Unbalanced AVSD – A Congenital Heart Surgeons’ Society Inception Cohort: Initial/Baseline Imaging Form
Study Number: ______
Echo Yes No
2D Yes No
3DYes No
CT Yes No
MRI Yes No
Date of echo (MM/DD/YY) ☐☐/☐☐/☐☐
Height at echo ☐☐ cm
Weight at echo ☐☐.☐☐ kg
BSA ☐☐.☐☐m2
Initial Echo Report Received ☐Y ☐N
Initial Echo Film/CD Received ☐Y ☐N
Date Initial Echo Film/CD Received (MM/DD/YY) ☐☐/☐☐/☐☐
Initial Echo Film/CD Reviewed ☐ Y ☐ N
Date Initial Echo Film/CD Reviewed (MM/DD/YY) ☐☐/☐☐/☐☐
Initial Echo Reviewer: ______
Exclusion Criteria
Exclusion: If you answer NO to any of the following there is no need to continue completing the form.
AVSD ☐ Y ☐N
Complete ☐ Y ☐ N
AV Concordance ☐ Y ☐N
VA Concordance ☐Y ☐ N
Normal pulmonary venous connection ☐Y ☐N
Normal systemic venous connection (except LSVC) ☐ Y ☐N
Balanced/Unbalanced
RAVV Area ☐.☐☐ cm2
LAVV Area ☐.☐☐ cm2
Total ☐.☐☐ cm
AVVI 0.☐☐ (AVVI = LAVV Area/Total Area)
Malalignment:
Atrial ☐ Y ☐ N ☐ Cannot determine
If Yes, Malalignment towards ☐ Right ☐ Left
Ventricular ☐ Y ☐ N ☐ Cannot determine
If Yes, Malalignment towards ☐ Right ☐ Left
☐ Meets Criteria for Unbalanced☐ Border Line☐ Does not Meet Criteria for Unbalanced
Morphology
ASD
Ostium primum ASD: Y N Cannot determine
If yes: ______
ASD size ______cm(largest diameter)
Primum ASD RestrictiveY N Cannot determine
Additional ASD Y N Cannot determine
Additional ASD Type ______
VSD
Inlet VSD SizeSmall Medium Large Cannot determine
Inlet VSD size ______cm
Inlet VSD Restrictive Y N Cannot determine
Inlet VSD direction of flow in systole ☐Left to Right ☐Right to Left ☐Cannot determine
Inlet VSD direction of flow in diastole ☐Left to Right ☐Right to Left ☐Cannot determine
Common AV Valve RegurgitationNone Trivial Mild Moderate Severe Cannot determine
Right AV Valve regurgitation None Trivial Mild Moderate Severe Cannot determine
Left AV Valve regurgitation None Trivial Mild Moderate Severe Cannot determine
Rastelli Type ☐A ☐B ☐C ☐ cannot determine
Right AV Valve
Hypoplasia:None Trivial Mild Moderate Severe Cannot determine
Color inflow diameter at annulus ☐☐.☐☐cm
Color inflow diameter at mid cavity or at smallest inflow portion ☐☐.☐☐cm
Left AV Valve
Hypoplasia:None Trivial Mild Moderate Severe Cannot determine
Color inflow diameter at Annulus☐☐.☐☐cm
Color inflow diameter at mid cavity or at smallest inflow portion ☐☐.☐☐cm
Papillary muscle abnormality ☐Y ☐N ☐Cannot determine
Type of Papillary muscle abnormality ☐ Too close ☐ Single ☐One Hypoplastic
Parachute ☐Y ☐N ☐Cannot determine
Double orifice LAVV☐Y ☐N ☐Cannot determine
Right Ventricle
RVEDD ☐☐.☐☐ cm
RVESD ☐☐.☐☐ cm
RV Dysfunction Systolic ☐ None ☐ Mild ☐ Moderate ☐ Severe ☐ Cannot determine
RV Dysfunction Diastolic☐ None ☐ Mild ☐ Moderate ☐ Severe ☐ Cannot determine
Right Ventricle Apex-forming ☐Y ☐N ☐Cannot determine
RV length From AV Valve to apex (at end of QRS complex) ☐☐.☐☐cm
RV width (from the crest of the septum- RV side- to the free wall) ☐☐.☐☐cm
RV volume _____cm3
RVEF_____
RVSP_____
Right Ventricular Outflow Tract
PV Annulus in systole☐☐.☐☐mm
PV stenosis:☐None ☐Mild ☐Moderate ☐Severe ☐Cannot determine
PV regurgitation: ☐None ☐Trivial ☐Mild ☐Moderate ☐Severe ☐Cannot determine
MPA hypoplasia/stenosis ☐Y ☐N ☐Cannot determine
LPA hypoplasia/stenosis ☐Y ☐N ☐Cannot determine
RPA hypoplasia/stenosis ☐Y ☐N ☐Cannot determine
MPA Diameter ☐☐mm
LPA Diameter☐☐mm
RPA Diameter☐☐mm
RVOTO ☐Y☐N ☐Cannot determine
If yes, level of obstruction ☐ Sub-valve ☐ Valvar ☐ Supravalvar ☐ Cannot determine
Peak gradient ☐☐ mmHg
Mean gradient ☐☐ mmHg
Peak velocity ☐☐ m/second
Mean velocity ☐☐ m/second
Left Ventricle
LV Hypoplasia ☐None ☐Mild ☐Moderate ☐Severe ☐Cannot determine
LVEDD: ☐☐.☐☐cm ☐ Cannot determine
LVESD: ☐☐.☐☐cm ☐ Cannot determine
LV systolic endocardial length ☐☐.☐☐cm ☐ Cannot determine
LV diastolic endocardial length ☐☐.☐☐ cm ☐ Cannot determine
LV dysfunction Systolic☐None ☐Mild ☐Moderate ☐Severe ☐Cannot determine
LV dysfunction Diastolic☐None ☐Mild ☐Moderate ☐Severe ☐Cannot determine Left Ventricle Apex-forming ☐ Y ☐ N ☐ Cannot determine
LV length from AVV to apex (at end of QRS complex) ☐☐ .☐☐ cm
LV width (from crest of septum- LV side- to free wall) ☐☐ .☐☐ cm
LV volume _____cm3
LVEF_____
Left Ventricular Outflow Tract
LVOT diameter in systole ☐☐.☐☐cm ☐Cannot determine
Left Ventricular Outflow Tract Obstruction: ☐Y ☐N ☐Cannot determine
LVOTO Level of stenosis: ☐Sub-valvar ☐Valvar ☐Supravalvar ☐Cannot determine
LVOTO Type of Subvalvular Stenosis: ☐Fibromuscular ridge ☐Tunnel ☐Discrete membrane ☐Cannot determine
LVOTO Type of Supravalvar Stenosis: ☐Discrete ☐Diffuse ☐Cannot determine
LVOTO☐ No gradient
Peak gradient ☐☐ mmHg☐ Cannot determine
Mean gradient ☐☐ mmHg☐ Cannot determine
Peak velocity ☐☐ mmHg☐ Cannot determine
Mean velocity ☐☐ mmHg☐ Cannot determine
Aortic Valve
Aortic Annulus in systole ☐☐.☐☐cm ☐Cannot determine
Aortic Valve Thickening ☐None ☐Mild ☐Moderate ☐Severe ☐Cannot determine
Number of Leaflets ☐Uni ☐Bi ☐Tri ☐Cannot determine
Stenosis ☐None ☐Mild ☐Moderate ☐Severe☐Cannot determine
Regurgitation ☐None ☐Trivial ☐Mild ☐Moderate ☐Severe ☐Cannot determine
Aortic Arch
Arch Hypoplasia☐Y ☐N☐Cannot determine
If YES, ☐Mild ☐Moderate ☐Severe
Coarctation ☐Y ☐N☐Cannot determine
Location of Coarctation: ☐Transverse ☐LSCA ☐Isthmus ☐Descending aorta ☐Cannot determine
Interrupted Arch ☐Y ☐N ☐Cannot determine
Right Aortic Arch ☐Y ☐N ☐Cannot determine
Aortic Arch measurements
Ascending Aorta (measured from parasternal LA view in systole, just above the ST junction):
☐☐.☐☐cm ☐Cannot determine
Transverse Arch:☐☐.☐☐mm☐Cannot determine
Arch at LSCA ☐☐.☐☐mm ☐Cannot determine
Isthmus / Coarctation:☐☐.☐☐cm ☐Cannot determine
Descending aorta☐☐.☐☐mm ☐Cannot determine
Peak Arch gradient ☐☐ mmHg☐No gradient ☐Cannot determine
Mean Arch gradient ☐☐ mmHg☐No gradient ☐Cannot determine
Peak Arch velocity ☐☐.☐☐ m/second☐No gradient ☐Cannot determine
Mean Arch velocity ☐☐.☐☐ m/second☐No gradient ☐Cannot determine
Flow direction in ascending arch: ☐Antegrade ☐Retrograde ☐Bidirectional ☐Cannot determine
Flow direction in transverse arch: ☐Antegrade ☐Retrograde ☐Bidirectional ☐Cannot determine
Flow direction in descending arch: ☐Antegrade ☐Retrograde ☐Bidirectional ☐Cannot determine
Ductus Arteriosus
Ductus patent ☐ Y ☐ N ☐ Cannot determine
Ductal flow restrictive ☐ Y ☐ N ☐ Cannot determine
Ductal flow in systole ☐ Left to Right ☐ Right to Left ☐ Cannot determine
Ductal flow in diastole ☐ Left to Right ☐ Right to Left ☐ Cannot determine
LSVC☐ Y ☐ N ☐ Cannot determine
Atria
LA systolic dimension ☐☐.☐☐cm
RA systolic dimension ☐☐.☐☐cm
Associated Cardiac Lesions
Tetralogy of Fallot☐Y ☐N ☐Cannot determine
Systemic venous anomalies ☐Y ☐N ☐Cannot determine
Pulmonary venous anomalies ☐Y ☐N ☐Cannot determine
Ventricular dominance ☐RV ☐LV
Additional Measures of Unbalance:☐ Y ☐ N
RAVV overrides LA☐Y ☐N
LAVV overrides RA ☐Y ☐N
Angle RV inflow –LV inflow ______degrees
Distance IAS - LVAVV ring ______cm
Distance RAVV hinge-RAVV groove ______cm
Distance LAVV hinge-LAVV groove ____ cm
Size AV valve _____ cm
Mural leaflet length_____cm
Mural leaflet width _____cm
Version Date: 9 Nov 2011 Page 1 of 5