Cross-sectional echocardiography in the evaluation of aortic valve prolapse associated with ventricular septal defect

Frequency of Development of Aortic Valve Disease in Unrepaired Perimembranous Ventricular Septal Defects

We sought to determine the natural history of aortic valve disease in patients with unrepaired perimembranous ventricular septal defects (pVSDs) and to identify echocardiographic parameters predictive of increased risk of surgical repair of pVSD because of aortic valve disease. We retrospectively analyzed all echocardiograms of patients with a diagnosis of pVSD at our institution from January 1999 to January 2015. All available echocardiographic data were collected. Patients were excluded if there was another structural cardiac anomaly other than bicuspid aortic valve, small patent foramen ovale, or ductus arteriosus. The prevalences of aortic valve prolapse and regurgitation, as well as aortic valve disease progression, were determined. A total of 2,114 echocardiograms from 657 patients with unrepaired pVSD were reviewed. Median age at the time of echocardiogram was 1.9 years (interquartile range [IQR] 0.2 to 5.4). Median duration of follow-up was 1.7 years (IQR 0.2 to 7.4). pVSD-associated aortic valve disease prompted surgical intervention in 1.5% (10 of 657) of patients. Median age at the time of surgery was 4.8 years (IQR 1.7 to 8.4). A pVSD-to-aortic annulus diameter ratio of 0.66 ± 0.05 was present in 90% (9 of 10) of patients who underwent surgical closure because of pVSD-associated aortic valve disease. In conclusion, pVSD-associated aortic valve disease is uncommon, and progression of aortic regurgitation is rare. These data suggest that the majority of patients with pVSD do not require frequent follow-up and that frequent follow-up can be saved for a subset with echocardiographic markers placing them at higher risk of aortic valve diseases.

Prevalence and development of additional cardiac abnormalities in 1448 patients with congenital ventricular septal defects

OBJECTIVE

To determine by modern echocardiographic techniques the prevalence and development of cardiac abnormalities associated with ventricular septal defect (VSD).

METHODS

Consecutive patients referred to a tertiary centre for paediatric cardiology and attenders at an adult congenital heart disease clinic had details of clinical outcome prospectively recorded. Patients with VSD in association with conotruncal abnormalities, atrioventricular septal defects, and univentricular heart were not included in the study.

RESULTS

1448 patients with VSD were assessed between 1991 and 1998. 1127 (78%) patients had isolated defects; of these 862 (76%) were perimembranous and 265 (24%) were muscular. Of the remainder, 284 (19.6% of the total population) patients had VSD associated with one other significant cardiac abnormality: 35 (2.4%) with two and two (0.1%) with three other abnormalities. The most common associated cardiac abnormalities were infundibular pulmonary stenosis (5.8%), aortic valve prolapse (3.6%), pulmonary valvar stenosis (2.7%), osteum secundum atrial septal defect (2.2%), persistent ductus arteriosus (1.9%), and coarctation of the aorta (1.5%). In the cohort of 743 patients followed up from birth, cumulative mortality was 4% by the age of 8 years and most deaths occurred within the first year of life in infants with associated genetic abnormalities such as trisomy 13 or 18. Of the 594 patients attending the adult congenital clinic with VSD, aortic regurgitation due to aortic root prolapse developed in 45 (7.6%) patients. Most of these cases were detected before the patient was 30 years old.

CONCLUSIONS

In 22% of patients with congenital VSD there were significant associated cardiac abnormalities. Some of these abnormalities, such as aortic prolapse and regurgitation or infundibular pulmonary stenosis, may develop or progress subsequently and therefore should be sought during the initial assessment and monitored during follow up. Follow up to the age of 30 years allows the detection of most cases of aortic regurgitation. The prognosis from VSD is excellent and the risk of endocarditis in a population informed of the need for antibiotic prophylaxis is small.

Echocardiographic characteristics of perimembranous ventricular septal defects associated with aortic regurgitation

Development of aortic regurgitation (AR) can complicate an isolated perimembranous ventricular septal defect (VSD). The objective of this study was to identify echocardiographic features of perimembranous VSDs associated with AR. Echocardiograms were evaluated for the presence of aortic cusp override, aortic cusp movement abnormality, and presence of color flow mapping across the ventricular septum in a standard, parasternal long-axis view. Echocardiograms of 26 patients with isolated VSDs were included in the study, 13 had AR and 13 had no evidence of AR. Aortic cusp override in the apical 5-chamber and subcostal coronal views were correlated with the presence of AR, with high sensitivity and low specificity. Flow across the septum in the parasternal long-axis view was associated with AR, with moderate sensitivity and specificity. Aortic cusp movement abnormalities had high sensitivity and low specificity. Our data indicate that these findings may identify patients with perimembranous VSD susceptible to AR.

An unusual cause of diastolic mitral regurgitation as a result of sterile perforation of the mitral valve

We report the case of a 50-year-old man in whom a supracristal ventricular septal defect led to aortic regurgitation and, thus, to consecutive sterile perforation of the anterior mitral leaflet, culminating in the development of severe systolic and diastolic mitral regurgitation. Aortic regurgitation as a result of valve prolapse caused by a supracristal (conal) ventricular septal defect is a well-known phenomenon. The same is true for the origin of mitral jet lesions in patients with infective endocarditis of the aortic valve. As of yet, there have been no reports about the acquisition of mitral valve perforations in patients without the history of vegetations. Moreover, the occurrence of diastolic mitral regurgitation is usually associated with atrioventricular pressure reversal, a phenomenon that was not present in our patient. The unique comorbidity was easy to detect with Doppler echocardiography, supported by transesophageal 2-dimensional and dynamic 3-dimensional echocardiography for preoperative surgical treatment.

[Aortic valve complications associated with subarterial infundibular ventricular septal defect. Echocardiograpic follow-up]

INTRODUCTION AND OBJECTIVES

Interventricular fibromuscular septal defects of the outlet tract are subarterial infundibular ventricular septal defects (VSDs). This anatomical situation predisposes to aortic cusp prolapse (AoP) and/or regurgitation (AoR).

METHODS

In order to determinate the frequency of VSDs and the presence or development of aortic valve alterations detected by two-dimensional echocardiography, we studied 35 patients with VSDs. The defect area and presence, severity, and evolution of AoP and/or AoR were evaluated. Ten anatomic specimens were studied to verify the echocardiographic correlation.

RESULTS

Subarterial infundibular defect was present in 6.9% of all ventricular septal defects. The average age at time of diagnosis was 5,8 years. VSDs diameter and gradient did not change during follow-up. At time of diagnosis, 30 patients (87%) did not have AoR, but during an average follow-up of 8 years, 11 (32%) developed it. By the end of the study, 46% had AoR. When the time to progression of AoR was compared in the group that developed it versus the group that did not, the median values were similar in both groups. There was a greater tendency to development and/or progression of regurgitation in small VSDs. The echo-anatomic correlation was precise.

CONCLUSIONS

Aortic valve damage was a frequent finding in VSD. Most cases did not progress to more severe AoR. Small VSDs developed more severe regurgitation in less time. Surgery must be considered when AoR is detected. Regular evaluation by echocardiography is important in follow-up.

Evolution of aortic regurgitation following simple patch closure of doubly committed subarterial ventricular septal defect

We reviewed the Doppler echocardiographic findings of the aortic valve and associated aortic regurgitation (AR) in 55 patients who underwent patch closure of doubly committed subarterial ventricular septal defect (VSD). The maximal diameter of the VSD measured > or = 5 mm, whereas the postoperative follow-up interval was > or = 5 years. Twenty-three patients underwent closure before they developed aortic cusp prolapse or AR (group A). In 15 patients the VSD was closed when aortic cusp prolapse was recognized, but AR was absent (group B). Aortic cusp prolapse with AR was detected before closure in a further 15 patients (group C). Of 8 patients with no AR before closure, AR was detected during follow-up in 6 group A and in 2 group B patients. In group C, AR resolved after surgery in 4 patients, whereas AR grade improved in a further 8 patients and remained unchanged in 3. Although residual AR was more frequent in patients with aortic cusp prolapse and AR before closure, it was silent and asymptomatic.

Considerations in the surgical management of ventricular septal defect and aortic insufficiency--a case report

A 23-year-old man presented with progressive exercise-related dyspnea and easy fatigability. He gave a history of a murmur of aortic insufficiency since childhood. Cardiac catheterization demonstrated severe aortic insufficiency. At surgery the patient was found to have prolapse of the right coronary cusp into a significant supracristal ventricular septal defect. Repair was carried out with a Dacron patch closure of the septal defect and replacement of the valve with a 29-mm St. Jude valve. The patient recovered uneventfully and is fully active and employed 5 years later. Review of the literature documents that this is an uncommon lesion. The approaches to preoperative diagnosis include transesophageal echo. The management techniques have included ventricular septal defect closure, alone and with valvuloplasty, and septal defect closure with aortic valve replacement. The anatomic and patient characteristics guide selection of the most suitable management of these patients.

Aortic valve prolapse and aortic regurgitation associated with subpulmonic ventricular septal defect

The natural development of aortic valve deformity was studied in 315 patients with subpulmonic ventricular septal defect. The patients with early development of aortic regurgitation had a pulmonary-to-systemic flow ratio of > 1.5, normal right ventricular pressure, and severe aortic regurgitation.

Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilatation of the sinus of Valsalva, and ventricular septal defect

BACKGROUND

Although the syndrome of ventricular septal defect and aortic regurgitation was described a long time ago, there is still no agreement about the anatomic and functional components of the syndrome and the optimal methods of management.

OBJECTIVE

Our objective was to describe a new simple technique of anatomic correction of all the components of the syndrome, based on redefining the salient anatomic and functional features of the syndrome.

METHODS

Anatomic correction of the syndrome is achieved through a transaortic approach with the placement of a series of pledget-supported mattress sutures using autogenous pericardium. The sutures are used to close the ventricular septal defect, plicate the aortic sinus, and correct the outward and downward displacement of the anulus of the aortic valve. The technique is designed to correct all the anatomic functional components including severe aortic regurgitation when present.

RESULTS

Between 1972 and 1996, 46 patients with this syndrome underwent surgical treatment. The current technique was used in most of the patients operated on before 1981 and in all patients since that date. There were no early or late deaths during a follow-up period varying from 3 months to 24 years (mean 8.4 years). Aortic regurgitation was abolished in 16 and improved in the remaining patients, The hemodynamic results have been maintained except in five patients operated on early in the series, in whom additional procedures on the cusps were performed.

CONCLUSIONS

Anatomic correction of all the components of the syndrome of prolapsing right coronary cusp, dilatation of the sinus of Valsalva, and ventricular septal defect, can be achieved by a very simple technique. This technique can be applied in young children and prevents progression and secondary changes. Early correction in all patients with this syndrome is warranted.

Noninvasive Evaluation of Aortic Valve Anatomy

Although aortic valve anatomy is three-dimensionally complex, careful echocardiographic investigation can yield surgically relevant information. The promise of intravascular and transesophageal imaging is in yielding the raw data of sufficient resolution to make the three-dimensional reconstruction clinically meaningful. (ECHOCARDIOGRAPHY, Volume 13, May 1996)

Implication of anterior septal malalignment in isolated ventricular septal defect

OBJECTIVE

The aim was to define the long term prognosis of isolated ventricular septal defect (VSD) with anteriorly malaligned outlet septum.

DESIGN

Cohort study.

SETTING

University hospital, tertiary medical care centre.

PATIENTS

Between July 1986 and June 1993, 63 patients were studied with an isolated VSD and anteriorly malaligned outlet septum (59 perimembranous; 4 muscular outlet).

MAIN OUTCOME MEASURES

The diagnosis of septal malalignment, aneurysmal transformation, right ventricular obstruction, subaortic ridge, and aortic valve prolapse was based on echocardiographic criteria, then confirmed by angiography in 33 patients and by surgery in 28. An actuarial curve for each event was obtained by Kaplan-Meier non-parametric analysis and the significance was examined by log-rank test.

RESULTS

Aneurysmal transformation decreased the size of the VSD in 52% of the patients, but was also associated with the appearance of subaortic ridge (p < 0.05). Progressive obstruction in the right ventricle was observed in 51%, more often in those without aneurysmal transformation (p < 0.05). Aortic valve prolapse was quite common whether or not aneurysmal transformation occurred (33% and 23%, respectively). This was attributed to the location of the VSD and the anterior malalignment of the outlet septum. Surgery was performed in 28 patients at a median age of 50 months because of significant left to right shunt (n = 5), or the development of obstruction in right ventricle (n = 9), aortic valve prolapse (n = 3), or combinations (n = 11). The presence of subaortic ridge per se was not considered to be a surgical indication.

CONCLUSIONS

Anteriorly malaligned VSDs have variable presentation. Careful echocardiographic evaluation is needed to identify various combinations of progressive right ventricular obstruction, aneurysmal transformation, subaortic ridge, or aortic valve prolapse. In extreme cases a patient may have a pathology complex comprising right ventricular outflow obstruction, subaortic ridge, aortic valve prolapse, and anteriorly malaligned VSD.

Echocardiographic evaluation of the development of aortic valve prolapse in supracristal ventricular septal defect

The development and timing of aortic valve prolapse (AoVP) and aortic regurgitation (AR) was studied by two-dimensional echocardiography in 99 consecutive patients with supracristal ventricular septal defect (VSD). Thirty patients (30%) had aortic valve prolapse (VSD + AoVP group), and 31 patients (31%) had AoVP with AR (VSD + AoVP + AR group). In the VSD + AoVP group, AoVP was detected first by echocardiography at the age of 6.8 +/- 4.2 years (mean +/- SD). In the VSD + AoVP + AR group, the interval from detection of AoVP to the appearance of AR was 3.4 +/- 2.0 years. The configuration of the prolapsed aortic valve was echocardiographically classified into two types: tear-drop type (small) prolapse and box type (large) prolapse. The frequency of tear-drop type prolapse was not significantly different between VSD + AoVP and VSD + AoVP + AR groups (43% versus 32%, respectively), indicating that even minor AoVP can result in AR. Four infants (4%) had AoVP at the ages of 1, 5, 7, and 11 months, respectively. All infants had tear-drop type prolapse. Two infants developed AR by colour flow mapping at the ages of 3 and 11 months, and the interval from prolapse to AR was only 2 and 4 months, respectively.

CONCLUSION

Aortic valce involvement can develop under the age of 1 year in supracristal VSD. Regular evaluation by two-dimensional echocardiography with colour flow mapping is important in the follow-up of children with supracristal VSD.

Doppler echocardiographic evaluation of ventricular septal defects in adults

Ventricular septal defects account for 10% to 15% of all congenital heart defects observed in adults. The type of defects observed tend to fall at the extreme ends of the spectrum: small restrictive defects with minimal shunts, and large nonrestrictive defects associated with severe occlusive pulmonary vascular disease. Doppler echocardiography has evolved into a powerful diagnostic modality that comprehensively evaluates the anatomical and pathophysiological consequences of a ventricular septal defect. The spectrum of findings caused by ventricular septal defects is the subject of this review.

Aortic valve prolapse with aortic regurgitation assessed by Doppler color-flow echocardiography

The incidence of and the Doppler color-flow echocardiographic characteristics of aortic valve prolapse with nonrheumatic aortic regurgitation were examined. Aortic valve prolapse was observed in 21 of 243 patients (15 men and 6 women) with aortic regurgitation as detected by Doppler color-flow echocardiography (rheumatic, 112; nonrheumatic, 131) in 1247 consecutive patients. Patients with aortic valve prolapse included three patients with essential hypertension and one with annuloaortic ectasia. The remaining 17 patients (7% of those with aortic regurgitation) had no other associated cardiovascular disease (idiopathic aortic valve prolapse). Prolapse of the mitral or the tricuspid valve or both was associated with aortic valve prolapse in seven patients. Aortic regurgitation jet was markedly deviated from the axis of left ventricular outflow tract toward the anterior mitral leaflet or the interventricular septum in 17 of 21 (81%) patients with aortic valve prolapse, whereas 28 of 110 (25%) patients with nonrheumatic aortic regurgitation without prolapse and 17 of 112 (15%) patients with rheumatic aortic regurgitation without prolapse showed the deviation of regurgitant jet (p < 0.001). In conclusion, idiopathic aortic valve prolapse is one of the significant causes of aortic regurgitation, and a marked deviation of regurgitant jet is a characteristic Doppler color-flow echocardiographic finding of aortic regurgitation that results from aortic valve prolapse.

Doubly committed subarterial ventricular septal defects: echocardiographic features and surgical implications

Doubly committed subarterial (supracristal, subpulmonary) ventricular septal defects are often complicated by aortic regurgitation resulting from aortic valve herniation into the defect. The clinical, echocardiographic and catheterization findings in 48 patients aged 0.3 to 46.4 years (median 9.5) with a doubly committed subarterial ventricular septal defect were reviewed. Aortic valve herniation was present in 38 (79%) and 55% of these had aortic regurgitation. The prevalence of both findings increased gradually with advancing age. The defect was closed surgically in 41 patients. Surgery during the first 2 years of life (median 0.4 year) was performed in 13 patients (group I), mainly because of a large shunt with a pulmonary to systemic flow ratio (Qp/Qs) 3.8 +/- 1.4 (mean +/- SD). Aortic regurgitation was present preoperatively in two patients (15%), persisted postoperatively in one patient and did not develop in any after repair (median duration of follow-up 2.3 years, range 0.1 to 7.4). In the other 28 patients (group II) surgery was performed between 4.8 and 46.4 years of age (median 11.5). These patients were generally less symptomatic and had a smaller shunt (Qp/Qs 1.5 +/- 0.5, p less than 0.001). Preoperative aortic regurgitation was present in 18 (64%). It persisted in 15 postoperatively, but in 13 of these it had diminished. Two-dimensional echocardiography in multiple views identified the site of the ventricular septal defect in all patients. Serial echocardiographic examinations demonstrated the progressive nature of aortic valve herniation, the partial occlusion of the defect by the herniated sinus and the development of aortic regurgitation. These findings suggest that timely surgical closure of these defects may prevent aortic regurgitation.

Doubly committed subarterial ventricular septal defect: new morphological criteria with echocardiographic and angiocardiographic correlation

To gain a better understanding of the anatomy of doubly committed subarterial defects and its relation to findings at cross sectional echocardiography and angiocardiography, eight necropsy specimens from patients with this condition were examined, and preoperative echocardiograms and angiocardiograms from 313 patients with surgically or necropsy confirmed outlet defect were reviewed. Of these, 48 had doubly committed subarterial defects. Morphological review showed that doubly committed defects are roofed by the arterial valves in fibrous continuity because of lack of both the outlet septum and the "septal" aspect of the subpulmonary infundibulum. Angiocardiography had a lower sensitivity (50%) than echocardiography (95%) for diagnosis of doubly committed defects, but each was highly specific. In five (14%) of 35 available echocardiograms the arterial valves were normally offset, but in the remainder they were at the same level. The ventriculoarterial connection was concordant in 37/48 (77%), discordant in five (10%) of 48, and double outlet right ventricle in six (13%) of 48. Displacement of the fibrous raphe between the arterial valves in relation to the ventricular septum below was associated with outflow obstruction in 14 patients (pulmonary in nine and aortic in five). These features were readily identified by echocardiography. Thus echocardiography is not only a more accurate method than angiocardiography of recognising these defects, but also shows that the arterial pole of the heart is architecturally abnormal.