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Number 09-11: Gerbode Ventricular Septal Defect after Ross Procedure
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Number 09-11: Gerbode Ventricular Septal Defect after Ross Procedure

From: Benjamin Cheong, MD and Erika G. L.C. Odisio, MD
Institution: St Luke's Episcopal Heart, Department of Radiology, Houston, Texas, US 

***This case (09-11) and the previous one (09-10) represent a short case series on the role of CMR to assess different complications of the Ross procedure.

Clinical history: A 26-year-old male patient with past medical history of aortic coarctation repair (by an prosthetic graft between the ascending and descending aorta) and Ross procedure for aortic valvular stenosis. The patient is also known to have significant stenosis in his neo-pulmonic valve.  Cardiac magnetic resonance (CMR) was ordered to evaluate the cardiovascular morphology.

Cine CMR: A series of 4-chamber images without gaps were obtained.  Movie 1 demonstrates a systolic jet originating from the membranous portion of the interventricular septum into the right atrium, adjacent to the tricuspid annulus plane (dark jet).  Similar finding is seen in Movie 2, obtained in the orthogonal orientation. The corresponding image from surface echocardiogram is shown in Figure 1 (coloured jet).

 

       

Movie 1                                                  Movie 2

 

 

Figure 1

 

 

 

Movie 3

 

The volume rendered 3-D MRA (Movie 3) demonstrating the widely patent bypass graft between the ascending and descending thoracic aorta for aortic coarctation repair.

Perspective: Left ventricle-right atrium (LV-RA) communication is mostly congenital and extremely rare (<1% of all congenital heart disease) finding.  This was first classified by Gerbode et al. in 1958(1,2). Acquired LV-RA communications can be secondary to endocarditis, trauma, myocardial infarction (1) or valve replacement (1,3). This defect was likely a postoperative complication of the Ross procedure. Cardiac MR imaging was able to show the type and location of the defect, and to help quantify the degree of shunt across the defect (4).

References:

1. Cheema OM, Patel AA, Chang SM, Dipan JS. Gerbode Ventricular Septal Defect Diagnosed at Cardiac MR Imaging: Case Report. Radiology. 2009; 252:50-52.

2. Ramasubbu K., Coselli J, Zoghbi WA. Unusual complication of aortic root reconstruction with sparing of the aortic valve: left ventricular outflow tract to right atrial fistula. J Am Soc Echocardiogr 2006; 19(4): 469.e5-469.e9.

3. Wasserman SM, Fann JI, Atwood JE, Burdon TA, Fadel BM. Acquired left ventricular-right atrial communication: Gerbode-type defect. Echocardiography. 2002; 19:67-72.

4. 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(3): 433-446.

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COTW handling editor: Chiara Bucciarelli-Ducci

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