Aortic regurgitation during systole: color flow mapping and Doppler interrogation following the Damus-Kaye-Stansel procedure

Accuracy of systolic aortic regurgitation in the diagnosis of heart failure: a predictive approach

BACKGROUND

Systolic aortic regurgitation (SAR) is a curious phenomenon that has been found to be associated with heart failure (HF). We aimed to determine de diagnostic value of SAR as a black box predictive tool in patients with suspected HF admitted to hospital with dyspnea as leading symptom.

METHODS AND RESULTS

Cross-sectional study including 269 consecutive patients admitted to hospital with dyspnea as leading symptom without definite clinical diagnosis. SAR was defined by echocardiography as the presence of blood flow from the aorta to the left ventricular outflow tract during a complete systole. The reference standard was the presence of HF diagnosis at discharge. SAR was present in 9 (3.3%) patients. Prevalence of HF was 40.3%. Specificity of SAR in the diagnosis of HF was high at 99.4% (95% CI 96.5-99.9%). Sensitivity was 7.5% (95% CI 3.9-14.2%). Positive predictive value (PPV) was 88.9% (95% CI 56.5-98.0%). Positive likelihood ratio was 11.85. Estimated PPV of SAR was significantly higher than 50% for any hypothetical prevalence of HF.

CONCLUSION

In patients admitted to hospital with dyspnea, the finding of systolic aortic regurgitation in echocardiography has a high PPV for HF diagnosis at discharge.

Systolic aortic regurgitation: a not-so-rare phenomenon

In a normal cardiac cycle, aortic and pulmonary regurgitation are diastolic phenomena. Aortic regurgitation has been observed in ventricular systole in patients with arrhythmias, extracorporeal circulation and palliative surgical correction of complex congenital heart disease. Systolic aortic regurgitation is explained as the inability of the ventricular beat to overcome the aortic pressure in patients with valvular incompetence. Beyond its potential as an elegant quiz about heart physiology, clinical association of systolic aortic regurgitation with heart failure and syncope has been described. Illustrative examples of both aortic and pulmonary systolic regurgitation are presented, an image of "continuous" aortic regurgitation is displayed, and technical issues on its diagnosis are briefly commented.

Designing therapeutic strategies for patients with a dominant left ventricle, discordant ventriculo-arterial connections, and unobstructed flow of blood to the lungs

The palliation of the cyanotic child with a dominant morphologically left ventricle, discordant ventriculo-arterial connections, and obstruction to the pulmonary outflow tract has continued to evolve and mature. The evolution began in the early days of surgical palliation with the Blalock-Taussig shunt, extended to construction of cavopulmonary shunts, if required, and then to the Fontan procedure and its subsequent modifications. This journey took nearly 30 years to complete. There is increasing clinical data to document the beneficial effects of this approach, with ever-improving outcomes. Some aspects of the history of the cavopulmonary shunt have been previously reviewed in this journal and elsewhere, as have analysis of outcomes for some groups of patients considered for surgical completion of the Fontan circulation. While there has been some ongoing interest in ventricular septation since the early success of Sakakibara et al., this approach has largely been abandoned. Considerably more challenges and debate resonate in the surgical algorithms defined for patients whose hearts are characterized by a dominant left ventricle, discordant ventriculo-arterial connections, and unobstructed flow of blood to the lungs. This latter group will be the focus of this review, as will the aetiology of the myocardial hypertrophy that is particularly frequent in this group of patients, its clinical recognition, indeed its anticipation, and the multiple surgical strategies designed to prevent or treat it. All these manoeuvres are considered to optimise suitability for, and outcome from, creation of the Fontan circulation.

Modified Damus-Kaye-Stansel procedure for single ventricle, subaortic stenosis, and arch obstruction in neonates and infants: midterm results and techniques for avoiding circulatory arrest

BACKGROUND

A modified Damus-Kaye-Stansel procedure is one of several options for palliation of single ventricle with subaortic obstruction, but results in neonates have been disappointing. In the presence of arch obstruction, this procedure is typically performed with circulatory arrest, which may contribute to neurologic insult.

METHODS

Since 1990, a modified Damus-Kaye-Stansel procedure has been performed in 14 neonates and seven infants with single ventricle and subaortic stenosis, including 15 with arch obstruction. Diagnoses were double-inlet left ventricle (n = 12), tricuspid atresia (n = 2), and other forms of hypoplastic ventricle with subaortic obstruction (n = 7). Three patients underwent concurrent bidirectional Glenn shunt. In the most recent seven patients with arch obstruction, arch repair was achieved with an end-to-side anastomosis of the descending aorta to the ascending aorta with continuous upper body perfusion.

RESULTS

One early death occurred among the 14 neonates (7%) and three among the infants, for an early mortality of 19%. At a median follow-up of 33 months, there were no late deaths or neurologic complications. Nine patients underwent subsequent bidirectional Glenn anastomosis, including three who had Fontan completion and one who later underwent conversion to a partial biventricular repair. One patient required a transplant for cardiomyopathy of unknown etiology. The remaining 12 patients are considered good candidates for Fontan completion. No patient has recurrent arch obstruction. Four patients have mild (n = 1) or trivial (n = 3) semilunar valvular regurgitation.

CONCLUSION

The modified Damus-Kaye-Stansel procedure is an effective primary palliation for single ventricle and subaortic stenosis, with or without arch obstruction. Results are especially encouraging in neonates. Arch repair can be achieved without circulatory arrest to the brain.

Doppler color flow echocardiography: indispensable application to congenital heart disease

Doppler color flow imaging has become indispensable in the diagnosis and management of patients with congenital heart disease. Certain defects may not be possible, or may be very difficult to diagnose by two-dimensional echocardiography alone. Such examples include multiple ventricular septal defects, anomalous pulmonary venous connection, coronary artery malformations, and the hypertensive patent ductus arteriosus. Additionally, color flow Doppler echocardiography significantly provides additional information, and reduces the time for fetal and transesophageal echocardiographic studies. Doppler color flow imaging has become an essential part of the echocardiographic examination. Experience has broadened the use of this important technological advance, with anticipation of an ever expanding future for its clinical application.

Damus-Stansel-Kaye procedure: technical modifications

The Damus-Stansel-Kaye procedure has been applied for the relief of outflow tract obstruction caused by a restrictive bulboventricular foramen or subaortic stenosis in patients with complex univentricular heart disease. The procedure may also be part of a biventricular repair of a Taussig-Bing transposition of the great arteries. This report details technical modifications of the procedure to ensure unobstructed blood flow from the pulmonary artery to the aorta and to maintain the integrity of the pulmonary and aortic valves.