Malaligned outlet septum with subpulmonary ventricular septal defect and abnormal ventriculoarterial connection: a morphologic spectrum defined echocardiographically

Impact of prenatal diagnosis and anatomical subtype on outcome in double outlet right ventricle

BACKGROUND

We sought to investigate the influence of prenatal diagnosis and risk factors for adverse outcomes in double outlet right ventricle (DORV) not associated with heterotaxy.

METHODS

Patients with a pre or postnatal diagnosis of DORV from 2000 to 2007 were identified and classified into 3 subgroups: subaortic ventricular septal defect (VSD) and normal great artery (GA) arrangement (=VSD type), tetralogy of Fallot type, and transposition of the GA type (=TGA type). Patients with heterotaxy, atrioventricular septal defect, valve atresia, and ventricular hypoplasia were excluded. Complex postnatal care was defined as prematurity, need for prostaglandins, surgical repair <2 months, or univentricular palliation. Risk factors for complex postnatal care and demise were sought in multivariable logistic regression models. One hundred fort-five patients were included (93 prenatal, 52 postnatal).

RESULTS

There were 24 pregnancy terminations and 7 in utero deaths. Fetal demise was associated with abnormal karyotype (odds ratio [OR] 1.9, P = .01), any tricuspid valve regurgitation (OR 10.6, P = .01), and hydrops (OR 23.8, P = .02). Of 114 liveborn patients, 23 were tetralogy-type, 67 VSD-type, and 24 TGA-type patients. Postnatal survival of liveborn patients at 1 year was similar in pre- versus postnatally diagnosed patients (84% vs 85%). Abnormal GA relationship (OR 2.9, P = .02), subpulmonary VSD (OR 6.0, P = .001), unobstructed pulmonary blood flow at birth (OR 2.8, P = .05), and aortic coarctation (OR 9.0, P = .007) were associated with suboptimal postsurgical outcomes.

CONCLUSION

Double outlet right ventricle, even without heterotaxy, is associated with complex postnatal care and high risk of early demise. Morphologic subtype, irrespective of pre- or postnatal diagnosis, is a major determinant of outcome.

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

Double outlet right ventricle associated with cor triatriatum sinistrum

Echocardiographic examination of a newborn infant showed a double outlet right ventricle with subpulmonary ventricular septal defect. The left atrium was divided by a membrane-like structure into a proximal chamber receiving pulmonary veins and a distal compartment containing left atrial appendage. To our knowledge, this is the first report of cor triatriatum sinistrum associated with double outlet right ventricle.

Conal anatomy in 119 patients with d-loop transposition of the great arteries and ventricular septal defect: an echocardiographic and pathologic study

OBJECTIVES

We sought to study the range of conal morphology in transposition of the great arteries with ventricular septal defect and their embryologic and surgical implications.

BACKGROUND

Conal anatomy in transposition of the great arteries and ventricular septal defect is variable and might affect surgical repair.

METHODS

Conal anatomy was explored using two-dimensional echocardiography in 119 patients with transposition of the great arteries and a large ventricular septal defect who presented between 1984 and 1991. The influence of conal anatomy on surgical technique was determined by review of the operative reports. Specimens of transposition of the great arteries with unusual conal anatomy were selected from the Cardiac Registry for comparison with the echocardiograms.

RESULTS

One hundred five patients (88.2%) had subaortic conus only with no subpulmonary conus (Group 1). Subarterial conus was present bilaterally in eight patients (6.7%) (Group 2). Four patients (3.4%) had only subpulmonary conus with no (or minimal) subaortic conus (Group 3). Among these four patients, the aorta was posterior to the pulmonary artery in one patient, side by side relative to the pulmonary artery in two patients and slightly anterior in the fourth patient. Subarterial conus was absent bilaterally in two patients (1.7%) (Group 4); the aorta was slightly posterior in one and side by side with the pulmonary artery in the other.

CONCLUSIONS

This variability of conal anatomy in transposition of the great arteries with ventricular septal defect implies four mechanisms by which transposition can occur. The conal anatomy appeared to affect surgical repair in Groups 1 and 2 insofar as it influenced ventricular outflow tract obstruction. In Groups 3 and 4, an arterial switch operation was performed in four of the six patients. The posterior location of the aorta obviated the need for the Lecompte maneuver in two of these four patients. In the remaining two cases in Groups 3 and 4, the condition was repaired by directing the left ventricular outflow across the ventricular septal defect to the aorta using a patch, with or without placement of a conduit from the right ventricle to the pulmonary artery.

Determinants of outcome in hospitalized infants with congenital heart disease

To identify determinants of adverse outcome in this era of early, definitive treatment, retrospective data were analyzed for 1988 on infants aged less than 1 year with congenital cardiac disease hospitalized at The Johns Hopkins Hospital. In this cohort of 108 infants, 34% (37 of 108) had complex cardiac disease, 33% (36 of 108) had major extracardiac anomalies, 88 patients (81%) underwent 116 surgical procedures, 37% (40 of 108) were hospitalized for greater than 28 days and 29% (31 of 108) died during the first year. Univariate analysis showed that complex disease (i.e., severe ventricular hypoplasia, ventricular septal malalignment or outflow atresia), extracardiac anomalies, early initial presentation, and prolonged stay in the intensive care unit were significantly associated with infant death, whereas surgery was associated with a significantly increased rate of survival. The findings for complex disease and surgery persisted in multiple logistic regression analysis. It is concluded that outcome in most infants with congenital cardiac defects is now extremely favorable, and that major research and preventive efforts should focus on complex congenital cardiac defects.

Surgical management of severe aortic outflow obstruction in lesions other than the hypoplastic left heart syndrome: use of a pulmonary artery to aorta anastomosis

Between December 1985 and April 1990, 50 infants with a variety of congenital cardiac lesions other than the hypoplastic left heart syndrome underwent surgical relief of aortic outflow obstruction by creation of a pulmonary artery to aorta anastomosis. The patients were grouped anatomically by ventriculoarterial alignment. Nineteen had normally aligned great arteries (group I); 25 had transposition of the great arteries, all with a univentricular heart of left ventricular morphology (group II); and 6 had a double-outlet right ventricle (group III). All patients had either aortic stenosis with atresia, subaortic stenosis or a restrictive ventricular septal defect. Sixteen had normal arch anatomy; 34 had arch anomalies consisting of arch hypoplasia (n = 17), coarctation (n = 11), interruption of the arch (n = 4) and complex arch anomalies (n = 2). Surgery was performed at a median age of 10 days (range 2 to 184). Of the 50 infants, 33 survived. No significant difference in early survival (30 days) was noted among the groups of varying ventriculoarterial alignment (68% group I, 72% group II, 83% group III) (p greater than 0.05). Overall actuarial survival was 63% at 18 months. Analysis of actuarial survival by arch anatomy, although not statistically significant, revealed a trend toward better survival at 18 months postoperatively in infants with normal arch anatomy (81%) than in infants with arch anomalies (54%). Of the 33 survivors, 26 have proceeded to the next surgical stage, including the Fontan procedure in 8, superior cavopulmonary anastomosis in 13 and biventricular repair in 5.(ABSTRACT TRUNCATED AT 250 WORDS)