Successful one-stage surgical repair in a rare adult patient with berry syndrome

BACKGROUND

Berry syndrome is a rare congenital cardiac malformation, herein we report an adult male patient who was successfully repaired by one-stage surgery.

CASE DESCRIPTION

18-year-old male patient presenting symptoms of chest tightness and shortness for over a year presented to outpatient clinic in our department to have corrective procedure heart. CTA revealed an Aortopulmonary Window (APW) type III, measuring 4.6 cm in maximum diameter. The right pulmonary artery originated from the ascending aorta, and the pulmonary trunk exhibited dilation with dimensions of 8.3 cm × 5.7 cm × 5.9 cm. Additional findings included Interrupted Aortic Arch (IAA) type A, intact ventricular septum, and Patent Ductus Arteriosus (PDA). Echocardiography showed bidirectional shunt at the level of APW in severe pulmonary hypertension. The right heart catheterization indicated a mean pulmonary artery pressure of 70mmHg and a pulmonary artery resistance of 5 Wood units. We evaluated after two weeks of treatment with epoprostenol at a rate of 20 ng/(kg. min) and found a significant improvement in pulmonary-artery pressure. Finally, we communicated with the patient's family and decided to proceed with the procedure.

CONCLUSIONS

For complex cardiovascular malformations, the ideal treatment strategy must be tailored to the characteristics of the patient to provide maximum efficacy and safety.

Case Series of Berry syndrome: A rare constellation of fatal cardiac anomalies

Berry syndrome is an extremely rare constellation of several congenital cardiac anomalies consisting of aortopulmonary window, aortic origin of the right pulmonary artery (AORPA), interrupted aortic arch or hypoplastic aortic arch or coarctation of the aorta, and an intact ventricular septum with high neonatal mortality rates. The disease is fatal with high mortality (90%) in the neonatal period with surviving patients mostly developing pulmonary hypertension. We describe the clinical presentation and diagnostic clues in two patients with Berry syndrome.

Heart failure in a newborn with tetralogy of Fallot: uncommon association of a common anomaly

Heart failure in tetralogy of Fallot in the newborn period is rare and is usually due to either large aortopulmonary collaterals or absent pulmonary valve syndrome with severe pulmonary regurgitation. Pink tetralogy of Fallot and tetralogy of Fallot with disconnected pulmonary arteries from the aorta may present beyond the newborn period with heart failure when Pulmonary vascular resistance (PVR) falls. We describe the diagnostic and therapeutic pathway in a rare case of heart failure in newborn with tetralogy of Fallot.

Late Identification of a Stealthy Aorto-Pulmonary Window: A Case Report

The term "aortopulmonary window" (APW), often referred to as "aortopulmonary septal defect," refers to a rare congenital medical disorder where there is an improper direct link between the main pulmonary artery and the ascending aorta. It can be combined with other cardiac congenital conditions or be an isolated lesion. Herein, we report the incidental discovery of a minor, restrictive aortopulmonary septal defect in a 60-year-old male who denied having any clinical symptoms. Incidentally detected APW in adulthood is uncommon and, hence, can be readily overlooked, a fortiori, in asymptomatic patients.

Intermediate outcome for the single-stage surgical repair of aortopulmonary window associated with interrupted aortic arch

OBJECTIVES

Aortopulmonary window (APW) associated with interrupted aortic arch (IAA) is a rare cardiac malformation with significant mortality and morbidity. This study aimed to report the intermediate outcomes of single-stage stage repair concentrating on the surgical techniques and postoperative reintervention for this rare cardiac lesion.

METHODS

Eleven patients were diagnosed with IAA-associated APW and underwent single-stage surgical repair at Vietnam National Children's Hospital.

RESULTS

The APW anatomy types were the types I, II, and III in 1, 4, and 6 patients, respectively. The IAA morphology was type A in nine patients and type B in two patients. The median age was 27 (interquartile range [IQR] 6-79) days, and median weight was 3.5 (IQR 2.8-4.5) kg. The aortic arch was repaired using direct end-to-side tissue anastomosis in seven patients, and patch aortoplasty was performed in four patients. Six patients underwent APW closure with an intra-aortic baffle, and five patients required right pulmonary artery detachment and reimplantation. One early death occurred. Four patients required reinterventions: one patient required reoperation due to aortic stenosis and three required balloon angioplasty for either recurrent aortic arch stenosis (n = 1) or right pulmonary stenosis (n = 2) with a mean follow-up time of 3.1 (IQR 0.5-4.3 years).

CONCLUSIONS

Single-stage repair of IAA-associated APW can be achieved with good survival outcomes in children. However, the need for repeat reintervention or reoperation remains high, and the growth of both the aorta and pulmonary arteries should follow carefully with patient's growth.

CLINICAL REGISTRATION NUMBER

VNCH-RICH-18-96.

Congenital unilateral absence of right pulmonary artery with VSD and wide aortopulmonary window in an adult patient: a case report

Unilateral absence of pulmonary artery (UAPA) is a very rare condition, with an estimated prevalence of 1 in 200,000 population, which is commonly associated with various cardiovascular anomalies or can occur in an isolated manner. Isolated cases survive to adulthood and remain asymptomatic, but they may frequently experience hemoptysis, repeated infections, or symptoms like dyspnea and chest pain. Due to the rarity of the disorder and its ambiguous appearance, diagnosis can be very challenging.

Case presentation

We present a case of a 28-year-old male who visited our center with the diagnosis of ventricular septal defect with Eisenmenger syndrome elsewhere for further evaluation and was found to have right-sided UAPA with ipsilateral pulmonary hypoplasia and some associated cardiac anomalies.

Clinical discussion

Discussions are held regarding typical chest radiograph findings, diagnostic methods, and possible therapies.

Conclusion

Physicians should be aware of UAPA, which might go undiagnosed for several years despite regular medical care and can show up later in life, causing chronic respiratory symptoms along with Eisenmenger syndrome and ventricular septal defect like in our case.

Aortopulmonary window and coronary anatomy - still a pre-operative diagnostic trouble!

We present a case of aortopulmonary window in which the diagnosis of anomalous left coronary artery originating from pulmonary artery was made intra-operatively even if the coronary arteries anatomy was correctly studied pre-operatively with echocardiography. No evidence of coronary anomalies or indirect sings of coronary anomalies has been noted. Should we improve our pre-operative diagnostic accuracy and how?

Evaluation of aortopulmonary window using virtual dissection of multidetector computed tomography angiography data sets

AIM

The present study sought to evaluate the morphology and associated cardiovascular anomalies in patients with aortopulmonary window on virtual dissection of multidetector computed tomography (CT) angiography data sets.

MATERIAL AND METHODS

We conducted a retrospective search of our departmental database from January 2014 to September 2021 to identify patients with aortopulmonary window and relevant information was extracted from the electronic case records and from routine examination as well as virtual dissection of CT data sets.

RESULTS

An aortopulmonary window was observed in 26 patients (20 males; 6 females). Based on location of the defect, a distal aortopulmonary window was the most common subtype, seen in 13/26 (50%) patients followed by a proximal, complete and intermediate subtypes seen in 7/26 (27%), 5/26 (19%) and 1/26 (4%) patients respectively. Associated ventricular septal defect was observed in 9/26 (34.6%) patients while an interrupted aortic arch was present in 5/26 (19.2%) patients. Tetralogy of Fallot was seen in 5/26 (19.2%) patients. Anomalous origin of right pulmonary artery from ascending aorta and crossed pulmonary arteries were seen in 2/26 (7.6%) patients each. An isolated aortopulmonary window without any simple/complex congenital anomaly was seen in 10/26 (38.5%) patients.

CONCLUSION

Aortopulmonary window is associated with a wide gamut of cardiovascular lesions, with ventricular septal defect being the commonest associated anomaly followed by tetralogy of Fallot and interrupted aortic arch respectively. Virtual dissection of multidetector CT angiography allows detailed anatomical evaluation of aortopulmonary window, allowing a clear visualization of the defect and associated cardiovascular anomalies.

Tetralogy of Fallot with double aortic arch and aortopulmonary window: a very rare trifecta

Tetralogy of Fallot with an aortopulmonary window and double aortic arch is very rare. This complex coexistence may be over a wide clinical spectrum. Herein, we present an asymptomatic 8-day-old infant who was diagnosed as having tetralogy of Fallot, double aortic arch, and an aortopulmonary window using transthoracic echocardiography while being examined for microcephaly.

Aortopulmonary Communication between the Arterial Trunks in Tetralogy of Fallot with Pulmonary Atresia

We reported a case where a 14-year-old Tetralogy of Fallot/pulmonary atresia patient with a rare tubular aortopulmonary communication between the arterial trunks, allowing for well-growth of the pulmonary vasculature. The patient underwent successful one-stage unifocalization, right ventricle-pulmonary artery conduit, and ventricular septal defect closure. The tubular communication was considered as an aortopulmonary window as opposed to the major aortopulmonary collateral, based on its exclusively intrapericardial course. We highlighted the importance of cross-section imaging in diagnosis and surgical decision-making in such situations.

Tetralogy of Fallot with pulmonary atresia and aortopulmonary window may mimic common arterial trunk

Tetralogy of Fallot with pulmonary atresia is a group of congenital cardiac malformations, which is defined by the absence of luminal continuity between both ventricles and the pulmonary artery, and an interventricular communication. Pulmonary arterial supply in patients with tetralogy of Fallot with pulmonary atresia can be via the arterial duct or from collateral arteries arising directly or indirectly from the aorta (systemic-to-pulmonary artery collaterals), or rarely both. The rarest sources of pulmonary blood flow are aortopulmonary window and fistulous communication with the coronary artery.Herein, we describe an outflow tract malformation, tetralogy of Fallot with pulmonary atresia and aortopulmonary window, which was misdiagnosed as common arterial trunk. We emphasise the morphological differences.

A Rare Case of Adult Aortopulmonary Window Combined with Anomalous Origin of the Right Pulmonary Artery from the Aorta Leading to Eisenmenger Syndrome

Aortopulmonary window is a rare congenital heart disease that can increase pulmonary vascular resistance, exacerbate left-to-right shunt and lead to heart failure and respiratory tract infections. Most patients die during childhood. We report a 53-year-old male patient with a large aortopulmonary window combined with anomalous origin of the right pulmonary artery from the aorta, with Eisenmenger syndrome and without surgery.

Rerouting anomalous coronary artery origin in aortopulmonary window in newborn

Coronary artery anomalies may accompany the aortopulmonary window and, if not noticed, may cause catastrophic consequences. The repair of the aortopulmonary window is quite straightforward; however, establishing a normal coronary pattern may challenge the repair. When the anomalous origin of the coronary artery is on the defect rim, right at the location where sutures are to be placed, it may interfere with proper suture placement. A technique to overcome such a technical obstacle and reroute the anomalous right coronary in such cases is described.

Topsy-turvy heart: A first recorded case report with intracardiac anomaly

Topsy-turvy heart is a rare congenital anomaly; it has a specific characteristic of cardiac malrotation and superior-inferior arrangement of right/left ventricles. A five-day-old patient was diagnosed antenatally with hypoplastic left heart and right hydronephrosis and had been admitted to the hospital with symptoms of respiratory distress. The postnatal imaging studies revealed an abnormal ventricular arrangement with a large aortopulmonary window, ventricular septal defect (VSD), and the upside-down orientation resulting in the posterior-inferior displacement of the common arterial confluence and, in turn, the left main bronchial stenosis. For the first time, the diagnosis of a topsy-turvy heart with the intracardiac anomaly (VSD) was confirmed.

Prenatal diagnosis of fetal aortopulmonary window by two- and four-dimensional echocardiography with spatiotemporal image correlation

BACKGROUND

Aortopulmonary window (APW) is a rare congenital heart disease which challenges most screening sonographers. The current study aims to summarize the two-dimensional (2D) and four-dimensional (4D) sonographic features in the fetal diagnosis.

METHODS

Ten cases of fetal APW were retrospectively reviewed, including 6 and 4 fetuses with distal and proximal defects, respectively. In addition, 40 normal fetuses with similar gestational age were also enrolled. The angle (α) between the pulmonary artery and aorta, and the length (D) of the ductus/pulmonary artery before its convergence with aorta were measured and compared between the normal and APW fetuses, respectively. Cardiac volumes of APW fetuses were acquired with spatial temporal image correlation (STIC) technique and post-analyzed to obtain 4D rendered images.

RESULTS

The D and the α were smaller and greater in distal APW fetuses than those in the normal fetuses, respectively (both P < .01), while no difference presented between the proximal APW fetuses and the normal fetuses. The ductus was absent for all distal APW fetuses, while it was normal for proximal APW fetuses. In 9 of 10 fetuses (90%), the 4D rendered image could be successfully obtained, which clearly showed the abnormal blood communication between the two great arteries in space.

CONCLUSION

It is essential to scan around the three-vessel view and three-vessel trachea view to identify fetal APW using grayscale and color Doppler echocardiography. Distal APW is always with an increasing angulation between aorta and the pulmonary artery, and without the presence of normal ductus. 4D STIC technique may provide additional spatial relationships of the great arteries and thus help the diagnosis and consultation.

Incidental diagnosis of a large aortopulmonary window with reversible pulmonary arterial hypertension in adult age and its surgical management

Aortopulmonary window (APW) is a rare congenital cardiac condition. A large number of patients with a large APW usually die within 1 year of age. It is extremely rare to find cases of APW surviving till adult age and it is still rare to surgically treat such patients who are incidentally detected in adult age because such subsets of patients invariably have associated pulmonary vascular obstructive disease in advanced stage and thus there is therapeutic dilemma to surgically correct these patients. Although cases of uncorrected AP window presenting in adulthood have been reported but literature on surgically treated AP window in adult populations is limited. We describe case of APW in a 26-year-old male patient who was diagnosed incidentally while suspecting infective endocarditis and was subsequently surgically closed successfully with polytetrafluoroethylene patch after confirming reversibility of pulmonary arterial hypertension which is the key for successful outcome.

Isolated persistence of the fifth aortic arch in an infant presenting with congestive heart failure

The persistence of the fifth aortic arch (PFAA) in postnatal life is an extremely rare and controversial cardiovascular malformation. PFAA is defined as an extra-pericardial vessel arising from the ascending aorta proximal to the origin of the brachiocephalic arteries, terminating either in the dorsal aorta or in the pulmonary arteries through the persistently patent arterial duct. An isolated PFAA with systemic-to-pulmonary connection best fits this definition, while the vast majority of cases reported as PFAA may have alternative embryological explanations. We present a unique case of a 5-week-old patient with an isolated PFAA with systemic-to-pulmonary connection, who presented with congestive heart failure. A first differential diagnosis was made with distal aortopulmonary window and an atypical patent arterial duct. A careful analysis of the case and a systematic review of the literature made us conclude for an isolated PFAA, which is one of the only five cases ever reported.

Prenatal Diagnosis of Aortopulmonary Window by 2-Dimensional Echocardiography: Summary of 8 Cases

Aortopulmonary window (APW) is a rare congenital heart anomaly. A total of 8 cases with APW confirmed by echocardiography and surgery were retrospectively reviewed and the echocardiographic features analyzed. Among the 8 APW cases, 5 were type II and 3 were type III, the latter of which includes 2 cases complicated with Berry syndrome. Prenatal echocardiography can provide accurate information for the diagnosis of fetal APW. The prognosis depends on the timing of surgery and the nature of the associated cardiac anomalies.

Transposition of the great arteries: When echocardiography does not match the clinical picture

Aortopulmonary window (APW) is a rare form of congenital heart disease seen in isolation or with complex cardiac lesions. APW has been associated with other cardiac defects such as interrupted aortic arch and Tetralogy of Fallot, but few cases have been reported of APW associated with transposition of the great arteries (TGA). In a newborn with TGA and intact ventricular septum, diagnosis of APW requires a high index of suspicion. This article reviews the literature on TGA with APW and illustrates the importance of additional evaluation in neonates with TGA when oxygen saturation and PaO2 do not match predicted clinical values.

Anomalous origin of the right coronary artery from the pulmonary artery associated with an aortopulmonary window

Anomalous origin of the right coronary artery (RCA) from the pulmonary artery is a rare entity that causes chronic left-to-right shunting of blood from the RCA, through the coronary collaterals into the pulmonary artery. This results in persistent myocardial ischemia and ventricular dysfunction. Association of this anomaly with an aortopulmonary window worsens the condition further due to an additional shunt. We encountered a combination of these two anomalies along with an ostium secundum atrial septal defect in a 10-month-old baby who presented with excessive crying and failure to thrive. Evaluation by transthoracic echocardiography and cardiac computed tomography scan confirmed the diagnosis. Intrapulmonary baffle was done using a pericardial patch to connect the RCA origin to ascending aorta through the aortopulmonary window, similar to Takeuchi procedure. Concomitantly, ostium secundum atrial septal defect was also closed.

The prenatal diagnosis of aortopulmonary window by fetal echocardiography

OBJECTIVE

The purpose of this study was to analyze the fetal echocardiographic features and the associated anomalies of prenatal aortopulmonary window (APW).

METHODS

We retrospectively reviewed the fetal echocardiographic database (n = 24 000) in our hospital between May 2012 and December 2017. The general clinical information, fetal echocardiographic features, and the associated anomalies in patients with APW were analyzed. Four patients had undergone whole genome sequencing using fetal tissues.

RESULTS

Six cases of APW confirmed by autopsy were identified in our fetal echocardiographic database. On the three-vessel view, a communication between the pulmonary artery trunk and ascending aorta was noted above the two semilunar valves in all cases. The most frequent type of APW among the cases was type II, and all cases were associated with other cardiac anomalies. No pathogenic or suspected pathogenic copy number variation or insertion-deletions were detected in this series.

CONCLUSION

Prenatal diagnosis of APW is feasible, which is helpful during prenatal consultations, so that parents can make better decisions regarding postpartum treatment options and pregnancy outcomes.

Type A interrupted aortic arch and type III aortopulmonary window with anomalous origin of the right pulmonary artery from the aorta

Interruption of the aortic arch, aortopulmonary window, and anomalous origin of the right pulmonary artery from the ascending aorta are very rare congenital anomalies. It is even rarer to have all three anomalies in the same setting. We present a case of a newborn who was diagnosed with these lesions and describe the primary repair of these anomalies.

Prenatal Diagnosis of Aortopulmonary Window: A Case Series and Literature Review

Aortopulmonary window (APW) is a rare congenital heart defect, characterized by a connection between the ascending aorta and the pulmonary trunk before bifurcation. Prenatal diagnosis of APW is essential, as a surgical correction early after birth is required in most cases to prevent congestive heart failure secondary to high pulmonary blood flow. We report a series of three cases of APW that were detected by prenatal echocardiography. The key feature of diagnosis is demonstration of connection between the pulmonary artery and the aorta above the level of the two semilunar valves. Based on our cases and literature review, diagnostic clues for prenatal diagnosis of APW are summarized and proposed.

Percutaneous closure of an aortopulmonary window using Amplatzer Duct Occluder II: Additional Sizes: the first reported case

To date, there are no reported cases of the Amplatzer Duct Occluder II: Additional Sizes' use in percutaneous closure of an aortopulmonary window. We report a case of percutaneous closure of an aortopulmonary window in a 4.5-month-old, 6 kg child. Owing to the patient's low weight, high risk of damage to the pulmonary valve, as well as the possibility of aortic and pulmonary artery obstruction, classic implants were deemed unsuitable and a decision was made to use the Amplatzer Duct Occluder II: Additional Sizes. The implant performed very well - the soft waist filled the aortopulmonary connection and both retention discs were properly shaped and pressed against vessel walls. Echocardiogram performed 12 hours after the procedure confirmed a correct occluder position. Low-profile retention discs had no impact on pulmonary valve function, despite the defect's proximity to the valve. No obstruction of the aortic or pulmonary artery lumen was noted. The Amplatzer Duct Occluder II: Additional Size implant is a safe and useful device for percutaneous closure of an aortopulmonary window in a carefully selected group of patients.

Tricuspid atresia associated with aortopulmonary window: diagnostic and therapeutic dilemmas

The association of tricuspid atresia with aortopulmonary window is exceptionally rare. We report a patient with tricuspid atresia, normally related great arteries, non-restrictive ventricular septal defect, and no pulmonary stenosis (type IC) with an aortopulmonary window who underwent successful initial surgical palliation. The unique anatomical feature of this case, other than the presence of the aortopulmonary window, was the absence of pulmonary stenosis at the level of either the ventricular septal defect or the pulmonary valve. All other reported cases have described some degree of restriction of anterograde pulmonary flow due to pulmonary stenosis or atresia.

Fetal aortopulmonary window: case series and review of the literature

Aortopulmonary window is a rare congenital cardiac anomaly characterized by communication between the aorta and the pulmonary artery above the semilunar valves. Prenatal diagnosis is rare. We report four fetuses with aortopulmonary window and review the relevant literature. Approximately half of the reported cases had additional cardiac defects. None had chromosomal abnormalities. In cases with normal cardiac connections, the diagnosis can be made prenatally on the standard three-vessel view, as seen in two of our cases. In one fetus with complete transposition of the great arteries, the diagnosis was made retrospectively on sagittal views. In the remaining case, the window was seen postnatally but could not be identified retrospectively due to the abnormal superoinferior relationship of the ventricles and vessels. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Current outcomes of one-stage surgical correction for Berry syndrome

OBJECTIVES

Berry syndrome is a combination of distal aortopulmonary window (APW), aortic origin of the right pulmonary artery (RPA), intact ventricular septum, and interrupted aortic arch. We present here our current experience of primary repair of this syndrome with the goal of optimizing treatment for this rare condition.

METHODS

From January 2003 through December 2015, 16 infants with Berry syndrome underwent one-stage repair at Shanghai Children's Medical Center. Three different surgical correction techniques were used to repair the APW and aortic origin of the RPA, including intra-aortic baffle in 5, RPA detachment in 6, and RPA angioplasty with aortic cuff in 5 patients.

RESULTS

The median age at repair was 90.5 days (range, 8-170 days). The interrupted aortic arch morphology was type A in 14 and type B in 2 patients. The APW morphology was type IIa in 4, type IIb in 10, and type III in 2 patients. Hospital death occurred in 2 patients, and death at follow-up occurred in one other patient. Three patients who previously underwent RPA angioplasty with aortic cuff required reoperation for aortic or RPA stenosis. Freedom from reoperation was 84.8%, 75.4%, and 75.4%, respectively at 1, 5, and 10 years after surgery.

CONCLUSIONS

One-stage repair of Berry syndrome has achieved acceptable outcomes. Reoperations mainly are related to aortic or RPA stenosis, and the reoperation rate is higher when RPA arterioplasty is performed with an aortic cuff.

Prenatal Diagnosis of an Aortopulmonary Window With an Interrupted Aortic Arch

A prenatal aortopulmonary window with an interrupted aortic arch was detected in a 22-week-old fetus. The 3-vessel and trachea view showed a communication between the ascending aorta and the pulmonary artery. Early postnatal surgery was successful. A PubMed-based search identified all cases of prenatal aortopulmonary windows between 2002 and 2015. Nine articles were identified. The average gestational age at diagnosis was 28 weeks (range, 22-33 weeks). The most frequent aortopulmonary window was type I (40%). All cases were associated with congenital heart defects, mainly an interrupted aortic arch (50%). No chromosomal or extracardiac abnormalities were seen. Prenatal echocardiography is useful for early diagnosis of an aortopulmonary window. The prognosis depends on the time of surgery and the nature of the associated anomalies.

Closure of aortopulmonary window using Nit-Occlud® PDA-R device in a 3-month-old infant

Aortopulmonary window (APW) is a rare abnormality in which a pulmonary defect exists between the ascending aorta and the main pulmonary artery. Given that it may result in cardiac failure and pulmonary vascular disease in the early period, treatment needs to be performed without delay. In addition to surgical treatment, transcatheter closure may also be performed for selected patients. This study describes the case of an infant diagnosed with APW and who underwent successful transcatheter closure using a Nit-Occlud® PDA-R device.

One-Stage Surgical Repair for Berry Syndrome With Preoperative Diagnosis by 3-Dimensional CT

Berry syndrome is a rare congenital combination of an aortopulmonary window, an aortic origin of the right pulmonary artery, an interrupted aortic arch with a patent ductus arteriosus, and an intact ventricular septum. We report a successful one-stage surgical correction of Berry syndrome. Also, we demonstrate the importance of prompt clinical recognition with echocardiography and 3-dimensional reconstruction of computed tomography (3D-CT) and timely operation for the management of this rare cardiac anomaly.

Normal and abnormal development of the intrapericardial arterial trunks in humans and mice

AIMS

The definitive cardiac outflow channels have three components: the intrapericardial arterial trunks; the arterial roots with valves; and the ventricular outflow tracts (OFTs). We studied the normal and abnormal development of the most distal of these, the arterial trunks, comparing findings in mice and humans.

METHODS AND RESULTS

Using lineage tracing and three-dimensional visualization by episcopic reconstruction and scanning electron microscopy, we studied embryonic day 9.5-12.5 mouse hearts, clarifying the development of the OFTs distal to the primordia of the arterial valves. We characterize a transient aortopulmonary (AP) foramen, located between the leading edge of a protrusion from the dorsal wall of the aortic sac and the distal margins of the two outflow cushions. The foramen is closed by fusion of the protrusion, with its cap of neural crest cells (NCCs), with the NCC-filled cushions; the resulting structure then functioning transiently as an AP septum. Only subsequent to this closure is it possible to recognize, more proximally, the previously described AP septal complex. The adjacent walls of the intrapericardial trunks are derived from the protrusion and distal parts of the outflow cushions, whereas the lateral walls are formed from intrapericardial extensions of the pharyngeal mesenchyme derived from the second heart field.

CONCLUSIONS

We provide, for the first time, objective evidence of the mechanisms of closure of an AP foramen that exists distally between the lumens of the developing intrapericardial arterial trunks. Our findings provide insights into the formation of AP windows and the variants of common arterial trunk.

Diagnosis of the double aortic arch and its differentiation from the conotruncal malformations

PURPOSE

The clinical and radiological characteristics of the double aortic arch (DAA) and its differentiation from conotruncal malformations (CTM) were reported in order to familiarize pediatric practitioners with these congenital heart diseases.

MATERIALS AND METHODS

From July 1994 to December 2006, a total of 6 patients (4 male and 2 female, aged 16 days to 6.5 years) with DAA were enrolled in this retrospective study. The study modalities included chart recordings, plain chest radiographs, barium esophagograms, echocardiograms, cardiac catheterization, cardiac angiograms, surgery, magnetic resonance imaging, and chromosome analysis. Patients with incomplete vascular rings or with right aortic arches and left ligamentum were excluded. In addition, the clinical and radiological profiles of 38 patients with CTM, including dextro-transposition of the great arteries (d-TGA) (n=28), hemitruncus arteriosus (HTA) (n=3), type I truncus arteriosus (TA) (n=4), and the aortopulmonary window (APW) (n=3), were comparatively reviewed.

RESULTS

All 6 patients with DAA presented with postprandial choking and respiratory distress that prompted their initial visit to the hospital. One of the 6 patients presented with congestive heart failure, and none with cyanosis. Esophagograms showed indentations in 5 patients with DAA. All patients with d-TGA presented with cyanosis and heart failure, while patients with HTA, type I TA, and APW manifested overt heart failure. Suprasternal and subcostal approaches of the echocardiography may offer diagnostic windows for DAA. As for CTM, parasternal and subcostal approaches could always determine the causality. Cardiac catheterization with angiography comprehensively delineated the pathology.

CONCLUSION

In case of postprandial choking and respiratory distress in neonates and infants, barium esophagograms can indicate the presence of DAA. Diagnosis of DAA and its differentiation from the CTM can be achieved by echocardiography, angiography, or magnetic resonance imaging.

Aortopulmonary window with anomalous origin of the right coronary artery from the pulmonary trunk

A case of aortopulmonary window associated with an anomalous origin of the right coronary artery from the pulmonary artery in a 3-month-old boy is reported. Angiographic diagnosis could be difficult because of the simultaneous filling of both great arteries that obscure the origin of the anomalous vessel; however, a careful evaluation of the angiogram may contribute to an accurate diagnosis. The surgical correction of this association of defects requires the connection of the aorta with the anomalous coronary ostium. An intrapulmonary tunneling procedure by means of a baffle is described.