SEGMENTAL ANALYSIS of cardiac defects ppt

SEGMENTAL ANALYSIS

1. SEGMENTAL ANALYSIS

2. The “segmental approach a flexible and easy to understand complex hearts based on morphology of each of the three segments (atria, ventricles, great arteries) and the two connecting segments (AV canal and infundibulum or conus),

3. Sequential Segmental Approach Identify situs of the thoraco-abdominal organs. Determine cardiac position within thorax. Atrial Situs. Ventricular Situs. Atrioventricular connection and alignment. Ventriculo -arterial connection and alignment. Conal (infundibular) anatomy. Relationship between the great arteries. Description of associated malformations

4. Visceroatrial Situs Situs : position or arrangement of structures or organs that are not bilaterally symmetric. Solitus : Normal Inversus : mirror image of normal Thoracic Situs: The right main bronchus take a more vertical course and branches at an earlier point than the more horizontally oriented left bronchus. The morphologically left bronchus is long, and it branches only after it has been crossed by its accompanying pulmonary artery, making the bronchus hyparterial.

5. Situs Inversus Situs Solitus Situs A mbiguous

6. RIGHT ISOMERISM LEFT ISOMERISM Bilateral morphologic right atria Bilateral morphologic left atria Bilateral trilobed lungs Bilateral bilobed lungs Symmetric liver Interrupted inferior vena cava Partial anomalous pulmonary venous return Partial anomalous pulmonary venous return Asplenia Polysplenia

7. CARDIAC POSITION AND ORIENTATION Position of the heart in the chest with regard to its location and orientation of its apex. Location of heart in the chest Levoposition : to the left Mesoposition : central Dextroposition : to the right Cardiac orientation is the base to apex orientation of heart Levocardia : apex directed to left of midline. Mesocardia : apex oriented inferiorly in the midline Dextrocardia: apex directed to right of midline.

8. ATRIAL MORPHOLOGY The right & left atria are identified morphologically by their respective atrial appendages and veins emptying into them RIGHT ATRIUM Triangular, broad based, anterior appendage . Receives IVC, SVC & coronary sinus. Septum secundum (limbus of fossa ovalis) lies on RA side. Pectinate muscles extend to av junction Crista Terminalis is in RA. LEFT ATRIUM Narrow, fingerlike posterior appendage . LA receives all 4 pulmonary veins Septum primum lies on LA side. Pectinate muscles do not extend to av junction LA is smooth with fewer trabeculations

9. A: The right atrial appendage (RAA) is broad-based and is best seen in the subcostal plane and, as shown here, in the parasternal long view swept rightward. B: The left atrial appendage (LAA) is long and thin and is best seen in the parasternal axis view.

10. Pulmonary veins to LA

11. VENTRICULAR LOOPING

12. D Loop L Loop

13. VENTRICLE MORPHOLOGY LEFT VENTRICLE Small apical trabeculations Smooth upper surface No moderator band More basal septal attachment of av valve No Chordal attachment to the IVS Mitral – Aortic continuity RIGHT VENTRICLE Large apical trabeculations Coarse septal surface Moderator bands More apical attachment of av valve Chordal attachment of IVS Tricuspid – pulmonary discontinuity Crescentic in cross section

14. ATRIO-VENTRICULAR CONNECTION Concordant (normal) Discordant; RA to the morphologic LV, LA into the morphologic RV Ambiguous : Half atrioventricular junction, concordant, half, discordant Absent connection Double-inlet

15. A-V connection in functionally univentricular hearts Double inlet: Functionally univentricle connected to two seperate atria with two seperate atrioventricular valves. Single inlet: Two separate atria with only one of the atria connected to the functional univentricle via one atrioventricular valve. The other atria connection is atretic Common inlet: Both atria are connected to a functional univentricle via one atrioventricular valve. Straddling ; is a feature of the chordae tendineae of an atrioventricular valve and describes chordae that cross a ventricular septal defect and have their attachments in the opposite ventricle. Overriding ; is the feature of the wall annulus which describes the annulus that crosses a ventricular septal defect and thus lies “over” more than one ventricle.

16. Potential atrioventricular connections

17. Univentricular AV connections Absent LEFT AV connection Absent RIGHT AV connection Double inlet : RV Morphology Double inlet : LV Morphology

18. GREAT ARTERIES Relative position of semilunar valves to eachother at the heart There are 6 possibilities Solitus : usual, AoV IS rightwards and posterior to PV Inversus: AoV is leftwards and posterior to the PV D-malposition: AoV is rightwards and anterior to the PV L-malposition: AoV is leftwards and anterior to the PV Anterior : AoV is directly anterior to the PV Posterior : AoV is directly posterior to the PV

19. Potential ventriculoarterial connections

20. Subpulmonary : Absence of subaortic infundibular free wall, found in normal heart. Subaortic : Absence of subpulmonary infundibular free wall, found in D-loop TGA. Bilaterally present : In double outlet RV , but rarely in TGA. Bilaterally Absent : In double outlet LV. Conus - The conus (or infundibulum) is the space formed by the muscular segment of the heart that connects the ventricles with the great arteries and a lows separation between the atrioventricular and semilunar valves.

21. Conal morphology A: Subpulmonic (usually leading to a normal ventriculoarterial relationship). B: Subaortic (usually leading to transposition of the great vessels). C: Bilateral (usually leading to double-outlet right ventricle). D: Bilaterally absent.

22. Nomenclature for Ventriculoarterial relation Concordant (normal) Ventricular septal defect Discordant Transposition Double outlet ventricle With subaortic VSD subpulmonary VSD doubly committed VSD non-committed VSD Common arterial trunk Ventriculoarterial Overriding : more than half of the area of the outlet overrides the ventricular septum.

23. MORPHOLOGICAL DIFFERENTIATION OF ATRIUM. Atrial Morphology The right & left atria are identified morphologically by their respective atrial appendages and veins emptying into them. Right Atrium ∙ Triangular, broad based, anterior appendage . ∙ Receives IVC, SVC & coronary sinus. ∙ Septum secundum ( limbus of fossa ovale ) lies on RA side. ∙ Crista Terminalis is in RA. Left Atrium ∙ Narrow, fingerlike posterior appendage . ∙ LA receives all 4 pulmonary veins ∙ Septum primum lies on LA side . ∙ LA is smooth with fewer trabeculations

24. Pulmonary veins to LA

25. Limbus of Fossa Ovalis Morphological right atrium Has the limbus of fossa ovalis Morphological Left atrium Has the flap valve of fossa ovalis

26. MORPHOLOGICAL RIGHT ATRIUM LA RA ↖ Eustachian valve MORPHOLOGICAL RIGHT ATRIUM Receives insertion of the Eustachian valve IVC drains into it Coronary sinus drains into it

27. Right atrial appendage short and stout Left atrial appendage Long & finger-like

28. VENTRICLES Morphological Right ventricle ∙ Prominent muscle bundles crossing from septum to free wall (Largest is moderator band). ∙ Septal surface receives chordal insertions from the tricuspid valve septal leaflet. ∙ Muscular outflow tract. Morphological Left ventricle ∙ Smooth Septal surface. ∙ No septal insertion of mitral valve chordae . ∙ Mitral-aortic continuity.

29. Aorto -mitral continuity Systole Diastole

30. ATRIOVENTRICULAR VALVE always belongs to the appropriate ventricle Tricuspid valve  Belongs to RV ∙ Is closer to apex ∙ Has 3 leaflets, 3 papillary muscles ∙ Has chordal insertions onto septum Mitral valve  Belongs to LV ● Is farther from apex ● Is fishmouth / bicuspid ● Inserts onto 2 papillary muscles in LV

31. RV Morphology ∙ Large apical trabeculations ∙ Coarse septal surface ∙ Moderator bands ∙ Cresentic in cross section ∙ Tricuspid – pulmonary discontinuity

32. LV Morphology ∙ Small apical trabeculations ∙ Smooth upper surface ∙ No moderator band ∙ Mitral – Aortic continuity

33. AORTIC VALVE ∙ Location : The aortic valve is situated between the  left ventricle  and the  aorta . ∙ The  pulmonary valve  is to the right and in front of the aortic valve. ∙ Three semilunar cusps: Right coronary (right semilunar ), left coronary (left semilunar ), and a non-coronary cusp (posterior semilunar ). ∙ No associated papillary muscles. ∙ Aortic sinuses give rise to left and right main coronary arteries

34. Left Coronary Artery (LCA) : Origin : Arises from the aorta within the left cusp of the aortic valve. Branches : Left Anterior Descending (LAD) Artery :  Left Circumflex Artery(LCX) Posterior Descending Artery Ramus intermedius Right Coronary Artery (RCA) : Origin : Emerges from the right cusp of the aortic valve. Course : Travels down the right coronary sulcus toward the heart’s crux. Branches : Right Marginal Arteries Posterior Descending Artery Conus artery.

35. RCA

36. PULMONARY VALVE Location : ∙ The pulmonary valve is situated at the base of the  pulmonary trunk , just above the  infundibulum . ∙ It guards the outflow of blood from LCX the  right ventricle  into the pulmonary trunk. Structure : Composed of a  fibrous ring , the pulmonary valve has  three semilunar leaflets  (or cusps) ∙ Right cusp ∙ Left cusp ∙ Anterior cusp  

37. ∙The major difference between aortic and pulmonary valve is aortic valve giving rise to arch of aorta. ∙ The coronary sinus sometimes arise from the pulmonary artery in ALCAPA. Likely LAD arise from the aorta and RCA arises from pulmonary artery or vice versa. ∙ The aortic valve sometimes gives rise to the branch of PA. So bifurcation cannot be the feature of Pulmonic valve. ∙ Always aortic valve gives rise to arch of aorta. No possibility of pulmonary artery give rise to arch of aorta and branch vessels. RCA

38. standard approach for the echocardiographeR Usual atrial arrangement, atrioventricular and ventric­uloarterial concordance. Pulsatile abdominal aorta. IVC/SVC to right atrium. Four pulmonary veins to left atrium. Competent mitral and tricuspid valves with no stenosis. Good biventricular systolic function. No left or right ventricular outflow tract obstruction. Competent aortic and pulmonary valves. Usual coronary artery origins. Unobstructed branch pulmonary arteries. Unobstructed left-sided aortic arch with a normal branching pattern. No ASD/VSD/PDA .

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