Case report:
14-years old asymptomatic boy with holosystolic murmur heard over the
lower left sternal border. Zoomed apical 5 chamber view revealed a
perimembranous ventricular septal defect (VSD) which was closed by an
aneurysmal leaflet of the tricuspid valve (TV) (Figure A) .Color Doppler
across the defect showed left to right shunt (Figure B) Short axis view
at the level of the aortic valve showed that VSD was extending from 10
to 11 o’clock . (Figure C). Injection of bubbles showed negative
contrast inside the right ventricle indicating incomplete defect
closure. (Figure D) 3D Transesophageal Echocardiography (TOE) with
zoomed mode showed the entry point from the left ventricular side and
exit point from the right ventricular side.(Figure E) En-face viewing of
the TV from the right ventricular perspective showed an aneurysm-like
pouch formed by the anterior leaflet (Figure F) The left atrial and
ventricular size was normal and the shunt ratio was 1.3 so he was
treated conservatively.
Ventricular septal defect is the most common congenital anomaly.The
incidence of spontaneous closure is still undetermined .Different
mechanisms for anatomical closure have been proposed such as the
adherence of the septal leaflet and/or the anterior leaflet of the
tricuspid valve to the margins of the defect forming an aneurysm-like
pouch that maybe mistaken for an aneurysm of the membranous septum.
Echocardiography is the gold standard for evaluation of the site , size
and type of VSD and its relation to the tricuspid valve. Recently,
transcatheter closure is feasible and efficacious in properly selected
patients.