Understanding the spectrum of sinus venosus interatrial communications

Outcomes of the Modified Warden Procedure for Partial Anomalous Pulmonary Venous Connection Drainage to a High Location in the Superior Vena Cava

AIM

To report the safety and effectiveness of a modified Warden procedure.

METHOD

Twenty-six (26) patients underwent modified Warden surgery at our centre from September 2017 to September 2021. In all patients, the superior vena cava (SVC) was reconstructed by turning the atrial wall in the main body of the right atrium upwards and applying fresh autologous pericardial patches. There were 13 male patients and 13 female patients, and the median age of the patients was 7.0 (range, 0.3-47.0) years. The median follow-up time after surgery was 47.0 (range, 32.0-80.0) months.

RESULTS

The aortic cross-clamp time was 108.50±34.72 minutes, the cardiopulmonary bypass time was 154.81±41.65 minutes, the median postoperative mechanical ventilation time was 8.5 (range, 0.0-91.0) hours, the median intensive care unit stay was 43.5 (range, 15.0-352.0) hours, and the median length of postoperative hospital stay was 7.0 (range, 6.0-19.0) days. All patients were safely and successfully discharged from the hospital. No deaths or sinus node dysfunction occurred during the follow-up period. The mean gradient of the reconstructed SVC and/or the right pulmonary vein (PV) increased in eight patients and decreased to less than 1 mmHg in six patients. One (1) adult patient had already undergone two vascular interventions, and one child had persistent stenosis but did not undergo reoperation at the time of the study. In addition, two patients were subjected to pericardial windowing.

CONCLUSIONS

A modified Warden technique using a right atrial flap and autologous pericardium effectively corrected the high-plane connection between the PVs and SVC. This technique effectively avoids sinus node dysfunction; however, a short-term increase in the differential pressure of the re-established SVC or PV after the procedure is acceptable, and reintervention is required only in rare cases.

Virtual Reality for Preprocedure Planning of Covered Stent Correction of Superior Sinus Venosus Atrial Septal Defects

BACKGROUND

Covered stent correction (CSC) of a superior sinus venosus atrial septal defect is an alternative to surgery in selected patients, but anatomic variation means that assessment for CSC requires a 3-dimensional anatomic understanding. Heart VR is a virtual reality (VR) system that rapidly displays and renders multimodality imaging without prior image segmentation. The aim of this study was to evaluate the performance of the Heart VR system to assess patient suitability for CSC.

METHODS

In a blinded fashion, 2 interventionalists reviewed preprocedural computed tomography scans using Heart VR to assess the feasibility of CSC, including the potential need for pulmonary vein protection. The total review time using VR was recorded.

RESULTS

Using conventional imaging, 15 patients were deemed suitable for CSC, but at catheterization, 3 cases were unsuitable. Using VR, when both interventionalists agreed that a case was suitable for CSC (n=12), all proved technically feasible. In the 3 cases that were unsuitable for CSC, the interventionalists using VR were either uncertain (n=1) or did not agree on suitability (n=2). The strategy for pulmonary vein protection was correctly identified by interventionalist 1 and 2 in 9/12 and 8/12 cases, respectively. In cases where pulmonary vein protection was required intraprocedurally (n=5), this was correctly identified using Heart VR. Using VR, in 3 cases it was determined that pulmonary vein protection would be required, but this was not the case on balloon interrogation. VR data loading and review times were 82 seconds and 7 minutes, respectively. Verbal feedback indicated that Heart VR assisted in the assessment of case suitability.

CONCLUSIONS

Heart VR is a rapid and effective tool for predicting suitability for CSC in patients with a superior sinus venosus atrial septal defect and could be a feasible alternative to segmented virtual or physical 3-dimensional models.

Transcatheter versus surgical treatment for isolated superior sinus venosus atrial septal defect

BACKGROUND

The superior sinus venosus atrial septal defect is a congenital communication between the left and right atria. Open surgical approach by patch closure has historically been the only treatment option. Recently, a transcatheter approach has been developed. This study aims to compare the efficacy and safety of surgical and transcatheter approach in treatment of sinus venosus atrial septal defect.

METHODS

Between March 2010 and December 2020, 58 patients (median age: 45.4, range 14.8-73.8) underwent either surgical or transcatheter correction of superior sinus venosus atrial septal defect with partial anomalous pulmonary venous drainage.

RESULTS

Twenty-four patients (median age: 35.4, range 14.8-66.8) underwent surgery while 34 patients (median age: 46.8, range 15.5-73.8) had a transcatheter treatment. During the catheterization era, 41 patients was considered suitable for a transcatheter closure. In 5 patients, surgery was the patient's or referring physician's choice. In 2 cases, the procedure was unsuccessful; the remaining 34 were successfully closed (94.4% of cases). Intensive care unit stay (median of 1 day, range 0.5-4, vs. 0, range 0-2, p < 0.0001) and hospital stay (median 7 days, range 2-15 vs. 2 days, range 1-12, p < 0.0001), were significantly longer in the surgery group. Total early complication rate, consisted on procedural and in-hospital complication, were higher in the surgical group (62.5% vs. 23.5%; p = 0.005). However, complications in both groups were clinically mild. At follow-up, a small residual shunt was present in 6 patients (surgery group: 2 pts; catheterization group: 4 pts; p: NS). Imaging studies showed significant improvement of right ventricular size and unobstructed pulmonary venous return in all patients. No late complications occurred at follow-up.

CONCLUSIONS

Transcatheter correction of sinus venosus atrial septal defect is effective and safe in selected patients and may be considered as a valid alternative to surgery.

Multimodality imaging in delineation of complex sinus venosus defects and treatment outcomes over the last decade

BACKGROUND

Diagnosis of sinus venosus defects, not infrequently associated with complex anomalous pulmonary venous drainage, may be delayed requiring multimodality imaging.

METHODS

Retrospective review of all patients from February 2008 to January 2019.

RESULTS

Thirty-seven children were diagnosed at a median age of 4.2 years (range 0.5-15.5 years). In 32 of 37 (86%) patients, diagnosis was achieved on transthoracic echocardiography, but five patients (14%) had complex variants (four had high insertion of anomalous vein into the superior caval vein and three had multiple anomalous veins draining to different sites, two of whom had drainage of one vein into the high superior caval vein). In these five patients, the final diagnosis was achieved by multimodality imaging and intra-operative findings. The median age at surgery was 5.2 years (range 1.6-15.8 years). Thirty-one patients underwent double patch repair, four patients a Warden repair, and two patients a single-patch repair. Of the four Warden repairs, two patients had a high insertion of right-sided anomalous pulmonary vein into the superior caval vein, one patient had bilateral superior caval veins, and one patient had right lower pulmonary vein insertion into the right atrium/superior caval vein junction. There was no post-operative mortality, reoperation, residual shunt or pulmonary venous obstruction. One patient developed superior caval vein obstruction and one patient developed atrial flutter.

CONCLUSION

Complementary cardiac imaging modalities improve diagnosis of complex sinus venosus defects associated with a wide variation in the pattern of anomalous pulmonary venous connection. Nonetheless, surgical treatment is associated with excellent outcomes.

Multimodality Imaging of Sinus Venosus Atrial Septal Defect: A Challenging Diagnosis in Adults

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SVASD should be suspected in cases of unexplained RV volume overload.

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Direct visualization of SVASD with TTE is difficult in adults compared with children.

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TEE is helpful for diagnosing SVASD and associated pulmonary venous abnormalities.

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Multimodal imaging techniques offer incremental value in the workup of SVASD.

Sinus venosus defect of the pulmonary vein-type: An easily missed diagnosis

Atrial septal defects are one of the most common forms of congenital heart disease, however sinus venosus communications, particularly pulmonary vein-type defects, are rare and are easily misdiagnosed. Patients with pulmonary vein-type sinus venosus defects often present earlier than those with ostium secundum defects with significant right heart dilation. Correct diagnosis has important implications for management. We discuss the clinical courses and review multimodality imaging of three patients correctly diagnosed with pulmonary vein-type defects after an initial diagnosis of an ostium secundum atrial septal defect, in order to promote understanding of the unique anatomy of this entity.

Clarifying the anatomy of the superior sinus venosus defect

OBJECTIVES

We sought to clarify the variations in the anatomy of the superior cavoatrial junction and anomalously connected pulmonary veins in patients with superior sinus venosus defects using computed tomographic (CT) angiography.

METHODS

CT angiograms of 96 consecutive patients known to have superior sinus venosus defects were analysed.

RESULTS

The median age of the patients was 34.5 years. In seven (7%) patients, the defect showed significant caudal extension, having a supero-inferior dimension greater than 25 mm. All patients had anomalous connection of the right superior pulmonary vein. The right middle and right inferior pulmonary vein were also connected anomalously in 88 (92%) and 17 (18%) patients, respectively. Anomalous connection of the right inferior pulmonary vein was more common in those with significant caudal extension of the defect (57% vs 15%, p=0.005). Among anomalously connected pulmonary veins, the right superior, middle, and inferior pulmonary veins were committed to the left atrium in 6, 17, and 11 patients, respectively. The superior caval vein over-rode the interatrial septum in 67 (70%) patients, with greater than 50% over-ride in 3 patients.

CONCLUSION

Anomalous connection of the right-sided pulmonary veins is universal, but is not limited to the right upper lobe. Not all individuals have over-riding of superior caval vein. In a minority of patients, the defect has significant caudal extension, and anomalously connected pulmonary veins are committed to the left atrium. These findings have significant clinical and therapeutic implications.

Myocardial overexpression of ANKRD1 causes sinus venosus defects and progressive diastolic dysfunction

AIMS

Increased Ankyrin Repeat Domain 1 (ANKRD1) levels linked to gain of function mutations have been associated to total anomalous pulmonary venous return and adult cardiomyopathy occurrence in humans. The link between increased ANKRD1 level and cardiac structural and functional disease is not understood. To get insight into this problem, we have generated a gain of function ANKRD1 mouse model by overexpressing ANKRD1 in the myocardium.

METHODS AND RESULTS

Ankrd1 is expressed non-homogeneously in the embryonic myocardium, with a dynamic nucleo-sarcomeric localization in developing cardiomyocytes. ANKRD1 transgenic mice present sinus venosus defect, which originates during development by impaired remodelling of early embryonic heart. Adult transgenic hearts develop diastolic dysfunction with preserved ejection fraction, which progressively evolves into heart failure, as shown histologically and haemodynamically. Transgenic cardiomyocyte structure, sarcomeric assembly, and stability are progressively impaired from embryonic to adult life. Postnatal transgenic myofibrils also present characteristic functional alterations: impaired compliance at neonatal stage and impaired lusitropism in adult hearts. Altogether, our combined analyses suggest that impaired embryonic remodelling and adult heart dysfunction in ANKRD1 transgenic mice present a common ground of initial cardiomyocyte defects, which are exacerbated postnatally. Molecular analysis showed transient activation of GATA4-Nkx2.5 transcription in early transgenic embryos and subsequent dynamic transcriptional modulation within titin gene.

CONCLUSIONS

ANKRD1 is a fine mediator of cardiomyocyte response to haemodynamic load in the developing and adult heart. Increased ANKRD1 levels are sufficient to initiate an altered cellular phenotype, which is progressively exacerbated into a pathological organ response by the high ventricular workload during postnatal life. Our study defines for the first time a unifying picture for ANKRD1 role in heart development and disease and provides the first mechanistic link between ANKRD1 overexpression and cardiac disease onset.

Autopsy in adults with congenital heart disease (ACHD)

The adult congenital heart diseases (ACHD) population is exceeding the pediatric congenital heart diseases (CHD) population and is progressively expanding each year, representing more than 90% of patients with CHD. Of these, about 75% have undergone surgical and/or percutaneous intervention for palliation or correction. Autopsy can be a very challenging procedure in ACHD patients. The approach and protocol to be used may vary depending on whether the pathologists are facing native disease without surgical or percutaneous interventions, but with various degrees of cardiac remodeling, or previously palliated or corrected CHD. Moreover, interventions for the same condition have evolved over the last decades, as has perioperative myocardial preservations and postoperative care, with different long-term sequelae depending on the era in which patients were operated on. Careful clinicopathological correlation is, thus, required to assist the pathologist in performing the autopsy and reaching a diagnosis regarding the cause of death. Due to the heterogeneity of the structural abnormalities, and the wide variety of surgical and interventional procedures, there are no standard methods for dissecting the heart at autopsy. In this paper, we describe the most common types of CHDs that a pathologist could encounter at autopsy, including the various types of surgical and percutaneous procedures and major pathological manifestations. We also propose a practical systematic approach to the autopsy of ACHD patients.

The morphogenesis and associated anomalous pulmonary venous drainage in sinus venosus defect

BACKGROUND

Sinus venosus defect (SVD) is an unusual type of interatrial communication (IAC) and is virtually always associated with partial anomalous pulmonary venous drainage (PAPVD) of the right pulmonary veins (RPV) to the superior vena cava (SVC) or right atrium (RA). However, its definite morphogenesis is still elusive, and diagnostic fallibility continues.

METHODS

We conducted a retrospective review of the echocardiograms, cardiac catheterization data, computed tomographic findings, and surgical notes of 44 children with surgery-confirmed isolated SVD from 1977 to 2016. We investigated the location of the IAC and its boundaries within the atrial septum and its anatomic relationship with the adjacent structures, including the anomalously draining RPV. We also tried to explore any possible associated abnormalities which might be implicated in the morphogenesis of SVD.

RESULTS

Two distinct types of IAC were defined. Forty patients had an IAC that was located posterosuperior to the intact fossa ovalis (superior type), and all were associated with PAPVD of the right upper and often the right middle pulmonary veins to the SVC. The remaining 4 patients had an IAC that was located posterior to the intact fossa ovalis (inferior type), and all were associated with PAPVD of all the RPV to the RA. Another consistently associated abnormality was a defect between the anomalously draining RPV posteriorly and the SVC or RA anteriorly. All these 44 patients underwent successful surgical baffling the associated PAPVD via the IAC into the left atrium.

CONCLUSION

A defect between the RPV posteriorly and the SVC or RA anteriorly will result in SVD, and an unusual type of IAC, and PAPVD of the RPV to the SVC or RA. The IAC is not a true atrial septal defect in the atrial septum proper, but it actually represents the left atrial orifice of the unroofed RPV.

Demonstration of living anatomy clarifies the morphology of interatrial communications

Inferences made regarding the postnatal anatomy of the atrial septum still tend to be based on developmental evidence. Although atrial septation is a well-defined process, it is remarkably complex and remains poorly understood. It is now established, however, that the process involves the conjugation of several myocardial structures and mesenchymal tissues of both intracardiac and extracardiac origin. The resultant postnatal morphology is equally complex, evidenced by the fact that, in the normal heart, only the floor of the oval fossa, along with its anteroinferior muscular buttress, are true anatomical septums. In this regard, septums can be defined as partitions that can be removed without creating communications with the extracavitary space. The true septal components are surrounded by grooves, which themselves largely represent infolding of the atrial walls. These anatomical features can now accurately be revealed using virtual dissection of CT data sets. These images, when carefully reconstructed, demonstrated the anatomy with as much accuracy as when hearts are dissected in the autopsy room. Such virtual dissection, furthermore, shows the components as they are seen within the chest, thus facilitating understanding for those intending to undertake interventional therapeutic procedures. By preparing such images, we show the complexity of the normal atrial septum and its surrounds. We show that it is only defects within the oval fossa, or the much rarer vestibular defects, which can appropriately be illustrated in the context of a normally constructed heart.