1969
MAY,
VENTRICULAR VICTOR
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By
SEPTAL AORTIC
DEUTSCH,
M.D.,f
JOSEPH
H.
DEFECT ASSOCIATED INSUFFICIENCY*
LEONARD
YAHINI,
C.
M.I).,
BLIEDEN,
and
TEL-AVIV,
,\/7
ENTRICULAR mon
septal
congenital
however,
rare1’
sul+iciencv.
in
associated of
to
these
sufficienc
as
arises
ventricular
septal the
for
latter
tricular been
to
the
described In
in
addition,
tricular
outflow
and
is
valvular the aortic
pulmonic valve
not
syndrome
in a
these
parts:
ven-
(a)
insuf-
been
septum the
crista
in an
apex.
almost
The
on
septum
The
main,
The
bulboventricular
band
the anteThere are the
left
consists
part
bulky
along vertical
parietal
structures
septum. ventricular
supra-
passes
is the
side
3
of
muscular forms
portion
between
the
outflow
tracts
the
of both
these or
prolapse ventricular given
of
to
this
literature
deal
to
division
ven-
in
radiologic
reports
right
or the
of the
the
band
septum.
(b) the
M.D.,
has
infundibular
to
has
the
few
so
uncommon
stenosis through
septal defect.”9”#{176} Little attention
in
cusps left
from
septal
corresponding
results
mechanism to
due
is
no a
instances.6’9
obstruction
patients
onl’
same
two
wall
of the The
the
arise
The
direction
in-
Pulmonary
KRAUS,
M.D.
is more oblique and passes along rior wall of the right ventricle.
of
aortic into
tract.
due
ficiency
aortic
which
prolapse
outflow
the
complication the
the
is present of all yen-
The a
band,
ventricularis.
in-
literature
cent
defect
support
that
per
parietal is,
aortic
lesions
defects.’”5
septal
deficient
the
two
3-5
approximately
tricular
It
YONEL
N.
ISRAEL
is a corn-
with
According
combination
defect
malformation.
M.B., B.CH., NEUFELD,
HENRY
WITH
and
specifically
with
cases.”
In
this
paper
ventricular
we
septal
aortic
report
10
defect
associated
insufficiency
roen
tgenologi
with c
and
patients
with with
emphasis
angiocardiologi
on
the
c
fea-
tures. ANATOMY
For
the
normal
convenience
anatomic
reviewed
and
ularis
upper
and
septal
arching
pulmonary
From
the
Hospital,
reader the be briefly
will
lying
right
the Two the
Radiological
Department,
University
of Tel-Aviv
septal
Tel.Hashomer Medical
School,
the
relationships ventricular (2),
bulboventricular along
and
and
portion
(k). Note how the mates the posterior part and the right part. Ao = ascending trunk; RA = right RV = right ventricle.
ventricle bands
band
Normal of
supraventricularis
tricuspid
muscular
i.
portion
supraventric-
prominence
of the
FIG.
landmarks
crista
between
thickness,
the
important
The
wall
rings.
variable
*
i).
is a muscular
the
ment
some
(Fig.
defined
of features
of
the
Government
Hospital,f
Israel.
32
and
from
the
the membranous septum (i), crista septal band (,), and the of the ventricular septum of
membranous septum approxiaortic sinus (P) in its posterior aortic sinus (R) in its anterior aorta; PT = pulmonary atrium; TV = tricuspid valve;
Heart
Institute,
Tel-Hashomer
Govern-
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\OL.
io6,
Ventricular
No.
ventricles. It is continuous below and teriorly with the muscular septum reaches the pulmonary valve superiorly. the left ventricular aspect, it forms part of the ventricular septum below commissures between the right and aortic cusps.
Septal
anand On the the left
( c) The membranous portion is variable in size but rarely larger than cm. in diameter. Its anterior part is continuous with the posterior part of the bulbar septum. On the left ventricular aspect the membranous septum lies inferior to the commissures between the right and posterior aortic cusps.
On
membranous ferior to
the
the
right
septum crista
hidden behind the lets of the tricuspid
can
be
determined
the crista leaflet of
ventricular
aspect
is posterior supraventricularis septal valve.
by
supraventricularis. the tricuspid
and Its
the
anterior lower
septal
valve
the
and
inand
leafborder
band
of
The septal crosses the
membranous septum obliquely. It is attached to this septum and divides it into an atrioventricular part localized superiorly and posteriorly and an intraventricular part localized anteriorly and caudally. If the ventricular septal defect involves mainly the middle part of the membranous septum, there will be deficient support for the posterior and right aortic cusps and thus aortic insufficiency will involve these structures. If the ventricular septal defect is in the anterior portion of the membranous septum and part of the bulbar septum, the deficient support will involve mainly the right cusp. In the 2 cases described in the literature in which the ventricular septal defect caused prolapse of the pulmonary valve,6’9 the deficiency was more anteriorly located in the bulbar septum.
Defect
All of the patients underwent repeated roentgenologic examination. Righ t heart catheterization was performed in 9, Selective thoracic aortography in 8, and left ventriculography in 3 patients. In i patient selective right ventriculography was performed. CLINICAL
Seven years. agnosed initial ventricular systolic amination the first With sufficiency,
Of a group of 387 patients with ventricular septal defect studied at the Heart Institute, 10 cases were found to be accompanied by aortic insufficiency of the type under discussion.
the patients were males and their ages ranged from 6 to 27 Congenital heart disease was diearly in life in all patients. The clinical features were due to the septal defect ; the characteristic murmur was noted on routine exat birth in 4 cases and within year oflife in the remainder. the appearance of the aortic inthe diastolic murmur was a
characteristic clinical
DATA
of
3 females;
and
outstanding
examination.
This
feature murmur
was
on not
present in any of the cases before the age of 2 years. Other features of aortic run-off, such as the collapsing pulse, widening pulse pressure and signs of left ventricular hypertrophy, also tial electrocardiogram
became
apparent. The showed biventricular
ini-
hypertrophy but, subsequently, all cases showed a predominant left ventricular hy.. pertrophy pattern and in 6 of them a left ventricular strain pattern with negative T waves in left precordial leads was present. FINDINGS
ON
RIGHT
HEART
CATHETERIZATION
Right
catheterization was perIn 6 of them the pressures in the right ventricle and pulmonary artery were in the region of the upper limits of normal, but in i case a gradient of 25 mm. Hg was found across the pulmonary valve. The remaining 2 cases showed elformed
evated MATERIAL
33
case right I.
pulmonary
heart
in
9 cases.
pressures
in
the
right
ventricle.
In
the pressure was 95 mm. Hg in the ventricle and 25 mm. Hg in the artery,
and
in the
other
case
the
pressure was 95 mm. Hg in the right ventricle but the pressure in the pulmonary artery could not be recorded for technical
Deutsch,
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34
Blieden,
Kraus,
reasons. In I case the oxygen saturation was normal in the lesser circulation. In the other cases a step-up of at least 5 per cent in oxygen saturation was present between the right atrium and right ventricle. The maximal step-up present was i6 per cent. ROENTGENOGRAPHIC
FINDINGS
The roentgenographic findings reflected the natural history of the disease and were dependent on the relative severity of the two components of the lesion. The over-all size of the heart, on initial examination, was considered to be markedly increased in 2 cases, moderately increased in 5 cases and only slightly increased in 3 cases (Fig. 2).
Initially
the
biventricular
cardiomegaly
pearance
of aortic
enlargement
feature
With
insufficiency,
megaly was seen to ventricular enlargement atrial
was
enlargement. be was
was
ment
of the
to
the
ap-
not
a
heard
prominent
was
cases,
and
present
biventricular The
roentgenogram
revealed
megaly. monary
left heart border, was prominent
On the segment
aortic knob normal. culature was markedly A diagnosis of patent made
and
the
ductus
moderate
during
the
cardio-. the and
The pulmonary increased (Fig. ductus arteriosus was
ligated.
subsequent
pulthe
vas-
3A). was
Following
the operation a systolic-diastolic could still be heard. Follow-up grams
plain
murmur roentgenoyears
showed
that the aorta became progressively dilated while the pulmonary vasculature decreased (Fig. 3, B-E). Ten years following the operation right heart catheterization was performed
of 6o
mm.
and
a systolic
Hg
was
pressure
measured
gradient
between
the
Neufeld
MAY,
1969
right ventricle and the pulmonary artery. Selective right heart cardioangiography, performed at the same stage, showed that the right ventricle was enlarged and that a polypoid mass was present at the infundibular region during systole (Fig. , 4 and C), whereas the outflow tract of the right ventricle had a normal appearance during diastole (Fig. , B and D). The mass was subsequently shown by selective thoracic aortography to have been produced by a prolapsed right aortic cusp (Fig. 4, E and F). The latter investigation also revealed aortic insufficiency of moderate degree and no definite left-to-right shunt could be seen. This was, therefore, a case of patent ductus arteriosus and ventricular septal defect in which the patent ductus septal
was defect
ligated
and
complicated
SELECTIVE
Selective formed in insufficiency
This which production
case, sinuses in no I
the by
ficiency. The prolapse cusp eventually blocked septal defect and gave of the right ventricular
tation
enlarge-
clinically.
and
arteriosus
cardio-
dominated by left in all cases. Left
but slight enlargement was seen in 2 patients. Prominence of the ascending aorta on conventional roentgenograms was noted in 6 cases. The prominence of the pulmonary vasculature was related to the magnitude of the left-to-right shunt and was marked in 2 cases and moderate in the remainder. One patient deserves special mention. At the age of 3 years a systolic-diastolic murmur
in any
due
the
Yahini
ventricular aortic
THORACIC
AORTOGRAPHY
thoracic aortography 8 cases and demonstrated of
mild
investigation of the sinuses of aortic involved
the
insuf-
of the right aortic off the ventricular rise to obstruction outflow tract.
to
also was
moderate
sinus
peraortic
degree.
clearly involved
insufficiency. right
was
showed in the The only
dilain
i
both the right and the posterior in 4 cases, the posterior sinus only case and all the sinuses equally in
case.
When the right sinus was involved a characteristic step-like bulging was noted between the dilated upper part of the sinus and the ascending aorta. This bulging was best noted in the lateral aortograms (Fig. 5). In systole the dilated sinus descended and bulged anteriorly in the direction of the ventricular septal defect; the bulging, however, was most marked during diastole. This bulging of the right sinus was noted in more than half of the cases. In 3 of the cases in which dilatation of the posterior sinus was present, an additional pocket of
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Vol.
io6,
FIG.
2. Frontal
Ventricular
No.
insufficiency
roentgenograms
demonstrating
Septal
of the thorax of various cardiomegaly, prominent
Defect
patients with aortic arch and
35
ventricular increased
septal pulmonary
defect and aortic vasculature.
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36
Deutsch,
Blieden,
Kraus,
Yahini
and
Neufeld
MAY,
1969
C lic. .--
.
Series
patents, arterisLis,
ci ventricular
ciencv. .1) .t diagnosed;
grams
0
of
en
the
ptilmonarv
follo
septal
defect
aortic
arch
of
to
tile
Complete
liv and
of
One
and
segment
(B-D) 10
ng
of
ears.
12
of
the
patent ductus was showed cardio-
vasculature.
decrease
the enlargement the age of normal due
\ears
2
tgenograllls
a prominent over
)1iIlflS
\ears, with patent ductus septal defeCt and aortic insuffi10
the age
pulmonary
successive
I arged.
for
the
megalv, creased
rita1 r( elltgefl(
fr(
of
tlI
\cars
demonstrate
the
the jn,lnionarv vasculature aorta. (F) Roentgenogram lile pulmonary vasculature occlusion of the ventricular
the
prolapsed
the
left
ventricle
right
aortic are
in-
Roentgeno-
cusp.
moderately
and at
is Ihe en-
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VOL.
,o6,
No.
1
Ventricular
Septal
Defect
37
. Selective right ventriculography and thoracic aortography demonstrating right outflow tract obstruction caused by prolapse of the right aortic cusp into the right ventricular outflow tract (same patient as in Figure 3). (1 and C) Selective right ventriculograms in systole, anteroposterior and lateral projections. A round filling defect is visualized in the outflow tract of the right ventricle (arrow). (B and D) Selective right ventriculograms in diastole, anteroposterior and lateral projections. The right ventricular outflow tract has a normal appearance. (E) Selective thoracic aortogram. In systole the prolapsed right aortic cusp bulges anteriorly (arrow) corresponding to the filling defect seen in C. (F) Selective thoracic aortogram. In diastole the prolapsed cusp is less prominent.
FIG.
Deutsch,
38
Blieden,
Kraus,
Yahini
and
Neufeld
MAY,
1969
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‘i;
. Selective characteristic
thoracic step-like
11G.
aortograms of various patients bulging of the right aortic sinus
with involvement (arrow) and the
of the anteriorly
right tilted
aortic aortic
cusp. valve
The are
demonstrated.
contrast
material
could
be
caused
by
(Fig. the
prolapsed
6);
finding
position
of
valve
on of
the
tilted
anteriorl’,
this
aortic
selective
plane normal
valve
which
teriorly
(Fig.
c).
of
the
pathogno-
syndrome
in
is
the
is
contrast is
Left 3 cases.
VENTRICULOGRAPHY
ventriculography In 2 of the cases
the
usually
ventricle
septal
defect
could
6. Selective
thoracic A pocket-like
that
of
tilted
the pos-
There
is
natural
convincing
history
ventricular lesion
aortograms extension
be
filling of ventricular
the
the
demonstrated.
DISCUSSION
or
of
septal and
that
I
FIG.
marked,
not through
The
horizontal to
was
right
was performed in in which the aortic
lateral
aortographv.
valve in
LEFT
insufficiency not
valve
thoracic aortic
sinus
leaflet. but
of
the
the
probably
portion
suggestive
monic
with was
this
redundant
aortic
Another
view
continuous
seen
of various patients with is visualized below the
evidence
the defect
the
from
syndrome,
aortic
is
that the
primary
insufficiency
de-
I
prolapse involved
of the posterior cusp (arrow).
aortic
the the
cusp.
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VoL.
io6,
No.
Ventricular
i
velops with the passage of time. This has been demonstrated by clinical, laboratory and pathologic data.4’7’9”3”4 It is not known why aortic insufficiency occurs in these cases. Several factors have been implicated;9”2”4 these include the particular position of the ventricular septal defect, overriding of the aorta and displacement of the aortic leaflets downwards by the high velocity of blood through the ventricular septal defect; but there is sufficient evidence to refute all these theories. The explanation for the existence of aortic insufficiency in these cases of yentricular septal defect possibly lies in the developmental patterns of the ventricular septum. It is known that the muscular portion of the septum has to move from left to right in its development and that the aorta shifts from right to left.8 If these movements do not take place, the membranous septum is not continuous vertically with the muscular septum but an angle forms between them, and the membranous septum lies in a more horizontal plane than normally. In the ventricular septal defect produced by this failure of movement of the muscular septum, it can be assumed
that
the
abnormal
position
of the
membranous septum results in deficient support for the aortic valve cusps. Roentgenographic examination may definitely aid in the diagnosis of the syndrome. Firstly, in the usual case of ventricular septal defect, the aorta is normal or even small in size. If, in a known or suspected case
of ventricular
septal
defect,
the
aortic
shadow is seen to become progressively enlarged and, particularly, if excessive pulsations are present on fluoroscopy, the diagnosis of aortic insufficiency due to and superimposed on the ventricular septal defect should be strongly suspected. Secondly, if in a case of ventricular septal defect serial roentgenograms reveal a progressive decrease in pulmonary vasculature, the two possibilities which should be considered are that the ventricular septal defect is undergoing spontaneous closure or that the production of aortic insuffi-
Septal
Defect
ciency
39
and
subsequent has
prolapse
aortic
cusps
caused
complete defect. in the
closure of the ventricular In the latter case a parallel size of the aortic shadow
course,
confirm
the
partial
of or
the
almost
septal increase will, of
diagnosis.
From the practical standpoint, it is important to differentiate ventricular septal defect and aortic insufficiency from patent ductus arteriosus. in 10 per cent of the cases ofventricular septal defect and aortic insufficiency
reported
in the
literature,
pat-
ent ductus arteriosus was mistakenly diagnosed and the patients underwent exploratory thoracotomy.’2 It is not always possible to differentiate between these two conditions on auscultatory and phonocardiographic grounds. A roentgenologic clue may be provided by the size of the pulmonary
artery
which
is dilated
in
cases
of
patent ductus arteriosus, whereas the pulmonary artery segment is not prominent and may have a normal appearance in cases of ventricular septal defect and aortic insufficiency. At fluoroscopy, heaving pulsations of the aorta are characteristic of aortic insufficiency and are usually less prominent in patent ductus arteriosus. In the latter cases excessive pulsations are present in the prominent pulmonary artery segment. The relative size of the left atrium and left ventricle may aid in the differential diagnosis. In cases of patent ductus arteriosus
the
enlarged the shunt
left
atrium
and
left
to the same degree, volume. In cases
septal defect left ventricular
with aortic enlargement
ventricle
are
dependent of ventricular insufficiency is usually
on the the
more prominent feature. There are few reports on the diagnostic value of contrast roentgenography with regard to the diagnosis of ventricular septal defect and aortic insufficiency. Some authors used selective thoracic aortography and selective left ventriculography to evaluate
the
aortic
insufficiency
localize the ventricular Intravenous or selective cardiography has been stration of the ventricular
and
to
septal defect.9”4 right heart angioused for demonseptal defect by
Deutsch,
40
refilling
of
phase.”
The
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right
the
right
ventricle
importance
cardioangiography
and
of these
tricular
sinus
septal
selective
tho-
been
of the outflow may be due to or
Selective may
may
defect
steto a
right
aid diagnosis
occlude
when
levo
selective
however,
lesions.
cardioangiography in the differential
these conditions. The bulging
Kraus,
the
both
or valvular pulmonary a prolapsed aortic valve
combination heart stantially
in
of
racic aortography has not, sufficiently stressed. Obstruction in the region tract of the right ventricle infundibular nosis, to
Blieden,
subof
the
it descends
yenand
prolapses through the ventricular septal defect and a left-to-right shunt may, therefore, be missed during cardiac catheterization. This occurred in of the cases of Garamella et al.’ and in our case described above. Some of the cases mentioned in the literature in which operations were performed had infundibular pulmonic stenosis, and resection of the infundibulum was necessary.4”2 Nadas et al.9 reported cases with pressure
tricle cases
gradients
and had
between
the
pulmonary trunk, little hypertrophy
ventricular sumed that
infundibular
right
ven-
yet the
these right
and in region;
they
as-
the prolapsing valve had caused the pressure gradient. The case described above presents angiographic evidence that such a prolapse may cause significant right outflow tract obstruction and may almost completely occlude the defect between the ventricles. Selective thoracic aortography will demonstrate the presence of the aortic insufficiency
and,
in
certain
cases,
the
left-to-
right shunt at the ventricular level may also be demonstrated. In those cases in which there is prolapse of the right aortic cusp, the characteristic step-like bulging of the right aortic sinus suggests the diagnosis of aortic insufficiency produced by the presence of a ventricular septal defect. Since the right sinus is involved in 75 per cent of the cases,’2 the importance of this sign is evident. In one of our cases a pre-
Yahini
and
Neufeld
1969
MAY,
sumptive diagnosis of patent ductus arteriosus had been made. Selective thoracic aortography revealed the characteristic bulging of the right sinus with mild aortic insufficiency. In view of this finding, a diagnosis of aortic insufficiency of the type associated with ventricular septal defect was made and left ventriculography confirmed the diagnosis. Another characteristic sign was seen in 4 cases with prolapse of the posterior aortic cusp in which the redundant portion of the prolapsed cusp caused a pocket-like extension filled by contrast material below the involved cusp. The early diagnosis of this syndrome is important because the cases with mild aortic insufficiency may be repaired by plastic correction of the aortic valve and closure of the ventricular septal defect. However, once the aortic insufficiency increases, aortic valve replacement becomes necessary. SUMMARY
Ten cases of ventricular septal defect associated with aortic insufficiency are presented. In this syndrome the aortic insufficiency is a complication of the ventricular septal defect. The underlying anatomy is reviewed and a possible explanation for the presence of the aortic insufficiency is suggested. The roentgenographic and cardioangiographic features are stressed. Thoracic aortography may reveal characteristic deformities produced by the involved aortic sinuses and their prolapsed leaflets. Selective right ventriculography may aid in the evaluation of the obstruction of the right ventricular outflow tract. Henry
N. Neufeld, M.D.
Heart
Institute
Tel-Hashomer
Government
Hospital
Tel-Aviv, Israel REFERENCES I.
E.,
CARL550N,
prolapsed struction: 1965, 2.
COLLINS,
HARTMANN,
J. M. Ventricular
KISSANE,
aortic case
valve report.
and
EAST,
T.,
ilcta
A. F., JR., and septal defect with outflow tract obradiol.
(Diag.),
3, 554-560.
D.
M.,
GODFREY,
M.
P.,
VOL.
io6,
Ventricular
No.
P., with
HARRIS,
defect
Septal
and ORAM, S. Ventricular septal pulmonary stenosis and aortic Brit. Heart 7., 1958, 20, 363-
regurgitation. 369.
Downloaded from www.ajronline.org by 37.44.207.92 on 01/27/17 from IP address 37.44.207.92. Copyright ARRS. For personal use only; all rights reserved
3.
C.,
DUBOST,
and
munications sance
mal.
coeur,
1963,
de
6,
66-68i.
GARAMELLA,
W. H.,
DAHL,
surgical 27, 789-795.
II.
considera-
monic Am. 7.
L.,
J. J., CRUZ, A. B., JR., HEUPEL, J. C., JENSEN, N. K., and BER-
KECK, and
with
12.
through ventricular septal 7. Cardiol., 1966, J8, 127-13 I. E. W. 0., ONGLEY, P. A., KINCAID, SWAN,
H. J. C.
aortic
insufficiency:
8.
MALL,
study 27,
septal clinical
into
and
of membranous atrium.
34.
hemo-
septum
Anatom.
Rec.,
29!.
A. S.,
THILENIUS,
0.
G.,
LAFARGE,
Ventricular
N.,
FROMENT,
J., and
PHILIPSON,
defect 3955,
and 29,
J.,
GRAVIER,
R. Les communicainsuffisance anatomo coeur, 3962,
G. F. Combined
SALTZMAN,
septal Acta radiol.,
septal
medical 3964,
Circulation,
AERICHIDE, and
J.
regurgitation:
and aortic 44, 269.
insuffi-
BRAUNWALD, E., ROCKOFF, D. T., and MORROW, A. G. Ventricular septal defect and aortic regurgitation: clinical, hemodynamic and surgical con-
W. H.,
PLAUTH,
D.,
Scorr,
JR.,
MASON,
Am.
R. C.,
7.
MCGUIRE,J.,
Med.,
1965,
KAPLAN,
39, 552-567. S., FOWLER,
GREEN, R. S., GORDON, L. Z., SHABR., and DAVOLOS, D. D. Syndrome of ventricular septal defect with aortic insufficiency. Am. 7. Cardiol., 1958, 2, 530-553. STARR, A., MENASHE, V., and DOTTER, C. Surgical correction of aortic insufficiency assoETAI,
0. W., defect
A.
aortic
N. 0.,
defect.
of i8 proved cases. Circulation,
right
A., P.,
PERRIN,
siderations. 33.
ciated
203-238.
F. P. Aneurysm
projecting 1912, 6, 9. NADAS,
Ventricular
aspects.
S.
A. F. Prolapse of pul-
LYON,
valve
dynamic 1963,
and
pathologic 862-873.
ciency.
R. Ventricular septal defect with aortic insufficiency: successful surgical correction of both defects by transaortic approach. Am. 7. Cardiol., 1960, 5, 266-272. GOULD,
HAUCK,
ventricular
MAN,
6.
C. G., and defect with
tions interventriculaires avec aortique: a propos de 3 observations cliniques personelles. Arch. mal. 55, 289-3 10.
op#{233}r#{233}s.
F. H., JR., ONGLEY, P. A., and KIRKLIN, J. W. Ventricular septal defect with aortic
41
CAHEN,
insufli-
cas
4
30.
com-
ELLIS,
valvular incompetence: tions. Circulation, 3963, .
Les
avec
a propos
P.,
BLONDEAU,
J. R.
PADEANO,
interventriculaires aortique:
Arch. 4.
C.,
D’ALLAINES,
A.,
PIWNICA,
Defect
15.
with
ventricular
septal
defect.
Surg.,
Gynec. & Obst., 1960, JIl, 7 1-76. Woor, P., MAGIDSON, 0., and WILSON, P. A. 0. Ventricular septal defect with note on acyanotic Fallot’s tetralogy. Brit. Heart 7., ‘954, 16,
387-406.
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1. Peter M. Sanfelippo, James W. DuShane, Dwight C. McGoon, Gordon K. Danielson. 1974. Ventricular Septal Defect and Aortic Insufficiency. The Annals of Thoracic Surgery 17:3, 213-222. [CrossRef] 2. Katsuhiko Tatsuno, Souji Konno, Shigeru Sakakibara. 1973. Ventricular septal defect with aortic insufficiency. American Heart Journal 85:1, 13-21. [CrossRef]