Total anomalous pulmonary venous drainage. A clinical and anatomical study of 75 children

S, Chandhirasekar B, Goja S, Manjusha N, Pandey NN, Kapoor PM. Technical Details of Rechanneling of Obstructive Coronary Sinus Type of Totally Anomalous Pulmonary Venous Connection Using Malm's Coronary Sinus Cutback Technique and Left Atrial Augmentation: A Video Presentation

Obstructive coronary sinus totally anomalous pulmonary venous connection although rare, is associated with a high mortality. A 2-month-old female child diagnosed with obstructive coronary sinus type of totally anomalous pulmonary venous connection and severe pulmonary arterial hypertension underwent complete unroofing of the coronary sinus by the “coronary sinus cutback technique” of Malm with left atrial augmentation and atrial septal fenestration.

Implications of left atrial enlargement and patent foramen ovale creation on early surgical outcomes in patients with total anomalous pulmonary venous connection

INTRODUCTION

In patients with total anomalous pulmonary venous connection (TAPVC), left atrium (LA) is small and suprasystemic pulmonary artery (PA) pressures may be present in some patients. In our study, we studied the relationship between surgical LA enlargement and patent foramen ovale (PFO) creation separately on the outcomes of patients with TAPVC.

MATERIALS AND METHODS

Out of the 130 patients operated in our institute between January 2014 and December 2020, LA was enlarged in 60 patients. LA enlargement was done using a larger patch for atrial septal defect (ASD) closure. Thus, the LA volume was increased by shifting the patch towards the right atrium (RA). Suprasystemic or high PA pressures were present in 60 patients. In 33 patients, PFO was created. Early surgical outcomes were determined on the basis of vasoactive inotropic score (VIS), hours of ventilation, hours of inotropic support, intensive care unit (ICU) stay, and hospital stay.

RESULT

Between the LA enlarged and nonenlarged group there was statistically significant less VIS score (18 [13-27.5] vs. 24 [18-30], p value .019), hours of ventilation (23 [16-46.5] vs. 26 [18-60], p value .039), hours of inotropic support (45.5 [30-72] vs. 55 [38-84], p value .038), and ICU stay (7 [5-9] vs. 8 [7-10] p value .0352) and statistically nonsignificant less hospital stay (11.5 [9-13] vs. 12 [9-14], p value .424). In patients with preoperative suprasystemic or high PA pressures, there was a statistically significant less VIS score (16 [11-23.5] vs. 18 [13-25], p value .044), hours of ventilation (20 [14-37] vs. 22 [18-39], p value .038), hours of inotropic support (34 [29.5-71] vs. 38 [30-78], p value .042), and hospital stay (9 [5-12] vs. 11 [9-14], p value .038) and statistically nonsignificant less ICU stay (7 [5.5-9] vs. 7 [6-9], p value .886) in the group with a PFO with respect to the other group in which no PFO was created.

CONCLUSION

In patients with TAPVC, LA can be enlarged by using a large ASD patch and thus shifting the septum towards RA. Early surgical outcomes were improved with LA enlargement. In patients with suprasystemic or high PA pressures, leaving a PFO improved the postoperative outcomes.

Mixed type total anomalous pulmonary venous connection: Early results and midterm outcomes of surgical correction

BACKGROUND AND AIM OF THE STUDY

The morphological heterogeneity of anomalous pulmonary venous drainage in mixed type total anomalous pulmonary venous connection (TAPVC) has important implications in preoperative diagnosis and surgical repair resulting in high mortality in these patients.

METHODS

A retrospective review of 14 patients with mixed type TAPVC undergoing biventricular repair between January 2012 and December 2019 was conducted. A descriptive analysis was done, highlighting the anatomic variation, diagnostic and surgical approach, and surgical outcomes in these patients.

RESULTS

The most common anatomic pattern was "3 by 1" (79%) followed by "2 by 2" (21%). The correct diagnosis by transthoracic echocardiography was made in 10 (71%) of the 14 patients. In contrast, preoperative computed tomographic (CT) angiography was performed in 10 patients and correct diagnosis was obtained in 8 (80%) of them. Pulmonary venous obstruction was seen in one patient before surgery. The in-hospital mortality was 14% (2/14). Four patients had pulmonary hypertensive crisis in the postoperative period. The average follow-up was 54 ± 27 months (range: 17-98 months) after surgical repair, and all surviving patients were asymptomatic. There was no late death. No clinically apparent sequelae were seen in six patients in whom isolated left superior pulmonary vein drainage was left uncorrected.

CONCLUSION

An accurate diagnosis of anatomic pattern in mixed type TAPVC can be difficult to establish in all the patients before surgery. Detailed intraoperative assessment, individualized surgical approach, and aggressive perioperative management may reduce surgical mortality. Operative survivors have good midterm outcome.

Duplication and Deletion of 22q11 Associated with Anomalous Pulmonary Venous Connection

Anomalous pulmonary venous connection (APVC) is an uncommon congenital anomaly in which pulmonary venous blood flows directly into the right side of the heart or into the systemic veins. To identify whether there is any association between 22q11 CNVs and APVC, we analyzed the clinical data of 86 APVC patients and then studied the CNVs of 22q11 in 86 sporadic APVC patients by multiplex ligation-dependent probe amplification. The results showed that two patients carried the CNVs of 22q11, one patient had the deletion of 22q11 and the other had the duplication of 22q11. The incidence was significantly higher than that in the normal population (P < 0.01) that suggests a possible etiologic association between the duplication or deletion of 22q11 and the APVC in our patients.

Echocardiographic diagnosis of anomalous pulmonary venous connections: Experience of 84 cases from 1 medical center

We sought to evaluate the value of echocardiography in the diagnosis of different types of anomalous pulmonary venous connections (APVCs) and summarize the diagnostic experience. A total of 84 patients with APVC were confirmed by surgery (n = 82) or computerized tomography angiography (CTA) (n = 2) in the last 6 years (2008-2014) at the Wuhan Union Hospital. The total anomalous pulmonary venous connection (TAPVC) cases account for 60.7%, and partial anomalous pulmonary venous connection (PAPVC) cases account for 39.3% among the 84 cases that were identified. The 51 TAPVCs were classified by the Darling method-type I (41.1%), type II (52.9%), type III (1.9%), and type IV (3.9%). The most common drainage path of type I was common pulmonary drainage to the left innominate vein via vertical vein, and the coronary sinus drainage was the most common path in type II. Compared with surgical or CTA results, the sensitivity and specificity of echocardiography in the diagnosis of APVCs were 97.6% and 99.9%, respectively. The echocardiography misdiagnoses were mainly seen in PAPVCs. Of the TAPVCs and PAPVCs correctly diagnosed by echocardiography, the diagnostic accuracy of classification were 94% and 100%, respectively. Echocardiography has specific value in diagnosing and classification of APVC, especially the supracardiac and cardiac TAPVCs. Multiplane scan views and color Doppler improve the display of drainage pathway.

Total anomalous pulmonary venous connection : Autopsy considerations

Total anomalous pulmonary venous connection (TAPVC), where the pulmonary venous circulation drains into the systemic venous circulation rather than into the left atrium, may present a number of problems at autopsy. A 5-week-old infant is reported who died suddenly and unexpectedly who was found at autopsy to have infradiaphragmatic TAPVC into the portal vein. The only associated anomalies were a tri-lobed left lung, a patent ductus arteriosus, and drainage of the inferior vena cava into the both the right and left atria. This case demonstrates particular features that may lead to difficulties in establishing the diagnosis of TAPVC. Sudden death in the absence of symptoms in this age group raises the possibilities of sudden infant death syndrome (SIDS) and inflicted injury, both of which were discounted in this case. An autopsy approach is outlined to maximize chances of diagnosing this entity that includes meticulous inspection and dissection of cardiac vascular connections before evisceration, with photographic documentation of findings. Concurrent cardiovascular abnormalities, including valve atresias, septal defects, and left heart hypoplasia are likely in the presence of asplenia/polysplenia syndrome. Extracardiac anomalies may be present in the form of Holt-Oram, Ellis-van Creveld, and cat eye syndromes. Careful examination of the common draining vein for obstructive features is an important part of the postmortem assessment. The possibility of heritable cases requires referral of the family for genetic evaluation.

Anomalous pulmonary venous connections and related anomalies: nomenclature, embryology, anatomy, and morphology

This article combines material from three complementary overviews presented in the Symposium on Pulmonary Venous Anomalies during the Joint Meeting of the World Society for Pediatric and Congenital Heart Surgery and Sociedad Latina de Cardiologia y Cirugia Cardiovascular Pediátrica in Lima, Peru. We discuss the embryologic basis for nomenclature, the hierarchical diagnostic categories, and the important anatomic and morphologic characteristics of anomalous pulmonary venous connections. The anatomic descriptions help to guide an understandable and sensible approach to the diagnosis and surgical management of these various disorders.

A suggested new surgical classification for mixed totally anomalous pulmonary venous connection

The morphologic variations of mixed totally anomalous pulmonary venous connection are many and varied. In this review, we give an account of all cases previously described as mixed totally anomalous pulmonary venous connection, analyzing in detail those cases where an accurate anatomical description was provided. We identified 182 suitable cases, from 54 investigations, and reviewed the clinical presentation, anatomic variations, diagnostic features, and management of the patients described.Cross-sectional echocardiography, and cardiac catheterization, provided the necessary diagnostic information, and defined the anatomy before surgery in 139 patients. Magnetic resonance imaging and computerized tomographic angiography had been used for further clarification of the pulmonary venous anatomy. An obstructive pattern of drainage, involving one or more pulmonary veins, had been described in over half of the patients. We then grouped the lesions into categories that have a bearing on the appropriate surgical approach, discussing the appropriate repair for each group. For the overall group, the operative mortality remains high, at 22.9%. We submit that an increased appreciation of various types of mixed totally anomalous pulmonary venous connection may well contribute to improved future surgical management.

TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION IN A FOAL

An 8-day-old Arabian-Morgan cross colt underwent cardiac evaluation. The foal was tachycardic, tachypneic, exercise intolerant and had a loud right-sided heart murmur and cyanotic mucous membranes. Total anomalous pulmonary venous connection was diagnosed with echocardiography and confirmed at postmortem examination. Total anomalous pulmonary venous connection is a very rare congenital cardiac abnormality that has not been reported before in the horse.

Urgency of operation in infracardiac total anomalous pulmonary venous connection

BACKGROUND

Because the tendency for pulmonary venous obstruction in the infracardiac type of total anomalous pulmonary venous connection may be partially dependent on the connection of the descending vein to the portal vein, the inferior vena cava, or one of their tributary vessels, we reviewed our surgical experience with various subtypes of infracardiac total anomalous pulmonary venous connection.

METHODS

The urgency of operation in 4 neonates with infracardiac total anomalous pulmonary venous connection was reviewed.

RESULTS

Two patients with pulmonary venous obstruction in whom the descending vein connected to the portal vein were operated on immediately with successful outcome. One patient who had become critically ill after the ductus venosus had closed died before operation could be undertaken. One patient in whom the descending vein connected to the left hepatic vein was operated on electively with successful outcome.

CONCLUSIONS

In hemodynamically stable patients with no clinical or echocardiographic signs of pulmonary venous obstruction, some form of differentiation with regard to urgency of operation may be appropriate. When the descending vein connects to the inferior vena cava or a hepatic vein, the operation may be performed on a semi-elective basis. In contrast, when the descending vein connects to the portal vein or the ductus venosus, operation should generally not be delayed because of the high likelihood of obstruction.

Prenatal Diagnosis of Total Anomalous Pulmnonary Venous Connection

Total anomalous pulmonary venous connection remains a difficult diagnosis to make prenatally. The absence of normal pulmonary veins entering the left atrium may provide an indication of an abnormality. The authors discuss a case of total anomalous pulmonary venous connection in conjunction with hypoplastic left heart syndrome that was diagnosed in utero.

Echocardiographic spectrum of supracardiac total anomalous pulmonary venous connection

Although infracardiac total anomalous pulmonary venous connection (TAPVC) is almost always associated with venous obstruction, the incidence and location of obstruction in supracardiac TAPVC has not been completely delineated. This report summarizes our experience with 20 cases of supracardiac TAPVC diagnosed by transthoracic echocardiography from Jan. 1989 to Mar. 1997. Fifty percent were obstructed, and five different sites of narrowing were found. The most common sites of obstruction were at the level of the left pulmonary artery (left vertical vein) and at the insertion into the superior vena cava (right vertical vein). Because nonobstructed Doppler flow patterns are present proximal to the actual site of obstruction in the anomalous pathway, a thorough interrogation of the entire venous channel with two-dimensional and Doppler echocardiography is essential to provide complete preoperative anatomic and hemodynamic details to determine the nature and timing of surgery in this condition.

Rare Type of Mixed Total Anomalous Pulmonary Venous Drainage

We describe a rare form of total anomalous pulmonary venous connection in a neonate with major extracardiac congenital abnormalities. The infracardiac communication was hypoplastic, whereas the supracardiac connection had an intrapulmonary course through the left lung. There was an associated atrioventricular septal defect.

Total anomalous pulmonary venous drainage associated with fatal outcome in infancy and early childhood: an autopsy study of 52 cases

Clinicopathological details of 52 cases of total anomalous pulmonary venous drainage (TAPVD) taken from pediatric autopsy files from hospitals in Adelaide (Australia) Oxford and Edinburgh (United Kingdom) between 1957 and 1990 are presented. The patients ranged in age from a stillborn girl to a 15-month-old boy, with 42 cases (81%) dying in the first 3 months of life. While many patients had signs of a congenital cardiovascular anomaly prior to death, including tachypnea, tachycardia, central cyanosis, cardiac failure, heart murmurs, and difficulty in feeding, it was noteworthy that eight patients (16%) presented as sudden and unexpected death in the absence of significant antemortem symptoms and signs. Anomalous pulmonary venous drainage was also unsuspected prior to death in a total of 26 cases (53%) of those where relevant history was available (49 cases). Twelve infants (23%) underwent surgical correction, none of whom survived more than several weeks. TAPVD was isolated in 30 cases (58%) and was associated with other cardiac or congenital anomalies in 22 patients (42%). Just under half of nonisolated cases comprised the asplenia-heterotaxy syndrome. The points of drainage of the anomalous pulmonary veins were to the infradiaphragmatic veins (n = 21, 40%), left innominate vein (n = 13, 25%), coronary sinus (n = 7, 13%), right superior vena cava (n = 4, 8%), inferior vena cava above the diaphragm (n = 2, 4%), right innominate vein (n = 2, 4%), mixed left innominate vein and coronary sinus (n = 1, 2%), azygos vein (n = 1, 2%), and mixed right superior vena cava and left hemiazygos vein (n = 1, 2%). Twenty-three of 47 cases (49%) that were specifically examined revealed obstruction of the pulmonary veins or pulmonary hypertensive vascular changes on histology. These results emphasize that TAPVD needs to be excluded at autopsy as a causal factor in cases of sudden infant death even in the absence of antemortem symptoms and signs. Clues at autopsy include abnormal mobility of the heart, visceral situs inversus, and polyasplenia. The diversity of pulmonary-systemic venous anastomoses necessitates careful in situ dissection above and below the diaphragm and consideration of postmortem angiography.

Boy:girl ratio in children born with different forms of cardiac malformation: a population-based study

The boy:girl ratio was calculated for all live births with cardiac malformation in Bohemia (population 6.3 million) from 1977-1984. Complete coverage of all deceased children in Bohemia by necropsy and of all patients with heart disease by our center enabled us to collect reliable data. Of 4409 children born with a heart defect, there were 2296 boys and 2113 girls, a ratio of 1.09:1. In the total population of 664,218 children born during the same period of time, the ratio was 1.06:1. A higher proportion of boys was found with double outlet right ventricle (2.68:1), hypoplastic left heart (2.25:1), transposition of the great arteries (2.11:1), aortic stenosis (1.95:1), pulmonary atresia (1.55:1), tricuspid atresia (1.45:1), coarctation of the aorta (1.30:1), and corrected transposition of the great arteries (1.25:1). There were significantly more girls than boys with persistent ductus arteriosus (1:1.66), Ebstein's anomaly of the tricuspid valve (1:1.57), truncus arteriosus (1:1.22), atrioventricular septal defect (1:1.17), and tetralogy of Fallot (1:1.12). The difference in sex prevalence in the remaining heart defects was less than 10%.

Severe unconjugated hyperbilirubinaemia with infradiaphragmatic total anomalous pulmonary venous connection

An 8 day old girl with infradiaphragmatic total anomalous pulmonary venous connection presented with severe unconjugated hyperbilirubinaemia; exchange transfusion resulted in haemodynamic deterioration. Hyperbilirubinaemia is a rare complication of this condition, however exchange transfusion should be avoided. The diagnosis can be made on the neonatal unit by ultrasound demonstration of dilated hepatic portal veins.

Atypical total anomalous pulmonary venous connection: two channels leading to infracardiac terminations

Reported is a rare case of total anomalous pulmonary venous connection (TAPVC) where veins from each lung joined a homolateral confluence. From each confluence, a vein descended into the abdomen, the vein from the right lung joining the ductus venosus, while the vein from the left joined the portal vein. In TAPVC to systemic veins, multiple connections are rare. Multiple connections are most common at supracardiac and cardiac levels, less common at supra- and infracardiac levels, and rare at cardiac and infracardiac levels. From the literature, it is evident that multiple connections at one body level, as in our case, are rare.

Restrictive interatrial communication in total anomalous pulmonary venous connection

Restriction to systemic blood flow at the atrial level in total anomalous pulmonary venous connection (TAPVC) may play a role in the early development of congestive heart failure in some patients. Over a 4-year period, 21 patients with TAPVC without extracardiac obstruction presented from 1 day to 10 months of age (mean 2.6 months). Of 21 patients, 17 (81%) presented after 1 month of age with moderate to severe congestive heart failure. In the first week after birth 4 patients presented with minimal symptoms of congestive heart failure. A small patent foramen ovale (3 mm or less in diameter) was found in 19 of 21 patients (90%) by 2-dimensional echocardiography or angiography. Balloon or blade and balloon atrial septostomy was performed in these 19 patients and resulted in significant decreases in mean right to left atrial pressure gradient (from 2.8 to 0.25 mm Hg, p less than 0.001), systolic pulmonary to femoral artery pressure ratio (from 0.80 to 0.60, p less than 0.001), and systemic arterial oxygen saturation (from 84% to 79%, p less than 0.01). One patient had nonfatal complications. Surgery was performed in 19 patients from 2 weeks to 29 months (mean 12 months) after catheterization, with 1 operative death (5% mortality). Four patients required early total correction because of persistent heart failure; 15 had elective surgical repair. One of 2 unoperated patients died of pneumonia at 2.5 years of age. A restrictive interatrial communication develops after the first month of extrauterine life in most patients with TAPVC. Atrial septostomy results in improved hemodynamic conditions and clinical palliation.(ABSTRACT TRUNCATED AT 250 WORDS)

Complete correction of total anomalous pulmonary venous drainage: experience with 53 patients

From January, 1973, to August, 1984, 53 infants with total anomalous pulmonary venous drainage (TAPVD) underwent a corrective operation in our unit. TAPVD was of the supracardiac type in 41% of the patients, cardiac in 17%, infracardiac in 36%, and mixed in 6%. Overall operative mortality was 23%; it was highest at 42% in the infracardiac group. Factors determining the outcome were the anatomical type of the lesion, the degree of pulmonary venous obstruction, the severity of pulmonary hypertension, and the young age of the patients. In addition, surgical experience appears to be an important factor in determining the outcome. During the study, hospital mortality decreased considerably to 11%. A corrective procedure offers the only chance of survival for patients with TAPVD. With some experience, excellent results can be obtained.

Assessment of total anomalous pulmonary venous connection by two-dimensional echocardiography

Twenty-three patients with total anomalous pulmonary venous connection were studied by two-dimensional echocardiography. In all cases the diagnosis was made before invasive procedures, with surgical or angiocardiographic confirmation. Eleven patients had supracardiac drainage (three to the coronary sinus, two to the right atrium,) and seven had infracardiac drainage. In the majority of cases the precise pattern of drainage could be identified by combining suprasternal, praecordial, and subcostal views. In 12 cases where the suprasternal cut was used a pulmonary venous confluence could be identified, having a cross-like structure in nine, with three others appearing as a dilated channel behind and separate from the left atrium. Thus, two-dimensional echocardiography reliably makes the diagnosis of total anomalous pulmonary venous connection and in the majority the precise pattern of drainage can be determined.

Infradiaphragmatic total anomalous pulmonary venous drainage: surgical treatment and long-term results

Since 1971, 20 infants (1 day to 3 months old) with infradiaphragmatic total anomalous pulmonary venous drainage (TAPVD) have undergone repair at The Hospital for Sick Children, Great Ormond Street, London. All patients were seen with severe cyanosis (mean partial pressure of arterial oxygen, 35.8 mm Hg) and pulmonary edema. All had a persistent ductus arteriosus. Right-sided pressures were equal to or greater than systemic in 17 patients. During surgical repair, the confluence of the pulmonary veins was anastomosed to the left atrium. The descending vein was ligated in 11, divided in 4, and left open in 5 patients. Atrial septal defects were closed with a patch in 6 and sutured in 14. Eight patients died (40%). Acidosis on admission was significantly greater among nonsurvivors (mean pH, 7.29 +/- 0.02) than survivors (mean ph, 7.37 +/- 0.02) (p less than 0.05). Twelve survivors are well four months to 8 years after operation. All are asymptomatic and none requires cardiac medication. Six have undergone repeat catheterization, demonstrating normal pressures and no shunts. We conclude that the mortality of patients with infradiaphragmatic TAPVD depends mainly on the condition of the child on admission.

Cross-sectional echocardiographic imaging of supracardiac total anomalous pulmonary venous drainage to a vertical vein in a patient with Holt-Oram syndrome

We report the unusual association of total anomalous pulmonary venous drainage in a three-year-old with Holt-Oram syndrome and a new technique for imaging vertical vein drainage of anomalously draining pulmonary veins by suprasternal cross-sectional echocardiography.

Concepts and practices in surgery for total anomalous pulmonary venous connection

In the last ten years there have been extensive refinements in the surgical approach to total anomalous pulmonary venous connection (TAPVC). This communication reviews determinants of hosptal mortality and controversies in surgical management. As examples of current experience with repair of TAPVC, recent results at the University of Alabama and a combined analysis of hospital mortality for Alabama, Children's Hospital Medical Center in Boston, and Green Lane Hospital are reported. From July, 1974, to July 1977, the Alabama hospital mortality among the 17 infants with supracardiac, cardiac, and infracardiac TAPVC was 12% (2 infants).

Total anomalous pulmonary venous connection. Report of ten cases and review of the literature

Ten cases of total anomalous pulmonary venous connection, all presenting at or below the age of eight weeks, are presented: three below the diaphragm, two to the coronary sinus, one to the right atrium, three to the left vertical vein, and one to the right superior vena cava. Six patients had other cardiac anomalies, and surgical mortality represented 75%. A review of the subject is presented.

Infradiaphragmatic total anomalous pulmonary venous return. Review of clinical and pathological findings and results of operation in 28 cases

Twenty-eight cases of infradiaphragmatic total anomalous pulmonary venous return are presented, 17 without associated complex intracardiac anomalies (group A), and 11 with additional complex lesions (group B). The anomalous site of connection was to the portal vein in 19 cases (68%), to the inferior vena cava in 4 (14%), the ductus venosus in 2 (7%), to the left hepatic vein in 2 (7%), and unknown in one. A patent foramen ovale was present in 82 per cent of cases in group A and 40 per cent in group B and was frequently associated with a small left atrium and left ventricle. Nine cases (8 in group A; 1 in group B) had surgical correction, with 3 long-term survivors. The surgical mortality was 66 per cent. The postoperative haemodynamic status of the 3 surviving patients is very satisfactory, though 1 had a residual atrial septal defect. Factors which adversely affected the surgical outcome were: (1) a critically ill infant, (2) small left atrium and left ventricle, (3) a patent foramen ovale rather than atrial septal defect, (4) systemic arterial oxygen saturation less than 70 per cent, and (5) pulmonary arterial pressure in excess of systemic arterial pressure. The mortality for the entire series was 93 per cent.

Total anomalous pulmonary venous drainage in infancy

Between May 1971 and December 1975, 39 infants had operations for correction of total anomalous pulmonary venous drainage. Fourteen of the 39 patients were under 1 month of age at the time of operation. Twenty-four patients had supracardiac, 7 intracardiac, and 6 infracardiac total anomalous pulmonary venous drainage, and 2 had a mixed type. The overall hospital mortality was 36 per cent. There have been no late deaths. The improvement in survival rate in this series is attributed to: (1) earlier recognition and prompt referral, (2) an aggressive approach to diagnosis involving complete cardiac catheterisation and angiocardiography, (3) vigorous preoperative care, (4) early complete correction including construction of a large anastomosis and enlargement of the left atrium when indicated, and (5) intensive postoperative management paying particular attention to fluid balance and treatment of pulmonary complications. Operative mortality was highest in patients with total anomalous pulmonary venous drainage directly to the superior vena cava, and in those with infradiaphragmatic drainage of whom all had pulmonary venous obstruction. Mortality was not closely related to age, body weight, or severity of pulmonary hypertension.

Structural study of pulmonary circulation and of heart in total anomalous pulmonary venous return in early infancy

Quantitative morphometric techniques have been applied to the injected and inflated lung and to the heart in 9 infants with total anomalous pulmonary venous return dying with obstruction to pulmonary venous return. In 5 (mean age at death 55 days) pge 20 days) to an infradiaphragmatic site. Structural changes were present in the pulmonary circulation in all patients, even in the youngest, an 8-day-old child. In both types of total anomalous pulmonary venous return increased arterial muscularity was severe, as shown by increase in wall thickness and by extension of muscle into smaller and more peripheral arteries than normal; these changes tended to increase with age. Where the pulmonary venous blood drained to a supradiaphragmatic site, the severity of arterial medial hypertrophy correlated inversely with the magnitude of the pulmonary: systemic flow ratio, increasing as the pulmonary blood flow fell. Vein wall thickness was increased and in all but the youngest child the veins were 'arterialised'. At the lung periphery the arteries and alveoli appeared to have multiplied normally. Arterial size varied according to whether pulmonary venous blood drained above or below the diaphragm; the diameter of pre- and intra-acinar arteries was increased only in cases where the pulmonary venous return drained to a supradiaphragmatic site, being normal when it drained to an infradiaphragmatic site. In the heart the left ventricle was of normal size in all but one case. Dilation and severe hypertrophy of the right ventricle and septum were present only in cases of drainage to a supradiaphragmatic site. In the older patients with the latter anomaly dilation of the pulmonary arteries and right ventricle suggested that a large left-to-right shunt had preceded the onset of obstruction to pulmonary venous return and that the more severe right ventricular and septal hypertrophy in these cases might be the result of a longer duration of pulmonary hypertension. In contrast, in total anomalous pulmonary venous return to an infradiaphragmatic site it appears that obstruction to pulmonary venous return develops soon after birth and prevents a large increase in pulmonary blood flow, and thus neither the pulmonary arteries nor the right ventricle become dilated. In infants with total anomalous pulmonary venous return and obstruction to pulmonary venous return, it is striking how rapidly the pulmonary circulation develops new muscle.

Successful correction of total anomalous pulmonary venous connection in a 2.5 kilogram premature neonate

A 16 day old 2.5 kg premature infant with total anomalous pulmonary venous drainage to the coronary sinus was successfully treated with use of profound hypothermia and total circulatory arrest. To the best of our knowledge, this neonate is the smallest to successfully undergo correction of this anomaly. A plea is made for a more aggressive approach in early recognition and assessment of these critically ill infants, followed by early surgical correction.

Echocardiographic features of total anomalous pulmonary venous connection

Seven patients, four months to ten years of age, with total anomalous pulmonary venous connection (TAPVC) were studied by echocardiography. The diagnosis was confirmed by cardiac catheterization, angiography, and surgery in each. The connection was to the left vertical vein in four patients, to the coronary sinus in one, to the inferior vena cava in one, and directly to the right atrium in one. All patients exhibited the echocardiographic criteria of right ventricular diastolic volume overload (RVDVO). In addition, an echo-free space was identified dorsal to the posterior wall of the left atrium. Indocyanine green dye studies done in one of the patients provided evidence that this echo-free space represents the common pulmonary venous chamber. The combination of echocardiographic evidence of RVDVO and demonstration of an echo-free space dorsal to the left atrium is strongly suggestive of TAPVC and should allow an early diagnosis in infants with this anomaly.

Balloon atrial septostomy for total anomalous pulmonary venous return

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Total anomalous pulmonary venous drainage in infants. I. Clinical and hemodynamic findings, methods, and results of operation in 37 cases

Thirty-seven infants with total anomalous pulmonary venous drainage have been operated upon at The Hospital for Sick Children, Great Ormond Street, London, with 13 survivors. Most were rapidly deteriorating when admitted. Cardiac catheterization, angiography, and operation were urgently undertaken to achieve the maximum salvage. Physical examination, plain radiography, and electrocardiography were insufficient for accurate diagnosis. Survival was closely related to the degree of pulmonary hypertension, which was dependent on the type of anomalous venous drainage and the presence of pulmonary venous obstruction. The prognosis was good for patients over 3 months of age, especially those without pulmonary venous obstruction, provided that they arrived in the hospital in reasonable condition. The best survival rate, nine of 11 cases, was achieved in those patients between 3 and 12 months of age with supracardiac drainage.