Ventricular Septal Defect X-ray Findings
Transcript of Ventricular Septal Defect X-ray Findings
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Left to Right Shunts
Left to Right Shunts
William Herring, M.D. © 2002
In Slide Show mode, to advance slides, press spacebaror click left mouse button
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7 yo acyanotic female
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Atrial Septal Defect
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Atrial Septal DefectFour Major Types
Ostium secundum
Ostium primum
Sinus venosus
Posteroinferior
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Atrial Septal DefectGeneral
4:1 ratio of females to males
Most frequent congenital heart lesion initially diagnosed in adult
Frequently associated with Ellis-van Creveld and Holt-Oram syndromes
Associated with prolapsing mitral valve
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Atrial Septal DefectOstium Secundum Type
Most common is ostium secundum (60%) located at fossa ovalis
High association with prolapse of mitral valve
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Normal
Right atrium open looking into left atrium through ASD
© Frank Netter, MD Novartis®
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Atrial Septal DefectOstium Primum Type
Ostium primum type usually part of endocardial cushion defect
Frequently associated with cleft mitral and tricuspid valves
Tends to act like VSD physiologically
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Looking through ostium primum defect at cleft mitral valve
Proximity of ostium primum defect to tricuspid valve
© Frank Netter, MD Novartis®
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Atrial Septal DefectSinus Venosus Type
Sinus venosus type located high in inter-atrial septum
90% association of anomalous drainage of R upper pulmonary vein with SVC or right atrium
Partial anomalous pulmonary venous return
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© Frank Netter, MD Novartis®
Right atrium open looking into left atrium through ASD
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Atrial Septal DefectPosteroinferior Type
Most rare type
Associated with absence of coronary sinus and left SVC emptying into LA
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Atrial Septal DefectPulmonary Hypertension
Rare in ostium secundum variety (<6%)Low pressure shunt from LA RA
More common in ostium primum varietyBehaves physiologically like VSD
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37 yo female with severe PAH 2° ostium primum type of ASD
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Atrial Septal DefectX-Ray Findings
Enlarged pulmonary vessels
Normal-sized left atrium
Normal to small aorta
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Atrial Septal DefectComplications
Large shunts associated withPulmonary infections and cardiac arrythmias
Higher incidence of pericardial disease with ASD than any other CHD
Bacterial endocarditis is rare
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LA Ao
ASD
PDA
VSD
Differentiating ASD, PDA and VSD
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Atrial Septal DefectWhy the Left Atrium Isn’t Enlarged
LARA
RV LV
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1 yo acyanotic female
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Ventricular Septal Ventricular Septal DefectDefect
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Ventricular Septal DefectGeneral
Most common L R shunt
Shunt is actually from left ventricle into pulmonary artery more than into right ventricle
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Ventricular Septal DefectTypes
Membranous
Supracristal
Muscular
AV canal
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Ventricular Septal DefectMembranous
Membranous = perimembranous VSD (75-80%–most common)
Location: Posterior and inferior to crista supraventricularis near right and posterior (=non-coronary) aortic valve cusps
Associated with: small aneurysms of membranous septum
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Right ventricle opened
Cristasupraventrularis
Normal
© Frank Netter, MD Novartis®
Membranous VSD
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Aneurysm of membranous septum
Normal
© Frank Netter, MD Novartis®
© Frank Netter, MD Novartis®
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Ventricular Septal DefectSupracristal
Supracristal = conal VSD (5%–least common)
Crista supraventricularis= inverted U-shaped muscular ridge posterior and inferior to the pulmonic valve high in interventricular septum
On CXR: right aortic valve cusp may herniate aortic insufficiency
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LV open RV open
© Frank Netter, MD Novartis®
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Ventricular Septal DefectMuscular
Muscular VSD (5–10%)
Low and anterior within trabeculationsof muscular septum
May consist of multiple VSDs = “swiss-cheese septum”
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Swiss cheese
© Frank Netter, MD Novartis®
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Ventricular Septal DefectAV Canal
Atrioventricular canal = endocardial cushion type = posterior VSD (5–10%)
Location: adjacent to septal and anterior leaflet of mitral valve
Large VSD pulmonary hypertension, eventually shunt reversalEisenmenger’s physiology
Very large VSD CHF soon after birth
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© Frank Netter, MD Novartis®
Large posterior VSD(AV canal)
© Frank Netter, MD Novartis®
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Ventricular Septal DefectNatural History
Natural history of VSD is affected by two factors:Location of defect
Muscular and perimembranous have high incidence of spontaneous closure
Endocardial cushion defects have low rate of closure
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Ventricular Septal DefectNatural History
Size of the defectLarger the defect, more likely to CHF
Smaller the defect, more likely to be asymptomatic
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Ventricular Septal DefectEisenmenger Physiology
Progressive increase in pulmonary vascular resistance Intimal and medial hyperplasia
Reversal of L R shunt to R L shunt
Cyanosis
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Ventricular Septal DefectClinical Course
Neonates usually asymptomatic because of high pulmonary vascular resistance from birth to 6 weeks
Common cause of CHF in infancy
Bacterial endocarditis may develop
Severe pulmonary hypertension Eisenmenger’s physiology/cyanosis
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Ventricular Septal DefectX-ray Findings
Prominent main pulmonary arteryAdult
Shunt vasculature (increased flow to the lungs)
LA enlargement (80%)
Aorta normal in size
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5 yo acyanotic male
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Ventricular Septal DefectWhy Left Atrium Is Enlarged
LARA
RV LV
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4 mos old acyanotic female
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Ventricular Septal DefectPrognosis
Spontaneous closure occurs in 40% during first 2 years of life
60% by 5 years
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Ventricular Septal DefectIndications For Surgery
Greater than 2:1 shunt, surgery required before pulmonary arterial hypertension develops
CHF unresponsive to medical management
Failure to grow
Supracristal defects because of their high incidence of AI
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8 mos old acyanotic female
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Patent Ductus Patent Ductus ArteriosusArteriosus
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Patent Ductus ArteriosusGeneral
Higher incidence in Trisomy 21
Trisomy 18
Rubella
Preemies
Predominance in females 4:1
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Patent Ductus ArteriosusAnatomy
Ductus connects pulmonary artery to descending aorta just distal to left subclavian artery
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Ductus Arteriosus
© Frank Netter, MD Novartis®
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Ductus ArteriosusPhysiology
In fetal life, shunts blood from pulmonary artery to aorta
At birth, increase in arterial oxygen concentration constriction of ductus
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Ductus ArteriosusNormal Closure
Functional closureBy 24 hrs of life
Normal anatomic closureComplete by 2 months in 90%
Closure at 1 year in 99%
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Patent Ductus ArteriosusPathophysiology
Ductus may persistBecause of defect in muscular wall of ductus, or
Chemical defect in response to oxygen
Anatomic persistence of ductus beyond 4 months is abnormal
Blood is shunted from aorta to pulmonary arteries
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Patent Ductus ArteriosusClinical
Common cause of CHF in premature infantsUsually at age 1 week (after HMD subsides and pulmonary arterial pressure falls)
Wide pulse pressure
Continuous murmur
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Patent Ductus ArteriosusX-ray Findings
Cardiomegaly
Enlarged left atrium
Prominent main pulmonary artery (adult)
Prominent peripheral pulmonary vasculature
Prominence of ascending aorta
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Patent Ductus ArteriosusWhy Left Atrium Is Enlarged
LARA
RV LV
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Patent Ductus ArteriosusCalcifications
Punctate calcification at site of closed ductus is normal finding
Linear or railroad track calcification at site of ductus may be seen in adults with PDA
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Patent Ductus ArteriosusPrognosis
Spontaneous closure may occur
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Patent Ductus ArteriosusComplications
CHF
Failure to grow
Pulmonary infections
Bacterial endocarditis
Eisenmenger’s physiology with advanced lesions
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2 yo old cyanotic female
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Partial or TotalPartial or TotalAnomalous Pulmonary Anomalous Pulmonary
Venous ReturnVenous Return
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Cyanosis With Increased Vascularity
Truncus types I, II, III
TAPVR
Tricuspid atresia*
Transposition*
Single ventricle
* Also appears on DDx of Cyanosis with Inc Vascularity
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Two Types
Partial (PAPVR)Mild physiologic abnormality
Usually asymptomatic
Total (TAPVR)Serious physiologic abnormalities
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Normal heart
Return of blood from lungs is by
four pulmonary veins to LA
RA LA
RV LV
PA Ao
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PAPVRGeneral
One of the four pulmonary veins may drain into right atrium
Mild or no physiologic consequence
Associated with ASDSinus venosus or ostium secundum types
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Partial Anomalous Pulmonary Return
Return of blood from
lungs is mostly to LA
One vein abnormally
connected to right heart
Frequently associated with sinus venosus or secundum ASD
RA LA
RV LV
PA Ao
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TAPVRGeneral
All have shunt through lungs to Ü R side of heart
All must also have R L shunt for survivalObligatory ASD to return blood to the systemic side
All are cyanotic
Identical oxygenation in all four chambers
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TAPVRTypes
Supracardiac
Cardiac
Infracardiac
Mixed
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TAPVRSupracardiac Type—Type I
Most common (52%)
Pulmonary veins drain into vertical vein (behind left pulmonary artery)
left brachiocephalic vein SVC
DDx: VSD with large thymus
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Left Brachiocephalic vein
Left superior vena cava
Right superior vena cava
Vertical vein
Pulmonary veins
© Frank Netter, MD Novartis®
Right atrium
TAPVR-Supracardiac Type 1
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TAPVR-Supracardiac Type 1
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TAPVRSupracardiac Type 1—X-ray Findings
Snowman heart = dilated SVC+ left vertical vein
Shunt vasculature 2° increased return to right heart
Enlargement of right heart 2° volume overload
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TAPVR-Supracardiac Type 1
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RA LA
RV LV
PA Ao
TAPVR–Type I–Supracardiac type
Blood moves through L
brachiocephalic v to R SVC
Blood from lungs drains
into left vertical vein
to L SVC
Increased return to right heart overloads lungs shunt vessels
ASD provides RL shunt to
allow oxygenated blood to reach body (moderate cyanosis)
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TAPVR–Type I–Supracardiac type
“Snowman Heart”
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TAPVRCardiac Type—Type II
Second most common: 30%
Drains into coronary sinus or RACoronary sinus more common
Increased pulmonary vasculature
Overload of RV CHF after birth
20% of I’s and II’s survive to adulthoodRemainder expire in first year
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Coronary sinus
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TAPVR-Coronary Sinus-Type II
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TAPVR–Type II–Cardiac Type
Blood returns from lung to RA
or coronary sinus
ASD provides RL shunt to
allow oxygenated blood to reach body (moderate cyanosis)
Increased return to right heart overloads lungs shunt vessels
RA LA
RV LV
PA Ao
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TAPVRInfracardiac Type—Type III
Percent of total: 12%Long pulmonary veins course down
along esophagusEmpty into IVC or portal vein (more
common)Vein constricted by diaphragm as it
passes through esophageal hiatus
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Pulmonary veinsPortal vein
© Frank Netter, MD Novartis®
TAPVR-Type III-Infradiaphragmatic
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TAPVRInfracardiac Type—Continued
Severe CHF (90%) 2° obstruction to venous return
Cyanotic 2° right Ü left shunt through ASD
Associated with asplenia (80%), or polysplenia
Prognosis=death within a few days
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TAPVR–Type III–Infracardiac type
ASD provides R L shunt to allow oxygenated blood to reach body (cyanotic)
CHF vasculature
RA LA
RV LV
PA Ao
Blood returning from lungs pulmonary veins which are constricted by diaphragm CHF
To portal v IVC RA
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TAPVRMixed Type—Type IV
Percent of total: 6%
Mixtures of types I – III
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Unknowns
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ASD (primum) with PAHASD (primum) with PAH
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TAPVR from below diaphragmTAPVR from below diaphragm
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VSDVSD
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ASDASD
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The End