Coronary arterial patterns in double-outlet right ventricle

Neurosurgical Emergency in an Adult With Single Ventricle Physiology: A Case Report

The anesthetic management of a patient with uncorrected congenital heart disease presenting for noncardiac surgery is quite challenging. When this becomes a neurosurgical emergency, the need to balance cerebral and complex circulatory physiologies tests the anesthesiologist's preparedness. The principal clinical challenges we faced were preventing increases in intracranial pressure while maintaining the circulatory physiology using the "cardiac grid" approach to hemodynamic management in a case of acyanotic double outlet right ventricle with a posterior fossa space-occupying lesion. Point of care preoperative echocardiography enabled us to understand the altered circulatory physiology and successfully manage this patient.

Coronary Arteries in Childhood Heart Disease: Implications for Management of Young Adults

Survival of patients with congenital heart defects has improved dramatically. Many will undergo interventional catheter or surgical procedures later in life. Others will develop atherosclerotic or post-surgical coronary heart disease. The coronary artery anatomy in patients with congenital heart disease differs substantially from that seen in the structurally normal heart. This has implications for diagnostic procedures as well as interventions. The unique epicardial course seen in some defects could impair interpretation of coronary angiograms. Interventional procedures, especially at the base of the heart, risk injuring unusually placed coronary arteries so that coronary artery anatomy must be delineated thoroughly prior to the procedure. In this review, we will describe the variants of coronary artery anatomy and their implications for interventional and surgical treatment and for sudden death during late follow-up in several types of congenital heart defects including: tetralogy of Fallot, truncus arteriosus, transposition of the great arteries, double outlet right ventricle, congenitally corrected transposition of the great arteries and defects with functionally one ventricle. We will also discuss the coronary abnormalities seen in Kawasaki disease.

Imaging of congenital coronary artery anomalies

Imaging of the coronary arteries is an important part of the evaluation of children with congenital heart disease and isolated congenital coronary artery anomalies. Echocardiography remains the main imaging modality and is complemented by MRI and CT angiography in the older or difficult-to-image child. We review echocardiography, MRI, and CT angiography for coronary artery imaging, with emphasis on techniques. The clinical implications of isolated congenital coronary artery anomalies are also addressed, along with a discussion about the current consensus on optimal management of these anomalies.

Short- and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial

BACKGROUND

Transcatheter pulmonary valve placement is an emerging therapy for pulmonary regurgitation and right ventricular outflow tract obstruction in selected patients. The Melody valve was recently approved in the United States for placement in dysfunctional right ventricular outflow tract conduits.

METHODS AND RESULTS

From January 2007 to August 2009, 136 patients (median age, 19 years) underwent catheterization for intended Melody valve implantation at 5 centers. Implantation was attempted in 124 patients; in the other 12, transcatheter pulmonary valve placement was not attempted because of the risk of coronary artery compression (n=6) or other clinical or protocol contraindications. There was 1 death from intracranial hemorrhage after coronary artery dissection, and 1 valve was explanted after conduit rupture. The median peak right ventricular outflow tract gradient was 37 mm Hg before implantation and 12 mm Hg immediately after implantation. Before implantation, pulmonary regurgitation was moderate or severe in 92 patients (81% with data); no patient had more than mild pulmonary regurgitation early after implantation or during follow-up (>or=1 year in 65 patients). Freedom from diagnosis of stent fracture was 77.8+/-4.3% at 14 months. Freedom from Melody valve dysfunction or reintervention was 93.5+/-2.4% at 1 year. A higher right ventricular outflow tract gradient at discharge (P=0.003) and younger age (P=0.01) were associated with shorter freedom from dysfunction.

CONCLUSIONS

In this updated report from the multicenter US Melody valve trial, we demonstrated an ongoing high rate of procedural success and encouraging short-term valve function. All reinterventions in this series were for right ventricular outflow tract obstruction, highlighting the importance of patient selection, adequate relief of obstruction, and measures to prevent and manage stent fracture. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00740870.

Coronary artery anatomy in children with congenital heart disease by computed tomography

AIMS

To evaluate electron beam computed tomography (EBCT) for recognition of coronary artery patterns in children with congenital heart diseases.

METHODS

Institutional review board approval was obtained; informed consents were not required. A total of 226 children diagnosed with Tetralogy of Fallot (n=122), double outlet right ventricle (n=52), transposition of the great arteries (n=34), and congenitally corrected transposition (n=18) who had undergone cardiac EBCT at our institution between 1995 and 2002 were identified. Iodinated contrast medium was injected with arterial phase acquisition. The two radiologists and one pediatric cardiologist that interpreted the EBCT images and cardiac angiograms, respectively, were blinded to each other's results. Surgical and cardiac angiogram findings were compared to the EBCT results. Descriptive statistics were used to compare efficacy.

RESULTS

Numerous aberrant patterns were clearly identified on the EBCT images. Pattern IX occurred in most patients with Tetralogy of Fallot or double outlet right ventricle. Patterns I and 0 are the most common coronary artery types in transposition of the great arteries and congenitally corrected transposition, respectively. Overall diagnostic accuracy for all disease groups was 82.7%. The diagnostic accuracy of the coronary arterial anatomy by EBCT increased with older age, and was more than 90% in individuals aged over 3 months.

CONCLUSION

EBCT is effective for identification of the coronary anatomy of children with specific congenital heart diseases, except for neonates and small infants less than 3 months of age.

Coronary artery embryogenesis in cardiac defects induced by retinoic acid in mice

BACKGROUND

Although normal coronary artery embryogenesis is well described in the literature, little is known about the development of coronary vessels in abnormal hearts.

METHODS

We used an animal model of retinoic acid (RA)-evoked outflow tract malformations (e.g., double outlet right ventricle [DORV], transposition of the great arteries [TGA], and common truncus arteriosus [CTA]) to study the embryogenesis of coronary arteries using endothelial cell markers (anti-PECAM-1 antibodies and Griffonia simplicifolia I (GSI) lectin). These markers were applied to serial sections of staged mouse hearts to demonstrate the location of coronary artery primordia.

RESULTS

In malformations with a dextropositioned aorta, the shape of the peritruncal plexus, from which the coronary arteries develop, differed from that of control hearts. This difference in the shape of the early capillary plexus in the control and RA-treated hearts depends on the position of the aorta relative to the pulmonary trunk. In both normal and RA-treated hearts, there are several capillary penetrations to each aortic sinus facing the pulmonary trunk, but eventually only 1 coronary artery establishes patency with 1 aortic sinus.

CONCLUSIONS

The abnormal location of the vessel primordia induces defective courses of coronary arteries; creates fistulas, a single coronary artery, and dilated vessel lumens; and leaves certain areas of the heart devoid of coronary artery branches. RA-evoked heart malformations may be a useful model for elucidating abnormal patterns of coronary artery development and may shed some light on the angiogenesis of coronary artery formation.

Results of arterial switch operation for primary total correction of the Taussig-Bing anomaly

BACKGROUND

This study evaluates the results of the arterial switch operation for early total repair of double-outlet right ventricle with subpulmonary ventricular septal defect (the Taussig-Bing heart).

METHODS

From 1986 through April 2003, 27 patients with Taussig-Bing anomaly underwent arterial switch operation. Twenty patients were neonates (n = 11) or infants younger than 3 months (n = 9). Obstruction of aortic arch (n = 19) or subaortic right ventricular outflow tract obstruction (n = 20) and unusual coronary artery patterns (n = 19) were common. Total correction as a single procedure was performed in 21 patients. Events are depicted by Kaplan-Meier curves.

RESULTS

There was 1 patient hospital death at 2 months after repair. One patient died late that was not cardiac related. Survival was 92% +/- 6% at 8 months and remained constant thereafter. Four patients underwent reoperation (1 for residual aortic arch obstruction and 3 for subvalvular and valvular pulmonary stenosis). Freedom from reoperation decreased to stabilize at 83% +/- 8% after 2 years. The risk to have right ventricular outflow tract obstruction develop was 33% +/- 10% at 1 year, increasing slowly and leveling out at 57% +/- 12% at year 5 and thereafter. Statistical analysis revealed no significant risk factor for death or need for reoperation.

CONCLUSIONS

The Taussig-Bing anomaly should be corrected in the neonatal period or in early infancy by arterial switch operation, closure of the ventricular septal defect, and simultaneous correction of associated cardiovascular anomalies as a one-stage procedure. Right ventricular outflow tract obstruction often complicates the postoperative course and is the main cause for reintervention.

Double-outlet right ventricle: Pathology and angiocardiography

Double-outlet right ventricle is but one form of abnormal ventriculoarterial connection. The definition that more than half of each great artery originates above the morphologically right ventricle is arbitrary. As pointed out by Lecompte, those features that should be defined in hearts with the ventriculoarterial connection of double-outlet right ventricle (and indeed other forms of abnormal ventriculoarterial connection) include the nature of the infundibular septum, ventriculoinfundibular fold, trabeculoseptomargin-alis, attachments of infundibular septum to anterior or posterior limb of trabeculoseptomargin-alis, the size and position of the ventricular septal defect, the spatial relation of great artery(s) to the ventricular septal defect, the spatial relationship between the great, and the distance between the tricuspid and pulmonary valves and the semilunar valves. Copyright 2000 by W.B. Saunders Company

Surgical outcome of double-outlet right ventricle with subpulmonary VSD

BACKGROUND

Optimal management of double-outlet right ventricle with subpulmonary ventricular septal defect remains controversial. We reviewed our 7-year experience with patients who had this anatomic configuration.

METHODS

Between January 1992 and January 1999, 20 patients underwent an arterial switch operation (ASO group), and 12 underwent a bidirectional Glenn procedure followed by a modified Fontan in 10 (Glenn/Fontan). Mean follow-up was 23 +/- 18 months.

RESULTS

An initial palliative operation was done in 19 patients (9 in the ASO group, 10 in the Glenn/Fontan group). There were no deaths in the Glenn/Fontan group. Four patients in the ASO group died within 33 days postoperatively. Two of them had a single coronary artery, 1 had a straddling mitral valve, 1 had a hypoplastic aortic arch, and 1 had multiple ventricular septal defects. Three patients had reoperation for subaortic stenosis (n = 2) or pulmonary stenosis (n = 1) after the ASO. Four patients (3 in the ASO group, 1 in the Glenn/Fontan) required a pacemaker for postoperative complete atrioventricular block. Actuarial survival at 5 years for the entire group was 87% (70% confidence interval, 81% to 93%).

CONCLUSIONS

The ASO remains our preferred treatment for infants with double-outlet right ventricle and subpulmonary ventricular septal defect. However, associated anatomic defects are important risk factors.

Clinical results of arterial switch operation for double-outlet right ventricle with subpulmonary VSD

OBJECTIVE

An arterial switch operation is considered a good alternative for the repair of double-outlet right ventricle (DORV) with atrioventricular concordance connection and subpulmonary ventricular septal defect (VSD) when intraventricular rerouting is not feasible. The clinical results of an arterial switch operation with ventricular septal defect closure for this anomaly were studied.

METHODS

Between 1986 and 1997, 27 patients ranging from 10 days to 5 years of age (mean 0.4 years) underwent an arterial switch operation with ventricular septal defect closure for the correction of double outlet right ventricle with subpulmonary VSD. The 50% rule was used to define double-outlet right ventricle. Arch anomalies were associated in nine cases, and were corrected either previously or simultaneously. A subarterial muscle resection was performed in 14 without any subsequent stenosis of the ventricular outflow tract. The relationship of the great arteries was mostly anteroposterior in 15 and mostly side by side in 12. The left coronary artery (main trunk or circumflex artery) courses behind the pulmonary artery in 15/27 (six/15 in the anteroposterior relation and ten/12 in the side by side relation). The Lecompte maneuver was used to reconstruct the pulmonary artery in all but five cases with a side by side relationship of the great arteries.

RESULTS

There was one operative death (3.7%) and three late deaths. The actuarial survival rate was 83 +/- 8% at 9 years. Right ventricular outflow tract obstruction including peripheral pulmonary stenosis developed in seven cases operated on in the early era. The reoperation free rate was 46 +/- 20% at 9 years.

CONCLUSION

Although double-outlet right ventricle with subpulmonary VSD has complex features, including an aortic arch obstruction and coronary artery anomalies, an optimal definitive surgical repair using an arterial switch operation can be performed safely with a thorough understanding of this variable anomaly. The prevention of right ventricular outflow tract obstruction at the time of an arterial switch operation may thus help improve the rate of late morbidity.

Echocardiographic diagnosis of single coronary artery in double-outlet right ventricle

We report the echocardiographic diagnosis of the combination single coronary artery and double-outlet right ventricle, initially recognizing this coronary artery variation by imaging in the subcostal coronal axis. This combination occurs in approximately 11% of patients with double-outlet right ventricle and raises important issues regarding coronary artery transfer in an arterial switch repair.