MITRAL ATRESIA ASSOCIATED WITH PULMONARY VENOUS ANOMALIES

Supracardiac total anomalous pulmonary venous connection with severe rheumatic mitral valve disease

A rare association of supracardiac total anomalous pulmonary venous connection (TAPVC) along with severe rheumatic mitral regurgitation is presented. The patient, a 28-year-old female, underwent successful repair of the TAPVC along with pericardial patch closure of the atrial septal defect and replacement of the mitral valve with a mechanical prosthesis. 

Unusual form of total anomalous pulmonary venous connection with double drainage

A patient with complex congenital heart disease was diagnosed by two-dimensional echocardiography. Total anomalous pulmonary venous connection (TAPVC) was suspected because of the results of two-dimensional echocardiography, but the exact anatomy was delineated by cineangiocardiography as an unusual form of TAPVC with double drainage or connections to the left superior vena cava at nearly the same level. The clinical implications and possible embryogenesis for such a condition are discussed.

Levoatriocardinal vein in mitral atresia mimicking obstructive total anomalous pulmonary venous connection

This report briefly describes two cases of levoatriocardinal vein, in the setting of mitral atresia and a restrictive interatrial shunt, with clinical as well as echocardiographic features mimicking obstructive total anomalous pulmonary venous connection. One patient died of pulmonary hypertensive crisis, and the other survived the palliative procedures including the atrioseptectomy and pulmonary artery banding. The echocardiography, cine-angiocardiography, and magnetic resonance image for such an anomalous channel are presented. It is tempting to speculate that the thrombocytopenia and indirect hyperbilirubinemia be associated with the destructive consumption of thrombocytes and red blood cells in the serpentine levoatriocardinal vein.

Morphological features of the levoatriocardinal (or pulmonary-to-systemic collateral) vein

Three cases with an anomalous pulmonary-to-systemic collateral vein (levoatriocardinal vein) connecting the left atrium or one of the pulmonary veins to a systemic vein are described. In two of these cases the atrial septum is intact, the left atrioventricular connection is absent (mitral atresia), and the anomalous vein is the escape channel for pulmonary venous return. In the remaining case, a muscular membrane divides the left atrium, separating the pulmonary venous component from the distal component. The collateral vein may be mistaken for the vertical vein that is associated with totally anomalous pulmonary venous connections, but in all our cases the pulmonary veins inserted normally into the left atrium. Cross-sectional echocardiography, including conventional and color flow Doppler mapping, should overcome potential difficulties in diagnosis.

Echocardiographic demonstration of an unusual pulmonary venous pathway in a patient with left ventricular inflow obstruction

A newborn infant with mitral atresia and a restrictive patent foramen ovale had normal pulmonary venous connection to the left atrium demonstrated by echocardiography. However, pulmonary venous blood then coursed through an unusual pathway in the roof of the left atrium into the right atrium. This case illustrates the need for the echocardiographer to be reminded of and then search for unusual drainage pathways in cases of left ventricular inflow obstruction, even when the pulmonary veins connect normally.

Patterns of anomalous pulmonary venous connection/drainage in hypoplastic left heart syndrome: diagnostic role of Doppler color flow mapping and surgical implications

Differentiation between anomalous connection and anomalous drainage of the pulmonary veins in hypoplastic left heart syndrome is important before either the Norwood procedure or heart transplantation is performed. To determine the prevalence of echocardiographically detected anomalous connection or drainage, or both, of pulmonary veins in patients with this syndrome, preoperative two-dimensional echocardiographic and Doppler color flow mapping studies of 317 patients who underwent the stage I Norwood procedure were reviewed. The term "connection" was used to describe the precise anatomic attachment of the pulmonary veins and the term "drainage" to describe the physiologic end point of pulmonary venous flow. Twenty patients (6.3%) had anomalous connection or drainage, or both, of the pulmonary veins by preoperative echocardiographic and Doppler examination. The subcostal and suprasternal scans best showed the anatomic details of the pulmonary veins. All these patterns were confirmed intraoperatively and could be grouped as follows: 1) partial anomalous connection and drainage (two patients); 2) total anomalous connection and drainage (eight patients); 3) normal connection with total anomalous drainage (eight patients); and 4) normal connection with partial anomalous drainage (two patients). The advantage of adding Doppler color flow mapping to two-dimensional echocardiography and conventional Doppler study was clearly demonstrated in the detection of small accessory vertical veins, their course and the presence or absence of obstruction. Doppler color flow mapping was especially helpful in detecting anomalous drainage of the right pulmonary veins to the right of the superior attachment of the septum primum.

Hypoplastic left heart syndrome with premature closure of foramen ovale: report of an unusual type of totally anomalous pulmonary venous return

We report on a case of hypoplastic left heart syndrome (HLHS), associated with premature closure of the foramen ovale and an unusual type of totally anomalous pulmonary venous return. The existence of an anomalous connection of the right upper pulmonary vein to the superior vena cava-right atrial (SVC-RA) junction and the existence of the anomalous intrapulmonary venous channel between right upper and lower pulmonary vein allowed all the pulmonary blood to drain into the SVC-RA junction, whereas she had only partially anomalous pulmonary venous connection. The several intrapulmonary venous channels helped to delay the progression of pulmonary venous obstruction. Chromosomal analysis revealed that the patient had XO Turner syndrome. We conclude that all infants with HLHS should be carefully evaluated for the existence of anomalous pulmonary venous return. Two-dimensional Doppler echocardiography is one of the most useful techniques for evaluating such anomalies.

Mitral atresia with premature closure of the oval foramen, right-sided levoatriocardinal vein and thrombus formation in the left atrium

We describe a 4-week-old baby with mitral atresia, hypoplastic left ventricle, ventricular septal defect, preductal coarctation and premature closure of the oval foramen whose only outlet from the left atrium was a stenosed right-sided levoatriocardinal vein and who in addition developed left atrial thrombi. Cross-sectional echocardiography was extremely helpful in establishing the diagnosis.

Rare type of intrapulmonary drainage of one lung by the other with total anomalous pulmonary venous return

A rare form of obstructed total anomalous pulmonary venous drainage is presented. A neonate with asplenia, pulmonary atresia and complex congenital heart disease also had drainage of the left lung forming a venous confluence that proceeded in an intrapulmonary fashion through the right lung. A hypoplastic pulmonary venous channel then emerged from the right upper lobe leading to the superior vena cava. Pulmonary venous obstruction was suspected on initial plain chest X-ray examination and on angiography, which revealed the pulmonary artery to be larger than anticipated. Administration of prostaglandin E1 may allow augmentation of pulmonary blood flow and angiographic definition of this association in infants with asplenia complex.

Atresia of left atrioventricular orifice. Anatomical investigation in 62 cases

Sixty-two hearts without a patent exit from the left atrium to the ventricular mass have been studied. All had situs solitus and laevocardia. The material consisted of 32 cases with coexistent aortic atresia and 30 cases with patent aortic root. Five hearts with aortic atresia were biventricular with atrioventricular concordance and imperforate left atrioventricular valves, and 27 hearts were univentricular of right ventricular type, with absent left atrioventricular connection. The anatomy of this group was uniform, with extreme hypoplasia of all the left cardiac segments. Among the cases with patent aortic root, five were biventricular, with atrioventricular concordance and imperforate left atrioventricular valves, and 24 had absent left atrioventricular connection, 15 with univentricular heart of right ventricular type and nine with univentricular heart of left ventricular type. The final heart had double inlet univentricular of left ventricular type with an imperforate left atrioventricular valve. In this second group the aorta was larger in cases with discordant ventriculoarterial connection or in those with double outlet from the main ventricular chamber. A normal sized aorta without aortic arch obstruction was observed in nine instances. These are of great interest in terms of surgical anatomy since definitive palliation may be feasible.

[Agenesis of the ductus arteriosus Botalli and premature closure of the foramen ovale, in combination with mitral valve atresia, hypoplastic left ventricle, transposition of the great arteries, and pulmonary valve atresia (author's transl)]

Agenesis of the Ductus arteriosus Botalli is a rare anomaly, which is known to occur in combination with truncus arteriosus, tetralogy of Fallot with pulmonary valve agenesis and also in simple tetralogy. The authors report on a case, where neither a ductus nor any remnant of it could be found in a complex heart malformation consisting of premature closure of the Foramen ovale, mitral atresia, hypoplastic left ventricle, transposition of the great arteries, pulmonary valve atresia and hypoplastic pulmonary artery. Speculations as to the pathogenesis of this anomaly presume slowing and eventual arrest of the ductal blood flow as a consequence of closure of the Foramen ovale in early fetal life. Thus total involution and disappearance of the distal part of the sixth aortic arch also on the left side seem conceivable.

Premature closure of the foramen ovale with levoatriocardinal vein

Two cases of the hypoplastic left heart syndrome with premature closure of the foramen ovale and levoatriocardinal veins are described and the literature is reviewed. One of the patients is the only case with both mitral and aortic valve atresia. The other is associated with the asplenia syndrome, double-outlet right ventricle without ventricular septal defect, and an anomalous connection of the left atrium to the right auricle.

Mitral atresia with normal aortic valve: a study of eighteen cases and a review of the literature

Eighteen cases of mitral atresia with normal aortic valve plus 68 cases from the literature are analyzed. A new classification based on anatomical findings is proposed. Pulmonary stenosis or atresia is frequent in the type with transposition of the great arteries. The rare instances of normal or large left ventricle are due to a large ventricular septal defect, or to straddling or displaced tricuspid valve. The clinical, radiologic and electrocardiographic findings have been summarized and correlated with the different physiopathological situations. In our catheterized cases an oxygen saturation step-up was found in the right atrium together with left atrial hypertension. In seven cases mitral atresia was demonstrated by selective left atrial contrast injection. The average age at death was six months. Among the cases surviving one year or more, the association of atrial septal defects or pulmonary stenosis was frequent. Enlargement of the interatrial communication, accompanied by other palliative measures, is the only available surgical procedure.

Alternate pathways to pulmonary venous flow in left-sided obstructive anomalies

In cardiac anomalies causing severe obstruction in the left side of the heart, such as aortic atresia, mitral atresia, or occasionally severe aortic stenosis, maintenance of circulation depends upon shunting of pulmonary venous blood into the right atrium. The usual pathway by which the shunt is achieved is across the atrial septum through the foramen ovale. When this route is closed or severely narrowed, alternate but less common pathways may exist. These involve either anomalous connections of pulmonary veins to systemic veins or communications with the coronary venous system. In the latter, as commonly occurs in aortic atresia, left ventricular myocardial sinusoids carry pulmonary venous blood from the left ventricular cavity and into the cardiac veins. In other instances of severe left-sided obstruction, a direct communication may exist between the left atrium and the coronary sinus.

Microangiography of the pulmonary arterial system in "hypoplastic left heart syndrome"

Microangiographic examination of the pulmonary arterial system in 12 newborn infants with concomitant stenosis or atresia of the aortic and mitral orifices showed that the intrapulmonary arterial pattern is influenced by the state of the foramen ovale. In infants with aortic atresia with a prematurely closed foramen ovale, that is cases in which the left side of the heart is a cul-de-sac, there is moderate or prominent tortuosity of the intralobular pulmonary arteries indicating congenital pulmonary hypertension. This feature is less prominent or absent in infants with valvular insufficiency of the foramen ovale, regardless of the postnatal age of the patient.

Total anomalous pulmonary venous return with intact atrial septum and associated mitral stenosis

Total anomalous pulmonary venous return with an intact atrial septum is an uncommon lesion. With associated mitral stenosis each lung has a different pulmonary flow, individual vascular resistance, and function. This represents the first reported case of this anomaly treated by total correction and mitral valve replacement. Pulmonary flow reverted to normal distribution and heart size decreased, with a reversion of vascular changes on the chest radiograph one year after operation.

Congenital mitral atresia

Images

Intrapulmonary segment in anomalous pulmonary venous connection. Resemblance to scimitar syndrome

Three cases showing a large anomalous venous channel in the right lung are presented. In each case the large vein was a part of a pulmonary venous collateral system in association with anomalous pulmonary venous connection, partial in one case, and total in two. In two of the cases, each of which was an example of total anomalous pulmonary venous connection, the anomalous vein in the right lung received the entire venous system of the left lung. In the two cases with conventional roentgenograms the anomalous vein within the right lung was apparent. Its shape, in some respects, resembled that of the anomalous pulmonary vein in the scimitar syndrome. Selective pulmonary arteriography appears to offer the best means of differentiation between an anomalous vein of the type described here and that of anomalous drainage of the hypoplastic right lung to the inferior vena cava (the scimitar syndrome).