Morphologic spectrum of truncal valvar origin relative to the ventricular septum: Correlation with the size of ventricular septal defect Iki Adachi,

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Morphologic spectrum of truncal valvar origin relative to the ventricular septum: Correlation with the size of ventricular septal defect Iki Adachi, MD, Anna Seale, MD, Hideki Uemura, MD, FRCS, Karen P. McCarthy, BS, Philip Kimberley, Siew Yen Ho, PhD, FRCPath, FESC The Journal of Thoracic and Cardiovascular Surgery Volume 138, Issue 6, Pages 1283-1289 (December 2009) DOI: 10.1016/j.jtcvs.2009.05.009 Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Truncal origin was categorized as having 1 of the following 5 types: exclusive origin from either ventricle, predominant origin from either ventricle, or centrally located. The prevalence of each group in both the autopsy and clinical series is shown. B, The measurements made on the VSD to determine the “width” and “depth.” LV, Left ventricle; RV, right ventricle; VSD, ventricular septal defect. The Journal of Thoracic and Cardiovascular Surgery 2009 138, 1283-1289DOI: (10.1016/j.jtcvs.2009.05.009) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Photographs illustrating VSD and its relation to the truncal valve in 4 hearts with the common trunk arising from “center” (A), “exclusively from LV” (B), and “exclusively from RV” (C, D). All photographs except for that in (B) were taken from right ventricular side. The heart with balanced origin (A) has a VSD that is wide in shape compared with others. In the heart (B), the trunk is committed exclusively to the LV. In the heart (C), the truncal–mitral fibrous continuity is still maintained, albeit to a lesser extent than usual. By contrast, the heart (D) has a persistent ventriculo-infundibular fold interposing between the truncal, mitral, and tricuspid valves, creating valvar discontinuity. Consequently, the VSD is no longer “subtruncal.” IVS, Interventricular septum; LV, left ventricle; RV, right ventricle; VSD, ventricular septal defect; Tr, truncal root; SMT, septomarginal trabeculation; VIF, ventriculo-infundibular fold. The Journal of Thoracic and Cardiovascular Surgery 2009 138, 1283-1289DOI: (10.1016/j.jtcvs.2009.05.009) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Graphs showing the results of measurements on a VSD size according to truncal origin. The “width” and “depth” of the defect are standardized with the truncal valvar diameter of the corresponding heart. The red circle represents a heart with the mitral–truncal fibrous discontinuity. LV, Left ventricle; RV, right ventricle; %width, width/truncal valvar diameter; %depth, depth/truncal valvar diameter. The Journal of Thoracic and Cardiovascular Surgery 2009 138, 1283-1289DOI: (10.1016/j.jtcvs.2009.05.009) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Parasternal long-axis echocardiographic images obtained at end diastole from 4 patients in the clinical series with different types of truncal origin. The valvar annulus and its hinge points are marked with the yellow dotted line and the red circle, respectively. The valvar diameter is divided into 5 equal portions (notched line), and truncal origin is determined by a perpendicular line from the crest of the ventricular septum indicated with the arrow. IVS, Interventricular septum; LA, left atrium; LV, left ventricle; RV, right ventricle; Tr, truncal root. The Journal of Thoracic and Cardiovascular Surgery 2009 138, 1283-1289DOI: (10.1016/j.jtcvs.2009.05.009) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Schematic illustrations of the ventricles and atrioventricular junctions in cross-section show the relationship of the truncal valve to the ventricular septum. Any imbalance of the ventricular volume might cause change in the ventriculoarterial relationship owing to the digression of the ventricular septum. Similarly, location of the truncal valve itself could alter this relationship. In hearts with common atrioventricular junction, the anterior location of the truncal valve results in RV origin of the truncal valve. M, Mitral valve; T, tricuspid valve; L, left atrioventricular valve; R, right atrioventricular valve; LV, left ventricle; RV, right ventricle. The Journal of Thoracic and Cardiovascular Surgery 2009 138, 1283-1289DOI: (10.1016/j.jtcvs.2009.05.009) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

The Journal of Thoracic and Cardiovascular Surgery 2009 138, 1283-1289DOI: (10.1016/j.jtcvs.2009.05.009) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions