Anomalous midline location of the descending aorta: a cause of compression of the carina and left mainstem bronchus in infants

Tracheopexy and aortopexy for circumflex aortic arch on a small infant

Circumflex aortic arch is a rare vascular ring anomaly, which is often associated with tracheobronchomalacia. Aortic uncrossing is the definitive repair of this condition, which is a major high-risk operation; therefore, it is not suitable for small patients such as newborn infants or individuals who have severe comorbidities. We present a case of the circumflex aortic arch with tracheobronchomalacia in a 2.7-kg infant who underwent successful innovative combined surgery of the airway and the aorta.

Descending aorta translocation for bronchial stenosis caused by shorter interaortic distance

BACKGROUND AND AIM OF THE STUDY

Numerous anatomic relationships of arteries could cause extrinsic compression of the trachea or bronchus. We report a rare left bronchial stenosis just caused by shorter inter-aortic distance.

METHODS

One patient wih recurrent coughing and wheezing was diagnosed as left emphysema.Cardiac computed tomography (CTA) shows a shorter distance between ascending aorta (AAo) and descending aorta (DAo) caused left bronchial stenosis with extrinsic compression of right pulmonary artery.

RESULTS

A translocation of the descending aorta was performed in this patient, and postoperative CTA showed that the DAo was translocated to the AAo and the left main bronchial stenosis was relieved.

CONCLUSIONS

Translocation of the DAo was necessary for the rare left bronchial stenosis caused by shorter inter-aortic distance and could bring a good outcome.

Airway obstruction in children with complex conotruncal cardiac anomalies

The incidence of airway obstruction in patients with complex CHD other than vascular rings and absent pulmonary valve syndrome is unknown. We reviewed pre-operative CT and clinical data of children with conotruncal abnormalities to assess for airway obstruction. Airway obstruction was common (41% of patients), often moderate to severe, of diverse aetiology, and most commonly associated with a right aortic arch. Patients with airway obstruction showed a trend towards a higher mortality rate. Patients with complex conotruncal abnormalities should be assessed for airway obstruction as it may help predict the need for additional interventions and assist with prognostication.

Aortopexy - an effective strategy for relief of left main bronchus compression

Congenital anomalies of aortic arch and pulmonary arteries can cause airway compression in children. We present a rare case of left main bronchus compression between the right pulmonary artery and descending thoracic aorta, which was successfully treated by aortopexy.

Descending Aortic Translocation and Right Pulmonary Artery Reimplantation for Midline Descending Aorta and Crossed Pulmonary Arteries in an Infant

Left mainstem bronchial compression by a midline descending thoracic aorta is a rare anatomic variant. Translocation of the descending thoracic aorta to the ascending aorta has recently been described to treat this condition. We performed an aortic translocation and right pulmonary artery reimplantation in a 4-month-old infant with severe pulmonary hypertension secondary to right pulmonary artery stenosis and left bronchial compression by a midline descending thoracic aorta. The procedure was successful in ameliorating the patient's left mainstem bronchial compression and pulmonary hypertension. Descending aortic translocation should be considered when the left bronchus is compressed causing respiratory symptoms.

Short-length ligamentum arteriosum as a cause of congenital narrowing of the left main stem bronchus

An entity that has received little attention as cause or recurrent respiratory disorder is the narrowing of the left main stem bronchus. When not associated with congenital heart disorders, this condition has been ascribed to primary localized malacia of the bronchial cartilages or to the anterior displacement of the descending aorta in front to the adjacent vertebral bodies. Four girls were evaluated for recurrent/chronic respiratory symptoms. A pulsatile extrinsic compression on the posterior bronchial wall of the left main stem bronchus was detected, pressed between the descending aorta, posteriorly, and the left pulmonary artery, anteriorly. The two arteries were closely linked together by a short-length ligamentum that was resected, allowing the mobilization of the aorta with posterior aortopexy, stabilizing the space created between the pulmonary artery and the descending aorta. The reduced compression on the left main bronchus resulted in the enlargement of its caliber and in a marked improvement of the respiratory symptoms. Pediatr Pulmonol. 2016;51:1356-1361. © 2016 Wiley Periodicals, Inc.

Useful signs for the assessment of vascular rings on cross-sectional imaging

Vascular rings can be challenging to diagnose because they can contain atretic portions not detectable with current imaging modalities. In these cases, where the compressed airway and esophagus are not encircled by patent, opacified vessels, there are useful secondary signs that should be considered and should raise suspicion for the presence of a vascular ring. These signs include a double aortic arch, the four-vessel sign, the distorted subclavian artery sign, a diverticulum of Kommerell, a ductal diverticulum contralateral to the aortic arch, and a descending aorta contralateral to the arch or circumflex aorta. If none of these findings is present, a ring can be excluded with confidence.

Ventricular and atrial mechanics and their interaction in patients with congenital scoliosis without clinical heart failure

OBJECTIVES

This study sought to evaluate left ventricular, right ventricular, and left atrial mechanics and their interactions in patients with congenital scoliosis without clinical heart failure.

METHODS

A total of 23 patients with a median age of 14 years and a median Cobb's angle of 61° were studied. Ventricular and atrial myocardial deformation was measured using speckle tracking echocardiography. The results of the patients were compared with 22 controls.

RESULTS

Compared with controls, the patients had a significantly greater annular a velocity (p=0.04) and lower e/a ratio (p=0.03); the left ventricular deformation significantly decreased in radial global (p=0.04) and segmental systolic strain and early diastolic strain rate (p=0.03); the left atrial deformation showed a significantly lower positive strain (p=0.02), greater negative strain (p=0.01), and active contractile strain rate (p=0.01). For the patients, the Cobb's angle was negatively correlated with the left ventricular global radial systolic strain (r=-0.65, p=0.001), left atrial positive strain (r=-0.68, p<0.001), and the left atrial negative strain was positively correlated with the left ventricular circumferential late diastolic strain rate (r=0.46, p=0.01). The left atrial conduit strain rate was positively correlated with the left ventricular circumferential early diastolic strain rate (r=0.42, p=0.03). The left atrial active contractile strain rate was positively correlated with the left ventricular longitudinal late diastolic strain rate (r=-0.4, p=0.03).

CONCLUSIONS

Impaired left ventricular and altered left atrial mechanics occur relatively early in patients with congenital scoliosis, and are correlated with the severity of their scoliosis. Our findings provide evidence of preclinical heart dysfunction in patients with this disorder.

Aortopexy with preoperative computed tomography and intraoperative bronchoscopy for patients with central airway obstruction after surgery for congenital heart disease: postoperative computed tomography results and clinical outcomes

Bronchoscopy-guided aortopexy is a surgical management option for patients with central airway obstruction after congenital heart surgery. This study aimed to evaluate the usefulness of bronchoscopy-guided aortopexy based on midterm follow-up evaluation with computed tomography (CT) and clinical outcome. From January 2004 to August 2011, bronchoscopy-guided aortopexy was performed for 16 patients (median age 0.5 years, M:F = 10:6) who had central airway obstruction caused by extrinsic compression (13 in the left main bronchus, 2 in the trachea, 1 in the diffuse trachea and bronchus) after congenital heart surgery. The surgical site for aortopexy was determined by the anatomic relationship between the aorta and the compressed bronchus according to preoperative CT and intraoperative bronchoscopy. The median follow-up period was 2.3 years. The ratios of the diameter and area of stenosis at the narrowed point were estimated using pre- and postoperative CT. Almost all the patients (15/16) showed relief of their preoperative symptoms. The median extubation time was 18 h. The stenosis diameter and area ratios significantly improved, as shown by with the immediate postoperative CT (7.7-48.5%, p = 0.003; 54.8-80.5%, p = 0.006). Airway stenosis of more than 75% (p = 0.013), immediate diameter ratio improvement of <50% (p = 0.015), preoperative severe respiratory insufficiency (p = 0.038), and male sex (p = 0.024) were associated with recurrent minor respiratory susceptibility. Bronchoscopy-guided aortopexy is a safe and reliable surgical management choice for central airway obstruction after congenital heart surgery. Furthermore, airway improvement after aortopexy was maintained during the midterm follow-up evaluation, according to CT measurements.

Left main bronchus compression as a result of tuberculous lymphnode compression of the right-sided airways with right lung volume loss in children

RATIONALE

The superior mediastinal space is confined by the sterno-manubrium anteriorly and the vertebral column posterior. An abnormal relationship between the superior mediastinal structures may result in compression of the left main bronchus. In patients with right-sided pneumonectomy an exaggerated compensatory response may lead to stretching and compression of the remainder of the intra-thoracic airway. Lymphobronchial TB mimics pneumonectomy when it causes compression of the bronchus intermedius, between nodal lymphnode groups with resultant volume loss in the right lung and displacement of the mediastinum to the right. The left main bronchus may be at risk of compression due to rotation and displacement of the major vessels.

AIM

To report pediatric cases of right-sided lymphobronchial TB with volume loss, demonstrate the use of angle measurements to quantify mediastinal dynamics and support a pathogenetic theory for left main bronchus compression.

MATERIALS AND METHODS

CT scans in children with TB and right lung volume loss, were compared retrospectively with controls using angle measurements based on descriptions of the aorta-carinal syndrome and the post-pneumonectomy syndrome. The Mann-Whitney U-test was used to compare groups.

RESULTS

The "Pulmonary bifurcation angle" between the main pulmonary arteries reached statistical significance (P = 0.025). The "Pulmonary outflow tract rotation" angle (pulmonary trunk with the mid sagittal plane) approached statistical significance (P = 0.078). The left main bronchus ranged from complete obliteration in two patients to 0.7 cm. In 16 of 30 patients the size was reduced to less than 75% of expected.

CONCLUSION

In children with right lung volume loss from TB, the compression of the contralateral bronchus is due to narrowing of the pulmonary artery bifurcation angle as the main trunk rotates towards the midline. This is comparable to the post-pneumonectomy syndrome.

Obstructive lung disease is common in children with syndromic and congenital scoliosis: a preliminary study

BACKGROUND

It is well known that restrictive lung disease (RLD) is associated with scoliosis. This study identifies that obstructive lung disease (OLD) is associated with syndromic scoliosis and congenital scoliosis.

METHODS

We searched a local database for patients with scoliosis who underwent a pulmonary function testing (PFT) from 2004 to 2009. All patients with congenital scoliosis or syndromic thoracolumbar scoliosis with a Cobb angle of ≥40 degrees and acceptable and repeatable PFT testing were included in the study. OLD was defined as an forced expiratory volume in the first second/forced vital capacity ratio below 95% confidence interval. Bronchoscopy videos and computed tomography scans or magnetic resonance images were reviewed to identify anatomic causes of lower airway disease.

RESULTS

A total of 18 patients met the criteria for inclusion. The median age at diagnosis was 11.3 years. The median primary Cobb angle was 60 degrees. The prevalence of OLD was 33% and RLD was 57%. The 6 children with OLD underwent preoperative bronchoscopy and chest computed tomography or magnetic resonance imaging to identify anatomic causes of lower airway obstruction. The 4 children with OLD and right-sided major thoracic curves had compression of the right mainstem bronchus between the spine (posterior) and the right pulmonary artery (anterior). The 2 children with OLD and left-sided major thoracic curves had compression of the left mainstem bronchus between the spine (posterior) and the descending aorta (anterior) or the left atrium (anterior).

CONCLUSIONS

In our study, the prevalence of OLD in children with congenital scoliosis or syndromic scoliosis was 33%, which was elevated when compared with the population prevalence of 2% to 5%. Mainstem airway compression from spine rotation was discovered to be the potential mechanism of disease.

LEVEL OF EVIDENCE

Level IV, prognostic study investigating the effect of a patient characteristic on the outcome of disease.

Imaging findings in pediatric patients with persistent airway symptoms after surgery for double aortic arch

OBJECTIVE

The purpose of this study was to review the imaging findings of children referred for cross-sectional imaging to evaluate persistent airway symptoms after surgical therapy for double aortic arch.

CONCLUSION

Airway narrowing is clearly shown on cross-sectional imaging in patients with persistent airway symptoms after surgical therapy for double aortic arch. Two patterns of airway compression are typically seen: narrowing of the trachea at the level of the postsurgical arch and narrowing of the left main bronchus as a result of compression from a midline descending aorta. Both patterns may be seen in patients regardless of whether the left or the right arch has been ligated.

Aberrant subclavian arteries: cross-sectional imaging findings in infants and children referred for evaluation of extrinsic airway compression

OBJECTIVE

The purpose of our study was to describe patterns of airway compression identified on cross-sectional imaging in infants and children with either right aortic arch and aberrant left subclavian artery or left aortic arch with aberrant right subclavian artery.

MATERIALS AND METHODS

Data from MR imaging and CT performed to evaluate pediatric patients for extrinsic airway compression were reviewed for cases that revealed an aberrant right or left subclavian artery. Clinical, endoscopic, and imaging findings in identified cases were reviewed. Recurrent patterns of extrinsic compression were reviewed among cases.

RESULTS

Twelve patients with right aortic arch with aberrant left subclavian artery and nine patients with left aortic arch and aberrant right subclavian artery were identified. All 12 with right aortic arch with aberrant left subclavian artery had airway compression shown, with multiple sites or diffuse compression in six. Of these 12 patients, nine had compression at the level of the arch and aberrant subclavian artery (10 had Kommerell's diverticulum), and nine had compression of the distal airway in association with a midline descending aorta. Five of the nine patients with left aortic arch and aberrant right subclavian artery had airway compression shown, all at the level of the arch and aberrant subclavian artery. None of these compressions was associated with either Kommerell's diverticulum or midline descending aorta.

CONCLUSION

Both right and left aberrant subclavian arteries can be associated with symptomatic airway compression, but the patterns of compression are different. The airway compression in right aortic arch with aberrant left subclavian artery is often associated with either Kommerell's diverticulum or midline descending aorta, whereas compression associated with left aortic arch and aberrant right subclavian artery is not.

Bronchial compression by posteriorly displaced ascending aorta in patients with congenital heart disease

BACKGROUND

We encountered several patients with posteriorly displaced ascending aorta and bronchial compression associated with congenital heart disease. We describe the helical computed tomography (CT) findings and explore the mechanism of airway compression.

METHODS

We retrospectively reviewed the clinical data and CT findings of 8 patients with posterior displacement of the ascending aorta. The bronchial stenosis was quantified on reformatted images perpendicular to the main-stem bronchi. On an axial image at the level of main bronchi, we measured depth of retrosternal space, interaortic distance, and aorto-spinal distance. To compare with control, we measured the same variables in 10 control patients.

RESULTS

In 7 patients, the main bronchus on the side of the aortic arch was squeezed between the ascending and descending aorta and showed slit-like stenosis. The right pulmonary artery was elongated around the ascending aorta in 5 patients and showed slit-like stenosis in 3. Patients with posterior displacement had significantly larger retrosternal space, smaller interaortic distance, and smaller aorto-spinal distance than did the control group. Aortopexy was undertaken in 3 patients. Follow-up computed tomograms of 2 patients showed improvement.

CONCLUSIONS

The posteriorly displaced ascending aorta may compress the main bronchus on the side of the aortic arch and right pulmonary artery against the descending aorta or spine. Even if the bronchial compression is mild with tolerable airway symptoms, these patients must be closely observed. When airway symptoms are severe, aortopexy should be considered.

Compression of the central airways by a dilated aorta in infants and children with congenital heart disease

BACKGROUND

Children with congenital heart disease often experience respiratory symptoms in the preoperative and perioperative periods, which can complicate their management. An uncommon but important cause of respiratory insufficiency in such children is external airway compression.

METHODS

We operated on 5 patients (median age, 6 months) with significant respiratory distress attributable to compression of the central airways by a dilated ascending aorta before or after repair of concomitant cardiovascular defects. Four of these patients had right aortic arch and 3 had pulmonary atresia with a ventricular septal defect and major aortopulmonary collaterals. In all patients, aortopexy was performed at the time of operation for the cardiovascular defects (n = 3) or after symptoms developed in the postoperative period (n = 2). The 3 patients in whom airway compression produced symptoms preoperatively also underwent reduction ascending aortoplasty.

RESULTS

Symptoms resolved immediately after operation in 3 patients, whereas symptoms persisted in the other 2 patients and tracheostomy was required. At follow-up of 20 months to 5 years, all patients are alive and well, with mild or moderate respiratory symptoms in the 2 patients who required tracheostomy, both of whom were decannulated within 13 months.

CONCLUSIONS

External airway compression can cause significant morbidity in patients with congenital heart defects other than vascular rings. In patients with respiratory symptoms in the context of a lesion that involves increased aortic outflow during intrauterine life and consequently, an enlarged ascending aorta, such as tetralogy of Fallot with pulmonary atresia, airway compression should be considered as a cause, especially if a right aortic arch is present or the patient also has pulmonary atresia with a ventricular septal defect and collaterals. Attempts to address this problem surgically may provide substantial relief, but increasing duration of airway compression is likely to lead to tracheal or bronchial malacia and persistent symptoms even after the compression is relieved.

Diagnosis and management of left main stem bronchus compression

There are four major variants of congenital vascular tracheal compression: innominate artery, aberrant subclavian, aorta or aortic arch anomaly, and pulmonary artery sling. These forms of vascular compression typically involve the trachea and/or the right main stem bronchus. We present eight cases of congenital vascular compression involving the left main stem bronchus. These cases represent a poorly understood variant of vascular tracheal compression. This variant represents approximately 10% of our pediatric tracheobronchial compression or stenosis patients. The finding, both noted endoscopically and now illustrated by magnetic resonance imaging, is caused by compression of the left main stem bronchus between the descending aorta and a portion of the pulmonary artery. Frequently, the descending aorta is in an abnormal anterior position with relation to the thoracic spine. Recognition of this entity is important in our experience and has influenced clinical management. In four of eight children, it required a surgical procedure directed toward the relief of the left main stem compression.