TWO CASES OF CONGENITAL DISEASE OF THE LEFT SIDE OF THE HEART

Echocardiographic characteristics of annulo-leaflet mitral ring

BACKGROUND

Annulo-leaflet mitral ring (ALMR) is a rare congenital cardiac anomaly caused by fibrous tissue on the atrial surface of the mitral valve, which can progress to cause severe stenosis. Because little information is available on the detailed echocardiographic features of the anomaly and their associations with surgical resection, this study was undertaken to address these questions.

METHODS

A retrospective single-center study of clinical and echocardiographic data from patients with ALMR from 2004 through 2012 was conducted. Data were analyzed for associations with surgical resection.

RESULTS

The median age at diagnosis of the 57 study patients was 1.8 years, and 63% were male. Isolated ALMR was found in six patients (11%). The remaining 51 patients (89%) had associated lesions: additional mitral valve abnormalities in 35 (61%), coarctation in 11 (19%), and subaortic stenosis in 15 (26%). ALMR was best visualized in the apical four-chamber view, and the lesion was indistinct from the parasternal long-axis view in 25% of patients. Seven patterns of ALMR were identified, differentiated by leaflet involvement (anterior, posterior, or both) and location (annular vs intraleaflet). Compared with other patterns, intraleaflet morphology had a higher mean mitral stenosis gradient than in patients without (8.4 vs 5.8 mm Hg, P = .01). Among the 57 patients, 32 (56%) underwent ALMR resection, at a median age of 1.5 years. Younger age at echocardiographic diagnosis (P = .02) and short chordae (P = .03) were associated with resection.

CONCLUSIONS

The morphology of ALMR as evaluated by echocardiography is heterogeneous and can be classified on the basis of lesion location and leaflet involvement. Intraleaflet morphology is associated with significant mitral stenosis; younger age at diagnosis and short chordae are associated with ALMR resection.

The "Polar Light Sign" is a useful tool to detect discrete membranous supravalvular mitral stenosis

Mitral valve stenosis caused by a discrete supravalvular membrane is a rare congenital malformation haemodynamically leading to significant mitral valve stenosis. When the supravalvular mitral stenosis consists of a discrete supravalvular membrane adherent to the mitral valve, it is usually not clearly detectable by routine echocardiography. We report about the typical echocardiographic finding in three young patients with this rare form of a discrete membranous supravalvular stenosis caused by a membrane adherent to the mitral valve. These cases present a typical echocardiographic feature in colour Doppler generated by the pathognomonic supramitral flow acceleration. Whereas typical supravalvular mitral stenosis caused by cor triatriatum or a clearly visible supravalvular ring is easily detectable by echocardiography, a discrete supravalvular membrane adjacent to the mitral valve leaflets resembling valvular mitral stenosis is difficult to differentiate by routine echocardiography. In our opinion, this colour phenomenon does resemble the visual impression of polar lights in the northern hemisphere; owing to its typical appearance, it may therefore be named as "Polar Light Sign". This phenomenon may help to detect this anatomical entity by echocardiography in time and therefore improve the prognosis for repair.

Mitral valve operations at a high-volume pediatric heart center: Evolving techniques and improved survival with mitral valve repair versus replacement

Mitral valve disease is quite variable and can occur as an isolated defect or in association with other complex left sided lesions. These lesions are often best described with detailed pre-operative imaging studies to define the valve anatomy and to access associated left heart disease. Depending on the type of mitral valve disease, various surgical repair techniques have led to improved survival in the recent era. We describe lesion specific approach to mitral valve repair and results.

The added value of real-time three-dimensional echocardiography in the diagnosis of supravalvar mitral ring: case report and review of the literature

Supravalvular mitral stenosis is a rare condition characterized by an abnormal ridge, with one or two orifices, covering and obstructing the mitral valve. Preoperative identification of the supravalvular ring is the target for obtaining good surgical results. Two-dimensional echocardiogram and transesophageal echocardiography both failed in reaching this objective. In this case, we showed that three-dimensional echocardiogram is a new technique that provides additional and more accurate echocardiographic characterization of congenital supravalvular mitral stenosis.

Supramitral Ring: Good Prognosis in a Subset of Patients With Congenital Mitral Stenosis

BACKGROUND

Management of congenital stenotic mitral valvular abnormalities remains an important therapeutic challenge. Supramitral ring constitutes a small but inadequately described subset that has a relatively good outcome with appropriate management.

METHODS

Between 1996 and 2004, 15 patients with supramitral ring were managed in this institution. The demographic and clinical features, diagnostic modalities, morphology of the rings, and the surgical management were studied retrospectively.

RESULTS

Accurate preoperative diagnosis was possible by transthoracic echocardiography in 11 patients (73%). The associated anomalies were ventricular septal defects in 8 patients (53%) and abnormalities of the left ventricular outflow tract in 7 patients (47%). A circumferential supramitral ring, separate from the mitral valve, was present in 8 patients (53%). In the remaining, the ring was attached circumferentially to the anterior and the posterior mitral leaflets and was most densely adherent at the posteroinferior commissure in 4 of these 7 patients (57%). Complete excision of ring was possible in all cases, without damage to the mitral valve. There was 1 in-hospital death (6%). At a mean follow-up of 30 months, 14 survivors continue to do well, with no significant recurrence of mitral stenosis.

CONCLUSIONS

Patients with supramitral ring constitute a subset of patients with congenital mitral stenosis who have a relatively good prognosis. In many cases, the supramitral ring is entirely separate from the mitral valve, and when attached, it is usually most prominent at the posteroinferior commissure. In both cases, complete resection is surgically feasible and usually provides lasting relief.

Mitral supravalvular ring: a case report

Supravalvular mitral stenosis is a rare condition characterized by an abnormal ridge, with one or two orifices, covering and obstructing the mitral valve. Preoperative diagnosis is difficult with transtoracic echo (TTE), angiography and magnetic resonance imaging (MRI).

In this case, a 36-year-old male, was admitted to our Heart department: He experienced progressive dyspnea on effort and at rest.

Diagnosis was made by transesophageal echocardiography which showed, on apical 4-chamber section, an anulare structure attached since a membrane to the atrial wall anterior mitral valve leaflet and just proximal to the posterior mitral leaflet.

Pre-operative identification of the supravalvular mitral ring is the target for obtaining good surgical results. Cineangiography and MRI both failed in reaching this objective, whereas, transesophageal echocardiography is the best method to identify this congenital heart disease.

Using TEE the identification is not only possible but also easier.

Anatomy and pathogenesis of aorticopulmonary septal defect

The pathologic anatomic features and associated cardiac anomalies of 13 patients with aorticopulmonary septal defect (APSD) and of 236 previously reported cases were analyzed. Morphologically, 3 types of APSD were distinguished: a defect with a more or less circular border located about halfway between the arterial valves and the bifurcation of the pulmonary trunk; a similarly located defect in which the border represents a helix; and a usually large defect in which there is no posterior (distal) border. The appearance of these 3 types of defects suggests a different developmental mechanism for each. Approximately half of the cases of APSD are not associated with other cardiovascular anomalies. Of the anomalies that do occur, anomalous origin of a coronary artery from the pulmonary trunk and interruption of the aortic arch (IAA) type A or severe preductal coarctation are seen far more often than expected. An association with DiGeorge syndrome, frequently noted with persistent truncus arteriosus (TA) and IAA type B, was not seen. Certain cardiac anomalies often seen with TA are rarely seen with APSD, and defects often seen with APSD are rarely seen with TA. These observations indicate that APSD and TA are pathogenetically unrelated even though located in the same region of the heart and, unlike TA and IAA type B, APSD is probably not due to a developmental error involving the neural crest.

Membranous supravalvular mitral stenosis: a treatable form of congenital heart disease

The clinical data, echocardiographic findings, operative anatomy and postoperative follow-up were assessed in 14 patients who had surgery for membranous supravalvular mitral stenosis between 1978 and 1985. The patients ranged in age from 6 weeks to 13 years at the time of operation, and 8 of the 14 had associated mitral valve abnormalities. Other associated lesions included ventricular septal defect (n = 7), coarctation of the aorta (n = 5), left superior vena cava (n = 6), subaortic stenosis (n = 3) and atrial septal defect (n = 1). Twelve of the 14 patients had successful removal of the supravalvular membrane, which was usually adherent to the valve, and 2 patients with associated mitral valve abnormalities underwent mitral valve replacement. There were no operative deaths. Review of preoperative two-dimensional echocardiograms, which were available in 11 patients, revealed two types of membranous supravalvular mitral stenosis in 10 patients. In four of these patients, the membrane was only evident after repeated stop action viewing from a single subcostal or parasternal location. The membrane was never seen in one patient. Eleven patients had follow-up in excess of 1 year, and there was one late death. Eight of the remaining 10 patients are asymptomatic, and 7 have no clinical evidence of residual mitral obstruction. Failure to recognize membranous supravalvular mitral stenosis can result in undue delay of cardiac surgery with resultant cardiopulmonary deterioration. Patients with evidence of left ventricular inflow obstruction should have extensive echocardiographic evaluation in an effort to detect membranous supravalvular mitral stenosis, which may be amenable to surgical repair.

Aorticopulmonary window associated with tetralogy of Fallot. Report of one case and review of the literature

A case of aorticopulmonary window associated with tetralogy of Fallot is reported with its clinical, hemodynamic, angiocardiographic, surgical, and necropsy findings. The difficulty in diagnosing a tetralogy of Fallot in the presence of a large aorticopulmonary shunt is emphasized. It is also noted that the only means of discovering the infundibular stenosis of the right ventricle is by angiocardiographic study of the right ventricular outflow tract. The difficulty in distinguishing truncus arteriosus from an aorticopulmonary window coexisting with a ventricular septal defect is discussed, and it is pointed out that the only means of differentiating these two anomalies is the angiocardiographic finding of two sigmoid valves. An embryological hypothesis concerning the pathogenesis of this association is also discussed.

Supravalvular stenosing ring of the left atrium

Two patients with supravalvular stenosing ring of the left atrium are described. In 1 patient with an associated ventricular septal defect and Wolff-Parkinson-White syndrome, the diagnosis of supravalvular stenosing ring was only suspected. This patient underwent correction but died 34 days after the operation because of pulmonary embolism. In the second patient a preoperative diagnosis was not made, and this contributed to his death following correction of tetralogy of Fallot. The association of these two anomalies is very rare. Differential diagnosis from other congenital anomalies producing obstruction of left atrial flow is discussed. The divergent microscopical features of the membrane in supravalvular stenosing ring of the left atrium and in cor triatriatum are described. The value of cardiac catheterization, angiography, and echocardiography as diagnostic aids is emphasized. The hazards of not recognizing and diagnosing this anomaly when associated with other cardiac malformations are pointed out.

Surgical Closure of an Aortic Septal Defect

Occurring just above the aortic and pulmonic valves, an aortic-pulmonary artery communication gives a left-right shunt which may be indistinguishable by clinical findings from a patent ductus arteriosus. Under some circumstances it is possible to identify the lesion by retrograde aortography. Because of increase in cardiac work, the shunt can produce cardiac strain. Whether or not the communication can be closed surgically depends upon the size of the opening and its distance above the coronary arteries. A case is here reported in which an aortic-pulmonary artery communication has been closed surgically.

The Diagnosis of Aortic Septal Defect by Retrograde Aortography

This rare congenital malformation is a round or oval opening between the ascending aorta and the main pulmonary artery above the semilunar valves. It is practically impossible to differentiate this malformation from a patent ductus arteriosus clinically because both malformations may present the same physical, fluoroscopic, roentgen and electrocardiographic findings. Even angiocardiography and cardiac catheterization do not differentiate these congenital malformations. The authors have studied 2 patients with aortic septal defects. One was operated at another clinic for a suspected patent ductus arteriosus, and the other case presented here was diagnosed by retrograde aortography.