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  • Abstract: Congenital heart disease x
  • Abstract: Aortic stenosis x
  • Abstract: Atrial septal defect x
  • Abstract: Coarctation of the aorta x
  • Abstract: Common arterial trunk x
  • Abstract: Complete and partial atrioventricular septal defect x
  • Abstract: Double inlet ventricle x
  • Abstract: Hypoplastic left heart x
  • Abstract: Large ventricular septal defect x
  • Abstract: Patent ductus arteriosus x
  • Abstract: Pulmonary atresia with intact ventricular septum x
  • Abstract: Pulmonary atresia with ventricular septal defect x
  • Abstract: Pulmonary stenosis x
  • Abstract: Supraventricular tachycardia x
  • Abstract: Tetralogy of Fallot x
  • Abstract: Transposition of the great arteries x
  • Abstract: Tricuspid atresia x
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Open access

Isaac Adembesa, Adriaan Myburgh and Justiaan Swanevelder


We present a patient with rheumatic heart disease involving all the heart valves. An intraoperative transoesophageal echocardiography confirmed severe mitral stenosis, severe aortic regurgitation, severe tricuspid regurgitation and stenosis, and severe pulmonary stenosis. The patient underwent successful quadruple valve replacement during a single operation at the Groote Schuur Hospital, Cape Town, South Africa.

Learning points:

  • Rheumatic heart disease can affect all the heart valves including the pulmonary valve.

  • Intraoperative transoesophageal echocardiography is key for diagnosis, monitoring and confirmation of successful surgical result during heart valve surgery.

  • Combined surgical procedure of all four valves is possible though associated with long procedural time.

Open access

Vishal Sharma, David E Newby, Ralph A H Stewart, Mildred Lee, Ruvin Gabriel, Niels Van Pelt and Andrew J Kerr

Stress echocardiography is recommended for the assessment of asymptomatic patients with severe valvular heart disease (VHD) when there is discrepancy between symptoms and resting markers of severity. The aim of this study is to determine the prognostic value of exercise stress echocardiography in patients with common valve lesions. One hundred and fifteen patients with VHD (aortic stenosis (n=28); aortic regurgitation (n=35); mitral regurgitation, (n=26); mitral stenosis (n=26)), and age- and sex-matched controls (n=39) with normal ejection fraction underwent exercise stress echocardiography. The primary endpoint was a composite of death or hospitalization for heart failure. Asymptomatic VHD patients had lower exercise capacity than controls and 37% of patients achieved <85% of their predicted metabolic equivalents (METS). There were three deaths and four hospital admissions, and 24 patients underwent surgery during follow-up. An abnormal stress echocardiogram (METS <5, blood pressure rise <20 mmHg, or pulmonary artery pressure post exercise >60 mmHg) was associated with an increased risk of death or hospital admission (14% vs 1%, P<0.0001). The assessment of contractile reserve did not offer additional predictive value. In conclusion, an abnormal stress echocardiogram is associated with death and hospitalization with heart failure at 2 years. Stress echocardiography should be considered as part of the routine follow-up of all asymptomatic patients with VHD.

Open access

Michelle Carr, Stephanie Curtis and Jan Marek

Congenital obstruction of the left ventricular outflow tract remains a significant problem and multilevel obstruction can often coexist. Obstruction can take several morphological forms and may involve the subvalvar, valvar or supravalvar portion of the aortic valve complex. Congenital valvar stenosis presenting in the neonatal period represents a spectrum of disorders ranging from the hypoplastic left heart syndrome to almost normal hearts. Treatment options vary dependent on the severity of the left ventricular outflow tract obstruction (LVOTO) and the variable degree of left ventricular hypoplasia as well as the associated lesions such as arch hypoplasia and coarctation.

Open access

Antigoni Deri and Kate English

This review article will guide the reader through the basics of echocardiographic assessment of congenital left to right shunts in both paediatric and adult age groups. After reading this article, the reader will understand the pathology and clinical presentation of atrial septal defects (ASDs), ventricular septal defects (VSDs), atrioventricular septal defects (AVSDs) and patent arterial duct. Echocardiography is the mainstay in diagnosis and follow-up assessment of patients with congenital heart disease. This article will therefore describe the echocardiographic appearances of each lesion, and point the reader towards specific features to look for echocardiographically.

Open access

Mashail Alobaidan, A Saleem, H Abdo and J Simpson


The case report of a 15-year-old patient with an unusual form of atrial septal defect is described. Echocardiography showed separation of the secundum and primum atrial septums due to abnormal posterior and leftward attachment of the primum septum into the roof of the left atrium. The morphology has been variably described as a ‘double’ atrial septum or ‘spiral’ atrial septal defect. Despite the technical challenge of this form of atrial septal defect, it was effectively closed by ensuring that all relevant septal structures were incorporated between the discs of the occlusion device. This was associated with a stable position and good medium-term outcome. This contrasts with the experience of others where device embolisation or technical failure has been described.

Learning points

  • The spiral atrial septal defect is characterised by an apparently ‘double’ atrial septum.

  • Such atrial septal defects (ASDs) have been associated with a high rate of technical failure of transcatheter closure.

  • 3D echocardiography assists in understanding the anatomy of the defect.

  • Following deployment of the ASD occlusion device transoesophageal echocardiography is essential to ensure that both septum primum and secundum are between the occluder discs.

  • Catheter closure can be successful if close attention is paid to the morphology of the defect and incorporation of margins within the discs of the septal occluder.

Open access

Alexandra Savis and John Simpson

Echocardiography is the imaging modality of choice to diagnose different types of atrial septal defect and to determine which defects are suitable for catheter occlusion. In addition to assessment of defect size and rims, transoesophageal echocardiography may be used to guide the procedure itself including device placement, procedural complications and post-procedural checks. This review covers a practical approach to this subject and is accompanied by online videos illustrating the technique.

Open access

J D R Thomson and S A Qureshi

Cardiac erosion related to transcatheter atrial septal defect closure devices is of increasing concern. Erosion is reported to have occurred with most of currently available occluder devices. Perhaps due to the very large number of implants worldwide, the Amplatzer (St Jude) occluder is associated with the majority of cardiac erosion events reported in the literature. Best current estimates of the incidence of erosion with the St Jude device are between one and three cases per 1000 implants. Most events occur early after implantation and it is rare, although not unheard of, for events to occur after a year following device insertion. It is important that those involved with closure programmes are vigilant for the problem, because device-related erosion is associated with a significant mortality risk. Despite considerable debate, the risk factors (either patient or device) for erosion remain unclear and require further investigation. Currently available data sets have focussed largely on erosion cohorts and are unable to place these cases in appropriate context with non-erosion closure cases. What is certain is that programmes implanting these devices must take care to implant appropriately sized devices and have in place plans to ensure that patients are both well informed and can access help and advice in the event of developing symptoms.

Open access

John Fryearson, Nicola C Edwards, Sagar N Doshi and Richard P Steeds

Transcatheter aortic valve implantation is now accepted as a standard mode of treatment for an increasingly large population of patients with severe aortic stenosis. With the availability of this technique, echocardiographers need to be familiar with the imaging characteristics that can help to identify which patients are best suited to conventional surgery or transcatheter aortic valve implantation, and what parameters need to be measured. This review highlights the major features that should be assessed during transthoracic echocardiography before presentation of the patient to the ‘Heart Team’. In addition, this review summarises the aspects to be considered on echocardiography during follow-up assessment after successful implantation of a transcatheter aortic valve.

Open access

Ying X Gue, Sanjay S Bhandari and Damian J Kelly

A 73-year-old male was brought into hospital with chest pain and inferior ST elevation on ECG. The patient immediately proceeded to the catheter lab for primary percutaneous coronary intervention. Angiography did not identify any culprit lesions to account for the patient’s electrocardiographic changes and ongoing symptoms of chest pain. Bedside echocardiography revealed critical aortic stenosis. Intra-aortic balloon pump (IABP) was inserted, resulting in resolution of chest pain and ST-segment changes. The patient underwent successful aortic valve (AV) replacement without the need for coronary intervention. This is a rare presentation of critical aortic stenosis (AS) presenting as ST-segment elevation myocardial infarction (STEMI).

Learning points:

  • Aortic stenosis (AS) affects 2–9% of population above 65 years old and increases with age.

  • AS induces ischaemia via abnormal cardiac coronary coupling.

  • Focused clinical examination in patients with ST-segment elevation myocardial infarction (STEMI) is vital prior to cardiac catheterisation.

  • Detection of murmurs should be followed on by an echocardiography examination.

  • Other differentials of STEMI include acute aortopathy, endocarditis with embolus, myopericarditis and intracranial haemorrhage.

Open access

Lindsey E Hunter and Anna N Seale

This review article will guide the reader through the background of prenatal screening for congenital heart disease. The reader will be given insight into the normal screening views, common abnormalities, risk stratification of lesions and also recent advances in prenatal cardiology.