Factors Precluding a Successful Biventricular Repair in Critical Aortic Stenosis | Patient Case Quiz

A two-day-old, full-term infant was transferred to a level 3 neonatal intensive care unit (NICU). She did well until 36 hours of life, at which time she developed marked tachypnea with grunting and retractions. Serum glucose was 95 mg/dL (normal). Lower extremity pulse oximetry was 88%. She was placed on oxygen by nasal cannula with no significant change. Blood and urine cultures were obtained, antibiotics administered, and transfer arranged. Prostaglandin E-1 was initiated, but the infant continued to decline with worsening SpO2, requiring intubation.

Figure 1

Figure 1

Patient's aortic valve (parasternal short axis)

Upon arrival, Heart rate was 166 BPM. All four extremity systolic blood pressures were in the 60s (mm Hg). Pre- and post-ductal SpO2 on 50% Fi02 were 88% and 84%, respectively. There was good air entry and clear lung fields, with a right ventricular (RV) heave and normal S1 but a loud, split S2. There was a harsh II-III/VI continuous murmur at the left upper sternal border that radiated throughout the precordium. There was no brachiofemoral delay. An arterial blood gas (ABG) demonstrated pH 7.31, pCO2 47, and pO2 42; with lactate 4.5 mmol/L. An echocardiogram was performed (Figure 1).

Which of the following echocardiographic parameters is best associated with a successful biventricular repair in this case?

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