Extracardiac lesions and chromosomal abnormalities associated with major fetal heart defects: comparison of intrauterine, postnatal and postmortem diagnoses

OBJECTIVES

The clinical outcome of prenatally diagnosed congenital heart defects (CHD) continues to be affected significantly by associated extracardiac and chromosomal abnormalities. We sought to: determine the frequency and type of major extracardiac abnormalities (with impact on quality of life) and chromosomal abnormalities associated with fetal CHD; and compare the extracardiac abnormalities detected prenatally to the postnatal and autopsy findings in affected fetuses, to find the incidence of extracardiac abnormalities missed on prenatal ultrasound.

METHODS

We reviewed the computerized database of the Division of Cardiology of the Hospital for Sick Children in Toronto to identify all cases of major CHD detected prenatally from 1990 to 2002. Medical records, fetal echocardiograms and ultrasound, cytogenetic and autopsy reports were reviewed. The types of CHD detected were grouped into categories and the frequencies of major extracardiac and chromosomal abnormalities in these categories were noted. Prenatal ultrasound findings were compared with those at autopsy or postnatal examination.

RESULTS

Of 491 fetuses with major structural CHD, complete data were obtained for 382. Of these, there were 141 (36.9%) with major extracardiac abnormalities at autopsy or postnatal exam, of which 46 had chromosomal abnormalities and 95 did not. In the absence of chromosomal abnormalities, the organ systems most affected were urogenital (12.2%) and gastrointestinal (11.6%). CHDs with the highest incidence of extracardiac abnormalities (>25%) included: heterotaxy, single left ventricle and tricuspid atresia, hypoplastic left heart syndrome and tetralogy of Fallot. Ninety-four of 334 (28.1%) fetuses tested had chromosomal abnormalities. The most common chromosomal abnormalities were trisomies 21 (43.6%), 18 (19.1%) and 13 (9.6%), monosomy X (7.4%) and 22q11.2 deletion (7.4%). Of 289 extracardiac abnormalities from the complete series, 134 (46.4%) were not identified prenatally. Of the missed extracardiac abnormalities, 65 were considered not detectable at prenatal ultrasound, so 23.9% (69/289) of detectable extracardiac abnormalities were missed prenatally.

CONCLUSIONS

Major extracardiac and chromosomal abnormalities are common in fetuses with major fetal CHD. Many important associated extracardiac abnormalities may be missed prenatally, which should be taken into consideration in the prenatal counseling for fetal CHD.

Fetal sonographic diagnosis of aortic arch anomalies

Aortic arch anomalies refer to congenital abnormalities of the position or branching pattern, or both of the aortic arch. Although aortic arch anomalies are not uncommon, reports on their prenatal diagnosis are scarce. Insight into the hypothetical arch model is crucial to understanding anomalies of the aortic arch in the fetus. Recognition of the trachea, three major vessels, ductus arteriosus and descending aorta in the axial views of the upper mediastinum is necessary for a complete fetal cardiac assessment. Clues to aortic arch anomalies include abnormal position of the descending aorta, absence of the normal 'V'-shaped confluence of the ductal and aortic arches, a gap between the ascending aorta and main pulmonary artery in the three-vessel view, and an abnormal vessel behind the trachea with or without a vascular loop or ring around the trachea. Meticulous attention to anatomic landmarks will lead to successful prenatal diagnosis of important vascular rings making early postnatal management possible.

Fetal cardiac dextroposition in the absence of an intrathoracic mass: sign of significant right lung hypoplasia

We reviewed our experience of fetal cardiac dextroposition in the absence of an intrathoracic mass. Ten cases were found by fetal echocardiography to have a normal cardiac axis, but the heart was shifted into the right chest and the amount of right lung tissue was reduced. At birth seven of the infants had confirmed structural heart disease (70%), including three with scimitar syndrome. Two infants had additional extracardiac anomalies (20%). Seven infants born at term had clinical pulmonary hypertension with a diagnosis of right lung hypoplasia in all of them. Two neonates died owing to significant heart disease (one with scimitar syndrome and the other with hypoplastic left heart syndrome). Of the three pregnancies that were terminated, the two fetuses with autopsies had severe right lung hypoplasia. Fetal cardiac dextroposition and right pulmonary artery hypoplasia in the absence of an intrathoracic mass are important signs of right lung hypoplasia, which can be associated with significant pathologic cardiac and extracardiac conditions.

Diagnosis of left juxtaposition of the atrial appendages in the fetus

We describe two cases of left juxtaposition of the atrial appendages in which fetal echocardiograms provided a clue to the diagnosis. Both cases were associated with complex cyanotic congenital heart disease. The clue to the diagnosis was found at the three-vessel view. Abnormal vascular spaces were seen on the left side of the cross-sections of the great arterial trunks.

Non-invasive determination of the systolic peak-to-peak gradient in children with aortic stenosis: validation of a mathematical model

Doppler derived systolic pressure gradients have become widely applied as noninvasively obtained estimates of the severity of aortic valvar stenosis. There is little correlation, however, between the Doppler derived peak instantaneous gradient and the peak-to-peak gradient obtained at catheterisation, the latter being the most applied variable to determine severity in children. The purpose of this study was to validate a mathematical model based on data from catheterisation which estimates the peak-to-peak gradient from variables which can be obtained by noninvasive means (Doppler derived mean gradient and pulse pressure), according to the formula: peak-to-peak systolic gradient = 6.02+/-1.49*(mean gradient)-0.44*(pulse pressure). Simultaneous cardiac catheterization and Doppler studies were performed on 10 patients with congenital aortic valvar stenosis. Correlations between the gradients measured at catheter measured, and those derived by Doppler, were performed using linear regression analysis. The mean gradients correlated well (y = 0.67 x +11.11, r = 0.87, SEE = 6 mm Hg, p = 0.001). The gradients predicted by the formula also correlated well with the peak-to-peak gradients measured at catheter (y = 0.66 x +14.44, r = 0.84, SEE = 9 mm Hg, p = 0.002). The data support the application of the model, allowing noninvasive prediction of the peak-to-peak gradient across the aortic valvar stenosis.

Factors affecting the prognosis of Ebstein's anomaly during fetal life

BACKGROUND

The echocardiographic criteria that have been used to evaluate severity of Ebstein's anomaly in utero are the same as those applied after birth.

OBJECTIVE

The objective of this study was to establish prognostic criteria that take into account the peculiarities of the fetal hemodynamics.

METHOD

The video recordings of eight fetuses with Ebstein's anomaly were retrospectively reviewed.

RESULTS

The following indexes had no prognostic significance either on fetal or neonatal outcome: the ratio of functional tricuspid opening over the diameter of the annulus, the degree of displacement of the tricuspid valve opening, and the degree of tricuspid regurgitation. The index of severity (based on the surfaces of right atrium + atrialized right ventricle) and the cardiothoracic ratio had a significant impact only on neonatal survival. The smallest fossa ovalis were found in two fetuses who had hydrops. Fetuses who reached term without problems had higher left ventricular outputs. A positive linear correlation was found between the z score of the left ventricular output and the size of the fossa ovalis (r = 0.81, p < 0.05).

CONCLUSION

The prognosis of Ebstein's anomaly during fetal life is not influenced by criteria described for postnatal life and may be related to factors that control the volume load of the left ventricle.

Right aortic arch with retroesophageal left aberrant innominate artery

Right aortic arch with a left retroesophageal innominate artery (type D double aortic arch) is rare. The diagnosis is made by aortography. The present case is the first known patient to undergo a magnetic resonance imaging study that outlined the anomaly clearly.

Prenatal diagnosis of a fetal ventricular diverticulum associated with pericardial effusion: successful outcome following pericardiocentesis

Congenital cardiac diverticula are rare abnormalities that may occur as isolated malformations. In this report, we describe a case of an isolated congenital cardiac diverticulum complicated by a large serous pericardial effusion diagnosed ultrasonographically at 19 weeks' gestation. Therapeutic pericardiocentesis at 20 weeks' gestation resulted in complete resolution of the effusion with a normal fetal outcome. There is only one previous report of a prenatal diagnosis of a cardiac diverticulum complicated by a pericardial effusion and that patient underwent termination of pregnancy (Carles et al., 1995). Given the otherwise favourable prognosis for this lesion, and the excellent response in this case, pericardiocentesis should be considered in similar cases.

Surgical repair of complete atrioventricular septal canal defects with absent posterior leaflet

We report 2 cases of absence of the posterior (left mural) leaflet in complete atrioventricular septal defect. Closure of the atrioventricular septal defect was successfully accomplished in both cases. We describe the technique of left atrioventricular valve repair that led to a competent reconstructed valve.

Cardiac dysfunction late after cardiotoxic therapy for childhood cancer

Despite a wealth of data documenting acute cardiac injury from anthracycline therapy and/or mediastinal radiotherapy used for childhood cancer, little information is available on the long-term consequence of these insults. Twenty-nine patients (mean age 15 +/- 4.3 years) from The Late Effects Follow-Up Clinic For Childhood Cancer study, who had been in continuous, complete remission and off chemotherapy for a minimum of 2 years (mean follow-up 7.2 +/- 3.2) were studied. All patients had normal ejection fractions before and during cancer therapy and all were in New York Heart Association class I at the time of study. Systolic and diastolic functions were assessed by 2-dimensional echocardiography, Doppler flow velocity, and radionuclide angiography, and results were compared with normal control subjects. Left ventricular mass and mass index were significantly reduced in the patient population. Fractional shortening was decreased overall and end-systolic wall stress was much higher in patients than in controls. However, contractility, as assessed by the relation of wall stress to rate-corrected velocity of shortening, was decreased by > or = 2 SDs in only 6 of 28 patients, and the force-mass relation was actually increased in the patient group as a whole. Mitral valve inflow velocities were significantly increased but the pattern was abnormal. These results suggest a pattern consistent with a thin-walled, complaint left ventricle with reduced muscle mass performing under above-normal levels of wall stress. Contractility measurements were normal or increased in the group, but some patients clearly demonstrated development of reduced contractile function.(ABSTRACT TRUNCATED AT 250 WORDS)

Small aortic root in childhood: surgical options

Aortic valve replacement in the pediatric population is complicated by the often complex nature of the left ventricular outflow tract obstruction. Techniques to enlarge the annulus frequently are necessary. From 1977 to 1991, 32 children underwent an annular enlargement procedure at The Hospital for Sick Children, Toronto. During this same era, 110 children underwent a total of 138 aortic valve replacements. Eleven had the annulus enlarged with a posterior patch technique and implantation of a valve (mechanical 8, porcine heterograft 2, homograft 1) ranging from 20 to 25 mm in diameter. Twenty-two children had an anterior annular enlargement (aortoventriculoplasty) and aortic valve replacement with a valve (mechanical 8, porcine 2, homograft 12) 12 to 27 mm in diameter. One child had a posterior patch enlargement performed, followed by a second operation involving anterior annular enlargement. There was one early death in the posterior annuloplasty group and one late death due to failure of a bioprosthetic valve. There were five hospital deaths in the anterior annuloplasty group (22%; 70% confidence interval [CI], 14% to 32%) and two late deaths. Actuarial survival for the 32 children was 78% (70% CI, 70% to 86%) at 5 years and 65% (70% CI, 48% to 82%) at 10 years after repair. Younger children (age less than 1 year) had a significantly worse survival at 5 years (33%; 70% CI, 14% to 52%) than older children (88%; 70% CI, 82% to 95%). The survivors are well, and no reoperations have been necessary because of the children's outgrowing their valve.

Drug therapy for fetal arrhythmias

Diagnosis of specific types of fetal arrhythmias, especially tachyarrhythmias, is still difficult, often making semi-blind treatment inevitable. Published reports of many experienced clinicians show that digoxin remains a mainstream drug for therapy for fetal SVT and AF; digoxin is used as an initial monotherapy or in combination with other drugs if unresponsive to digoxin alone. It remains to be evaluated whether this treatment strategy offers overall better clinical outcomes than other approaches. Verapamil and propranolol are used in combination with digoxin, although successful control by propranolol seems rare. Quinidine and procainamide reportedly are effective in some cases. Reports on successful outcomes of flecainide therapy have emerged recently, although possible negative inotropic actions are of concern. Amiodarone is effective in some cases with incessant tachycardias, but risks of fetal thyroid dysfunction preclude its use as a firstline drug in uncomplicated fetal SVT cases. Empiric findings still prevail in the area of fetal drug therapy for arrhythmias, especially tachycardias. Heterogeniety of the conditions, lack of comparative studies, and difficulty in monitoring fetal drug level, let alone unbound drug concentrations, further complicate assessment of efficacy of different modes of treatment. Problems identified throughout this review have yet to be solved. Despite all these uncertain factors, however, it is clear that no one can undermine never-ending efforts of many clinicians in this exciting field of medicine.

Experience with the Damus-Kaye-Stansel procedure for children with Taussig-Bing hearts or univentricular hearts with subaortic stenosis

Anastomosis of the pulmonary artery to the ascending aorta is the essence of a technique for repair of complete transposition proposed by Damus, Kaye, and Stansel. Our Institutional experience with the Damus-Kaye-Stansel procedure (DKS) is limited to 9 children with double-outlet right ventricle and 38 with univentricular heart plus subaortic stenosis. Thirty-eight children (81%) survived the DKS procedure, and there were three late deaths during the mean follow-up of 3.1 years. Five-year survival is 72% (+/- 8%). All six children surviving a DKS and biventricular repair of double-outlet right ventricle have required conduit replacement at a mean interval of 46 months. In the children with univentricular heart, relief of subaortic stenosis with the DKS was successful in all except two. The late function of the semilunar valves is of concern, as 36% of the aortic and 52% of the pulmonary valves have some degree of incompetence.

Survival analysis of infants under age 18 months presenting with tetralogy of Fallot

The trend to perform early primary repair of tetralogy of Fallot prompted us to review our experience in the current era with the traditional protocol consisting of palliation during infancy, if required, and repair after infancy. During a 10-year period, 270 infants with tetralogy of Fallot presented aged less than 18 months. Thirteen infants (4.8%) had major noncardiac lesions that precluded definitive care for their congenital heart disease. Twenty infants (7.4%) had major associated cardiac lesions (atrioventricular septal defect or absent pulmonary valve syndrome, or both). Survival in this group was poor, with only 58% +/- 12% reaching the age of 10 years. Four of the seven deaths occurred before intracardiac repair was performed. The remaining 237 infants presented with isolated tetralogy of Fallot. Eight-nine percent +/- 2.3% survived to age 10 years. Sixty percent of these infants required palliation, and survival in these infants did not differ from that in those who never required palliation. However, 19 infants (8%) required palliation in the first month of life. In these children, survival to age 10 years was significantly lower (77%), secondary palliation was frequently required (n = 11), and a transannular patch or conduit at the time of repair (10 of 14 patients) was more likely needed than it was in children who had not undergone a palliative procedure during the neonatal period. The survival in infants with tetralogy of Fallot is unlikely to be different, regardless of whether primary repair or a staged repair is carried out. The quality of survival, including the exercise capability and absence of arrhythmias, must be assessed to determine which protocol is superior.

Results of the Fontan procedure for patients with univentricular heart

One hundred twenty-four consecutive patients with univentricular heart undergoing the Fontan operation were reviewed. Patients with tricuspid atresia or biventricular heart with hypoplasia of one ventricle were excluded. Eighty-four patients had left ventricular morphology. Atrioventricular connection was double-inlet (n = 76), common (n = 29), absent left atrioventricular connection (n = 14), and absent right atrioventricular connection (n = 5). Actuarial survival was 77% (70% confidence limits, 73% to 81%) at 1 year, 66% (70% confidence limits, 60% to 72%) at 5 years, and 49% (70% confidence limits, 36% to 61%) at 10 years, indicating a continuing risk for premature death. Multivariate analysis identified preoperative ventricular function and hypertrophy as risk factors for survival. High postrepair right atrial pressure (greater than 15 mm Hg) emerged as a strong intraoperative predictor of survival. Logistic regression analysis of these factors predicts high probability of death for certain subgroups of patients after the Fontan operation. Forty-four percent (n = 53) of these original 124 patients are alive and in New York Heart Association class I at follow-up. Thirty-eight percent (n = 33) of survivors have worse ventricular function than preoperative. Long-term survival is disappointing. Certain identifiable subgroups of patients with univentricular heart have unacceptable risks for the Fontan operation and should have alternate management. High postrepair right atrial pressure is an ominous sign, and if it persists the Fontan should be fenestrated or taken down.

Thromboexclusion of the right ventricle in children with pulmonary atresia and intact ventricular septum

Twelve children with pulmonary atresia and intact ventricular septum underwent closure of the tricuspid valve as a part of a new surgical procedure. In two cases a concomitant Fontan operation was performed. In each patient the right ventricle was very small and right ventricular pressure was higher than systemic pressure. Ventricle-coronary connections provided flow of desaturated blood from the right ventricle into the coronary arteries in 11 of 12 cases. Five of the 12 children did not survive operation and postmortem examination of each revealed severe acute and chronic myocardial ischemic damage and high-grade obstruction or interruption of the proximal left anterior descending coronary artery. Preoperative angiography demonstrated occlusive changes in the coronary arteries, resulting in right ventricular dependent circulation, in all five children who died and in one child who survived operation. Seven children who survived operation are well 4 months to 3.5 years later. Two have undergone subsequent successful Fontan operation and two others are considered suitable candidates for this operation. Tricuspid valve closure is recommended for a carefully selected group of infants with pulmonary atresia and intact ventricular septum provided a right ventricular-dependent coronary circulation can be excluded on the basis of preoperative coronary cineangiography.

Results of surgery for hypertrophic obstructive cardiomyopathy

Between 1971 and March 1986, 61 patients underwent surgery for hypertrophic obstructive cardiomyopathy. Age at operation varied from 3.5 to 76 years (mean 38). The standard approach was a generous transaortic myectomy. One-quarter of the patients underwent concomitant repair of associated lesions. There was one operative and two late deaths, for an actuarial 5 years survival 93% (+/- 8%). Average follow-up is 3 years per patient. Sixty-four percent of these patients are asymptomatic and another 30% were in New York Heart Association class II. Persistent symptoms were usually related to arrhythmias. Early atrioventricular block did not occur, but two patients were paced for complex arrhythmias 3 and 4 years after surgery. Hemodynamic studies (n = 22), two-dimensional echocardiographic (n = 47), and Doppler assessments (n = 23) demonstrated a left ventricular outflow tract pressure gradient of 70 and 14 mm Hg before and after surgery, respectively, left ventricular diastolic pressure of 18 and 14 mm Hg, percent of patients with mitral regurgitation of 70% and 30%, percent of patients with systolic anterior motion of 100% and 35%, and percent of patients with aortic insufficiency of 9% and 49%. Eight-six percent of the patients catheterized had no resting obstruction. Subaortic myectomy produces symptomatic improvement by reducing the left ventricular outflow tract pressure gradient, mitral regurgitation, and left ventricular end-diastolic pressure, and probably improves longevity.

High persistence rate of established coronary artery lesions secondary to Kawasaki disease among a panethnic Canadian population

The incidence of resolution of proximal coronary artery lesions subsequent to Kawasaki disease over an 11-year period was studied retrospectively. In 28 patients proximal coronary artery lesions were identified by two-dimensional echocardiography or angiography at 1 to 3 months after disease onset. Follow-up data were adequate in 27 patients, 17 of whom were boys; 18 were white, two black, four Oriental (non-Japanese), and three of East Indian origin. Age at onset of Kawasaki disease ranged from 11 weeks to 9 years (mean 2.5 years). Coronary artery lesions were categorized as ectatic (internal diameter greater than 3 mm in those less than 5 years of age) or aneurysmal (internal lumen of a segment one and one-half times larger than an adjacent segment). Resolution was assessed by two-dimensional echocardiography or angiography during a follow-up period of 3 months to 11 years (mean 2.7 years). Apparent resolution (vessel diameter less than 3 mm) of coronary artery lesions occurred in four (15%) patients--one with aneurysmal lesions, three with ectatic lesions--all within 1 year of disease onset. Eight patients developed myocardial infarction; one of these patients died. The resolution rate was less than previously reported. This high rate would warrant closer attention to the state and sequelae of coronary artery lesions, including obstructive coronary artery disease, in follow-up assessments.

Congenital aortico-right atrial communications. The dilemma of differentiation from coronary-cameral fistula

Four cases of an unusual form of aortico-right atrial communication are described. All patients were asymptomatic but had an atypical continuous murmur on examination. A distinctive appearance was noted on the angiograms, with a large tortuous tunnel noted superior to the left sinus of Valsalva, passing posterior to the aortic root before terminating near the right atrial-superior vena caval junction. This structure was readily identified by two-dimensional echocardiography. The defect was successfully closed surgically in three of four patients. The presence of normal major coronary arteries and absence of any small myocardial coronary branches from the tunnel argues against the structure being a coronary-cameral fistula and supports the diagnosis of aortico-right atrial tunnel.

Cardiorespiratory status in long-term survivors of prematurity, with and without hyaline membrane disease

Forty-eight children, born at less than 33 weeks' gestation and without bronchopulmonary dysplasia (BPD) or Wilson-Mikity syndrome (WM) were studied at a mean age of 9.1 years, to identify the incidence and possible factors contributing to the development of long-term abnormalities in pulmonary function. As neonates, 30 children had hyaline membrane disease (HMD) of whom 21 required ventilation. Eighteen did not have HMD, of whom 9 required ventilation for nonrespiratory reasons. All patients had grown normally. Four of the 48 (8.3%) had clinical asthma, 5 had persisting chest x-ray abnormalities (10.6% of 47 chest x-rays performed), each having been ventilated for HMD. There was a close association between duration of ventilation, oxygen administration, and subsequent abnormal chest x-ray. Electrocardiogram and M-mode echocardiograms were normal in all but 2 patients. Only 3 patients had significant restrictive lung disease, 3 had evidence of significant airways obstruction, and 13 (27.7%) had signs of air trapping. Methacholine challenge was positive in 30 of 46 patients (65.2%). The incidence of a positive methacholine challenge did not correlate with history of HMD, duration of ventilation, or high oxygen administration. There is an increased incidence of airway hyperreactivity in survivors of prematurity, not associated with any identified therapeutic maneuver during the neonatal period.

Complications resulting from use of arterial catheters: retrograde flow and rapid elevation in blood pressure

Arterial catheters, routinely used in neonatal intensive care units, have been associated with serious complications. In the present studies, retrograde blood flow occurring during routine flushing of peripheral and umbilical catheters is described. This retrograde flow is associated with a significant elevation of blood pressure at distant sites. These phenomena depend on the volume flushed and on the velocity of the flushing process. These phenomena can be prevented by flushing a small volume of 0.5 mL for a period of five seconds.

The progressive nature of subaortic stenosis in congenital heart disease

Data derived from serial hemodynamic and angiocardiographic investigations on pediatric patients not subjected to intervening intracardiac operations support the view that subaortic stenosis in congenital heart disease tends to be a progressive disorder. Our data are obtained from two groups of patients. The first comprised 22 patients with discrete subaortic stenosis in relative isolation. The second was made up of 19 patients with the fibrous or fibromuscular forms of discrete subaortic stenosis associated with a perimembranous ventricular septal defect. The results from both groups support our initial contention. The progressive character of subaortic stenosis in these two situations illustrates the dynamic nature of congenital heart disease, and the tendency of a changing form and function.

Bilateral ductus arteriosus (or remnant): an analysis of 27 patients

Bilateral ductus arteriosus (DA) was clinically recognized in 27 patients studied angiographically from 1963 through May 1983. Distal bilateral DA origin of non-confluent pulmonary arteries was identified in 15 patients, ectopic or distal ductal origin of 1 pulmonary artery in 9 patients (5 without evidence of intracardiac disease) and isolation of the left subclavian artery in 3 (all 3 of whom had a right aortic arch). Other conditions reported to be associated with bilateral DA include interruption of the aortic arch with isolation of a subclavian artery, aortic atresia with interruption of the aortic arch in which bilateral DA supports the entire systemic circulation, bilateral DA complicating forms of congenitally malformed hearts other than those just stated, and, rarely, bilateral DA in isolation. Understanding the symmetric or paired nature of the primitive aortic arch system in the developing human heart facilitates recognition of the patterns of fourth and sixth arch anomalies seen with bilateral DA.

Surgery for congenital heart defects diagnosed with cross-sectional echocardiography

Between August 1980 and July 1982, 70 children were operated on for congenital heart defects without the use of cardiac catheterization and/or angiocardiography (7.5% of the total of 929 operations). The diagnosis was established by clinical examination, chest x-ray, electrocardiography, and comprehensive cross-sectional echocardiography. The following lesions were repaired: coarctation of the aorta in infancy (n = 28), total anomalous pulmonary venous drainage (n = 6), aortic valvular/subvalvular lesions (n = 11), mitral and tricuspid valve lesions (n = 4), simple transposition of the great arteries (n = 3), vegetations (n = 3), persistent truncus arteriosus (n = 2), and others (n = 13). Three diagnostic errors occurred, and in four children the initial diagnosis was not complete. No child died as a consequence of an error or incomplete diagnosis, and in only one instance was an inappropriate operation carried out (abdominal coarctation of the aorta). We conclude that operation on selected patients can be safely performed on the basis of noninvasive investigation.

Intracranial arteriovenous malformation with aneurysm of the vein of Galen as cause of heart failure in infancy. Echocardiographic diagnosis and results of treatment

Images

Left ventricular outflow tract obstruction coexisting with ventricular septal defect

Images

Congenital mitral stenosis. Anatomical and functional assessment by echocardiography

Digitised left ventricular echocardiograms were studied in nine children with congenital mitral stenosis to assess the severity of inflow obstruction. In six children the two prime indices of mitral stenosis were abnormal, with a prolonged time from minimum dimension to 20 per cent dimension change and a reduced peak dimension change during diastole. In three, however, these values did not suggest inflow obstruction, depsite significant gradients at cardiac catheterisation. Two-dimensional echocardiography was performed in 10 children with congenital mitral stenosis to determine the mitral annular size and the morphology of the valve and subvalvular apparatus. The annular size and number of papillary muscles could be assessed along with the detection of combined mitral abnormalities. Two-dimensional studies can reliably delineate the type of mitral abnormality, and should be performed in all cases with congenital heart disease having a high incidence of associated left ventricular inflow obstruction. Digitised M-mode left ventricular echocardiography is in general unreliable in assessing congenital obstruction, though it may be of some value in individual cases.