Figure 23f

In patients with Eisenmenger's syndrome, in response to substantial left-to-right shunting, morphologic alterations occur in the small pulmonary arteries and arterioles (inset), leading to pulmonary hypertention and the resultant reversal of the intracardiac shunt (arrow). In the small pulmonary arteries and arterioles, medial hypertrophy, intimal cellular proliferation, and fibrosis lead to narrowing or closure of the vessel lumen. With sustained pulmonary hypertension, extensive atherosclerosis and calcification often develop in the large pulmonary arteries. Eisenmenger's syndrome may occur in association with a ventricular septal defect (ass shown), but it also may occur in association with an atrial septal defect or patent ductus arteriosus.

Brickner, M.E., Hillis, L.D., and Lange, R.A., Medical Progress: Congenital Heart Disease in Adults (first of two parts), The New England Journal of Medicine, p 334-343

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