Atrioventricular Canal (Septal) Defects. Norman H Silverman MD. D Sc (Med),FACC, FAHA
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1 Atrioventricular Canal (Septal) Defects Norman H Silverman MD. D Sc (Med),FACC, FAHA
2 Embryology of the A-V Canal Looping NHS. Formation of the Atrial Septum
3 Embryology of the A-V Canal NHS. Development of the A-V Canal Cono-ventricular development
4 Moorman and Anderson
5
6 Pathology of AVSD PA The Atrioventricular Junction is Common in all cases of AV Canal Defects AO Courtesy of Robert Anderson The aorta is "Sprung" out of its usual position because of the common AV Junction. NHS. ML SBL IBL CS Ant.TL IL
7 Separate valvar orifices For RV & LV Features of AV Canal Courtesy of Diane Spicer.
8 Features of AV Canal The phenotypic feature is the common atrioventricular junction Courtesy of Diane Spicer.
9 Features of AV Canal The phenotypic feature is the common atrioventricular junction Courtesy of Diane Spicer.
10 The Gooseneck Deformity Inlet-outlet disproportion is a feature of all AV Canal Defecgts
11 Cleft Valve and Papillary Muscle Position As papillary muscles support commisures
12 Goals of Ultrasound 1. Define the extent of the atrial communication. 2. Define the type and extent of the ventricular communications. 3. Demonstrate the valve morphology attachments and function. 4. Display the shunting patterns, the magnitude of the shunt. 5. Type of atrioventricular valve regurgitation, magnitude position and direction. 6. Assess the commitment of the atrioventricular junction to the underlying ventricular mass and the size of the underlying ventricle (balance). 7. Recognize associated anomalies.
13 Type C AVSD - UCSF
14 Mayo Clinic Drawings Rastelli A Rastelli B Rastelli C
15 AVSD Concept by Echo
16 Rastelli Classification- AVSD B A C
17 Rastelli Type A PA LV RV Subcostal Oblique
18 Rastelli Type C AO PA LV RV Subcostal Oblique
19 LV Outflow Obstruction
20 The Gooseneck Deformity
21 AV Septal Defect 3-D Left Side
22 AV Septal Defect 3-D Right Side
23 3 D Zoom Technique
24 TYPE A, AVSD: A V Valvar Regurgitation ASD2 ASD1 RA LA A 4 Ch. RV LV PV
25 AVSD Type C : AV valve regurgitation RA LA RV LV A 4 Ch.
26 Entrainment
27 Left Ventricular -Right Atrial Shunt
28 Atrioventricular Septal Defects: Left AV Valvar Leakage
29 Atrioventricular Septal Defects:Associations- Sub AS
30 Ostium Primum ASD. (Same Patient)
31 Ostium Primum ASD.
32 The connecting tongue and the Partial Canal
33 Partial Atrioventricular Septal Defects:Associations - The Tricuspid Pouch Lesion
34 Atrioventricular Septal Defects:Associations - The Tricuspid Pouch Lesion
35 Cleft in the Left Atrioventricular Valve
36 NHS. The So-Called Cleft Mitral Valve
37 The so-called Cleft Mitral Valve
38 Left Atrioventricular Valve & Regurgitation 3D Normal Mitral Valve 3D Cleft Left Atrioventricular Valve Surgical View of Cleft Courtesy of Jeff. Smallhorn
39 New Contributions of 3 D Echocardiography.
40 The So-called Cleft Mitral Valve
41 3 D Zoom Technique
42 Single papillary muscle as a risk factor
43 Single left ventricular papillary muscle Parachute MV RV LV Subcostal Sagittal View
44 Isolated ventricular component of an AVSD
45 Isolated ventricular component of an AVSD
46 Isolated ventricular component of an AVSD
47 Isolated ventricular component of an AVSD
48 AVSD :Secundum ASD Type A. AVSD LA RA LV RV Subcostal Coronal
49 AVSD: Parasternal Short Axis of VSD VSD RV PA RA LA AO
50 Atrioventricular Septal Defects: Associations- DORV
51 Atrioventricular Septal Defects:Associations- Tetralogy of Fallot
52 Dextrocardia, Right Isomerism and R Dom. AVSD ASD2 ASD1 RA LA RV LV R Apex
53 Type A AVSD. Left Isomerism A MRV MLV Apex Rt
54 Unbalanced Atrioventricular Septal Defects
55 Left Dominant AVSD When is the right ventricle too small? This is less clear than for right ventricular dominance. Options include: cheating on the patch a one and a half ventricle repair single ventricle repair
56 Atrioventricular Septal Defects:Right Dominant Associations
57 Atrioventricular Septal Defects:Right Dominant Associations
58 Left Dominant AVSD
59 L Dominant AVSD RA LA EFF RV LV
60 Unbalanced Atrioventricular Canal Defects Repair related to:- Size of the ventricle Volume Length Size of the amount of tissue over the valve Area Quality of the valvar tissue The presence of associated defects Outflow tract Vascular abnormalities NHS.
61 Philosophy for Repair of Unbalanced AVSD s Relative advantages of a one vs. a two ventricle repair. Is a prosthetic valve worse or better than a one ventricle repair. Are there extraneous factors which would prevent a two ventricle repair.
62 Left Dominant AVSD When is the right ventricle too small? This is less clear than for right ventricular dominance. Options include: cheating on the patch a one and a half ventricle repair single ventricle repair
63 R. DOM. AVSD ( L. ISOMERISM) RA LA CS RV A 4 Ch. (L) LV
64 Left Isomerism, AVSD, (Rt. Dom.) PA AVVO LV RV
65 NHS. Questionable LV Size? Cor Triatriatum
66 Short axis change pre- and postop. TAPVR
67 Preoperative/postoperative echo in unbalanced Van Son & Phoon
68 Indexed LVEDV= 14.8±9.1 ml /m 2 Potential Indexed LV EDV= 32.2±18.8 Dimension Measurements Van Son & Phoon Indexed LV long axis dimension =8.9±1.4 cm/m 2 RV/LV Long axis ratio= 0.65±0.1 L AV Valve/Total Valve Ratio = 0.30±0.06 LV/RV Area Ratio= 0.27±0.01 NHS.
69 Postoperative echocardiographic dimensions Postoperative dimensions LV EDV Index 35.6± 3.9 ml. /m 2 LV/RV long ratio 0.88±0.11 L AV Valve / total Valve ratio = 0.42± 0.03 LV/RV area ratio= 0.88 ± 0.18 /m 2 Van Son, Phoon et al. Ann Thorac Surg. 1997;63:1567
70 NHS. LV Volume change real and calculated
71 NHS. Unbalanced AVSD. Cohen et al.
72 Balance :Summary! Balance is a complex issue! Treatment is based on several factors:! morphological factors! direct vs. indirect! surgical preference! philosophical factors! Echocardiography provides one of many determinants! Inspection of the morphology at surgery is the final point of arbitration. NHS
73 Conclusion Balance is a complex issue Treatment is based on several factors: morphological factors direct vs. indirect surgical preference philosophical factors Echocardiography provides one of many determinants Inspection of the morphology at surgery is the final point of arbitration. NHS
74 Postoperative Findings
75 Atrioventricular Septal Defects: Postop. L AV Valve
76 AV Valve Regurgitation- Pre- and Post Op
77 Tetralogy and AVSD ( Type C ): Pre & Post Repair
78 AVSD Postop. Contrast & Color Doppler Studies Subcostal Coronal View DAO RA LA LV RV
79 Postoperative breakdown of left AV valve repair Subcostal coronal view RA LA RV LV
80 Dehisced Sutured Commisure ( Cleft ) P Lax RV LV Cl LA
81 Postop AVVR
82 Postop AVVR
83 NHS. AV Regurgitation & Stenosis
84 NHS. Postoperative Pearls- The AV Septal Defect
85 Annuloplasty
86 Postop AVVR
87 The Normal and Abnormal (Mitral) Annulus Effect of Annular Shape on Leaflet Curvature in Reducing Mitral Leaflet Stress Ivan S. Salgo,
88 Changes in Areal Strain in 3 Shape Valriations.
89 The End
90 .
91 The End
92 Goals of Ultrasound 1. Define the extent of the atrial communication. 2. Define the type and extent of the ventricular communications. 3. Demonstrate the valve morphology attachments and function. 4. Display the shunting patterns, the magnitude of the shunt. 5. Type of atrioventricular valve regurgitation, magnitude position and direction. 6. Assess the commitment of the atrioventricular junction to the underlying ventricular mass and the size of the underlying ventricle (balance). 7. Recognize associated anomalies.
93 Thank You!
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