5 Shunting Lesions
Cardiac shunting lesions include atrial septal defects, ventricular septal defects, and patent ductus arteriosus as the most common lesions seen in congenital heart disease. These lesions may be seen in isolation or in association with other congenital heart disease.
Atrial Septal Defects
Atrial deptal defects represent defects in septation of the atria. They are common, representing as much as 10% of cases of congenital heart disease. Anatomic types of defects include (Fig. 5-1):

Figure 5-1 Diagram of the atrial septum showing several types of atrial septal defects.
(Adapted from Fyler DC [ed], Nadas’ Pediatric Cardiology. Philadadelphia: Hanley & Belfus, 1992.)
Patent Foramen Ovale

Figure 5-2 Diagram of atrial septal components, showing foramen ovale (FO; arrow), septum primum (Sept 1°), left atrium (LA), left ventricle (LV), fossa ovalis, superior limbic bands (SLB) and inferior limbic bands (ILB), atrioventricular septum (AVS), right atrium (RA), and right ventricle (RV).
(From Keane JF, Lock, JE, Fyler DC [eds], Nadas’ Pediatric Cardiology, 2nd ed. Philadelphia: Elsevier/Saunders, 2006.)


Figure 5-3 Subcostal image of a patent foramen ovale (PFO). A, A flap of tissue is seen partially occluding the communication. B, Subcostal image a PFO with color Doppler. Left-to-right shunting is seen. The size of the defect is overestimated by the width of the color jet compared with the two-dimensional size of the defect in part A.
Ostium Secundum Atrial Septal Defect

Figure 5-4 Subcostal image of a secundum atrial septal defect (ASD). A, In this two-dimensional image, the true size of the atrial septal defect is seen. Septal rims are noted superior and inferior to the defect. Right atrial enlargement is also seen. B, With color on the same image, a red color jet is seen representing left-to-right flow across the defect.
Ostium Primum Atrial Septal Defect
Sinus Venosus Atrial Septal Defects: Two Types

Figure 5-5 Subcostal image of a sinus venosus defect located in the most superior and posterior region of the atrial septum. This defect is associated with partial anomalous pulmonary venous return.
The Echocardiography (Echo) Exam: Step-by-Step Approach
Step 1: Evaluate the Location of the Atrial Septal Defect
Key Points
Step 2: Evaluate the Atrial Septal Defect Dimensions and Position
Step 4: Determine the Size of the Shunt
Post-Device Atrial Septum Defect Closure Evaluation: Special Considerations
Ventricular Septal Defects
A ventricular septal defect is a communication within the interventricular septum that seperates the left ventricle (LV) and RV, allowing for shunting for blood between the ventricles. VSDs represent 20% of congenital heart disease. VSDs can be classified as follows (Fig. 5-6):

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