SHA24/027002

Echocardiographic evaluation of LVOT Amjad Kouatli, MD, FAAP, FACC Consultant Pediatric Cardiologist King Faisal Specialist Hospital & Research Centre

Anatomy

LVOT is a tube Formed by: The upper conal septum The anterobasal LV free wall Anterior mitral leaflet Guarded by aortic valve

Imaging TTE

Parasternal long axis

Apical 5 chambers view

Subxifoid coronal view

TEE 30-50ยบ 120-130ยบ

3D

Abnormalities of LVOT Abnormal aortic valve Abnormal conal septum and anterior muscular wall Abnormal septal leaflet of mitral valve

Abnormalities Of aortic valve Abnormal cusps Bicuspid (AS) Monocuspid (AS) Dysplastic leaflets (AS, AI) Abnormal annulus Small (AS) Dilated (AI)

Aortic cusps

The Journal of Thoracic and Cardiovascular Surgery May 2007

Bicuspid aortic valve Circular , fish mouth opening

Aortic valve doming in systole

Aortic annulus If small, LVOT is usually small Seen in neonatal LVOTO variants

Significant independent factors associated with greater survival benefit for the Norwood procedure versus biventricular repair

- Lower Z- score of aortic valve - Younger age - Lower LV length - Higher grade of EFE - Absence of TR - Large AAO

Journal of the American Society of Echocardiography Pettersen et al 923 Volume 21 Number 8 2008

Pediatr Cardiol 26:356–360, 2005

Must R/O VSD Small aortic annulus without VSD

Small aortic annulus with VSD

Abnormalities of outlet septum and free wall Anterior deviation Posterior deviation Dynamic bowing due to RV hypertension Hypertrophy Sub aortic membrane

Anterior deviation of conal septum

TOF

Posterior deviation of conal septum

IAA Severe coarctation

Pre- op echo of 37 patients with IAA Predictors for post-op development of LVOTO

LVOT area Type of IAA B >A

Strong predictors

AV diameter AV area LVOT diameter

Are not predictors

Dynamic Posterior deviation of conal septum

Severe PAH

Septal hypertrophy

HCM Hypertrophy is typically asymmetric IVS usually has the most hypertrophy

Sub aortic membrane may be associated with VSD, DCRV

Abnormalities of anterior mitral valve leaflet Forms intra-cavity curtain that partially separates the LV inflow and the LVOT It actually forms part of the outflow tract

Abnormalities Cords SAM

Cords originates from the mitral leaflets and inserted in the LVOT septum causing LVOTO Seen in AVSD and straddling MV Pseudotendons Originates from the papillary muscle and inserted in LV septum or the other papillary muscle

Cord

SAM Systolic anterior motion of anterior mitral valve leaflet

HCM AVSD Post mitral valve repair

31 years old Large valve 22 cm2 elongated anterior and posterior leaflets 29 years old Large valve 18 cm2 elongated and large anterior leaflet

60 years old Large valve due to elongation and large lateral scallop of posterior leaflet

Normal valve area 11 cm2

LVOTO Redundant and long anterior mitral leaflet Conal septum hypertrophy

Systolic anterior motion SAM of the anterior mitral valve leaflet

LVOT becomes RVOT Persistent subaortic conus Pushes AO anteriorly and superiorly DORV

DORV with sub aortic VSD

Deformed LVOT

Goose neck deformity AV canal Due to apical displacement of the common AV valve

Conclusion Echo can provide valuable information regarding LVOT All components of LVOT must be evaluated Morphometric date in addition to the presence of VSD play a major role in choosing the preferred surgical option The effect of LVOTO on the left ventricle should be addressed (echocardiographically and clinically)

Thank You