Utility of 3-Dimensional Echocardiography in Patients With Complex Intracardiac Connections and Ventricular Septal Defects

Figures

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  Figure 1. Double-Outlet Right Ventricle, Pulmonary Atresia, Aorta Arising From the Right Ventricle, and Large Perimembranous-Outlet VSD Transthoracic 2-dimensional echocardiography subxiphoid coronal image at the level of the ventricular septum demonstrates the superior–inferior dimension of the ventricular septal defect (VSD) (green line), with a measurement of 5.5 mm. The VSD size was concerning for potential obstruction of the left ventricle to aorta baffle pathway (red arrow). AO = aorta; LV = left ventricle; RV = right ventricle.

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  Figure 2. Double-Outlet Right Ventricle, Pulmonary Atresia, Aorta Arising From the Right Ventricle, and Large Perimembranous-Outlet VSD (A and B) Transthoracic subxiphoid 3-dimensional echocardiography (3D-echo)-derived biplane imaging demonstrated that the ventricular septal defect (VSD) was elliptical and larger than previously determined by 2-dimensional echocardiography. The VSD is visualized in the coronal (A) and corresponding orthogonal plane (B). The VSD was larger in its anterior–posterior dimension (red line) than its superior–inferior dimension (green line). (C) Rendered 3D-echo image of the ventricular septum from the right ventricular side demonstrates that the VSD is elliptical. The continuous red line marks the boundary of the VSD en-face. The yellow arrow indicates the aortic valve, and the blue arrow points to the prominent infundibulum septum superior to the defect. AO = aortic valve; Dist = distance; IS = infundibulum septum. Abbreviations as in Figure 1.

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  Figure 3. Congenitally Corrected Transposition of the Great Arteries With Pulmonary Atresia and Remote Muscular VSD Transthoracic 2-dimensional echocardiography subxiphoid coronal view shows the superior–inferior dimension of the ventricular septal defect (VSD) (green line). The red line marks the long baffle pathway from the VSD to the aorta. Although the VSD appeared to be moderate in size, there was a concern for possible obstruction after the creation of the intraventricular baffle because of the long distance from the VSD to the aorta. MV = mitral valve; TV = tricuspid valve. Abbreviations as in Figure 1.

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  Figure 4. Congenitally Corrected Transposition of the Great Arteries With Pulmonary Atresia and Remote Muscular VSD Transthoracic 3-dimensional echocardiography (3D-echo) multiplanar reformatted image obtained from subxiphoid coronal views demonstrating the anatomical relationship between the ventricular septal defect (VSD), tricuspid valve (TV), and aortic outflow tract (red dot). (A) Base coronal view obtained in this patient showing the pathway from the morphologic left ventricle (LV) to the aorta (yellow arrow). (B) A 60° view of the ventricular septum shows the infundibulum septum forming the superior border of the VSD (blue arrow) and the TV apparatus (yellow dot) below and away from the VSD. (C) A 120° image of the ventricular septum as visualized from the LV. There is no mitral valve tissue crossing the VSD. (D) Rendered 3D-echo en-face view of the ventricular septum from the right side, showing a large elliptical VSD and the TV apparatus (yellow dot) away from the potential baffle path from the VSD to the aorta (red dot). Based on 3D-echo, we determined that VSD enlargement was not required. This was relevant because the conduction fibers would be running along the superior margin…

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  Figure 5. Dextrocardia, Mirror-Image Atrial Arrangement, Concordant Atrioventricular Connections, Double-Outlet Right Ventricle, Aorta to the Left of the Pulmonary Artery, and Remote Muscular-Inlet VSD (A) Transthoracic 2-dimensional echocardiography (2D-echo) subxiphoid coronal view showing the left-sided morphologic right atrium, tricuspid valve (TV) apparatus with chordal insertion to the rightward aspect of the ventricular septum (yellow arrow), and the large muscular-inlet ventricular septal defect VSD (red arrow). (B) Transthoracic 2D-echo subxiphoid coronal view showing parallel outflow tracts arising from the morphologic right ventricle (RV). The aorta is to the left of the pulmonary trunk. The outflow tracts are separated by the infundibulum septum (red asterisk). The VSD is not seen in this plane. (C) Transthoracic 2D-echo subxiphoid sagittal view showing the potential ventricular baffle pathway from the left ventricle (LV) to the pulmonary artery (red arrow), which appears to be unobstructed. The TV and the aorta are not visualized in this plane. Although 2D-echo demonstrated the intracardiac connections, we could not simultaneously visualize the spatial relationship of the…

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  Figure 6. Dextrocardia, Mirror-Image Atrial Arrangement, Concordant Atrioventricular Connections, Double-Outlet Right Ventricle, Aorta to the Left of the Pulmonary Artery, and Remote Muscular-Inlet Ventricular Septal Defect Coronal cardiac computed tomography image demonstrating the potential ventricular baffle pathway from the left ventricle to the pulmonary artery (red arrow) and the presence of a prominent subpulmonary infundibulum septum (red asterisk), but the atrioventricular valves are not visualized. PA = pulmonary artery. Abbreviations as in Figure 1.

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  Figure 7. Dextrocardia, Double-Outlet Right Ventricle, Pulmonary Atresia, Aorta Arising From the Right Ventricle, and Outlet VSD With Inlet Extension (A and B) Transthoracic 2-dimensional echocardiography (2D-echo) subxiphoid coronal sweep with some imaging planes indicating that the ventricular septal defect (VSD) was clear of tricuspid valve (TV) apparatus (A), whereas in others the TV is clearly traversing the VSD (B). It is difficult to understand the extent of the VSD and the exact relationship to the TV. (C and D) Rendered transthoracic 3-dimensional echocardiography images obtained from the same window as the previous 2D-echo images clearly depict the extent of the VSD and its spatial relationship with the TV. (C) Perspective of the ventricular septum from the left ventricular side. The continuous red line depicts the boundary of the VSD. The yellow arrow points to the aortic valve seen through the VSD. The inlet component of the VSD is shrouded by the TV septal leaflet (black arrow), but the outlet portion of the VSD is unobstructed. (D) Perspective of the ventricular septum from the right ventricular side. The yellow arrow points to the aortic valve. The TV (black arrow) obscures…

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  Figure 8. Dextrocardia, Double-Outlet Right Ventricle, Pulmonary Atresia, Aorta Arising From the Right Ventricle, and Outlet Ventricular Septal Defect With Inlet Extension Coronal cardiac computed tomography image demonstrating the potential ventricular baffle path from the left ventricle to the aorta (red arrow); however, it does not show the tricuspid valve apparatus partially obstructing this path. Abbreviations as in Figure 1.