VENTRICULAR SEPTAL DEFECT ASSOCIATED WITH AORTIC INSUFFICIENCY*

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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]

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