to the patient' right and the air artifact within the stomach seen on the left. Video 2.1C shows the anatomy of the same organs and vessels, but in a patient with situs inversus. The liver is to the patient's left, and the position of the aorta and IVC are reversed. To most easily determined cardiac position, Videos 2.1A, 2.1C, 2.1D is obtained in the imaging plane which is angled superiorly across the diaphragm until the cardiac structures come into view (Videos 2.1B, 2.1E, 2.1F). Video 2.1B is taken from a patient with normal cardiac anatomy. It shows the atria visualized near the midline, but with the left atrium (LA) posterior and slightly to the left of the right atrium (RA). The ventricles are to the left of the atrial structures with the apex of both ventricles being oriented inferiorly and to the left. These findings are consistent with normal cardiac position and orientation or situs solitus with levocardia. In contrast, the Video 2.1E l is taken from an examination of a patient with situs inversus totalis and dextrocardia. The atria are again found near the midline, but now the left atrium is posterior and slightly rightward. The ventricles are positioned inferiorly and to the right of the atria, with their apices oriented inferiorly into the right. This is the mirror image of the normal position and orientation, or situs inversus with dextrocardia. V LV, left ventricle; RV, right ventricle.
Defining Cardiac Position and Sidedness. The images in these video clips illustrate the imaging technique used to determine cardiac position and sidedness, both in patients with normal anatomy and in those with complex male positions. Video 2.1A, 2.1D display the anatomy of the upper abdominal organs and great vessels. Normal abdominal sidedness is shown in the Video 2.1A, with the liver (L) positioned to the patient' right and the air artifact within the stomach seen on the left. Video 2.1C shows the anatomy of the same organs and vessels, but in a patient with situs inversus. The liver is to the patient's left, and the position of the aorta and IVC are reversed. To most easily determined cardiac position, Videos 2.1A, 2.1C, 2.1D is obtained in the imaging plane which is angled superiorly across the diaphragm until the cardiac structures come into view (Videos 2.1B, 2.1E, 2.1F). Video 2.1B is taken from a patient with normal cardiac anatomy. It shows the atria visualized near the midline, but with the left atrium (LA) posterior and slightly to the left of the right atrium (RA). The ventricles are to the left of the atrial structures with the apex of both ventricles being oriented inferiorly and to the left. These findings are consistent with normal cardiac position and orientation or situs solitus with levocardia. In contrast, the Video 2.1E l is taken from an examination of a patient with situs inversus totalis and dextrocardia. The atria are again found near the midline, but now the left atrium is posterior and slightly rightward. The ventricles are positioned inferiorly and to the right of the atria, with their apices oriented inferiorly into the right. This is the mirror image of the normal position and orientation, or situs inversus with dextrocardia. V LV, left ventricle; RV, right ventricle.
Note the marked decrease in tissue Doppler early diastolic mitral annulus (e') velocities in patients with restrictive cardiomyopathy (typically below 8 cm/s), while patients with constrictive pericarditis have normal or increased e' velocities.
Depicted in a parasternal long-axis view without and with color Doppler.
A: Apical four-chamber view with focus on the left ventricle in a 2-year-old patient with dilated cardiomyopathy and poor systolic function. Note that while no thrombus in seen in this initial 4-chamber image, a thrombus can be noted in the left ventricle when sweeping posteriorly (B). This highlights the need for thorough imaging of the ventricular walls in patients at risk for ventricular thrombus.
Dilated origin of the right coronary artery (RCA) in a child with a right coronary-to-right ventricular fistula. The coronary is markedly dilated, measuring 5 mm in diameter, and tortuous as it arises from the aorta (Ao) because of the increased flow through the fistula.
Cineangiogram through a pigtail catheter advanced retrograde to the ascending aorta in a patient with double outlet right ventricle with normally related great arteries and mitral valve hypoplasia status post extracardiac, non-fenestrated Fontan procedure demonstrates an unobstructed Damus-Kaye-Stansel anastomosis. There is no significant neoaortic or aortic valve regurgitation. There is a large coronary artery fistula arising from the left main coronary artery. Courtesy of Renelle George, MD (AngioAtlas.org)
Double-inlet left ventricle with normally related great arteries; parasternal views. Long-axis view showing the anterior hypoplastic right ventricle (RV), enlarged left ventricle (LV), and a muscular ventricular septal defect). The LV gives rise to the aorta (Ao)
Double-inlet left ventricle with normally related great arteries; parasternal views. Short-axis view at the level of atrioventricular valves showing classic. appearance of both the right (R) and left (L) atrioventricular valves committed to the LV posterior to the large ventricular septal defect
Double-inlet left ventricle with normally related great arteries; apical views.
This video represents a “sweep” through the anatomy of the infant with DOLV described in Figures 51.23 to 51.25 and Videos 51.1 and 51.2. The right ventricle and most of the ventricular septum have been “cropped” out of the image. Both great arteries are committed to the left ventricular chamber in this case, with only the most anterior aspect of the aortic root overriding the ventricular septal defect (not seen in the planes included in this video). A, anterior; F, “foot” or inferior; H, “head” or superior; L, left; P, posterior; R, right.
These simultaneous two-dimensional and color Doppler echocardiographic images were taken from a neonatal examination of a child with DOLV (also illustrated in Figs. 51.23 and 24). The outflow anatomy is typical of a conotruncal malformation and in this plane would be indistinguishable from a case of tetralogy of Fallot. There is mitral to aortic valve continuity (absence of subaortic conus) and the aortic annulus overrides the ventricular septum by roughly 50%. The color flow is especially prominent exiting the anterior right ventricle (RV) and entering the aorta, because the VSD provided the only outlet from the RV in this case.
These simultaneous two-dimensional and color Doppler echocardiographic images were taken from the same neonatal examination of a child with DOLV as in Video 51.1. Here the plane of sound has been angled anteriorly to demonstrate both great arteries (aorta to the patient's right). Both semilunar valves are committed to the left ventricular outlet, but neither has any significant subvalvar conus muscle. The color Doppler image (right panel) shows no obstruction to aortic flow. There was a mild gradient (mean = 20 mm Hg) through the pulmonary outlet. The red color signal in the main pulmonary artery (MPA) represents left to right flow entering the MPA from the ductal artery which remained patent at the time of the examination.
Dysplastic pulmonary valve seen on anterior sweep from standard apical window.
Failure of central coaptation, resulting in severe regurgitation, as shown by the systolic color jet
Left ventricular mid-short axis view.
Apical 4-chamber view.
This first branch is the left brachiocephalic artery. It divides into the left common carotid artery and the left subclavian artery. Note that the right common carotid artery can be seen coursing rightward just after the take-off of the brachiocephalic artery.
This first branch is the right brachiocephalic artery. The branch divides into the right common carotid artery and the right subclavian artery.
In systole, turbulent flow out the left ventricular outflow tract is begins at the level of the membrane. A narrow jet of aortic insufficiency is noted in diastole.
Left ventricular function appears normal and the aortic valve is normal in appearance.
The obstruction extends for approximately 1.5 cm from immediately below the aortic valve.
While the bicuspid nature of the valve cannot be identified from this view, the cusps are clearly seen to “dome”, resulting in a reduced effective valve orifice.
As is most common, the right and left coronary cusps are fused to create a large cusp with a thickened raphe at the site of the fused commissure. The valve opens with the “fish mouth” appearance characteristic of a bicuspid aortic valve.
The origin of the left coronary artery from the left coronary sinus is also demonstrated.
Parasternal long-axis view of endocardial fibroelastosis involving a left ventricular papillary muscle group and some left ventricular endocardial segments (grade 2).
Endocarditis associated with a Melody valve in an adult with tetralogy of Fallot.
Hyperacute rejection, taken 4 days after transplant. The patient had presented with immediate systolic and diastolic dysfunction on reperfusion at the time of transplant, with progressive thickening of the myocardium over the first few days despite intensive antirejection treatment and ECMO rescue. Note the diffuse, infiltrative appearance of the myocardium.
Subcostal sagittal image in a patient with a prominent Eustachian valve. The Eustachian valve is seen anterior to the opening of the inferior vena cava into the right atrium.
Severe right pulmonary artery (RPA) stenosis in a patient who had repair of anomalous left coronary originating from the mid-RPA. Balloon occlusion is performed with the angiographic catheter in the proximal LPA to occlude flow distally forcing contrast into the tightly stenotic RPA.
Selective left pulmonary artery (LPA) injection in a patient with proximal LPA stenosis. With the frontal plane detector angled at 16 degrees cranial/6 RAO, the proximal LPA stenosis is completely foreshortened (see Video 16-4A). This assures the operator that the orthogonal view fully depicts the stenosis and that measurement of this segment will be accurate.
Four-chamber view of the same fetal aortic stenosis as shown in Figure 15.42 at 33 weeks#x0027; gestation, now with left ventricular hypoplasia.
Four-chamber view of fetal aortic stenosis with a left-to- right shunt across the patent foramen ovale.
Four-chamber view of fetal aortic stenosis with significant mitral regurgitation.
Arch view of fetal aortic stenosis with retrograde flow in the transverse aortic arch by color Doppler.
Left ventricular outflow tract view of fetal aortic stenosis at 22 weeks' gestation with significant left ventricular dilation and dysfunction.
The pulmonic valve leaflets are barely visible but appear flail.
The pulmonic valve leaflets are difficult to visualize.
Cineangiograms through a Berman angiocatheter in the Glenn circuit, distal conduit and inferior vena cava of a patient with double outlet right ventricle with normally related great arteries and mitral valve hypoplasia status post extracardiac, non-fenestrated Fontan procedure demonstrate an unobstructed Fontan circuit. There is no conduit stenosis and flow to the branch pulmonary arteries is unobstructed. Courtesy of Renelle George, MD (AngioAtlas.org)
Note how the interventricular septum bows into the left ventricle in systole.
Note connection and flow into the aorta from the left main system.
Right anterior oblique projection of the same right ventricular angiogram showing extensive right ventricle to coronary artery fistulae. The coronary circulation is bizarre and flow to the left ventricle appears tenuous.
This is the same patient shown in Video 16-12B.
This is the same patient shown in Video 16-11.
The tip of the catheter is in the high superior vena cava. Contrast injection demonstrates a patent bidirectional cavopulmonary (Glenn) anastomosis Fontan conduit. There is mild hypoplasia of the pulmonary artery to the left of the Glenn anastomosis.
Three-dimensional full-volume data set acquired from the short-axis parasternal window over seven heart beats showing the entire left and right ventricles including the atrioventricular valve planes.
Hand injection through the right internal jugular venous sheath in a patient with double outlet right ventricle, hypoplastic left ventricle, and bilateral superior vena cavae status post Glenn procedure demonstrates a widely patent right Glenn circuit. Courtesy of Renelle George, MD (AngioAtlas.org)
Right bidirectional Glenn shunt (cavopulmonary anastomosis). Color Doppler imaging of the Glenn shunt showing low-velocity laminar flow from SVC to the pulmonary artery.
Right bidirectional Glenn shunt (cavopulmonary anastomosis). Suprasternal short-axis view of the widely patent anastomosis between the right superior vena cava (SVC) and right pulmonary artery (RPA).
Gradient-spoiled echo cine magnetic resonance image. Compared with balance steady state free precession sequence, there is lower contrast between the blood and the myocardium which is mainly due to intracavitary flow; thus, the jet of tricuspid regurgitation can be better seen.
Stored fluoroscopy during deployment and locking of a 25mm Gore Cardioform Septal Occluder across the atrial septum of a patient with a fenestrated atrial septal defect. The left atrial disc is deployed first, and is pulled toward the right atrium before the right atrial disc is deployed. Courtesy of Renelle George, MD (AngioAtlas.org)
Stored fluoroscopy during release of a 25 mm Gore Cardioform Septal Occluder across the atrial septum of a patient with a fenestrated atrial septal defect. The device is in good position following release. Courtesy of Renelle George, MD (AngioAtlas.org)
Patient with Pulmonary artery band (PAB). High left parasternal short-axis image in a different patient with PAB; Color Doppler interrogation of the branch pulmonary arteries demonstrates potential distal migration of the band with early impingement of flow into the right pulmonary artery (RPA). Note the normal flow in the left pulmonary artery (LPA)
Color Doppler demonstrates branch pulmonary arteries after the LeCompte maneuver.
Hypoplastic left heart syndrome (HLHS); 3D echo. 3D echo is increasingly being recognized as the imaging modality of choice for evaluation of tricuspid valve morphology and the mechanism of tri
cuspid valve regurgitation
Hypoplastic left heart syndrome (HLHS); apical views. A: Four-chamber view demonstrating enlargement of the right ventri
cle (RV) and right atrium (RA).
Hypoplastic left heart syndrome (HLHS); postoperative stage I Norwood with restriction of the atrial septal defect (ASD). Color Doppler flow demonstrating aliased signal through the narrowed ASD.
Color Doppler interrogation of the aortic arch demonstrating the area of coarctation.
Hypoplastic left heart syndrome (HLHS); high left parasternal view. A:Characteristic color Doppler imaging of the aortic and ductal arches demonstrates right-to- left shunting (blue flow away from the transducer) in the ductus arteriosus with retrograde flow in the aortic arch (red flow toward the transducer)
Hypoplastic left heart syndrome (HLHS); postoperative evaluation of normal aortic arch. Color Doppler flow in the reconstructed aortic arch following Norwood procedure demonstrating mild flow acceleration in this anatomic transition zone secondary to the size discrepancy
Hypoplastic left heart syndrome (HLHS); postoperative stage I Norwood with restriction of the atrial septal defect (ASD). Subcostal long-axis (coronal) view showing restrictionof surgically created ASD with thickened tissue rims
Hypoplastic left heart syndrome (HLHS); subcostal views. Long-axis (coronal) video showing very dilated right atrium (RA) and small left atrium (LA). The secundum atrial septal defect is large and unrestrictive. The right ventricle (RV) is hypertrophied, and the left ventricle (LV) and mitral valve are severely hypoplastic
Hypoplastic left heart syndrome (HLHS); stage I Norwood with postoperative recurrent coarctation of the aorta. Suprasternal long-axis view of arch reconstruction showing recoarctation (asterisk) of aorta at the junction of the reconstructed aorta and native descending aorta (DA).
Hypoplastic left heart syndrome (HLHS); suprasternal view.
Infant with dilated cardiomyopathy and anomalous origin of left coronary artery from the pulmonary artery
Infant with limited collateralization who presents early with a severe dilated car
Straight AP frontal plane view of right ventricular injection shows the infundibular stenosis and thickened pulmonary valve leaflets, in addition to the pulmonary artery bifurcation.
90-degree straight lateral projection again shows right ventricle well in addition to the right-to-left shunt through the VSD with filling of the left ventricle.
Note the presence of severe right heart dilatation.
Intracardiac echocardiography of a Melody valve after a pulmonary valve-in-valve procedure. The valve leaflets are thin with full coaptation in diastole.
The leaflets are severely thickened and fused in the closed position. There is a coaptation defect and severe stenosis demonstrated on color flow Doppler echocardiography.
The flow from the VSD tracks anteriorly through the RV trabeculations, beyond the edge of the patch, making localization by the surgeon challenging. The residual shunt is not across the native ventricular septum.
Counterclockwise rotation of the transducer with tilting toward the left shoulder shows the length of the left anterior descending coronary artery (LAD) in the anterior interventricular groove. The LAD is ectatic with a distal fusiform aneurysm.
The high left parasternal window can be used to see the left coronary artery by tilting the transducer below the pulmonary artery. Note the fusiform aneurysm of the left anterior descending (LAD) coronary artery.
The parasternal short-axis view is optimal to start imaging the coronary arteries. LCA, origin of the left coronary artery; RCA, origin of the right coronary artery.
An aneurysm of the right coronary artery (RCA) seen from a subcostal coronal view tilted anteriorly toward the anterior atrioventricular groove.
Subcostal sagittal image from a patient with a very large atrial septal defect (ASD) and associated anomalous connection of the right pulmonary veins to the right atrium (RA). There is no superior rim. A very prominent Eustachian valve is seen entering the RA anterior to the inferior vena cava (IVC). The posterior-inferior rim is seen near the IVC entrance.
Note the catheter in the right ventricular infundibulum is directed towards the main pulmonary artery and is apposed to the valve tissue.
This is the same patient shown in Video 16-12A.
This is a newborn who had undergone radiofrequency perforation of an atretic pulmonary valve. Saturations were considered to be unacceptably low when prostaglandin was discontinued, and the duct nearly closed. Notice the pulmonary insufficiency into the relatively small right ventricular chamber. Also note the tubular, horizontal PDA anatomy. There is moderate constriction of the ductus near the pulmonary end.
The PDA stent was deployed and remained in excellent position. The stent was delivered under relatively low pressure and the small constriction in the stent was purposely not eliminated in this situation. As expected, the right ventricle gradually became more compliant, and saturations increased over time. On follow-up after 3 years, the patient was fully saturated and the ductus was still patent but with a relatively small volume of flow. Our routine is to close the PDA electively at around 6 years of age in these patients if the stented ductus has not closed spontaneously.
There was only a slight residual gradient into the left lower lobe.
The proximal left pulmonary artery has a tapering shape to the region of stenosis. The shape of the proximal pulmonary artery and proximity of the branching to the primary stenosis makes placement of a stent at this time, in this patient, less attractive than angioplasty.
A pigtail catheter is positioned in the body of the left ventricle from a retrograde approach and the cameras are angled to elongate the ventricular septum, which can help to visualize the aortic outflow tract and also evaluate for ventricular septal defects along the entire length of the ventricular septum. With injection, there is a distinct ridge of tissue below the aortic valve, consistent with a subaortic membrane and discrete subaortic stenosis.
Nonbacterial thrombotic (Libman-Sacks) endocarditis in systemic lupus erythematosus.
Analysis of left ventricular function with full-volume 3D data sets. Normal left ventricular end-diastolic, end-systolic, stroke volume, and ejection fraction in a normal subject. Calculation of regional volumes throughout the cardiac cycle and regional ejection fraction are also possible (bottom panel).
NCLV and tricuspid atresia.
A large VSD with cephalic infundibular deviation and pulmonar stenosis (TOF variant) and NCLV.
NCLV and apical ventricular septal defect.
The main pulmonary artery (MPA) is seen to divide proximally into the right pulmonary artery (RPA) and left pulmonary artery (LPA). The aorta (Ao) and superior vena cava (SVC) lie to the right of the MPA, respectively.
Aortic dissection along the posterior aspect of the aortic root and ascending aorta in a Marfan patient with marked aortic dilation.
A 43-year-old patient with Marfan syndrome had a Bentall procedure 15 years before this imaging study. The patient had subsequent descending thoracic aortic replacement for an aneurysm. Routine transthoracic echocardiogram demon strates a composite graft replacement of the ascending aorta (Bentall procedure) with normally functioning aortic mechanical prosthesis (arrowheads) and aneurysmal dilatation of the anastomosis of the right coronary artery with the aortic graft (CA) noted by 2-dimensional and color flow imaging.
Patient with Marfan syndrome and prior Bentall procedure..
Mediastinal tumor compressing the right ventricular outflow tract.
The right atrium, tricuspid valve annulus, and right ventricle are larger than the left atrium, mitral valve annulus, and left ventricle.
Parasternal long-axis view. Small tunnel from the aorta (Ao) to the left ventricle (LV), causing mild functional aortic regurgitation.
The branching pulmonary artery is seen arising from the left ventricle (inferior part of image), and the non-branching aorta is seen arising from the right ventricle (superior part of image). The atrioventricular valves are also well seen, and it is clear that the tricuspid valve has septal attachments, while the mitral valve does not.
Multislice render of the true short axis view covering the entire left ventricle from base to apex. This display is useful to evaluate wall motion abnormalities because it allows direct comparison among different myocardial segments.
Animation demonstrating venous baffle construction in the Mustard operation, whereby systemic venous return is directed to the LV and the pulmonary arteries.
Myocardial tagging images in the short axis at the basal, mid, and apical levels. The dark grids tag the myocardium, so its motion can be followed. Postprocessing allows calculation of myocardial deformation in all directions.
Native pulmonary valve implantation procedure: Transcatheter implantation of a Sapien S3 valve in the pulmonary valve position. The patient had tetralogy of Fallot and was status post VSD closure and transannular RVOT patch placement.
Suprasternal notch imaging in a newborn with a large vein of Galen malformation. Color Doppler interrogation of the descending thoracic aorta demonstrates marked retrograde diastolic flow (red signal) into the cerebral circulation.