Identifying Clinical Predictors of Proliferative Sickle Cell Retinopathy

PURPOSE

To identify systemic and/or ophthalmologic predictors of proliferative sickle retinopathy.

METHODS

Cross-sectional study comparing clinical, laboratory, and structural choriorretinal aspects between sickle cell disease patients with and without proliferative retinopathy. Patients underwent complete systemic and ophthalmologic evaluation. Enhanced depth spectral domain optical coherence tomography with choroidal binarization and optic coherence tomography angiography were performed and choriorretinal vascular components were compared.

RESULTS

Forty-five eyes from 45 sickle cell patients were included. Ninety-one percent of patients were diagnosed with sickle cell retinopathy, 29% with proliferative retinopathy. Mean corpuscular volume, lactate dehydrogenase, and percentage of fetal hemoglobin were reduced in the subgroup of patients with proliferative retinopathy when compared with patients without proliferative retinopathy (p ≤ 0.001; p = 0.04; p ≤ 0.001, respectively). The best predictor of proliferative retinopathy was mean corpuscular volume (AUC = 0.842; p = 0.001), followed by the percentage of fetal hemoglobin (AUC = 0.763, p = 0.009) and lactate dehydrogenase (AUC curve = 0.706; p = 0.039). No differences were found between groups in the quantitative analysis of retinal vascularization using OCTA and choroidal vascularization using OCT (p ≥ 0.05).

CONCLUSION

Fetal hemoglobin and mean corpuscular volume may be good predictors of proliferative sickle retinopathy. The association between proliferative retinopathy and reduced levels of lactate dehydrogenase and mean corpuscular volume points to hypoxia and not hemolysis as a possible driving force in its pathophysiology.

Application of optical coherence tomography angiography for microvascular changes in patients treated with hydroxychloroquine: a systematic review and meta-analysis

BACKGROUND

Retinal toxicity with long-term hydroxychloroquine (HCQ) treatment is a major concern. This systematic review aims to assess the application of optical coherence tomography angiography (OCTA) to detect microvascular alterations in patients under HCQ.

METHODS

PubMed, Scopus, Web of Science, and Cochrane Library databases were systematically searched until January 14, 2023. Studies using OCTA as a primary diagnostic method to evaluate the macular microvasculature of HCQ users were included. Primary outcomes were macular vessel density (VD) and foveal avascular zone (FAZ) at the superficial (SCP) and deep (DCP) capillary plexus. Meta-analysis was performed using a random-effects model.

RESULTS

Of 211 screened abstracts, 13 were found eligible, enrolling 989 eyes from 778 patients. High-risk patients due to longer duration of treatment presented lower VD in the retinal microvasculature than those with low-risk in SCP (P = 0.02 in fovea; P = 0.004 in parafovea) and in DCP (P = 0.007 in fovea; P = 0.01 in parafovea). When compared with healthy controls, HCQ users had lower VD in both plexus-no quantitative synthesis was presented.

CONCLUSIONS

Microvascular changes were found in autoimmune patients under HCQ treatment without any documented retinopathy. However, the evidence produced so far does not allow to draw conclusion concerning the effect of drug as studies were not controlled for disease duration.

Application of Optical Coherence Tomography Angiography Macular Analysis for Systemic Hypertension. A Systematic Review and Meta-analysis

BACKGROUND

Microvascular rarefaction due to hypertension has been linked to disease severity and end-organ complications. Optical coherence tomography angiography (OCTA) has been explored as a potential tool to evaluate the retinal microvascular network in hypertensive patients.

METHODS

PubMed, Scopus, Web of Science, and Cochrane were systematically searched to 10th of September of 2021, along with a manual search. Studies that used OCTA as a primary diagnostic method to evaluate the macular microvasculature of hypertensive patients were included. Meta-analysis was performed using a random-effects model. Primary outcomes were macular vessel density (VD) and foveal avascular zone (FAZ) at the superficial and deep capillary plexus.

RESULTS

Of 947 screened articles, 9 were found eligible for qualitative and quantitative analysis. VD in hypertensive patients was reduced when compared with controls in the fovea (0.93, 95% confidence interval [CI] 0.87-0.99, P = 0.023) and the parafovea (0.95, 95% CI 0.93-0.97, P < 0.001) of the superficial capillary plexus. FAZ was larger in the deep plexus of hypertensive patients (1.10, 95% CI 1.03-1.18, P = 0.003). VD reduction was found in patients with worsening blood pressure control in 3 studies and prolonged disease in 2 studies.

CONCLUSIONS

Microvascular rarefaction of the macula is found in hypertensive patients with a reduction of foveal and parafoveal VD and an increase of FAZ area. Disease duration and severity might be related to a microvascular rarefaction. OCTA could offer a novel tool for the assessment and follow-up of hypertensive patients.

Advanced echocardiographic function analysis in adolescents and young adults with corrected and residual coartation of the aorta

Funding Acknowledgements

Type of funding sources: None.

Introduction

This study aimed to assess systolic and diastolic heart function changes in patients with history of aortic coarctation using advanced echocardiographic imaging. Additionally, we sought to analyse which severity factors influenced these changes.

Methods

We performed a complete echocardiographic evaluation, with advanced functional analysis, including myocardial work analysis, to a random sample of 53 patients (age 12 to 40 years). These had a previous history of coarctation of the aorta (CoAo), which was either corrected (aortic transisthmic Doppler gradient (Dgrad) ≤20mmHg) or presented a significant residual gradient (Dgrad &gt;20mmHg). A control group of healthy individuals, matched for age, sex and BMI, was subjected to the same evaluation. Selected dependent variables were: E/A, E’, E/E’, atrial strain parameters, biplane ejection fraction, ventricular global longitudinal strain, and global myocardial work (GMW). One-way ANOVA with appropriate post-hoc tests was done to compare the distribution of dependent variables among controls (n = 31), patients with corrected coartation (cCOAO) (n = 36), and patients with residual coartation (rCOAO) (n = 17). Multivariable linear regression was used to evaluate the association, in the 53 patients, between the dependent variables and parameters of CoAo severity: systolic blood pressure (SBP), left ventricular indexed mass (LVmass), Dgrad, and the ratio of the narrowest diameter of the aortic arch to the aorta at the diaphragm level (Aoratio). Statistical significance was established as p &lt; 0.05.

Results

Patients with either cCOAO or rCOAO had lower E’ (p &lt; 0.001), higher E/E’ (p &lt; 0.001), lower atrial reservoir (p &lt; 0.001) and conduit (p &lt; 0.001) strain, when compared with controls (table 1). Patients with rCOAO had higher GMW when compared with either cCOAO or controls (p = 0.002). Multivariable regression analysis showed that both lower atrial reservoir and conduit strain were associated with a narrower aortic arch (lower Aoratio (p = 0.002 and p = 0.011, respectively); higher E/E’ with higher LVmass (p = 0.030); higher GMW with higher LVmass (p = 0.027) and Dgrad (p = 0.035). Patients subsequently submitted to an intervention for coartation treatment (n = 8) had lower atrial conduit (p = 0.007) and higher GMW (p = 0.015) when compared to all other patients (n = 45). Conclusion: Myocardial work emerged as a particularly useful tool as it was both significantly different between CoAo groups, and significantly higher in more severe patients, driven by the LV mass and residual gradient. This analysis may have a role in these patients’ clinical decision-making. Abstract Table 1

Non-central serous chorioretinopathy in a patient with systemic lupus erythematosus and hydroxychloroquine retinopathy

Subretinal fluid accumulation in a patient with systemic lupus erythematosus (SLE) may represent a diagnostic challenge. We present a case of a 43-year-old man with baseline diagnosis of SLE and hydroxychloroquine-associated maculopathy who reported progressive vision loss on the right eye, associated with corticosteroids use for an arthritic crisis. Ophthalmological examination did not reveal any acute finding. On optical coherence tomography, subretinal fluid in the perifoveal area was visible on the right eye, with corresponding enlargement of the visual field defect. An increased choroidal thickness was also visible. Fluorescein angiography revealed, on the right eye, two pinpoint areas of leakage and indocyanine green angiography signs of choroidal vascular hyperpermeability. Considering a diagnosis of a non-central central serous chorioretinopathy, corticosteroids use was interrupted, with resolution of the subretinal fluid. This case illustrates the relevance of a multimodal imaging approach to guide the diagnosis of patient with an SLE with subretinal fluid.

1167 Atrial strain predicts exercise capacity in patients with the fontan circulation

Funding Acknowledgements

None

Introduction

Atrial function has recently emerged as a valuable parameter, particularly for evaluation of ventricular diastolic dysfunction and heart failure. There is a strong need for reliable echocardiographic predictors of exercise capacity in univentricular hearts, but their particular anatomy makes it challenging. In this work we aimed to characterize the relationship between atrial strain and exercise parameters in the Fontan population.

Methods

Fontan patients followed in our outpatient clinic were prospectively evaluated with cardiopulmonary exercise test and transthoracic echocardiogram. The dominant atrium, i.e. the atrium connected to the dominant atrioventricular valve, was assessed with speckle-tracking echocardiography for active (εact), conduit (εcon), and reservoir (εres) strain; and εact/εres ratio. A single cardiac loop from the 4 chamber view was selected for this analysis and the ‘zero’ strain reference for atrial deformation analysis was set at the onset of the electrocardiogram P wave. Exercise capacity defined as the percentage of peak oxygen uptake (VO2), comparing with predicted values, was chosen as the dependent variable. Independent variables were selected among clinical and echocardiographic data. Statistical analysis was performed using SPSS version 23. T-student test was used for binomial and continuous variable correlation; single and multivariable linear regression was used for continuous variable correlation. Statistical significance was defined as p-value &lt; 0.05.

Results

Fifty-two Fontan patients were assessed. Nineteen (37%) were excluded due to inadequate deformation tracking of the atrial wall. Mean age was 18.0 years (SD 6.9, min. 10.0 - max. 36.0), mean age at Fontan surgery was 7.0 years (SD 2.9, min. 3.0 – max. 18.0). Peak VO2 as a percentage of the predicted value was 66.5% (SD 18.8, min. 36.4 – max. 118.6). εact was -11.1% (SD 3.7, min. -21.1 – max. -4.8), εcon was 10.6% (SD 6.5, min. -0.5 – max. 6.5), εres was 21.7% (SD 5.2, min. 13.2 – max. 34.4) and εact/εres ratio was 0.54 (SD 0.23, min. 0.22 – max. 1.04). On univariate analysis, all atrial strain variables correlated with peak VO2. After adjusting for collinearity, multivariable regression defined age (estimate -1.6, 95% CI: -2.5 to -0.9, p-value &lt; 0.001) and εact strain (estimate 1.8, 95% CI: 0.5 to 3.2, p-value = 0.011) as the strongest predictors of peak VO2 (r2= 0.479).

Conclusion

Peak VO2 defines exercise capacity and is a strong marker of prognosis in Fontan patients. There are very few echocardiographic variables capable of predicting it, in part due to a variable cardiac anatomy. We showed that atrial strain rate is a novel echocardiographic parameter that predicts peak VO2. In the Fontan circulation, a higher reliance on active atrial contraction for ventricular filling predicts lower exercise capacity. Therefore, atrial strain rate, whenever measurable, may provide a new method of risk stratification in this population.

Abstract 1167 Figure. Example of atrial strain curve.

Macular Ganglion Cell Layer and Peripapillary Retinal Nerve Fibre Layer Thickness in Patients with Unilateral Posterior Cerebral Artery Ischaemic Lesion: An Optical Coherence Tomography Study

The purpose of this study is to evaluate the macular ganglion cell layer (GCL) and peripapillary retinal nerve fibre layer (RNFL) thickness in patients with unilateral posterior cerebral artery (PCA) ischaemic lesions using spectral-domain optical coherence tomography (SD-OCT). A prospective, case-control study of patients with unilateral PCA lesion was conducted in the neuro-ophthalmology clinic of Centro Hospitalar Lisboa Central. Macular and peripapillary SD-OCT scans were performed in both eyes of each patient. Twelve patients with PCA lesions (stroke group) and 12 healthy normal controls were included in this study. Peripapillary RNFL comparison between both eyes of the same subject in the stroke group found a thinning in the superior-temporal (p = 0.008) and inferior-temporal (p = 0.023) sectors of the ipsilateral eye and nasal sector (p = 0.003) of the contralateral eye. Macular GCL thickness comparison showed a reduction temporally in the ipsilateral eye (p = 0.004) and nasally in the contralateral eye (p = 0.002). Peripapillary RNFL thickness was significantly reduced in both eyes of patients with PCA compared with controls, affecting all sectors in the contralateral eye and predominantly temporal sectors in the ipsilateral eye. A statistically significant decrease in macular GCL thickness was found in both hemiretinas of both eyes of stroke patients when compared with controls (p < 0.05). This study shows that TRD may play a role in the physiopathology of lesions of the posterior visual pathway.

Choroidal Thickness in Nonarteritic Anterior Ischaemic Optic Neuropathy: A Study with Optical Coherence Tomography

Nonarteritic anterior ischemic optic neuropathy (NA-AION) is the most common nonglaucomatous optic neuropathy in adults over 50 years of age. It is usually related to cardiovascular risk factors. The primary objective of this study was to evaluate choroidal thickness in patients with chronic NA-AION, and the secondary objective was to evaluate macular thickness in these patients. This cross-sectional study compared two groups: group 1 included 20 eyes of 20 patients with chronic NA-AION, and group 2 included 31 eyes of 31 healthy controls. In both groups, the choroidal thickness was measured using the enhanced depth imaging program of Heidelberg Spectralis® optical coherence tomography (Heidelberg Engineering, Heidelberg, Germany). The macular thickness was also measured using the automatic software of the same device. The mean follow-up time after NA-AION in group 1 was 57.17 ± 26.92 months. The mean choroidal thickness of the posterior pole was 244.38 ± 61.03 µm in group 1 and 214.18 ± 65.97 µm in group 2 (p = 0.004). The mean macular thickness was higher in group 2. Macular thickness is reduced in eyes that had an episode of NA-AION, whereas choroidal thickness is generally higher in these eyes when compared with normal eyes. The increase in choroidal thickness may be due to a local dysfunction in vascular autoregulatory mechanisms, which may predispose to ischemic phenomena.

[Extra-anatomic aortic bypass for repair of aortic arch diseases in adults]

Surgical management of aortic arch diseases in the adult are challenging. Use of extra-anatomic conduits are a well established form of treatment. We report a retrospective study of four patients operated on in our institution between 2000 and 2006, using this technique. Two patients had a median sternotomy, one a left thoracotomy and one a right thoracotomy. There were no perioperative mortality and all patients were alive and doing well after a mean follow-up of 19 months. In this subset of patients, surgical treatment should be individualized. In our experience, extra-anatomic bypass is a valuable, effective and safe surgical option.

[Implantation of mechanical prosthetic valves in the pediatric age group. Review of the last ten years]

Our aim is to evaluate the outcome of 13 patients, under the age of 18, who underwent 15 valve replacements with mechanical prostheses, from January 1985 through December 1995, in our Hospital. The mean age was 11.7 +/- 5.0 years (from eight months to 18 years); six patients were male. The follow-up was five months to 9.5 years. All of them were initially in NYHA classes III or IV, under medical therapy. Indication for valve replacement was rheumatic valve disease in five and congenital in eight. The mitral valve was replaced in eight patients, the aortic in three and both valves in two patients. Two patients (15%) died in the early post operative period. After the procedure there was a remarkable hemodynamic improvement of the remaining patients; the echocardiographic evaluation showed good left ventricular function in all patients and a reduction in systolic pressure of the pulmonary artery and dimensions of the right chambers of the heart. Two patients had perivalvular leaks. Nine patients were NYHA functional class I, one in class II and one in class III. All patients received warfarin anticoagulation and antibiotic prophylaxis for infective endocarditis. There was no incidence of anticoagulant related haemorrhage or thromboembolic or infectious events. One patient (7.6%) underwent valve replacement as the first procedure; the others underwent valvuloplasty before replacement of the valve. Although valve replacement in this population should only take place when conventional forms of therapy fail, in our group we observed low mortality and morbidity rates.

[The percutaneous closure of the ductus arteriosus in adults]

From May 1990 to June 1998, 116 patients were submitted to percutaneous closure of patent ductus arteriosus. There were 18 adult patients, aged 18 to 61 years. Two patients had residual ductus after an attempted surgical ligation and two other patients had a calcified ductus. A device was not implanted in three patients, two of whom because of pulmonary hypertension being considered irreversible. Another patient, with a very large duct, underwent attempted occlusion, but the device embolized to the pulmonary artery and was retrieved percutaneously in the same session. This patient was operated later. Complete duct occlusion, confirmed by color Doppler echocardiography, was achieved in 14 of the remaining 15 patients (93%; 95% CL: 81-100). This was performed with a single catheterization in 12 cases, with implantation of one or more detachable coils in 8 patients; with a Rashkind device in 3, and a combination of a Rashkind device and coils in 1. In two cases complete duct occlusion required a second catheterization for implantation of additional detachable coils, including one patient with intravascular hemolysis in whom resolution of this problem was achieved with additional coils. In recent years, we have preferentially used detachable coils implanted through 5 Fr catheters, with a controlled release mechanism. This is a safer and less expensive device. Patients with pulmonary hypertension can be submitted to a trial occlusion of the duct with a balloon catheter to evaluate the response of pulmonary artery pressures. Percutaneous closure of the patent ductus arteriosus can be performed with excellent results in adults. Complete occlusion was achieved in 14 of the 15 patients (93%) without pulmonary hypertension or extremely large ductus. This is similar to our results in the pediatric population.

[Extra-lobar pulmonary sequestration with broncho-esophageal fistula]

We describe a case of extra-lobar pulmonary sequestration with broncho-esophageal fistula in a newborn male who presented respiratory distress, cyanosis and feeding difficulties. The diagnosis was made with a swallowed contrast examination, nuclear magnetic resonance, digital subtraction angiography and confirmed by gross and histologic examination. The work of a multidisciplinary team was essential for an early diagnosis and the correct and effective treatment of this Cuncommon condition.

[Holter electrocardiography en pediatric cardiology: preliminary experience]

PURPOSE

Evaluation of the diagnostic value of continuous electrocardiographic recording (Holter monitoring) in Paediatric Cardiology.

STUDY DESIGN

Retrospective study based on the data records of the Arrhythmia Department regarding patients with less than 20 years of age with Holter monitoring performed between January 1983 and February 1995 (374 recordings).

PATIENTS

277 patients were studied, 163 were male and 114 female with a mean age of 12 +/- 5 years. Heart organic anomalies were present in 155 patients and 92 patients had previous cardiac surgery with cardiopulmonary bypass. Clinical indications for Holter recording were the evaluation of symptoms related to arrhythmias (38%), documented dysrhythmia (23%), arrhythmia detected on physical examination (18%) and evaluation of risk in patients without symptoms of arrhythmia (17%).

METHODS

Holter recordings were performed during 24 hours with two channels (modified V1 and V5).

RESULTS

Significant rhythm and conduction disturbances were found in 122 patients. These were ventricular premature complexes > or = 10/hour (27 patients), AV block (25 patients) and supraventricular premature complexes > or = 10/hour (22 patients). Holter recording revealed significant dysrhythmias in 52% of patients with previously documented dysrhythmia, in 43% of patients referred for assessment of risk without symptoms of arrhythmia, provided insight in 48% of requests due to arrhythmia detected on physical examination and 24% of requests for symptoms related to arrhythmias. In 13 patients the results of Holter recording led to therapeutic or diagnostic measures.

CONCLUSIONS

Holter recording showed an overall sensitivity of 44% in the detection of significant arrhythmias and led to therapeutic and additional diagnostic measures in 11% of these patients. Holter recording seems to provide important information in the evaluation of arrhythmias in the paediatric age group.

Evaluation of pulmonary artery anatomy using magnetic resonance: the importance of multiplanar and oblique imaging

Pulmonary artery anatomy was studied in 36 patients (age range 12 days to 12.83 years, mean 2.9 years) with right ventricular outflow tract obstruction over a 3-year period using a 1.5 Tesla Magnetic Resonance system. Gated spin-echo sequences were obtained in each patient. Image planes used were straight and oblique transverse, oblique coronal, and oblique sagittal. The studies were analyzed retrospectively and comparative angiographic, surgical, and postmortem data was available in all cases. As previously noted with other imaging modalities, multiple views and oblique cuts were found to increase significantly the quality and accuracy of the information acquired. In 12 of the 15 patients who had axial and coronal imaging of both branch pulmonary arteries, the pulmonary arteries were unequivocally demonstrated to at least the first hilar branch. However, early in our experience we missed a number of branch stenoses that developed following surgical anastomoses. These mistakes were caused by inadequate or inappropriate slice acquisition. Magnetic resonance is an important technique for imaging pulmonary arteries. Careful use of the appropriate imaging planes is essential for accurate demonstration of the anatomy.

Technique of percutaneous laser-assisted valve dilatation for valvar atresia in congenital heart disease

OBJECTIVE

To investigate the efficacy and safety of transcatheter laser-assisted valve dilatation for atretic valves in children with congenital heart disease.

DESIGN

Prospective clinical study.

SETTING

Supraregional paediatric cardiology centre.

SUBJECTS

Eleven children (aged 1 day-11 years; weight 2.1-35.7 kg) with atresia of pulmonary (10) or tricuspid (one) valve underwent attempted laser-assisted valve dilatation as part of the staged treatment of their cyanotic heart disease.

INTERVENTION

After delineating the atretic valve by angiography and/or echocardiography a 0.018 inch "hot tip" laser wire was used to perforate the atretic valve. Subsequently the valve was dilated with conventional balloon dilatation catheters up to the valve annulus diameter.

RESULTS

Laser-assisted valve dilatation was successfully accomplished in nine children. In two neonates with pulmonary valve atresia, intact ventricular septum, and coexistent infundibular atresia the procedure resulted in cardiac tamponade: one died immediately and one later at surgery. During a follow up of 1-17 months (mean 11) two infants with pulmonary valve atresia and intact ventricular septum died (one with congestive cardiac failure). The remainder are either well palliated and do not require further procedures (three), or are awaiting further transcatheter or surgical procedures because of associated defects (four).

CONCLUSIONS

Laser-assisted valve dilatation is a promising adjunct to surgery in this high risk group of patients. It may avoid surgery in some patients, and may reduce the number of surgical procedures in those requiring staged operations.

Determinants of hemodynamic results of balloon dilation of aortic recoarctation

Between October 1982 and May 1990, balloon dilation of aortic recoarctation was attempted in 27 patients. In 1 case dilation was not performed owing to suspected aortic perforation. The remaining 26 patients had 30 procedures. The age at the first dilation ranged between 2.6 months and 18.3 years. After dilation, systolic gradient decreased from 49 +/- 17 mm Hg to 20 +/- 17 mm Hg (p less than 0.001). A reduction of gradient to less than or equal to 20 mm Hg occurred after the first dilation in 17 of 26 (65%) patients. Residual gradients between 25 and 80 mm Hg were present in the remaining 9 patients. During follow-up of 2 months to 6.7 years, 5 of 17 patients with a good initial result developed further recoarctation (2 had successful redilation, 2 had reoperation, and 1 is awaiting repeat dilation). Of 9 patients with gradients greater than 20 mm Hg after the first dilation, 1 had successful redilation and 3 had reoperation. The remaining 5 patients are being managed conservatively. 2 patients developed aneurysms after dilation (1 immediately and the other at 2 months). In all, 15 patients (58%) had a good, and 11 (42%) a poor late hemodynamic result. Aortic diameters at different levels of the aortic arch and at the reconstructed isthmus (normalized to the aorta at the level of the diaphragm) were significantly higher in the group with a good late result than in that with a poor one. Balloon/aortic diameter ratio at diaphragm level also had a significant influence on the late results.

Countercurrent aortography: an alternative to cardiac catheterization in infancy

Countercurrent aortography via a peripheral artery was used to clarify the aortic arch anatomy in 25 infants in whom cross-sectional and Doppler evaluation was inconclusive. Ages ranged from 3 days to 11 months (median 9 days), and 80% were neonates. The suspected diagnosis was aortic coarctation in 21 infants, interrupted aortic arch in two, recoarctation in one, and vascular ring in one. A countercurrent aortogram provided adequate diagnostic information in 24 infants. A diagnosis of coarctation was confirmed in 15, interruption of the aortic arch in two, and vascular ring in one. In six infants countercurrent aortography excluded the presence of anomalies of the aortic arch. In only one infant, who had an anomalous origin of the right subclavian artery from the descending aorta, did this technique fail to provide adequate information. The only complication observed was transient ischemia of the arm in one patient. Countercurrent aortography is a minimally invasive procedure that can provide adequate angiographic information without the need for cardiac catheterization in patients with inconclusive echocardiographic evaluation. Injection into a right upper limb artery is preferred, because it gives better opacification of the ascending and transverse aortic arch than injection into a left one.

Absence of one atrioventricular connexion--a terminologic problem

We present a patient in whom the heart was right-sided, with usual atrial position, absence of the right-sided atrioventricular connexion, and a single outlet via the aorta from a dominant morphologically right ventricle. We use the case to illustrate potential problems in the terminology as used to describe the absence of one atrioventricular connexion. Our case shows why absence of one atrioventricular connexion must be classified according to the side of the missing connexion, and not the anatomy of the atrial or ventricular chambers involved. To simplify the approach to certain hearts, the use of the concept of one concordant or discordant atrioventricular connexion may be justified when the other atrioventricular connexion is absent.

Doppler evaluation of superior caval venous pathways after Mustard and Senning operations

Doppler waveforms from the superior caval vein were analysed to evaluate the patency of superior caval venous pathways following venous redirection (Mustard and Senning) operations for complete transposition. The group consisted of 26 unselected survivors of Mustard (9 patients) and Senning operations (17 patients). Patients were examined a mean of 5.9 (range 0.1-15.3) years following operation and their age at study ranged from 0.4-25.3 years, mean 7.3 years. Doppler waveforms were correlated with digital subtraction angiograms, which were performed in every patient within 24 hours of the Doppler study. Totally occluded superior caval venous pathways were identified in 3 patients with digital subtraction angiography. The remaining patients had angiographically patent pathways. In the 23 patients with patent pathways, Doppler waveforms demonstrated an initial systolic peak smaller than a second diastolic peak. In the 3 patients with totally occluded pathways, the pattern of the waveform was reversed, with the systolic larger than the diastolic peak. Doppler examination of the superior caval vein is a quick and simple bedside method of accurately determining patency of superior caval venous pathways after atrial redirection procedures for complete transposition.

[Atresia of the common pulmonary vein]

A case of common pulmonary vein atresia is presented, in which all pulmonary veins drain into a venous confluence without outlet. The criteria helpful in differentiating this condition from other forms of anomalous pulmonary disease in the neonatal period are discussed.