The syndrome of left isomerism: sonographic findings and outcome in prenatally diagnosed cases

Early and long-term outcomes following cardiac surgery for patients with heterotaxy syndrome

Objective

Heterotaxy syndrome is a complex multisystem abnormality historically associated with high morbidity and mortality. We sought to evaluate the early and long-term outcomes after cardiac surgery in heterotaxy syndrome.

Methods

This is a single-center retrospective review of patients with heterotaxy syndrome undergoing single-ventricle palliation or primary or staged biventricular repair from 1998 to 2018. Patients were stratified by single ventricle versus biventricular physiology, and the severity of atrioventricular valve regurgitation. Demographics, anatomic characteristics, and early and late outcomes, including the length of stay, mortality, and surgical or catheter reinterventions, were analyzed.

Results

Among 250 patients, 150 (60%) underwent biventricular repair. In-hospital mortality was 7.6% (n = 19). Median follow-up was 5.2 (range, 0-16) years. Among survivors to discharge, mortality was 19% (n = 44) and reintervention was 52% (n = 120). Patients with moderate/severe atrioventricular valve regurgitation were older (32 vs 16 months, P = .02), were more likely to experience adverse events during their index surgical admission (72% vs 46%, P < .001), and had longer in-hospital length of stay (20 vs 12 days, P = .009). Among patients with moderate to severe atrioventricular valve regurgitation, single-ventricle palliation is associated with a greater risk of unplanned reintervention compared with patients undergoing biventricular repair (hazard ratio, 2.13; CI, 1.10-4.12; P = .025).

Conclusions

There was no significant difference in early or late outcomes in single-ventricle versus biventricular repair strategies in heterotaxy. In the subgroup of patients with moderate/severe atrioventricular valve regurgitation, patients who underwent single-ventricle palliation were 2.5 times more likely to need a late reintervention compared with those undergoing biventricular repair.

Heterotaxy pattern associated with sinus node dysfunction in an adult: A case report

Key Clinical Message

A 26-year-old male patient admitted to the hospital ward with experience of repetitive syncopes for a year. The patient was diagnosed with sick sinus syndrome. The aim of this clinical report is to highlight the variability of anatomical findings associated with polysplenia pattern.

Abstract

This case report presents a 26-year-old male patient who presented to the medical ward with a complaint of repeating blackouts for a year. The patient was then diagnosed with sick sinus syndrome, and further investigations revealed left isomerism, polysplenia, and no congenital heart defects. Holter monitoring, ultrasonography, electrocardiography, and computed tomography were used to confirm the diagnosis. The patient underwent DDDR pacemaker implantation for the treatment of SA node dysfunction. The report highlights the variability of anatomical findings associated with polysplenia pattern and the various types of heartbeat disruptions that may occur in the atrial appendages of the left side isomerism.

Heterotaxy polysplenia syndrome presenting with bleeding from the greater curvature of stomach: a case report

Background

The “heterotaxy syndrome” also called “situs ambiguus” is a rare condition in which the internal organs of the chest and abdomen are abnormally arranged. This syndrome is usually associated with a spectrum of health-related conditions involving birth defects in organs like the heart, spleen, liver, lungs and others.

Case presentation

We present a case of a 29-year-old male who came with an episode of massive upper gastrointestinal bleeding. On arrival he was vitally unstable and after resuscitation underwent a contrast-enhanced CT scan examination. The CT scan identified the features of heterotaxy syndrome with left isomerism and an abnormal blush from the branch of splenic artery supplying the greater curvature of the stomach. Embolization of the splenic artery branches was performed with the help of gel foam. No abnormal blush was identified post-embolization. Later on, in his hospital stay the patient went into pulse less electrical activity and died.

Conclusion

Upper gastrointestinal bleed in the patients with heterotaxy syndrome is a rare presentation of a rare condition. Our case highlights the importance of diagnostic and interventional radiology in diagnosing such patients and identifying the site of bleed especially where endoscopic visualization is not possible and managing the bleeding efficiently.

Heterotaxy Syndrome with Increased Nuchal Translucency and Normal Karyotype Associated with Complex Systemic Venous Return. Ultrasound Diagnosis with Autopsy Correlation

Background: Prenatal ultrasound (US) detection of heterotaxy syndrome can be challenging, especially in identifying cardiovascular and associated anomalies. We present a new case of heterotaxy syndrome with anomalous systemic venous return (ASVR) fully displayed at autopsy. Case report: Left heterotaxy syndrome was diagnosed in a 19 weeks' of gestation fetus with right-sided stomach. The heart showed both ventricles with left morphology, a large ventricular septal defect, persistent left superior vena cava draining into the coronary sinus, ASVR with interrupted inferior vena cava (IVC) and azygous continuation. Autopsy dissection further identified the azygous draining into the left lower pulmonary vein (LLPV). Prenatal a-CGH on villous sampling showed 22q13.1 microduplication inherited from the father, not contributory to the phenotype. Conclusion/discussion: Heterotaxy syndrome requires US accuracy for anomaly identification, as they allow legal termination of pregnancy. Our case is unusual as IVC drained into the azygous vein and then into the LLPV.

Prenatal diagnosis of hepatic interruption of the inferior vena cava with azygos/hemiazygos continuation without structural heart defects: A case series

OBJECTIVES

To describe fetal spectrum and echocardiographic characteristics of interrupted inferior vena cava (IIVC) with azygos/hemiazygous continuation without other structural heart defects and to evaluate its association with visceral heterotaxy and isomerism, extracardiac and genetic anomalies, and to review neonatal outcome.

METHODS

This was a retrospective study of 14 fetuses with a confirmed diagnosis of IIVC with normal intracardiac anatomy. The following variables were collected; indication for referral, gestational age at diagnosis; associated isomerism and visceral heterotaxy, heart rhythm, genetic and extracardiac abnormalities, and fetal/neonatal outcome.

RESULTS

Among 36 fetuses with IIVC, 14 cases (38.8%) had normal intracardiac anatomy. These IIVC cases correspond to 0.19% (14/7250) of all fetal cardiac examinations, and to 1.5% (14/922) of all cardiac abnormalities. Six patients had visceral abnormalities. Atrial appendage morphology was clearly depicted in three fetuses, both appendages were left. One fetus had bradyarrhythmia revealing atrial ectopic rhythm. Six fetuses did not have any concomitant cardiac or visceral abnormalities, therefore regarded as isolated. All babies were delivered at term with a good prognosis.

CONCLUSION

Our study has shown that almost half of the IIVC cases without intracardiac structural anomalies displayed other findings of isomerism while the other half was isolated benign vascular variant. Therefore, prenatal diagnosis of IIVC should prompt a comprehensive evaluation for cardiac, situs, and visceral anomalies. The outcome is favorable.

Fetal Ultrasonic Evaluation of Bronchial Morphology in Fetuses with Isomerism

OBJECTIVE

The aim of the study was to evaluate whether fetal ultrasound could determine bronchial isomerism and distinguish left isomerism from right isomerism.

METHODS

We identified 110 healthy fetuses and 28 fetuses with isomerism. The outer angle between the tracheal midline and the inner margin of the bronchus is measured. The bronchial angles and the ratio of left/right bronchial angle were used to differentiate bronchial morphology and confirm the presence of bronchial isomerism in pathological cases.

RESULTS

The normal angles of the left and right bronchi were 146.98° (95% CI, 145.15-147.81°) and 167.37° (95% CI, 166.30-168.44°), separately. The cutoff bronchial angle of 156.5° was used to distinguish left bronchus from right bronchus. The bronchial isomerism could be identified in all pathological cases by autopsy and bronchial-atrial concordance occurred in 27 pathological cases (96.4%). In 21 pathological cases, the bilateral bronchial angle was <156.5 versus >156.5 differentiated left from right isomerism, respectively. The ratio of the left/right bronchial angle of >0.935 identified 92.9% (26/28) of all pathological cases, with a sensitivity of 89.7%.

CONCLUSIONS

Fetal ultrasound can detect the bronchial morphology and the presence of bronchial isomerism in fetuses with isomerism according to bronchial angles and the ratio of left/right bronchial angle.

Heterotaxy syndrome with complex congenital heart disease, facial palsy, and asplenia: A rare newborn finding

Heterotaxy syndrome is associated with asplenia/polysplenia and complex congenital heart disease. Facial palsy in heterotaxy is very rare. The management is still challenging with a poor prognosis. Proper counseling to the family about the disease course, treatment modalities, and outcomes is essential.

A Case Report of Left Atrial Isomerism in a Syndromic Context

The objective of our paper is to underline the importance of assessing microarray genetic analysis for the detection of chromosomal abnormalities in rare cases such as left atrial isomerism, mostly in the context of antenatally detected syndromes. We present the case of a 26-year-old primipara, at 26 weeks of gestation, with prior first trimester normal anomaly scan, who presented in our department accusing lower abdominal pain. An anomaly ultrasound examination of the fetus revealed cardiomegaly with increased size of the right atrium, non-visualization of the atrial septum or the foramen ovale, malalignment of the three-vessel view, location of the superior vena cava above the two-vessel view, slight pericardial effusion, and no interruption of the inferior vena cava nor presence of azygos vein being noted. Associated extracardiac abnormalities, such as small kidneys at the level of the iliac fossa, micrognathia, dolichocephaly with hypoplasia of the cerebellum, increased nuchal fold, and reduced fetal movements were also reported. A diagnostic amniocentesis was performed, and, while the conventional rapid prenatal diagnostic test of the multiplex quantitative fluorescent polymerase chain reaction (PCR) came as normal, the microarray analysis (ChAS, NCBI Built 37 hg 19, detection of microdeletions or microduplications larger than 100 kb) revealed two chromosomal abnormalities: a 22.84 Mb loss of genetic material in the 18q21.31-18q23 chromosomal region and a gain of 22.31 Mb of genetic material in the 20p13-20p11.21 chromosomal region. After the termination of pregnancy, a necropsy of the fetus was performed, confirming heterotaxy syndrome with a common atrium, no atrial septum, superior vena cava draining medianly, and pulmonary veins that drained into the lower segment of the left atrium due to an anatomically enlarged single common atrium. The extracardiac findings consisted of two bilobar lungs, dysmorphic facies, low-set ears, nuchal fold edema, and small kidneys located in the iliac fossa. These findings are conclusive evidence that left atrial isomerism is a more complex syndrome. The genetic tests of the parents did not reveal any translocations of chromosomes 18 and 20 when the Fluorescent in situ Hybridization (FISH) analysis was assessed. The antenatal detection of corroboration between different structural abnormalities using serial ultrasound examinations and cardiac abnormalities, together with the detection of the affected chromosomes, improves the genetic counseling regarding the prognosis of the fetus and the recurrence rate of the condition for siblings.

Heterotaxy Polysplenia Syndrome in Adulthood: Focused Review and a Case Report

Heterotaxy syndrome (Situs ambiguus) is a condition in which the internal organs are abnormally arranged in the chest and abdomen. Individuals with this condition have complex birth defects affecting the heart, lungs, liver, spleen, intestines, and other organs. Unlike situs inversus, it often causes serious health problems. This report describes a case of a 49-year-old Hispanic female with a significant medical history of situs ambiguous diagnosed at birth in Cuba. She has had little to no follow-up in adulthood due to being “healthy.” She presented to the emergency room with intractable pain in the left lower quadrant and left flank for two days. Heterotaxy syndrome was found incidentally on CT scan of the abdomen/pelvis (plain). She was further evaluated with chest X-ray, magnetic resonance imaging of abdomen/pelvis without and with contrast, transvaginal ultrasonography, renal/bladder ultrasonography, left upper quadrant (LUQ) ultrasonography, esophagogastroduodenoscopy (EGD) with biopsy, 2D echocardiogram, and pertinent laboratory tests. Certain unusual findings included azygos continuation of the inferior vena cava (IVC), numerous spleens, atrophic pancreas, dilatation of duodenal C sweep, pelvic mass (possibly arising from right ovary), multiple nabothian cysts, and cardiac dysfunctions (such as severe mitral regurgitation). This report further aims to identify anatomic variants, previously established or otherwise not, in heterotaxy syndrome. Also, there seems to be a lack of identifiable anomalies or associations in regard to female anatomy, particular to this case being the female pelvic anatomy. As previous reports and research have stated, identification of anomalies in this syndrome is key for adequate and optimal management.

Characteristics and outcomes of fetuses with laterality defects are the current outcomes better? A single center study

Objective: To analyze the more recent outcomes of fetuses with different laterality defects.Material and methods: Out of 1508 fetuses with congenital heart disease (CHD) diagnosed by echocardiography between January 1995 and December 2015, 94 (6.3%) presented abnormal visceroatrial situs: 42 till December 2002 (group 1, analyzed retrospectively) and 52 since then until December 2015 (group 2, analyzed prospectively). Twenty-one had left isomerism (Lisom), 22 right isomerism (Risom), 16 situs inversus- dextrocardia (SVI-dx), 5 situs inversus- levocardia (SVI-levo), and 30 situs solitus-dextrocardia (SSol-dx).Results: Seventy-six cases (81%) had CHD, more frequently complex atrioventricular defect. Eighteen cases showed normal heart: half of subgroups SVI-dx and SVI-levo, a third of SSol-dx. Postoperative mortality in continuing pregnancy in group 2 was 43.7 versus 40% in group 1, lower in SVs-dx (0 versus 50%) and Lisom (33.3 versus 66.7%), worse in Risom (71.4 versus 25%). Total mortality in group 2 was 48.3 versus 55% in group 1, better in Ssol-dx (37.5 versus 50%) and in Lisom (27.4 versus 71.4%). In isolated forms all but one case are alive.Conclusions: Our fetal cases presented a relevant mortality in both periods. The outcomes were slightly better in a more recent era in SSol and Lisom.What is known about this topic?Out of laterality defects, the heterotaxies (i.e. left and right isomerism) are known to be associated to a relevant mortality in fetal and neonatal cases.Heterotaxies have a variable position of the heart, but some authors evaluated only those with dextrocardia in their studies on different laterality defects.Controversial data are presented in the literature for the outcomes of fetuses with laterality defects. Many large studies analyzed the data of a very long time period in which it is opinable to compare the results of the treatment, because of a recent improved management and surgical techniques.What does this study add?Our study presents an experience of a single center with cases of different types of laterality defects observed during a routine fetal echocardiography, not only heterotaxies.The knowledge of different laterality defects and of their characteristics (association with cardiac and extracardiac anomalies or with normal heart) is useful for the prenatal counseling.We compare the postoperative and total mortality in more recent period (since 2003) with respect to the previous era (1995-2002).

Antenatal ultrasound diagnosis of small bowel non-rotation in complex left isomerism: a case report

•

A rare case of mixed isomerism and antenatally diagnosed non-rotation of bowel is reported.

•

Features of bowel non-rotation should be sought antenatally in cases of isomerism.

•

Mixed isomerism and postnatal sequelae should be considered when right and left sided pathology coexist.z

Presentation of case

A multiparous expectant mother was referred to our tertiary unit at 23 weeks with a complex fetal cardiac anomaly in the context of suspected heterotaxy syndrome. The cardiac findings were consistent with isomerism: the fetal cardiac position was levocardia with a single functioning double outlet ventricle and AV valve, pulmonary stenosis, and interrupted inferior vena cava (IVC) with azygous continuation. The fetal abdominal situs was also altered, with the stomach to the right, and the hepatobiliary system midline to left. The spleen was not identified antenatally or postnatally. At 36 weeks, ultrasound revealed an abnormal bowel pattern with small bowel loops on the right side of the abdomen and large bowel on the left, suggesting a diagnosis of non- rotation. The infant was delivered vaginally at 39 weeks. The cardiac diagnosis and non-rotation of the small bowel were confirmed by postnatal echocardiography and contrast fluoroscopy.

Discussion

Heterotaxy syndrome is traditionally classified into right or left isomerism depending on how and where the organs are anatomically arranged. The case presented here demonstrates mixed laterality and prenatal ultrasound features of non-rotation.

Conclusion

It is important to be informed of the embryological variants of isomerism and actively seek antenatal evidence of bowel non-rotation in such cases.

Prenatal Findings in Left Atrial Isomerism and an Overview of Heterotaxy Syndrome

Heterotaxy syndrome is a rare, complex disorder involving structural cardiac defects in combination with symmetrical development of abdominal viscera that are normally asymmetrical organs. The vast assortment of cardiac manifestations with accompanying abdominal visceral variations determines the prognosis of heterotaxy syndrome. This case study provides an example of the management of this disease, which is unique to the patient. This is a case report of heterotaxy syndrome diagnosed in utero at 29 weeks and 4 days.

A case of prenatally detected left isomerism and hemiazygos continuation of inferior vena cava

Heterotaxy syndromes are defined as the disorders that involve abnormal arrangement of viscera. We present a case of prenatally diagnosed left isomerism in a 30-year-old primigravida woman referred to our hospital for complex cardiac abnormality. Sonographic findings included heart block, unbalanced atrioventricular septal defect, interruption of the inferior vena cava with hemiazygos continuation, double superior vena cava, a right-sided stomach, and biliary atresia. The hemiazygos vein drained into the right atrium by the persistent left superior vena cava. This type of inferior vena cava interruption and continuation is rarely reported in prenatally detected cases of left isomerism. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:430-433, 2017.

Predictors of poor outcome among children with heterotaxy syndrome: a retrospective review

Objective

To determine predictors of poor outcome in patients with heterotaxy syndrome.

Methods

A retrospective review of children with heterotaxy syndrome, in a single tertiary paediatric cardiology centre, was conducted between 1 January 1997 and 1 January 2014 to determine predictors of poor outcome. Poor outcome was defined as death, cardiac transplantation or New York Heart Association (NYHA) functional class III or IV.

Results

There were 35 patients diagnosed with heterotaxy syndrome, 17 of whom were diagnosed antenatally. 22 patients had right atrial isomerism and 13 had left atrial isomerism. The median age of postnatal diagnosis was 2.5 days old (1 day to 19 months). 12 patients had a poor outcome; 6 patients died, 1 underwent cardiac transplantation and 5 had an NYHA functional class of >III. 5 patients had a biventricular repair and the remaining 30 had a univentricular repair. Type of atrial isomerism, univentricular or biventricular anatomy, severity of atrioventricular valve regurgitation or ventricular dysfunction, obstructed pulmonary venous return, occurrence of arrhythmia and presence of pulmonary atresia did not predict poor outcome. Fetal diagnosis also did not confer a survival advantage. The median duration of follow-up in this cohort was 65 months (2 days to 16.8 years).

Conclusions

Survival for patients with heterotaxy syndrome was 83% over a median follow-up of 65 months. 34% of patients had a poor outcome. None of the variables studied were predictive of death, transplantation or NYHA classification III or IV.

Extracardiac anomalies in prenatally diagnosed heterotaxy syndrome

OBJECTIVE

To assess the incidence and impact of extracardiac anomalies on the prognosis of fetuses with heterotaxy syndrome.

METHODS

All fetuses diagnosed with heterotaxy syndrome by three experienced examiners over a period of 14 years (1999-2013) were reviewed retrospectively.

RESULTS

In total, 165 fetuses with heterotaxy syndrome were diagnosed in the study period. One hundred and fifty (90.9%) had cardiac defects; extracardiac anomalies that did not involve the spleen were present in 26/165 (15.8%) cases. Of the total study cohort, termination of pregnancy was performed in 49 (29.7%) cases, intrauterine death occurred in 11 (6.7%), postnatal death occurred in 38 (23.0%) and 67 (40.6%) were alive at the latest follow-up, resulting in a total perinatal and pediatric mortality of 59.4%. Among the 105 liveborn neonates, 15 (14.3%) had extracardiac anomalies with significant impact on the postnatal course: one neonate died following repair of an encephalocele, six had successful treatment for various types of intestinal malrotation and/or atresia and one underwent hiatal hernia repair; the remaining seven had biliary atresia, of which five died and the two survivors are awaiting liver transplantation. The status of the spleen was assessed in 93/105 liveborn children and was found to be abnormal in 84/93 (90.3%). There were three cases of lethal sepsis, all associated with asplenia. Of the 38 postnatal deaths, 29 (76.3%) had a cardiac cause, seven (18.4%) had an extracardiac cause and in two (5.2%) the reason was uncertain.

CONCLUSIONS

Although the leading causes of death in fetuses and children with heterotaxy syndrome are cardiac, a small subset of fetuses have extracardiac anomalies with significant impact on outcome. These anomalies often escape prenatal detection, and therefore neonates at risk should be monitored for bowel obstruction, biliary atresia and immune dysfunction in order to allow timely intervention through a multidisciplinary approach. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Antenatally diagnosed right-sided stomach (dextrogastria): A rare rotational anomaly

AIM

Antenatal detection of right-sided stomach (dextrogastria) is rare, and its significance in regards to intestinal rotation is unclear. We aimed to review all cases of antenatally-diagnosed dextrogastria in our regional fetal medicine unit over 10years.

METHODS

A retrospective case-note review of patients identified from a prospectively-maintained database was performed.

RESULTS

Twenty cases of antenatally-diagnosed dextrogastria were identified from 2004 to 2014. There were 8 terminations and 1 intra-uterine death. One patient has no post-natal information obtainable. Ten infants were live-born, and 2 died secondary to cardiac disease in the neonatal period. All had significant cardiac/vascular anomaly on postnatal assessment, including the 3 neonates in whom dextrogastria was the only antenatal finding. Two neonates developed bilious vomiting and underwent Ladd's procedure. Operative findings were dextrogastria/malrotation in both. A third child had gastro-oesophageal reflux, and contrast demonstrated stable duodenal/midgut position. This child has not developed symptoms attributable to malrotation and not undergone surgery. All 3 of these infants had asplenia or polysplenia and were managed with antibiotic prophylaxis/immunisation. Five children in the series were not investigated for malrotation and have not come to surgical attention (one is known to be asplenic).

CONCLUSION

Antenatally-detected dextrogastria, even if apparently isolated, was always associated with postnatal significant cardiovascular anomaly, splenic abnormality or situs inversus. This may be important for antenatal counselling. We currently recommend postnatal echocardiography and splenic assessment, but reserve GI investigation/intervention for symptomatic malrotation owing to potential significant cardiac comorbidity.

Perinatal and infant outcomes of prenatal diagnosis of heterotaxy syndrome (asplenia and polysplenia)

Patients with heterotaxy syndrome (HS) have a range of anomalies and outcomes. There are limited data on perinatal outcomes after prenatal diagnosis. To determine the factors influencing perinatal and infant outcomes, we analyzed prenatal and postnatal variables in fetuses with HS from 1995 to 2011. Of 154 fetuses with HS, 61 (40%) had asplenia syndrome (ASP) and 93 (60%) had polysplenia syndrome (PSP). In the ASP group, 22 (36%) patients were elected for termination of pregnancy, 4 (10%) had fetal death, and 35 of 39 (90%) continued pregnancies were live born. In the PSP group, 12 (13%) patients were elected for termination of pregnancy, 5 (6%) had fetal death (4 with bradyarrhythmia), and 76 of 81 (94%) continued pregnancies were live born. Bradyarrhythmia was the only predictor of fetal death. In the live-born ASP group, 43% (15 of 35) died, 7 because of pulmonary vein stenosis, 4 postoperatively, and 4 because of noncardiac causes. In the live-born PSP group, 13% (10 of 76) died, 5 postoperatively, 2 from bradyarrhythmia, 1 from a cardiac event, and 2 from noncardiac causes. Pulmonary vein stenosis and noncardiac anomalies were independent risk factors for postnatal death. Only 8% of ASP patients achieved biventricular circulation, compared with 65% of PSP patients. In the live-born cohort, the 5-year survival rate was 53% for ASP and 86% for PSP. In conclusion, most PSP patients are currently alive with biventricular circulation in contrast with few ASP patients. Bradyarrhythmia was the only predictor of fetal death. Pulmonary vein stenosis and noncardiac anomalies were predictors of postnatal death.

Perinatal outcome in fetuses with heterotaxy syndrome and atrioventricular block or bradycardia

Congenital atrioventricular (AV) block is commonly associated with heterotaxy syndrome; together they have reportedly low survival rates (10-25%). However, information about perinatal outcome and predictors of non-survival after prenatal diagnosis of this association is scarce. Therefore, we studied fetuses with heterotaxy syndrome and bradycardia or AV-block diagnosed between 1995 and 2011, and analyzed pre and post-natal variables. The primary outcome was death and the secondary outcome was pacemaker placement. Of the 154 fetuses with heterotaxy syndrome, 91 had polysplenia syndrome, 22/91(24%) with bradycardia or AV-block. Thirteen (59%) patients had sinus bradycardia at diagnosis, 8 (36%) complete AV block, and 1 (5%) second-degree AV-block. Three patients elected for termination of pregnancy (3/22, 14%), 4 had spontaneous fetal demise (4/22, 18%), and 15 (15/22, 68%) were live-born. Of the fetuses with bradycardia/AV-block, 30% presented with hydrops, 20% had ventricular rates <55 beats/min, and 10% had cardiac dysfunction. Excluding termination of pregnancy, 15/19 fetuses (79%) survived to birth. Among the 15 live-born patients, 4 had bradycardia and 11 had AV-block. A further 3 patients died in infancy, all with AV-block who required pacemakers in the neonatal period. Thus, the 1-year survival rate, excluding termination of pregnancy, was 63% (12/19). Of the remaining 12 patients, 9 required pacemaker. Predictors of perinatal death included hydrops (p < 0.0001), ventricular dysfunction (p = 0.002), prematurity (p = 0.04), and low ventricular rates (p = 0.04). In conclusion, we found a higher survival rate (63%) than previously published in patients with heterotaxy syndrome and AV block or bradycardia diagnosed prenatally. Hydrops, cardiac dysfunction, prematurity and low ventricular rates were predictors of death.

Prenatal diagnosis of atrial isomerism in the Korean population

OBJECTIVE

To report our experiences in the prenatal diagnosis of atrial isomerism and postnatal outcomes.

METHODS

A total of 80 fetuses prenatally diagnosed with atrial isomerism were retrospectively analyzed between 1999 and 2011 at a single institution.

RESULTS

Of 43 fetuses with prenatally diagnosed right atrial isomerism (RAI), 40 cases were analyzed. The diagnostic accuracy was 93%. The main intracardiac anomalies in RAI were atrioventricular septal defect (AVSD), abnormal pulmonary venous connection, bilateral superior vena cava (BSVC), and pulmonary atresia. Among 28 live births, three infants were lost to follow up, and the overall survival rate was 60%. Of 37 fetuses with prenatally diagnosed left atrial isomerism (LAI), 35 were evaluated. The diagnostic accuracy was 97%. The main intracardiac anomalies in LAI were ventricular septal defect, BSVC, AVSD, double outlet right ventricle, and bradyarrhythmia. Among seven patients with bradyarrhythmia, only one showed a complete atrioventricular block. All fetuses had an interrupted inferior vena cava with azygous continuation. The overall survival rate was 90%.

CONCLUSION

Our study confirms the previous findings of fetal atrial isomerism. We also demonstrates a much lower prevalence of AVSD and complete heart block in LAI and a better survival rate in RAI. Although the postnatal outcomes for RAI were worse than those for LAI, successful postnatal surgery with active management improved the survival rate.

Successful blood sampling through azygos continuation with interrupted inferior vena cava. A case report and review of the literature

Interrupted inferior vena cava (IVC) with azygos continuation is a rare congenital anomaly, and is frequently associated with other cardiovascular malformations and situs anomalies, such as left isomerism. These patients usually develop deep vein thrombosis (DVT), and asymptomatic patients above 60 years of age are very rare. Here we report a case of interrupted IVC which we diagnosed in a 72-year-old woman. She was admitted to our hospital suffering from heart failure and supraventricular tachycardia. Echocardiography detected secundum atrial septal defect (ASD). An abnormal paravertebral pleural line on the chest X-rays indicated the existence of venous anomaly. Anatomical images obtained by Multidetector Computed Tomography (MDCT) helped us to successfully perform right heart catheterization procedures through azygos continuation including blood sampling from pulmonary veins. Even in elderly patients, a careful examination of chest X-rays can indicate undiagnosed venous anomalies; thus, it is critically important before planning surgical or interventional procedures.

Prenatal diagnosis, management and outcome of fetal dysrhythmia: a tertiary fetal medicine centre experience over an eight-year period

OBJECTIVE

To review the prenatal diagnosis, management and outcome of fetal dysrhythmia.

SUBJECTS AND METHODS

Prenatal diagnosis, management and outcomes of fetuses with dysrhythmia were reviewed retrospectively (01/01/1997 to 31/12/2004).

RESULTS

Over an 8-year period, 318 pregnant mothers were referred for assessment of suspected fetal dysrhythmias. Median gestation was 30 weeks (range 19-41). Fetal dysrhythmia was identified in 182 (57%) and classified as: (i) 126 atrial extrasystoles; (ii) 26 tachyarrhythmia, and (iii) 30 bradyarrhythmia. Of the fetuses with tachyarrhythmia, 23 had supraventricular tachycardia (SVT), 2 atrial flutter and 1 sinus tachycardia. One death associated with severe hydrops occurred in the tachyarrhythmia group. 19 cases of SVT were successfully treated in utero. Both cases of atrial flutter required direct current cardioversion in the neonatal period. In the bradyarrhythmia group, there were 15 isolated cases and 10 cases associated with congenital heart disease, with 73 and 20% survival, respectively.

CONCLUSIONS

Benign atrial extrasystoles are the commonest cause for referral and assessment of fetal dysrhythmia. The overall prognosis for SVT is good with the majority responding to transplacental therapy. In cases with congenital atrioventricular block, the outcome was less favourable, especially when the atrioventricular block was associated with congenital heart disease.

Intrapartum fetal heart rate monitoring in cases of congenital heart disease

OBJECTIVE

We evaluated the intrapartum fetal heart rate (FHR) patterns in fetuses with congenital heart disease (CHD).

STUDY DESIGN

One hundred sixteen cases of fetal CHD were identified at our institute between 2000-2007; 464 fetuses without CHD were used as controls. The incidences of abnormal FHR patterns and umbilical blood gases were compared.

RESULTS

More fetuses with CHD showed variant FHR than did control fetuses (46.6% vs 17.7%; P < .01). Cesarean section deliveries that were based on fetal indications were performed more frequently in fetuses with CHD than in control fetuses (12.9% vs 3.2%; P < .01). Isomerism and tetralogy of Fallot were observed frequently with variant FHR. When chromosomal abnormalities and intrauterine growth restriction were excluded, the fetuses with CHD showed more variant FHR than did the control fetuses.

CONCLUSION

Fetuses with CHD are more likely to show abnormal FHR patterns than are control fetuses. We suggest that cardiac abnormalities are associated with abnormalities in FHR patterns.

Right Atrial Isomerism – Preponderance in Asian Fetuses. Using the Stomach-distance ratio as a Possible Diagnostic Tool for Prediction of Right Atrial Isomerism

Introduction: To present the characteristics and spectrum of associated anomalies in right- and left-sided isomerism in our local population and to assess the possibility of using stomach-distance ratio (SDR) of less than 0.34 as a diagnostic tool to predict right atrial isomerism. Materials and Methods: This was a retrospective study of fetuses in our department over a period of 8 years with postnatally confirmed prenatal diagnosis of atrial isomerism. Results: In 22 cases, atrial isomerism was confirmed by post-mortem or postnatal echocardiography. Eighteen (81.8%) fetuses had right isomerism. Their main abnormal ultrasound findings were pulmonary stenosis or atresia (n = 9), atrioventricular septal defect (n = 10), right-sided stomach (n = 9), transposition of great arteries (n = 6), dextrocardia (n = 8), single ventricle (n = 4), juxtaposition of inferior vena cava and descending aorta (n = 5), ventricular septal defect (n = 2), interrupted inferior vena cava with azygous drainage (n = 2) and double outlet right ventricle (n = 3). Four (18.2%) fetuses had left isomerism. Their abnormal ultrasound findings were dextrocardia (n = 3), right-sided stomach (n = 3), atrioventricular septal defect (n = 2), double outlet ventricle (n = 2), ventricular septal defect (n = 1), pulmonary stenosis (n = 2) and interrupted inferior vena cava with azygous drainage (n = 1). 66.7% (12/18) of cases with right isomerism had SDR of less than 0.34 compared to 0% (0/4) of the cases with left isomerism (P = 0.02). Conclusion: Our study suggests an Asian predilection towards right isomerism compared to Western populations. We postulate that there may be racial differences in the expression of these 2 forms of isomerism. The ultrasound findings of complex heart disease and abnormal arrangement of great vessels in abdominal cavity, though important, are varied and non-specific evidence for either form of fetal atrial isomerism. There is a possibility of using the SDR <0.34 (representing stomach proximity to the fetal spine) as a possible diagnostic tool to predict right-sided atrial isomerism. Key words: Azygous vein, Cardiac defects, Dextrocardia, Heterotaxy syndrome, Stomach localisation, Stomach near spine, Visceral heterotaxy

Combined Scimitar syndrome and interruption of the inferior vena cava causing mega-azygous and hemiazygous veins

Computed tomography angiography detected scimitar syndrome with venous drainage to the inferior vena cava caudal to an interruption of the inferior vena cava in a 48-year-old woman. The hepatic veins drained to the supra-hepatic portion of the inferior vena cava cephalic to the interruption, which was a short area of atresia. Azygous and hemiazygous veins were massively enlarged since they drained the right lung, abdomen viscera exclusive of the liver and lower extremities. Inferior vena cava interruption by a short, focal atresia has not previously been described. The inferior vena cava immediately caudal to the interruption is presumed to remain patent because of the scimitar vein flow.

The area behind the heart in the four-chamber view and the quest for congenital heart defects

OBJECTIVE

To evaluate the spectrum of fetal cardiac defects associated with abnormal sonographic findings in the area behind the heart (ABTH) in the four-chamber view.

METHODS

This study included a retrospective review of 393 fetuses with congenital heart defects (CHD) detected in 2003-2005 at our tertiary referral center and a prospective evaluation of 4666 fetal echocardiograms, including 220 cases of CHD, performed between January 2006 and February 2007. The retrospective and prospective groups did not differ significantly with respect to cardiac anomalies or abnormal findings in the ABTH, allowing us to combine the 613 fetuses with CHD investigated over a 50-month period.

RESULTS

In the study period, 69 fetuses had abnormalities of the ABTH (75% with major CHD). In 28 fetuses, two equally sized vessels ran behind the heart. Of these, 26 had an interrupted inferior vena cava with azygos continuation and two had total anomalous infracardiac pulmonary venous connection. In 41 fetuses, only one vessel was visualized, but the descending thoracic aorta was positioned contralateral to the cardiac apex. Of these, 29 had levocardia with right descending aorta. All of them had a right aortic arch. The remaining 12 had dextrocardia with left descending aorta.

CONCLUSIONS

The ABTH in the four-chamber view is easy to evaluate and offers important diagnostic markers for fetal CHD. Thus, it might enhance the screening performance of the four-chamber view. Attention must be paid to the number of vessels behind the heart and their laterality.

Right aortic arch detected in fetal life

OBJECTIVE

To evaluate the prenatal distribution, associated conditions and outcome of the different types of right aortic arch (RAA) detected in fetal life.

METHODS

This was a retrospective review of all cases of RAA detected prenatally between 1998 and 2005 in two tertiary referral centers.

RESULTS

In the study period 71 cases of RAA were detected; 26 (37%) had RAA with aberrant left subclavian artery, 23 (32%) had RAA with mirror-image branching, 20 (28%) had RAA of unknown type and two (3%) had double aortic arch. While 20/26 cases with RAA and aberrant left subclavian artery were isolated findings, all 23 cases with RAA and mirror-image branching were associated with cardiac defects, namely tetralogy of Fallot (43%) or pulmonary atresia with ventricular septal defect (22%). Of the 20 cases with RAA, 19 of unknown type were associated with heterotaxy syndromes and had additional cardiac malformations and ambiguities of the situs. The two cases with DAA were isolated findings. Seven cases in our series (10%) had a microdeletion 22q11 and these were significantly associated with extracardiac malformations. The outcome in our series depended solely on the associated cardiac and extracardiac malformations, with the exception of one infant with isolated DAA, in whom a surgical correction was warranted.

CONCLUSIONS

RAA detected in fetal life is associated frequently with other cardiac/non-cardiac malformations, heterotaxy syndromes and microdeletions 22q11. The associated conditions vary depending on the branching type of the brachiocephalic vessels and the presence of extracardiac malformations.

Outcome of fetal cardiac defects

PURPOSE OF REVIEW

The present review summarizes the prenatal and postnatal outcome of cardiac anomalies and sustained arrhythmias diagnosed during fetal life.

RECENT FINDINGS

The outcome of sustained fetal arrhythmias has improved with greater experience using Sotalol for atrial flutter, and digoxin and amiodarone for 1: 1 reciprocating tachycardia. The outcome of fetal conduction system disease secondary to maternal Sjögren's antibodies has noticeably improved with transplacental dexamethasone. The postnatal prognosis for atrioventricular block associated with left atrial isomerism, however, remains very bleak. Assessing the effect of prenatal diagnosis on the outcome of structural defects remains difficult because of the high number of extracardiac anomalies and chromosome defects in this group. Preoperative survival is improved, but postoperative mortality has not improved. One clear advantage of prenatal diagnosis is the selection of fetuses that may benefit from in-utero intervention to limit the progression of their disease or lessen its severity at birth.

SUMMARY

For the most part, postoperative mortality of structural cardiac defects is not significantly improved by prenatal diagnosis. In-utero management of tachyarrhythmias and conduction system disease has improved postnatal outcome, except for the fetus with atrioventricular block and left atrial isomerism.

Spectrum of cardiovascular disease, accuracy of diagnosis, and outcome in fetal heterotaxy syndrome

Because there is a paucity of information regarding the diagnosis and outcomes of fetal heterotaxy syndrome (HS), this study sought to determine the spectrum of cardiac pathology, accuracy of diagnosis, and outcome of fetal HS. All cases of fetal HS encountered in the investigators' institution over a 10-year period through 2002 were identified. Prenatal and postnatal echocardiograms and medical records were reviewed. Seventy-one fetuses were diagnosed with HS, including 48 with left atrial isomerism (LAI) and 23 with right atrial isomerism (RAI). For LAI and RAI, most intracardiac lesions, the pulmonary venous connections, and superior vena caval anatomy were correctly diagnosed in utero (93%, 86%, and 77% accuracy, respectively), whereas hepatic venous connections and inferior vena caval-atrial connections in RAI were difficult to define (65% and 56% accuracy, respectively). Of 32 continued and followed pregnancies with LAI, 22 are currently alive at 48 +/- 30 months. Heart block and associated major extracardiac pathology were significantly more common in nonsurvivors with fetal LAI (p = 0.007 and 0.024, respectively). Outcomes were even worse for prenatally diagnosed RAI: of 14 continued pregnancies, only 3 are currently alive. In conclusion, fetal HS is associated with a broad spectrum of cardiac pathology, which can be diagnosed accurately in utero. Fetal LAI is associated with a mortality of 31%, with heart block and extracardiac pathology as primary risk factors for perinatal mortality. The outcome of prenatally diagnosed RAI is poor.

Fetal echocardiographic evaluation of atrial morphology and the prediction of laterality in cases of heterotaxy syndromes

OBJECTIVE

To evaluate whether abnormal atrial morphology, which is well recognized in autopsy series, is detectable by fetal echocardiographic examination of the four-chamber view, and can therefore be utilized to differentiate left from right isomerism in heterotaxy syndromes.

METHODS

This study was a retrospective review of 30 cases with prenatally diagnosed heterotaxy syndromes. Ultrasound video recordings and still images were reviewed with respect to atrial morphology in the four-chamber view. In 25 cases the morphology of both atria was sufficiently well visualized on the recordings to be evaluated and only these were included in the study.

RESULTS

Two types of atrial morphology were distinguished in our cohort: a sickle-shape with the tip pointing laterally and apically, and a blunt shape resembling the usual atrial appearance in the four-chamber view. Nineteen out of the 25 cases (76%) presented with isomerism of the atria in the four-chamber view. Thirteen had bilateral sickle-shaped atrial morphology, all associated with left isomerism. Six had bilateral blunt-shaped atrial morphology, all associated with right isomerism. The atria of the remaining six cases were not isomeric, the right atrium being sickle-shaped and the left blunt-shaped. Five of the latter cases were associated with left and one with right isomerism.

CONCLUSIONS

The majority of prenatally diagnosed heterotaxy syndromes seem to present with isomeric atrial morphology in the four-chamber view. In these cases a differentiation between left and right isomerism can be based on the two distinct types of atrial morphology. This may further enhance the prenatal differentiation of these syndromes.