Multimodality Imaging of a Gerbode Defect
2012; Lippincott Williams & Wilkins; Volume: 126; Issue: 1 Linguagem: Inglês
10.1161/circulationaha.111.088740
ISSN1524-4539
AutoresNegareh Mousavi, Douglas C. Shook, Niamh Kilcullen, Sary F. Aranki, Raymond Y. Kwong, Michael J. Landzberg, Ron Blankstein,
Tópico(s)Coronary Artery Anomalies
ResumoHomeCirculationVol. 126, No. 1Multimodality Imaging of a Gerbode Defect Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBMultimodality Imaging of a Gerbode Defect Negareh Mousavi, MD, MHSc, Douglas C. Shook, MD, Niamh Kilcullen, MD, Sary Aranki, MD, Raymond Y. Kwong, MD, Michael J. Landzberg, MD and Ron Blankstein, MD Negareh MousaviNegareh Mousavi From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology (N.M., N.K., R.Y.K., R.B.); Department of Anesthesiology (D.C.S.); Division of Cardiac Surgery, Department of Surgery (S.A.); and Boston Adult Congenital Heart Program, Department of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MW. , Douglas C. ShookDouglas C. Shook From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology (N.M., N.K., R.Y.K., R.B.); Department of Anesthesiology (D.C.S.); Division of Cardiac Surgery, Department of Surgery (S.A.); and Boston Adult Congenital Heart Program, Department of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MW. , Niamh KilcullenNiamh Kilcullen From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology (N.M., N.K., R.Y.K., R.B.); Department of Anesthesiology (D.C.S.); Division of Cardiac Surgery, Department of Surgery (S.A.); and Boston Adult Congenital Heart Program, Department of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MW. , Sary ArankiSary Aranki From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology (N.M., N.K., R.Y.K., R.B.); Department of Anesthesiology (D.C.S.); Division of Cardiac Surgery, Department of Surgery (S.A.); and Boston Adult Congenital Heart Program, Department of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MW. , Raymond Y. KwongRaymond Y. Kwong From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology (N.M., N.K., R.Y.K., R.B.); Department of Anesthesiology (D.C.S.); Division of Cardiac Surgery, Department of Surgery (S.A.); and Boston Adult Congenital Heart Program, Department of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MW. , Michael J. LandzbergMichael J. Landzberg From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology (N.M., N.K., R.Y.K., R.B.); Department of Anesthesiology (D.C.S.); Division of Cardiac Surgery, Department of Surgery (S.A.); and Boston Adult Congenital Heart Program, Department of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MW. and Ron BlanksteinRon Blankstein From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology (N.M., N.K., R.Y.K., R.B.); Department of Anesthesiology (D.C.S.); Division of Cardiac Surgery, Department of Surgery (S.A.); and Boston Adult Congenital Heart Program, Department of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MW. Originally published3 Jul 2012https://doi.org/10.1161/CIRCULATIONAHA.111.088740Circulation. 2012;126:e1–e2A 76-year-old woman with a history of aortic valve replacement was referred for echocardiography for routine postoperative evaluation. Transthoracic echocardiogram revealed evidence of an intracardiac shunt between the left ventricle (LV) and the right atrium (RA) (Figure 1A).Download figureDownload PowerPointFigure 1. Illustration of LV-RA shunt by (A) 2-dimensional transthoracic echocardgiography, (B) 2-dimensional transesophageal echocardiography, and (C) 3-dimensional transesophageal echocardiography. LV indicates left ventricle; RA, right atrium; RV, right ventricle; LA, left atrium; TV, tricuspid valve.A transesophageal echocardiogram confirmed the presence of an LV to RA shunt consistent with a Gerbode defect (Figure 1B and 1C). To further define shunt anatomy and to quantify the shunt ratio, cardiac MRI was performed. The cardiac MRI demonstrated abnormal flow from the LV to the RA (Figure 2A and 2B) as well as normal right ventricular size and function. By phase contrast imaging technique, the shunt volume was determined to be 28.4 cc/cardiac cycle corresponding to 2 L/min (Figure 2C). In addition, the pulmonary-to-systemic flow ratio was calculated as 1.7/1.0, consistent with a small to moderate left to right shunt.Download figureDownload PowerPointFigure 2. Cardiac MRI demonstration of the Gerbode defect. ECG-triggered breath-hold steady-state free procession showing the intracardiac shunt (arrow) in (A) short-axis view and (B) 4-chamber view. Through-plane phase contrast imaging of the Gerbode shunt (red circle) (C). LV indicates left ventricle; RA, right atrium; RV, right ventricle; LA, left atrium.In keeping with the current American College of Cardiology/American Heart Association guidelines for ventricular septal defect closure,1 given her normal right and left ventricular size and function as well as the lack of pulmonary hypertension or history of infective endocarditis, it was elected to manage the patient conservatively (with plan to monitor her in the future with serial noninvasive imaging) instead of any operative repair.The Gerbode defect is a type of communication between the LV and the RA. The congenital form of the LV-RA shunt is uncommon and was first classified by Gerbode in 1958.2 Acquired causes secondary to trauma, infective endocarditis and aortic or mitral valve surgery, have been described.3 The magnitude of the shunt is the main predictor of the long-term outcome. Phase-contrast MRI can accurately locate and quantify the severity of the eccentric flow across this septal defect.4This case demonstrates the complementary value of contemporary imaging techniques such as 3-dimensional transesophageal echocardiogram and cardiac MRI to noninvasively assess the anatomy and hemodynamics of intracardiac shunts. The high resolution of transesophageal echocardiogram confirmed the diagnosis and location of the defect. On the other hand, in addition to anatomic visualization, CMR was used to evaluate the shunt volume and fraction as well as the associated impact on right-sided heart function. Importantly, the data provided by these tests had a direct impact on clinical decision making as it was used to defer any surgical or catheter-based intervention.DisclosuresNone.FootnotesGuest Editor for this article was Leon Axel, MD, PhD.Correspondence to Ron Blankstein, MD, 75 Francis Street, Brigham and Women's Hospital, Boston, MA 02115. E-mail [email protected]orgReferences1. Warnes C, Williams R, Bashore T, Child J, Connolly H, Dearani J, Nido P, Fasules J, Graham T, Hijazi Z, Hunt S, King M, Landzberg M, Miner P, Radford M, Walsh E, Webb G. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease. Circulation. 2008; 118: e714– e833.LinkGoogle Scholar2. Gerbode F, Hultgren H, Melrose D, Osborn J. Syndrome of left ventricular-right atrial shunt: successful surgical repair of defect in five cases with observation of bradycardia on closure. Ann Surg. 1958; 148: 433– 436.CrossrefMedlineGoogle Scholar3. Wasserman SM, Fann JI, Atwood JE, Burdon TA, Fadel BM. Acquired left ventricular-right atrial communication: Gerbode-type defect. Echocardiography. 2002; 19: 67– 72.CrossrefMedlineGoogle Scholar4. Srichai MB, Lim RP, Wong S, Lee VS. Cardiovascular applications of phase-contrast MRI. Am J Roentgenol. 2009; 192: 662– 75.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Ting P, Lee K, Chou A and Chen S (2020) Surgical Repair of Acquired Gerbode Defect (Left Ventricle-to-Right Atrium Shunt) Caused by Intramyocardial Dissection After Redo Mitral Valve Replacement, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2020.01.035, 34:6, (1573-1576), Online publication date: 1-Jun-2020. Kretzer A, Amhaz H, Nicoara A, Kendall M, Glower D and Jones M (2018) A Case of Gerbode Ventricular Septal Defect Endocarditis, CASE, 10.1016/j.case.2018.03.005, 2:5, (207-209), Online publication date: 1-Oct-2018. Breatnach C and Walsh K (2018) Ruptured Sinus of Valsalva Aneurysm and Gerbode Defects: Patient and Procedural Selection: the Key to Optimising Outcomes, Current Cardiology Reports, 10.1007/s11886-018-1038-z, 20:10, Online publication date: 1-Oct-2018. Saker E, Bahri G, Montalbano M, Johal J, Graham R, Tardieu G, Loukas M and Tubbs R (2017) Gerbode defect: A comprehensive review of its history, anatomy, embryology, pathophysiology, diagnosis, and treatment, Journal of the Saudi Heart Association, 10.1016/j.jsha.2017.01.006, 29:4, (283-292), Online publication date: 1-Oct-2017. Ruivo C, Guardado J, Montenegro Sá F, Saraiva F, Antunes A, Correia J and Morais J (2017) Gerbode defect and multivalvular dysfunction: Complex complications in adult congenital heart disease, Echocardiography, 10.1111/echo.13561, 34:7, (1099-1101), Online publication date: 1-Jul-2017. Ozeke O, Celik E, Grbovic E, Colak A, Dogan P, Tufekcioglu O, Golbasi Z and Kisacik H (2013) Delayed left ventricular-to-right atrial communication (acquired Gerbode defect) after aortic valve replacementVerzögert aufgetretener Shunt zwischen linkem Ventrikel und rechtem Vorhof (erworbener Gerbode-Defekt) nach Aortenklappenersatz, Herz, 10.1007/s00059-013-3971-3, 40:1, (157-158), Online publication date: 1-Feb-2015. Vizzari G, Pizzino F, Crouch J, Ammar K, Gal A, Khandheria B and Kay J (2015) Congenital Gerbode Defect in a Patient With an Acute Myocardial Infarction and Cardiogenic Shock Masquerading as an Acute Ventricular Septal Defect, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2014.08.004, 29:5, (1311-1313), Online publication date: 1-Oct-2015. Taskesen T, Prouse A, Goldberg S and Gill E (2015) Gerbode defect: Another nail for the 3D transesophagel echo hammer?, The International Journal of Cardiovascular Imaging, 10.1007/s10554-015-0620-3, 31:4, (753-764), Online publication date: 1-Apr-2015. Yuan S (2015) Acquired left ventricle-to-right atrium shunt: clinical implications and diagnostic dilemmas, Wiener klinische Wochenschrift, 10.1007/s00508-015-0710-1, 127:21-22, (884-892), Online publication date: 1-Nov-2015. Müller U, Pittl U, Leontyev S, Dähnert I and Schuler G (2012) Gerbode ventricular septum defect covered by a ballooning membranous ventricular septum, Clinical Research in Cardiology, 10.1007/s00392-012-0521-6, 102:3, (245-247), Online publication date: 1-Mar-2013. (2017) Gerbode Defect. An Uncommon Complication of Infective Endocarditis, Journal of Cardiology & Current Research, 10.15406/jccr.2017.09.00307, 9:1 Chou H, Chen H, Xie J, Xu A, Mu G, Han F, Tse G, Li G, Liu T and Fu H (2020) Higher Incidence of Atrial Fibrillation in Left Ventricular-to-Right Atrial Shunt Patients, Frontiers in Physiology, 10.3389/fphys.2020.580624, 11 July 3, 2012Vol 126, Issue 1 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.111.088740PMID: 22753537 Originally publishedJuly 3, 2012 Keywordstransesophageal echocardiographymagnetic resonance spectroscopyPDF download Advertisement SubjectsComputerized Tomography (CT)EchocardiographyImaging
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