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Echocardiogram in Atrial Septal Defect
ILLUSTRATIVE ECHOCARDIOGRAMS Echocardiogram in Atrial Septal Defect* Abdul J. Ta;ik, M.D ., Gerald T. Gau, M.D . and Thomas T . Schattenberg, M.D., F.C.C.P.
index (RVD/body surface area) is 0.3 to 1.1 cm/ M2 (mean, 0.7 cm/ M2). The left ventricular internal dimension (LVD) is the vertical distance, measured at end-diastole, between the left septal echo and the endocardial portion of the left ventricular echo. The mean left ventricular internal dimension is 4.5 em (range, 3.5 to 5.3 em ). I The echocardiograrn of this patient (Fig 2 left) reveals two distinct abnormalities. First, both the RVD and the RVD index are increased to 2.9 em and 2.0 cm/M", respectively. Second, the ventricular septal motion is abnormal (paradoxic )-that is, both the left ventricular posterior wall echo and the septal echo move in the same direction during each cardiac cycle. These two findings constitute the typical echocardiographic features of atrial septal defect as described by Diamond et a\.2 However, these features are not pathognomonic of atrial septal defect because similar echocardiographic
The patient is a 42-year-old, essentially asymptomatic woman with known heart murmur since age 16 years . Physical examination revealed moderate right ventricular lift, grade 3/6 ejection systolic murmur along the upper left sternal border, and persistently split second heart sound with accentuated pulmonic component. Chest roentgenogram reveal ed marked prominence of the main pulmonary artery segment with increased pulmonary vasculature. An electrocardiogram revealed right ventricular conduction delay with right axis deviation.
Echocardiogram Figure 1 is a schematic drawing of an echoeardiogram demonstrating normal ventricular septal motion , as first described by Popp and associates. I The septal echo moves anteriorly during diastole; the maximal anterior motion occurs following the P wave of the electrocardiogram. During systole, the septal echo moves posteriorly, the maximal posterior motion occurring at the T wave of the electrocardiogram. Usually, a small notch is seen before the septal echo again moves anteriorly during ventricular diastole. In normal ind ividuals, the left ventricular posterior wall echo and the septal echo move in opposite directions during each cardiac cycle. The right ventricular dim ension (RVD) is the vertical distance, measured at end-diastole, between the right ventricular epicardial echo and the right septal echo. The normal mean value is 1.5 ern (range, 0.5 to 2.1 cm ). I The range of normal RVD o From
RVD IVS
LVD
~
the Mayo Clini c and Mayo Foundation , Rochester,
Minnesota,
Reprint request s: Section of Publications, Rochester, .\ f innesota 55901
LVC
.\ lauo Clinic ,
L PW
FIGURE 1. Diagram of echocardiograrn . Se e Figure 2.
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TAJIK, GAU AND SCHATTENBERG
2. Echocardiogram of patient with atrial septal defect . C\\' = chest wall; A\V = anterior wall; HV = right ventricular wall (the ahhreviations A \V and HV have lx -en used interchangeably) ; HVC = right ventricular cavity; IVS = interventricular septum; left ventricular cavity; LP\V LVC left ventricular posterior wall ; LAW = left atrial wall ; HVD right ventricleft ventricuular dimension; LVD lar internal dimension . FIGURE
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findings have been noted in other conditions which, as in atrial septal defect, also lead to diastolic volume overload of the right ventricle. These conditions include tricuspid insufficiency, " partial anomalous pulmonary venous connection with and without associated atrial septal defect," and total anomalous pulmonary venous drainage." We have now had the opportunity to obtain echocardiograms of 26 patients with atrial septal defects (pediatric as well as adult patients). Our overall results arc in agreement with and support those of Diamond and associates' original report. The mitral valve motion of this patient is completely normal (Fig 2 right). Cardiac catheterization confirmed the diagnosis of the atrial septal defect (secundum) . The pulmonic-to-systemic Bow
ratio (Qp/Qs) was 3.4; pulmonary vascular resistance was normal. REFERE:-:CES
Popp HL, Wolfe 5B, Hirata T, et al : Estimation of right and left ventricular size by ultrasound : a study of the echoes from the interventricular septum. Am J Cardiol 24 :.523-.530, 1969 2 Diamond ~fA , Dillon JC, Haine CL, et al : Echocardiographic features of atrial septal defect. Circulation 43 : 129· 13.5,1971 3 Tajik AJ, Gau GT, Ritter DG, et al : Echocardtographic pattern of right ventricular diastolic volume overload in children. Circulation (in prcss) 4 Tajik AJ, Gau CT, Schattenherg TT : Echocardiogram in total anomalous pulmonary venous drainage : report of case . Mayo Clin Proc 47 :247-2.50, 1972
CHEST, VOL. 62, NO.2, AUGUST 1972
index (RVD/body surface area) is 0.3 to 1.1 cm/ M2 (mean, 0.7 cm/ M2). The left ventricular internal dimension (LVD) is the vertical distance, measured at end-diastole, between the left septal echo and the endocardial portion of the left ventricular echo. The mean left ventricular internal dimension is 4.5 em (range, 3.5 to 5.3 em ). I The echocardiograrn of this patient (Fig 2 left) reveals two distinct abnormalities. First, both the RVD and the RVD index are increased to 2.9 em and 2.0 cm/M", respectively. Second, the ventricular septal motion is abnormal (paradoxic )-that is, both the left ventricular posterior wall echo and the septal echo move in the same direction during each cardiac cycle. These two findings constitute the typical echocardiographic features of atrial septal defect as described by Diamond et a\.2 However, these features are not pathognomonic of atrial septal defect because similar echocardiographic
The patient is a 42-year-old, essentially asymptomatic woman with known heart murmur since age 16 years . Physical examination revealed moderate right ventricular lift, grade 3/6 ejection systolic murmur along the upper left sternal border, and persistently split second heart sound with accentuated pulmonic component. Chest roentgenogram reveal ed marked prominence of the main pulmonary artery segment with increased pulmonary vasculature. An electrocardiogram revealed right ventricular conduction delay with right axis deviation.
Echocardiogram Figure 1 is a schematic drawing of an echoeardiogram demonstrating normal ventricular septal motion , as first described by Popp and associates. I The septal echo moves anteriorly during diastole; the maximal anterior motion occurs following the P wave of the electrocardiogram. During systole, the septal echo moves posteriorly, the maximal posterior motion occurring at the T wave of the electrocardiogram. Usually, a small notch is seen before the septal echo again moves anteriorly during ventricular diastole. In normal ind ividuals, the left ventricular posterior wall echo and the septal echo move in opposite directions during each cardiac cycle. The right ventricular dim ension (RVD) is the vertical distance, measured at end-diastole, between the right ventricular epicardial echo and the right septal echo. The normal mean value is 1.5 ern (range, 0.5 to 2.1 cm ). I The range of normal RVD o From
RVD IVS
LVD
~
the Mayo Clini c and Mayo Foundation , Rochester,
Minnesota,
Reprint request s: Section of Publications, Rochester, .\ f innesota 55901
LVC
.\ lauo Clinic ,
L PW
FIGURE 1. Diagram of echocardiograrn . Se e Figure 2.
213
214
TAJIK, GAU AND SCHATTENBERG
2. Echocardiogram of patient with atrial septal defect . C\\' = chest wall; A\V = anterior wall; HV = right ventricular wall (the ahhreviations A \V and HV have lx -en used interchangeably) ; HVC = right ventricular cavity; IVS = interventricular septum; left ventricular cavity; LP\V LVC left ventricular posterior wall ; LAW = left atrial wall ; HVD right ventricleft ventricuular dimension; LVD lar internal dimension . FIGURE
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findings have been noted in other conditions which, as in atrial septal defect, also lead to diastolic volume overload of the right ventricle. These conditions include tricuspid insufficiency, " partial anomalous pulmonary venous connection with and without associated atrial septal defect," and total anomalous pulmonary venous drainage." We have now had the opportunity to obtain echocardiograms of 26 patients with atrial septal defects (pediatric as well as adult patients). Our overall results arc in agreement with and support those of Diamond and associates' original report. The mitral valve motion of this patient is completely normal (Fig 2 right). Cardiac catheterization confirmed the diagnosis of the atrial septal defect (secundum) . The pulmonic-to-systemic Bow
ratio (Qp/Qs) was 3.4; pulmonary vascular resistance was normal. REFERE:-:CES
Popp HL, Wolfe 5B, Hirata T, et al : Estimation of right and left ventricular size by ultrasound : a study of the echoes from the interventricular septum. Am J Cardiol 24 :.523-.530, 1969 2 Diamond ~fA , Dillon JC, Haine CL, et al : Echocardiographic features of atrial septal defect. Circulation 43 : 129· 13.5,1971 3 Tajik AJ, Gau GT, Ritter DG, et al : Echocardtographic pattern of right ventricular diastolic volume overload in children. Circulation (in prcss) 4 Tajik AJ, Gau CT, Schattenherg TT : Echocardiogram in total anomalous pulmonary venous drainage : report of case . Mayo Clin Proc 47 :247-2.50, 1972
CHEST, VOL. 62, NO.2, AUGUST 1972