A review of aortic disease research in Malaysia

INTRODUCTION

Aortic disease includes conditions such as chronic aortic aneurysms, acute aortic syndromes and congenital aortic abnormalities, amongst others. This paper reviews all research on aortic disease performed in Malaysia and published between 2000-2016.

METHODS

A literature search was conducted in PubMed, Scopus, MyJurnal and the UKM Journal Repository. The search process was based on a previously published methodology. The medical subject headings (MeSH) search terms used were "aortic", "aorta" and "Malaysia".

RESULTS

Two-hundred-thirteen papers were identified, of which 60 papers were selected and reviewed on the basis of their relevance. The epidemiology, pathophysiology, clinical presentations, case reports, investigations, treatment and outcomes of aortic disease in Malaysia were reviewed and summarised. The clinical relevance of the studies performed are discussed.

CONCLUSION

The review provided an insight into the pathophysiology, prevalence and epidemiology of aortic diseases in Malaysia, how the condition is managed, and the outcomes of treatment. Limitations of the research performed in Malaysia to date were identified and recommendations for further research and improvement in clinical practice were recommended.

Clinical recognition of mid-aortic syndrome in children

Mid-aortic syndrome is characterized by narrowing of the abdominal aorta, usually with the involvement of renal arteries and other visceral branches. The combination of the presence of an abdominal bruit, diminished or absent pulsations of the lower extremities, and a blood pressure discrepancy between upper and lower extremities is the classic triad associated with mid-aortic syndrome. However, it has a wide variety of clinical symptoms, and awareness of the variable presentation can lead to early diagnosis of the vascular anomaly. We report three cases presenting at three different stages of this disease, such as hydrops fetalis, refractory hypertension, and intracerebral bleeding. In conclusion, these cases highlight the importance of blood pressure measurements in all patients and accurate physical examination for early recognition of a mid-aortic syndrome.

[Aortic vascular anomalies and Kommerell's diverticulum, an imagiologic diagnosis]

Aortic vascular anomalies are complex anatomic entities requiring often complex and problematic surgical approaches. The authors report the clinical case of a Kommerell's diverticulum and right-sided aortic arch. Right-sided aortic arch is an uncommon congenital defect of the aorta and it is rare in the setting of an otherwise normal heart. A right-sided aortic arch was described more than two centuries ago. Several classifications of these anomalies have been proposed on the basis of the arrangement of the arch vessels, relationships with the esophagus, or the presence of congenital heart anomalies. In the adult population, a right-sided aortic arch is often asymptomatic, unless aneurismal disease develops. This usually occurs at the level of the take-off of an aberrant left subclavian artery and is known as a Kommerell's diverticulum. In spite of its rarity, this condition is clinically relevant due to the mortality associated with rupture, morbidity caused by compression of mediastinal structures, and complexity of surgery.

Mid-aortic syndrome in a 3-year-old girl successfully treated by aorto-aortic grafting and renal artery implantation into the graft

Mid-aortic syndrome, an uncommon acquired or congenital condition characterized by segmental narrowing of the abdominal or distal descending thoracic aorta, is frequently accompanied by ostial stenosis of the aorta's branches. If left untreated, it can result in life-threatening complications secondary to severe hypertension.We report the case of a 3-year-old girl with congenital mid-aortic syndrome, who was diagnosed by chance in the course of a viral illness, and whose high blood pressure values were first dismissed as inaccurate. Attempts to achieve medical or endovascular control of her hypertension were unsuccessful. She was thereafter successfully treated by aorto-aortic bypass grafting, resection of the stenotic segments of both renal arteries, and implantation of the patent arterial segments into the graft.

An unusual combination of congenital anomalies in an adult patient: patent ductus arteriosus, Kommerell's diverticulum with aberrant right subclavian artery, and heterotaxy syndrome

The heterotaxy syndrome is a rare and sporadic disorder. This syndrome presents with situs ambiguus, splenic malformations such as asplenia or polysplenia, and congenital heart disease. Congenital heart diseases associated with this syndrome include a broad variety of manifestations. Patent ductus arteriosus is one of them and percutaneous transcatheter closure can be challenging in the setting of this syndrome. Kommerell's diverticulum is a saccular aneurysmal dilation at the origin of an aberrant subclavian artery, and can be related with other congenital anomalies. However, there is no previous report of Kommerell's diverticulum being found together with patent ductus arteriosus and heterotaxy syndrome.

Approach to the patient with Turner syndrome

Turner syndrome (TS) occurs in about 1:4000 live births and describes females with a broad constellation of problems associated with loss of an entire sex chromosome or a portion of the X chromosome containing the tip of its short arm. TS is associated with an astounding array of potential abnormalities, most of them thought to be caused by haploinsufficiency of genes that are normally expressed by both X chromosomes. A health care checklist is provided that suggests screening tests at specific ages and intervals for problems such as strabismus, hearing loss, and autoimmune thyroid disease. Four areas of major concern in TS are discussed: growth failure, cardiovascular disease, gonadal failure, and learning disabilities. GH therapy should generally begin as soon as growth failure occurs, allowing for rapid normalization of height. Cardiac imaging, preferably magnetic resonance imaging, should be performed at diagnosis and repeated at 5- to 10-yr intervals to assess for congenital heart abnormalities and the emergence of aortic dilatation, a precursor to aortic dissection. Hypertension should be aggressively treated. For those with gonadal dysgenesis, hormonal replacement therapy should begin at a normal pubertal age and be continued until the age of 50 yr. Transdermal estradiol provides the most physiological replacement. Finally, nonverbal learning disabilities marked by deficits in visual-spatial-organizational skills, complex psychomotor skills, and social skills are common in TS. Neuropsychological testing should be routine and families given support in obtaining appropriate therapy, including special accommodations at school.

Airway compression by the ascending aorta due to a thin thoracic cage

An 89-year-old woman with dyspnea and disturbed consciousness due to hypoventilation was admitted to our hospital. Chest radiography showed no abnormal shadow, but she was intubated for deteriorated hypoventilation. Bronchoscopy demonstrated obstruction of the left main bronchus at the carina. Computed tomography (CT) showed neither a mass lesion in the mediastinum nor an aortic aneurysm, but compression of the airway by the ascending aorta was observed. It was thought that the patient's thin thoracic cage was unable to support the weight of the ascending aorta, which consequently compressed the left main bronchus. After inserting stents into both main bronchi, the patient's consciousness improved, and respirator support was withdrawn. In aged, bedridden, thin patients with hypopnea or recurrent airway infection, CT and bronchoscopy should be performed to investigate airway patency.

Isolated interrupted aortic arch, a rare cause of hypertension in adults

Interrupted aortic arch (IAA) is a rare and usually lethal congenital malformation. Patients with complete IAA very rarely do reach adult age without previous surgical intervention. The present report describes a 26-year-old asymptomatic isolated IAA case with hypertension that was incidentally diagnosed. IAA just distal to the left subclavian artery and a markedly developed collateral circulation was demonstrated by cardiac catheterization and thoracic 3D magnetic resonance angiography. This case report was also interesting that only mild arterial hypertension of the upper extremities was incidentally found in the patient.

Bifid direct aortic arch origin of left vertebral artery: a unique vascular variant

The present report describes an unusual case of a duplicated origin of the left vertebral artery from the aorta discovered incidentally in a young patient. Computed tomographic angiography followed by conventional angiography demonstrated this anomaly. Angiographic findings and vertebral artery embryogenesis and anomalies are discussed.

[Rare variation of abdominal aorta breaking in two]

OBJECTIVE

To discuss a rare variation of abdominal aorta breaking in two.

METHODS

An in-patients, female, aged 76, admitted for asthenia of right extremities, underwent gadolinium-enhanced magnetic resonance angiography (MRA) of cerebral and abdominal vessels and abdominal MRI in whom the conventional angiography had failed to reveal this vascular abnormality.

RESULTS

MRA showed a clearly separated abdominal aorta. The upper part of the abdominal aorta terminated under the two renal artery branches and the lower part terminated at the level of L(3 - 4). The compensated enlarged superior and inferior mesenteric artery connected these two isolated parts of abdominal aorta.

CONCLUSION

This rare variation of abdominal aorta without any symptom is probably caused by some external force during the embryonic period.

A case of misdiagnosed interrupted aortic arch as primary hypertension for almost two decades

Hypertension is an increasingly important medical and public health issue. Appropriate diagnosis and treatment of hypertension is very important in both reducing the morbidity, mortality, and cost related to it. Interrupted aortic arch (IAA) is an uncommon and usually lethal congenital malformation. It is very rarely encountered in adult patients who generally present with nonspecific symptoms and hypertension. Substantial collateral circulation must be present to maintain blood flow to tissues below the aortic interruption and thus to enable survival. A 40-year-old man presented with general malaise, frequent headaches, weakness in his legs, and hypertension. He had suffered from effort intolerance since childhood. Physical examination revealed upper limb hypertension. Lower-limb pulses were not palpable. Transthoracic echocardiography, aortography, and gadolinium contrast-enhanced magnetic resonance angiography revealed complete interruption of the aortic arch just distal to the origin of the left subclavian artery. The present case describes an unusual case of IAA, in which the diagnosis was delayed until the age of 40 years. A complete physical examination would have ensured the correct diagnosis was made much earlier. As our case implies, physical examination maintains its pivotal role in the diagnosis of some forms of secondary hypertension, although various high-tech diagnostic tools are needed for confirmation.

Off-pump aortic arch repair through a median sternotomy for type B interrupted aortic arch with single ventricle physiology

BACKGROUND

The aortic arch repair for interrupted aortic arch (IAA) with the hypoplastic ascending aorta through a median sternotomy requires cardiopulmonary bypass (CPB), which is very invasive in neonates and complicates pulmonary artery banding (PAB) is staged repair.

METHODS

A 22-day-old neonate with a type B IAA having a functional single ventricle underwent arch repair and PAB through a median sternotomy without CPB. A partial occlusion clamp could be placed on the ascending aorta without cerebral malperfusion and the descending aorta could be directly anastomosed to the ascending aorta in an end-to-side fashion under stable circulatory condition. Thereafter, the tight PAB was performed with a circumference of 23mm without any difficulty.

RESULTS

The postoperative echocardiogram revealed no stenosis on the anastomotic site and the patient was discharged uneventfully.

CONCLUSION

This approach is effective in neonates with IAA who require staged repair, and least invasive for them.

Endobronchial ultrasound for detection of tracheomalacia from chronic compression by vascular ring

A 67-year-old female chronic smoker was evaluated for an asymptomatic right paratracheal mass and the diagnosis of double-arch aorta was made. She returned 2 years later with dyspnoea on exertion, productive cough and wheeze on lying supine. Flow volume curve showed variable intrathoracic airway obstruction, and bronchoscopy revealed extrinsic compression of the trachea by double-arch aorta with destruction of the cartilaginous layer visualized on endobronchial ultrasonography. Endobronchial ultrasonography may be a useful adjunctive tool for the identification of adults at risk of postoperative tracheomalacia where tracheopexy or airway stenting can be performed concurrently or sequentially if surgery is contemplated.

Surgery for aortic arch disease in the neonate

Disease of the aortic arch is a common component of congenital heart disease requiring surgical treatment in the neonate. While sometimes found in isolation, aortic arch disease must be placed into the larger context of frequently associated pathology. This review describes the anatomic variations of neonatal aortic arch pathology, surgical approaches and techniques, and expected outcomes.

Ischemic stroke complicating pediatric cardiovascular disease

BACKGROUND

After a year of unsuccessful treatment for hypertension, a young boy underwent a stenting procedure for aortic hypoplasia and awoke with hemiparesis and language deficits.

INVESTIGATIONS

Neuroimaging, echocardiography, craniocervical vascular imaging and prothrombotic testing.

DIAGNOSIS

Procedure-related acute arterial ischemic stroke and malignant cerebral edema with herniation.

MANAGEMENT

Anticoagulation with heparin, seizure prophylaxis and neuroprotective care, including external cooling for hyperthermia. Medical management of increased intracranial pressure and hemicraniectomy at 48 h for malignant cerebral edema. Treatment of deep vein thrombosis with inferior vena cava filter was also required. Long term treatments included extensive rehabilitation, aspirin, antiepileptics, antidyskinetics, antidepressants, antihypertensives and cosmetic skull reconstruction.

MRI of the Thoracic Aorta

Diseases of the thoracic aorta cause significant morbidity and mortality and can result in potentially catastrophic consequences. Conventional digital subtraction angiography (DSA) has been the gold standard for imaging for many years; however, this is associated with adverse effects and provides only limited information about vessel morphology. DSA is used primarily as a first-line investigation in the setting of trauma. Several other techniques also have been used in recent years, including CT and MRI. This article focuses primarily on the latter.

[Diverticulum of the ductus arteriosus. Cause of traumatic aortic ruptures?]

INTRODUCTION

According to angiographic studies 9-26% of all adult aortae show a ductus arteriosus diverticulum (DAD), i.e. an indention of the aortic wall at the insertion of the obliterated ductus arteriosus. This region is predisposed for traumatic aortic rupture. Up to now fixation at the transition from aorta transversa to fixed aorta descendens is regarded as cause. It is unclear whether ductus diverticulum favours traumatic aortic rupture.

MATERIAL AND METHODS

A total of 143 thoracic aortas (female symbol:37; male symbol:106, 17-91 years) were scanned histomorphologically for DAD. Calcification was quantified by CT multislice volume scan.

RESULTS

A DAD was detected in 44% of macroscopically non-calcified and slightly calcified aortic specimens. Histologically, autochthonal elastic and collagenous fibres of the media were disrupted. CT in macroscopically non-calcified aortas proved isolated calcification in 78%.

DISCUSSION

The incidence of 44% DAD-higher than in angiographic studies-can be explained by the method (histopathology), allowing diagnosis of diverticula down to microm. These morphological alterations are to be seen, at least in part, as a causative factor for the predilection to traumatic aortic ruptures.

Interrupted Aortic Arch Repair: Aortic Arch Advancement Without a Patch Minimizes Arch Reinterventions

BACKGROUND

Surgical repair of interrupted aortic arch (IAA) remains challenging and is associated with significant mortality and incidence of late arch obstruction, as recently reported by the Congenital Heart Surgeons' Society (CHSS). In particular, the CHSS reported that any technique other than direct anastomosis with patch augmentation is a risk factor for arch reintervention. The experience at Texas Children's Hospital with IAA repair using an aortic arch advancement technique without a patch was examined.

METHODS

Between July 1995 and December 2005, 60 patients underwent IAA repair using aortic arch advancement without a patch. Selective cerebral perfusion was used in 25 patients (42%). Cox proportional hazards models were used to analyze 20 variables to determine risk factors for death, arch reintervention, and left ventricular outflow tract (LVOT) reintervention.

RESULTS

Median age was 8 days (range, 2 to 271 days) and weight was 3.0 kg (range, 1.7 to 6.1 kg). IAA types were A in 18 (30%) and B in 42 (70%). Associated anomalies were multiple congenital anomalies in 30 (50%) patients, DiGeorge syndrome in 21 (35%), LVOT obstruction in 26 (43%), a single ventricle in 11 (18%), and truncus arteriosus in 6 (10%). Mean follow-up was 3.0 +/- 2.6 years. Five-year freedom from aortic arch reintervention was 100%. Survival at 30 days, 1 year, and 5 years was 93%, 78%, and 76%, respectively. Since July 2000, two of 32 patients have died for an overall survival of 94%. Risk factors for death are older age, multiple congenital anomalies, DiGeorge syndrome, and bicuspid aortic valve. Selective cerebral perfusion was an independent protective variable for survival. Survival for an IAA patient with a ventricular septal defect and no complicating cardiac anomalies was 100%.

CONCLUSIONS

Aortic arch advancement without a patch can be applied to IAA patients, with the expectation of a minimal need for arch reintervention. This technique affords an excellent survival, to which selective cerebral perfusion may be a contributing factor.

The management of hypoplastic left heart syndrome with a right aortic arch

The combination of hypoplastic left heart syndrome and a right-sided aortic arch is extremely rare and lethal. To the best of our knowledge, no patient with this combination has previously been reported as surviving initial palliation. The anatomic variant is associated with abnormalities in the arteries branching from the aortic arch, making it difficult to construct a reliable source of flow of blood to the lungs. We present here a patient with this combination who survived an initial Damus-Kay-Stansel procedure combined with placement of a conduit from the right ventricle to the pulmonary arteries, and who has subsequently undergone a successful bidirectional cavopulmonary anastomosis. We believe that the conduit placed from the right ventricle provides the most reliable source of flow of blood to the lungs at the time of initial palliation in this usual combination of cardiac lesions.

Congenital Aorto-azygous Fistula Treated with Coil Embolization: Case Report and Review of the Literature

Arteriovenous fistulas between the aorta and the azygous vein usually manifest as a continuous audible murmur mimicking a patent ductus arteriosus when observed at birth. Symptoms when present during childhood are related to dyspnea or cardiac insufficiency. Embolotherapy of congenital vascular malformations is possible. However when this less invasive treatment fails, surgical treatment is sometimes necessary. We describe the case of a 12-year-old child with a large thoracic arteriovenous fistula between the descending thoracic aorta and the azygous vein, which was closed successfully by coil embolization. Available data in the literature suggest that coil embolization of aorto-azygous fistulas is usually successful.

Diagnosis of Congenital Obstructive Aortic Arch Anomalies in Chinese Children by Contrast-Enhanced Magnetic Resonance Angiography

OBJECTIVE

The purpose of this study was to evaluate the accuracy of contrast-enhanced magnetic resonance angiography for the diagnosis of congenital obstructive aortic arch anomalies in children and compare it with transthoracic echocardiography and other MR imaging techniques (ECG gated T1-weighted spin-echo imaging and gradient-echo cine imaging).

MATERIALS AND METHODS

Contrast-enhanced magnetic resonance angiography, ECG gated T1-weighted spin-echo imaging, and gradient-echo cine imaging were performed for the diagnosis of congenital obstructive aortic arch anomalies in 416 patients from April 1999 to March 2005 (age range, 3 days to 12 years; mean age, 2.4 years) using a GE 1.5T MR scanner. Transthoracic echocardiography was performed in all patients prior to MR examination. Surgery and/or conventional X-ray angiocardiography were done in all patients to determine the final diagnosis.

RESULTS

The population consisted of 416 patients. Congenital obstructive aortic arch anomalies were diagnosed in 213 patients and ruled out in 203 patients by operation and/or conventional X-ray angiocardiography. Among the 213 patients with anomalies, coarctation of aorta was diagnosed in 174, interruption of aortic arch was diagnosed in 35, and persistent fifth aortic arch with fourth aortic arch interruption was diagnosed in 4 patients. Among the 35 patients with interruption of aortic arch, 21 were of type A, and 14 were of type B. The diagnostic sensitivity, specificity and accuracy of contrast-enhanced magnetic resonance angiography for congenital obstructive aortic arch anomalies were 98% (208/213), 99% (201/203) and 98% (409/416), respectively. The diagnostic sensitivity, specificity and accuracy of transthoracic echocardiography were 88% (187/213), 92% (186/203) and 90% (373/416), respectively. The diagnostic sensitivity, specificity and accuracy of other MR imaging techniques (ECG gated T1-weighted spin-echo imaging and gradient-echo cine imaging) were 89% (189/213), 84% (170/203) and 86% (359/416), respectively.

CONCLUSION

Contrast-enhanced magnetic resonance angiography is a reliable, noninvasive imaging technique for the diagnosis of congenital obstructive aortic arch anomalies in children. Occasionally, even more information can be obtained from this technique than from conventional X-ray angiocardiography. Contrast-enhanced magnetic resonance angiography is superior to transthoracic echocardiography and other MR imaging techniques (ECG gated T1-weighted spin-echo imaging and gradient-echo cine imaging) for diagnosis of congenital obstructive aortic arch anomalies in children.

Transplantation in truncus arteriosus combined with interrupted aortic arch

We present the case of an infant with truncus arteriosus combined with a dysplastic truncal valve not amenable to repair and interrupted aortic arch. Due to the disappointing results of truncal valve replacement we decided to perform cardiac transplantation. The infant survived transplantation and was discharged 4 weeks after surgery.

Ascending aortic aneurysm in a fetus due to a benign nodular myofibroblastic lesion

A fetal echocardiogram at 20 weeks of gestation revealed a large ascending aortic aneurysm in the presence of a normal aortic root and normal intracardiac anatomy. No other abnormalities were noted in the fetus. Upon termination of pregnancy, histopathological examination revealed an isolated benign nodular myofibroblastic lesion of likely hamartomatous origin, a first description of such pathology contributing to the formation of an aneurysm in the ascending aorta.

Feasibility and Utility of Three-Dimensional Color Flow Echocardiography of the Aortic Arch: The “Echocardiographic Angiogram”

Two-dimensional transthoracic echocardiography (2DE) is the most commonly used diagnostic modality to evaluate congenital and acquired abnormalities of the aortic arch. However, 2DE is frequently limited in this ability due to the three-dimensional character of the arch and its interrelationships with other vascular structures. Recently, three-dimensional echocardiography (3DE) with 3D color flow Doppler became commercially available. We examined the feasibility and utility of 3DE with 3D color Doppler in the evaluation of patients with congenital (native and postoperative) abnormalities of the aortic arch. We found that 3DE color flow provides important diagnostic information in patients with aortic arch anomalies, in a manner that is quick and user-friendly. In addition, 17 of the 26 patients had their 3DE findings confirmed by additional modalities, providing reasonably significant validation for our findings with 3DE.

Single-stage repair of interrupted aortic arch and Taussig-Bing anomaly

We report a case of successful single-stage repair of interrupted aortic arch with Taussig-Bing anomaly in a 5-month-old infant.

Aortic root dilatation is a rare complication of Noonan syndrome

Molecular analysis of the gene encoding the protein tyrosine phospatase, nonreceptor type 11 (PTPN11), identified a single base change at nucleotide 228 in an individual manifesting Noonan syndrome with aortic root widening and dysplastic aortic and mitral valves. This missense mutation changes glutamate to aspartate at position 76 of the protein (E76D or Glu76Asp), which likely disrupts intramolecular hydrogen bonding of this protein. There are few reports of aortic root dilatation in Noonan syndrome, and to our knowledge this is the first case with a confirmed PTPN11 mutation.

Aortic dilatation in patients with bicuspid aortic valve

The association of a bicuspid aortic valve (BAV) with abnormalities of the proximal thoracic aorta, including dilatation, aneurysm and dissection, has been previously described, leading to the hypothesis of a common underlying developmental defect involving the aortic valve and the aortic wall. Consequently, any patient with BAV should receive a careful assessment not only of the valve function, but also of the aortic root and the ascending aorta. Dilatation of the proximal thoracic aorta is a common finding in patients with BAV and is believed to be related to aortic rupture and dissection. Because progressive dilatation can occur, careful long-term surveillance of the aortic dimensions is required. Prophylactic surgical repair of the dilated aorta should be recommended more aggressively for patients with BAV than for those with a tricuspid aortic valve. However, the optimal timing of aortic surgery in BAV patients remains uncertain because of the limited data available on the natural history of asymptomatic aortic dilatation.

Complete repair of concomitant interrupted aortic arch and partial anomalous pulmonary venous connection

We report a rare case of concomitant presentation of partial anomalous pulmonary venous connection and type A interrupted aortic arch in a 4-week-old, 2.1 kg newborn. She presented in extremis and was found to have a closed ductus arteriosus with the entire left pulmonary venous return obstructed at its connection with the innominate vein. Emergent operative repair was performed in one-stage, consisting of aortic arch reconstruction and anomalous vein translocation. Postoperative recovery was unremarkable and the patient was discharged from hospital 12 days after operation.

Rare association of severe hypoplasia of the abdominal aorta with imperforate anus, colonic atresia, and choledochal cyst

Hypoplasia of the abdominal aorta (HAA) is a rare condition that causes marked hypertension. Although multiple etiologies have been postulated for HAA, congenital structural anomalies are rarely observed except in cases associated with some hereditary syndromes. The authors describe a neonatal case with HAA complicated by multiple anomalies including colonic atresia (CA), imperforate anus, choledochal cyst, facial cleft, and brain defects. This patient showed CA in the descending colon and caliber change in the transverse colon mimicking Hirschsprung disease, both of which were thought to be caused by vascular insult to the mesentery due to HAA. Although multiple surgical corrections were successfully performed, the hypertension was uncontrollable.

Congenital diseases of the thoracic aorta. Role of MRI and MRA

Aortic malformations may be associated with other congenital heart abnormalities or may present independently, as incidental findings in asymptomatic patients. For more than 30 years, conventional imaging techniques for detection and assessment of congenital anomalies of the aorta have been chest X-ray, echocardiography and angiography. In recent times, considerable interest in congenital aortic diseases has been shown, due to technical progresses of noninvasive imaging modalities. Among them, magnetic resonance imaging (MRI) almost certainly offers the greatest advantages, especially in young patients in which a radiation exposure must be avoided as much as possible. MRI provides an excellent visualization of vascular structures with a wide field of view, well suited for evaluation of the thoracic aorta malformations. With the implementation of magnetic resonance angiography (MRA) it is also possible to depict any relationship with supra-aortic or mediastinal vessels. Phase contrast technique allows identification of the hemodynamic significance of the aortic alteration. Some technical considerations, which include fast spin-echo, gradient-echo and, especially, MRA techniques with phase-contrast and contrast enhanced methods, are discussed and applied in the evaluation of congenital thoracic aorta diseases.

Aortic valvar atresia, interrupted aortic arch, and quadricuspid pulmonary valve: a rare combination

Aortic atresia and interrupted aortic arch is a rare cardiac combination. Review of the literature revealed nine cases. We present two patients with this combination and the additional finding of quadricuspid pulmonary valves, one of which was severely stenotic. In the latter patient, an aortopulmonary window was present. The other had a unique blood supply to the brachiocephalic arteries and ascending aorta from systemic collateral arteries. To the best of our knowledge, the association of a quadricuspid pulmonary valve with this combination has not been previously reported.

Double aortic arch associated with common inlet left ventricle

A double aortic arch is usually an isolated abnormality. We report a case with a previously undescribed combination of double aortic arch and common inlet left ventricle. The patient underwent division of the nondominant right aortic arch and the right ductus arteriosus at 2 months of age following a left modified Blalock-Taussig shunt. At 3 years of age, extracardiac total cavopulmonary connection was successfully performed via bidirectional cavopulmonary anastomosis.

Anomalous left coronary artery, ventricular septal defect, and double aortic arch

Anomalous origin of the left coronary artery from the pulmonary artery generally occurs in isolation. We report an infant diagnosed with double aortic arch and ventricular septal defect who was found to have an anomalous origin of the left coronary artery from the pulmonary artery at surgery. Successful ventricular septal defect repair, division of the arch, and aortic reimplantation of the left coronary artery was performed. This article describes a combination of lesions previously not described, highlights the altered presentation when multiple lesions coexist, discusses the propensity to miss the anomalous coronary, and reviews the literature that demonstrates the consequences of overlooking this defect.

Sixteen-row multislice computed tomography in infants with double aortic arch

BACKGROUND

The introduction of multislice computed tomography (MSCT) in 1998 has led to a considerable boost of CT angiography. Four-row MSCT has been employed in the diagnostic assessment of vascular rings. Sixteen-row MSCT is expected to further increase the diagnostic power of MSCT. We report three cases of double aortic arch diagnosed by a 16-row MSCT, and discuss the possible advantages of this diagnostic tool.

PATIENTS AND METHODS

From April 1, 2003, to September 1, 2003, three patients underwent 16-row MSCT at our institution to evaluate the possible presence of a vascular ring. All patients presented with stridor and feeding difficulties. MSCT was performed under bland sedation (chloral hydrate 60 mg/kg). ECG gating and breath hold were not employed. Three-dimensional reconstructions were employed to assess the presence of airway compromise as well as of vascular anomalies.

RESULTS

Scanning time averaged 4 s (3.8-4.5 s). Motion artefacts were not relevant. The CT scan showed the existence of a vascular anomaly as well as of a significant tracheal compression in all cases, and was considered conclusively diagnostic by the cardiac surgeons. All three patients underwent uncomplicated corrective surgery without further investigations.

CONCLUSION

Sixteen-row MSCT with 3D reconstruction allows a precise evaluation of the airway compromise and a detailed assessment of the anatomy of vascular anomalies. The very short scanning time allows to avoid deep sedation and anaesthesia, and to obtain higher image quality and spatial resolution, with a concomitant reduction of the radiation dose.

Late-onset dysphagia lusoria assessed by 3-dimensional computed tomography of an aortic arch abnormality

Symptomatic vascular rings causing late-onset dysphagia (dysphagia lusoria) are quite unusual in adults. We present a 42-year-old woman with a 1-year history of dysphagia from a right-sided aortic arch with an aberrant left subclavian artery and left-sided ligamentum arteriosum. Using a helical CT scan of the chest and a three-dimensional reconstruction software, her anatomic abnormality was completely delineated. Arch aortogram confirmed the anomaly. The patient underwent a left posteriolateral thoracotomy. Intraoperative findings correlated precisely with the preoperative reconstruction data. Division of the ligamentum resulted in a complete decompression of the esophagus and resolution of the patient's symptoms.

Right-Sided Double Aortic Arch in An Adult

A 27-year-old woman complained of a severe stridor caused by a right-sided double aortic arch with a right-sided descending thoracic aorta. A smaller left-sided aortic arch had an atretic segment located between the left common carotid artery and an aortic diverticulum from which the left subclavian artery originated. Through a left fourth thoracotomy, the atretic segment, which caused a compression of the trachea and esophagus, was ligated and divided. The ligamentum arteriosum could not be identified on that side. After the operation she was completely relieved of her symptoms.

Percutaneous embolization of a congenital aortocaval fistula--clinical case

Congenital aortocaval fistulae are a rare cause of left-to-right shunt. In this clinical case, an 8-year-old child was referred by the family doctor for pediatric cardiology consultation after detection of a chest murmur. Cardiac auscultation revealed a continuous murmur, best heard on the left sternal edge and back. During the study, cardiac angiography showed a large collateral vessel in the middle third of the thoracic aorta with a complex and sinuous route that ended at the superior vena cava. Percutaneous embolization was performed using a coil. Due to the large size of the collateral a total of three coils were necessary for complete occlusion. No complications were recorded and six-month follow-up confirmed absence of shunt. Compared to the surgical option, this procedure is less invasive and apparently with less risk to the patient.

Aorto-right atrial fistula

We report a child in whom a fistula connected the descending thoracic aorta to the right atrium. This is a previously unreported cardiac malformation. The patient was initially misdiagnosed as having a patent ductus arteriosus (PDA). On clinical examination and auscultation, the problem was different from PDA in that the continuous machinery murmur was better heard on the right parasternal area and posteriorly on the left. Surgical ligation of the fistula through a left thoracotomy abolished the murmur.

Congenital aortocaval fistula to the superior vena cava: a case report

Various systemic arteriovenous fistulas have been described. The arteriovenous fistula arising from the ascending aorta and draining separately into the superior vena cava is very uncommon. The authors report a case of congenital aortocaval fistula to the superior vena cava in a 22 year-old woman in whom the fistula was closed successfully.

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.