Cardiac neural crest ablation results in early endocardial cushion and hemodynamic flow abnormalities

Cardiac neural crest cell (CNCC) ablation creates congenital heart defects (CHDs) that resemble those observed in many syndromes with craniofacial and cardiac consequences. The loss of CNCCs causes a variety of great vessel defects, including persistent truncus arteriosus and double-outlet right ventricle. However, because of the lack of quantitative volumetric measurements, less severe defects, such as great vessel size changes and valve defects, have not been assessed. Also poorly understood is the role of abnormal cardiac function in the progression of CNCC-related CHDs. CNCC ablation was previously reported to cause abnormal cardiac function in early cardiogenesis, before the CNCCs arrive in the outflow region of the heart. However, the affected functional parameters and how they correlate with the structural abnormalities were not fully characterized. In this study, using a CNCC-ablated quail model, we contribute quantitative phenotyping of CNCC ablation-related CHDs and investigate abnormal early cardiac function, which potentially contributes to late-stage CHDs. Optical coherence tomography was used to assay early- and late-stage embryos and hearts. In CNCC-ablated embryos at four-chambered heart stages, great vessel diameter and left atrioventricular valve leaflet volumes are reduced. Earlier, at cardiac looping stages, CNCC-ablated embryos exhibit abnormally twisted bodies, abnormal blood flow waveforms, increased retrograde flow percentage, and abnormal cardiac cushions. The phenotypes observed in this CNCC-ablation model were also strikingly similar to those found in an established avian fetal alcohol syndrome model, supporting the contribution of CNCC dysfunction to the development of alcohol-induced CHDs.

Partial atrioventricular septal defect assessed by real-time three-dimensional echocardiography: a case report

A 48-year-old woman was admitted with a heart murmur and increased difficulty in breathing. Two-dimensional echocardiography revealed a defect in the lower part of the atrial septum [(primum atrial septal defect (ASD)] and a pouch at the interventricular septum. Color Doppler echocardiography detected grade 3/4 mitral regurgitation. Real-time three-dimensional echocardiography (RT-3DE) revealed a cleft in the anterior leaflet of the mitral valve toward the tricuspid valve, and the ASD located near the atrioventricular valves with 14mm in minor axis. Color Doppler three-dimensional echocardiography disclosed left-to-right ASD shunt toward the atrial posterior wall. No shunt through the pouch at the membranous part, left ventricular outflow obstruction, or partial anomalous pulmonary venous connection was observed. RT-3DE is quite useful to describe complicated congenital heart disease.

[Prognosis of atrioventricular canal in euploid foetus without abnormality of atrial situs]

Atrioventricular septal defects are commonly diagnosed during fetal life. Postnatal prognosis of atrioventricular septal defects associated with trisomy 21 and with heterotaxia sequences are relatively well known. However, predicting postnatal outcome in fetus with atrioventricular septal defects and normal chromosome and normal atrial situs remains a challenge. In a series of 141 fetal atrioventricular septal defects, we analyzed 80 fetuses with normal karyotype. Twenty-seven had an abnormal atrial situs. One fetus was lost for follow-up. Finally, 52 fetuses were included in the study. Termination of pregnancy was performed in 18 cases (34%). Six fetuses died in utero (18% of ongoing pregnancies). Twenty eight infants were born alive, 2 of them were lost for follow-up right after birth and 3 live born infants died postanatally (11%). Postoperative mortality was 3/15 (20%). Complete repair was proceed for 13 infants, palliative repair for 2; and 8 infants didn't have surgery at the end of follow-up because of partial or intermediate atrioventricular septal defect. The only factor significantly associated with poor outcome was the small size of the left ventricle. Isolated atrioventricular septal defects are of poor cardiac prognosis particularly when associated with left heart obstructions.

Common atrioventricular canal in a newborn foal--case report and review of the literature

This paper presents the embryological and pathological features as well as the terminology and classification of common atrioventricular canal, a type of endocardial cushion defect. The authors give a complete description of an extremely rare congenital cardiac malformation in an equine neonate. The diagnosis of a complete, balanced common atrioventricular canal of type C in Rastelli's classification scheme was based on two-dimensional, contrast and colour Doppler echocardiography and subsequent postmortem gross pathology. To support our diagnosis and study the pathophysiological effect of the alteration, physical examination, blood gas analysis and other laboratory tests, electrocardiography and thoracic radiography were also performed. Our search of the literature suggests that this type of developmental anomaly might account for a higher percentage of equine congenital cardiac defects than was thought earlier. We suppose that some previously described congenital heart abnormalities were misinterpreted: these anomalies could have actually represented some type of atrioventricular canal defect, resulting from the failure of the endocardial cushions to undergo complete and proper fusion.

Biventricular repair of right-dominant complete atrioventricular canal defect

Complete atrioventricular (AV) canal defects usually have right and left valve components of approximately equal size, although unbalanced forms do occur. Optimal management of unbalanced AV canal defects is controversial, with no proven guidelines for choosing between biventricular repair and univentricular palliation. We describe successful biventricular repair of a right-dominant unbalanced AV canal with severe left AV valve stenosis. This case illustrates that severely unbalanced AV canal defects can be repaired successfully by tailoring the AV valve to distribute it equally between the ventricles, The increase in left ventricular volume after surgery exceeded prediction based on conformational change alone.

Three-dimensional echocardiography improves the understanding of left atrioventricular valve morphology and function in atrioventricular septal defects undergoing patch augmentation

OBJECTIVES

We sought to address the role of 3-dimensional echocardiography in the evaluation of the left atrioventricular valve in children with an atrioventricular septal defect who underwent patch augmentation of their valve for either regurgitation or left ventricular outflow tract obstruction.

METHODS

Five children whose ages ranged between 4.5 and 9.2 years and who underwent patch augmentation of their left atrioventricular valve had a preoperative and postoperative transesophageal echocardiogram with 3-dimensional reconstruction to evaluate the left atrioventricular valve. The indication for operation was left atrioventricular valve regurgitation in 3 patients and left ventricular outflow tract obstruction in 2 patients. Three were rerepairs, and 2 were primary repairs. Both 3-dimensional morphology and color Doppler data were obtained. Two- and 3-dimensional findings were correlated with surgical observations through the use of direct inspection and video images obtained with a head-mounted super-VHS camera.

RESULTS

In each case there was precise correlation between the 3-dimensional and surgical findings as to the cause of leaflet failure in those with regurgitation. The site that would require leaflet augmentation could be determined by means of 3-dimensional echocardiography. Three-dimensional echocardiography provided more specific detail as to the morphology and function of the left atrioventricular valve than did its 2-dimensional counterpart.

CONCLUSIONS

Three-dimensional echocardiography provides detailed information about the status of the left atrioventricular valve in the atrioventricular septal defect and can aid in the planning of either primary or secondary repair.

Use of the mitral valve-tricuspid valve distance as a marker of fetal endocardial cushion defects

OBJECTIVE

The purpose of this study was to compare the mitral valve-tricuspid valve distance in second-trimester fetuses with normal cardiac anatomy versus those fetuses with endocardial cushion defects.

STUDY DESIGN

We identified fetuses between 16 and 24 weeks of gestation. The distance between the insertions of the medial leaflets of the mitral and tricuspid valves were obtained. Linear regression curves were generated.

RESULTS

The mean mitral valve-tricuspid valve distance for 86 fetuses with normal cardiac anatomy was 2.02 mm, compared with 0.37 mm in 13 fetuses with endocardial cushion defects ( P = .0001). Linear regression curve correlating mitral valve-tricuspid valve distance with gestational age showed a gradual slope (R 2 = 0.28; P < .0001). With a mitral valve-tricuspid valve distance < 5th percentile as a marker for the diagnosis of endocardial cushion defect gave a sensitivity of 69.2%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 95.6%, and a false-positive rate of 0% ( P = .0001).

CONCLUSION

The mitral valve-tricuspid valve distance is useful clinically in the detection of endocardial cushion defects in second-trimester fetuses.

Direct closure of the septum primum in atrioventricular canal defects

OBJECTIVE

The objective of this study was to assess the safety of directly closing the septum primum during the correction of atrioventricular canal defects.

METHODS

We performed a retrospective analysis of our experience with direct closure of the septum primum during the repair of atrioventricular canal defect. The series consisted of 28 consecutive patients presenting with a partial (15 patients) and complete (13 patients) atrioventricular canal defect. The cleft in the atrioventricular valve was closed completely in 25 patients and partially in 3 patients (those with a small left lateral leaflet). In complete atrioventricular canal, the ventricular septum defect was closed with a patch of polytetrafluoroethylene (Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) or xenopericardium. Follow-up was complete and ranged from 3 to 21 months (median 11 months).

RESULTS

There were no early or late deaths and no surgical complications. The septum primum defect was closed completely in all patients as assessed by echocardiography. All the patients were in sinus rhythmus, and none had even a temporary complete atrioventricular block. The surgical result and heart rhythm have remained stable over time.

CONCLUSIONS

Direct closure of the septum primum is an easy, quick, and safe procedure during repair of atrioventricular defects.

Direct closure of ostium primum defect in the repair of atrioventricular septal defect

BACKGROUND

Patch closure is generally performed for atrial septation of an atrioventricular septal defect. We recently developed a new surgical technique for repairing atrioventricular septal defects that avoids the use of any patch material for closing the atrial septal defect. We report our experience with this procedure.

METHODS

Seven patients (complete type: 5, partial type: 2) underwent this new operation. The diameters of the atrial septal defects were measured by transesophageal echocardiography. The preoperative electrocardiograms were compared with those taken after the operations.

RESULTS

Diameters of the atrial defects ranged from 3 to 10 mm. Electrocardiograms before and after the operations did not change. No significant atrioventricular valve regurgitation and no residual shunts were detected by postoperative echocardiography.

CONCLUSIONS

This method simplifies the repair of atrioventricular septal defects. In the short-term results, no arrhythmia and no valve regurgitation was seen.

Nonobstructive asymmetrical septal hypertrophy and ostium secundum-type atrial septal defect

We report a 36-year-old woman with hypertrophic cardiomyopathy with asymmetric septal hypertrophy without outflow tract obstruction associated with an ostium secundum-type atrial septal defect with significant hemodynamic repercussion. Diagnosis was established with transesophageal echocardiography. This is the second case of this rare association reported in the literature and the first evaluated by transesophageal echocardiography.

Transesophageal echocardiography (TEE) in congenital heart disease with focus on the adult

Remarkable innovations in medical and surgical approaches over the past several decades now allow for correction of major cardiac defects in children, even in early infancy. These advances have provided for survival of many pediatric patients with congenital heart disease into adulthood. Although transthoracic echocardiography remains the primary imaging technique for the characterization of simple and complex congenital cardiovascular malformations in the pediatric and adult age groups, high-resolution transesophageal imaging has markedly expanded the anatomic and hemodynamic assessment in these patients. The benefits of this imaging approach apply particularly to those with challenging or limited transthoracic examinations or poorly characterized congenital cardiovascular malformations. The utility of TEE in defining the anatomy of the usual spectrum of congenital cardiac malformations is well established. The transesophageal approach has been shown to provide additional diagnostic information over conventional transthoracic imaging for specific structural cardiac anomalies and in the perioperative setting, the opportunity for confirmation of preoperative diagnoses, and modification of the surgical plan if new or different pathology is identified. This imaging modality also may reliably provide for immediate detection of suboptimal surgical repairs and significant postoperative residua, potentially improving the efficacy of the surgical intervention. This accounts for the vital role of this technology in perioperative management and integration into the standard of care in many congenital heart centers. The usefulness of TEE also has been documented during diagnostic and therapeutic cardiac catheterizations of patients with structural cardiac anomalies, allowing for safer and more effective application of these technologies. The experience supports the use of TEE as a useful approach in the surveillance of the adult with operated and unoperated congenital heart disease.

[Adult patients after surgery of ostium primum type of atrial septal defects in childhood: echocardiography study]

The authors examined, using transthoracic and transoesophageal echocardiography, 36 adult patients (15 men) aged 22 +/- 3.1 years (18-29 years) who were operated 12.2 +/- 3.7 years previously on account of a defect of the atrial septum type ostium primum. In these patients no other congenital cardiac defect was present. In addition to closure of the defect in the patients complete suture of the "cleft" of the anterior cusp of the mitral valve was performed, in 7 partial suture of the "cleft" of the anterior cusp of the mitral valve and in 4 commissuroplasty. In one instance later reoperation with replacement of the mitral valve by a mechanical prosthesis was performed. The control group was formed by 16 healthy volunteers (5 men) aged 22.1 +/- 3 years (19-31 years). Patients operated in childhood on account of an atrial defect of the ostium primum type have on echocardiographic examination, as compared with healthy volunteers, larger atria and the left ventricle, a thicker interventricular septum and left ventricular wall and a higher velocity of left ventricular filling during the late diastole. Higher values of parameters of the size and volume of the left ventricle are associated with the presence of mitral regurgitation. More marked changes of systolic or diastolic left ventricular function are not present, there are not even any echocardiographic signs of higher pressure in the atria and pulmonary artery. In none of the patients a residual shunt at the level of the atrial septum is present. Mitral regurgitation is found in two thirds of the patients, only in one case it was however moderately severe (grade 3). From the results it does not ensue which type of surgery of the "cleft" of the mitral valve has the best long-term results. In none of the patients tricuspid regurgitation of a higher grade than grade 1 is present.

Successful total correction of complete atrioventricular canal, total anomalous pulmonary venous drainage and unroofed coronary sinus in an infant

An infant with complete atrioventricular canal, total anomalous pulmonary venous drainage into the left superior vena cava and an unroofed coronary sinus successfully underwent total correction. A homograft vein was used to connect the proximal left superior vena cava to the right atrium and can be recommended when other methods of correction of unroofed coronary sinus cannot be used.

[Ellis-van Creveld syndrome: an easy early diagnosis?]

Ellis-Van Creveld syndrome is a rare chondroectodermal dysplasia. Congenital heart disease is present in more than one-half of cases. The majority are partial atrioventricular septal defects and affect the atrial septum. Although isolated cases of the syndrome are uncommon, an early diagnosis is made in most of the patients because of their cardinal manifestations. The cases of two gypsy brothers with Ellis-Van Creveld syndrome and congenital heart disease (ostium primum atrial septal defect and single atrium), diagnosed during adulthood, are presented.

Intermediate and complete forms of atrioventricular canal

The surgical management of patients with complete atrioventricular canal has evolved over the past 20 years from a staged approach with preliminary pulmonary artery banding and eventual definitive repair, to an era of complete repair in early infancy. Although once considered high risk, the early mortality is now low and is primarily related to pulmonary hypertension secondary to a prolonged delay in diagnosis and referral. While controversy still exists over the techniques of repair, evaluation of outcome of atrioventricular canal should now be focused on the long-term function of the mitral valve, and the overall long-term survival. A detailed description of the single-patch technique and management of the atrioventricular valve, as well as an indepth discussion of outcome is presented.

Unbalanced atrioventricular septal defects

Complete atrial ventricular septal defects (AV canal) generally have right and left valve components equally divided. However, in unbalanced AV canal either right or left ventricle dominance may occur. The spectrum may vary between those readily able to undergo biventricular repair at no increased risk to those requiring a single ventricle approach in cases with severe hypoplasia of the ipsilateral ventricle. The most challenging diagnostic cases fall within the gray area between the two ends of the spectrum, in which one ventricle is not clearly hypoplastic. Diagnostic modalities that are used to evaluate these ventricles include echocardiography and angiographic ventriculography using volume formulae. Magnetic resonance imaging (MRI) has also recently been found to be a useful technique with which further experience is being developed. Once the determination of a single ventricle physiology has been made, early intervention (ie, pulmonary artery banding) to protect both the pulmonary vasculature and the ventricular function is performed. Follow-up with catheterization and bidirectional Glenn should be completed usually by around 4 to 6 months of age. This palliation and subsequent Fontan completion has had good results based largely on two factors: ventricular dominance, left being better than right, and the absence of pulmonary vascular hypertension.

Partial atrioventricular canal with congestive heart failure in the first year of life: surgical options

BACKGROUND

An important subgroup of patients with partial atrioventricular canal require an operation in the first year of life because of refractory congestive heart failure.

METHODS

From June 1982 to April 1995, of 128 patients with partial atrioventricular canal, 35 patients (27%) underwent surgical treatment at less than 1 year of life. Associated cardiac anomalies were present in 22 patients. Only 7 patients (20%) had Down's syndrome. Five patients with left ventricular hypoplasia underwent aortic coarctectomy (3 patients) or Norwood operation (2 patients). The other 30 patients underwent anatomic repair in 24 cases and aortic coarctectomy in 6. The surgical results of patients submitted for anatomic repair were retrospectively correlated with the echocardiographic mitral valve diameter.

RESULTS

There were 7 deaths (29%) after anatomic repair, 2 (22%) after aortic coarctectomy, and 2 (100%) after Norwood operation. Infants with a mitral valve diameter less than 2.5 x 10-2 m/m2 died at repair. In a mean follow-up of 73.5 months there were five secondary mitral valve plasties and three repairs after aortic coarctectomy.

CONCLUSIONS

Among patients with partial atrioventricular canal, there is an important subgroup with clinical signs of heart failure in the first year of life. Left-sided obstructive lesions and complex mitral valve anomalies seem to play a fundamental role in the clinical evolution and prognosis of these patients. The echocardiographic mitral valve diameter may be useful for determining the correct surgical indication.

Surgical management of complete atrioventricular canal associated with tetralogy of Fallot

Between 1984 and 1993, 12 children with an atrioventricular canal and tetralogy of Fallot underwent surgical repair. The mean(s.d.) age at operation was 58(18) months, and the mean(s.d.) body weight 15(4) kg. Nine patients underwent 11 palliative procedures. The ventricular septal defect was closed through a combined (right atrial and right ventricular) approach in nine cases, and through a right atrial approach in three, using a prosthetic patch with a wide anterior extension, secured with a running suture. The 'ostium primum' defect was closed with a separate prosthetic patch in 11 cases (double-patch technique). Right ventricular outflow obstruction was relieved by a composite infundibular patch (seven cases) or a transanular patch (five). There were four hospital deaths (33%). These were caused by low cardiac output in three cases and infection in one (three deaths occurred in patients with a transanular patch). One patient has so far died during follow-up. Assessment at 50(36) months by echo-Doppler showed moderate-to-severe 'mitral' regurgitation in three cases, and moderate 'tricuspid' regurgitation with right ventricular dysfunction in one case. Two patients have required further surgery.

[The use of Doppler echocardiography in the diagnosis of congenital heart disease in the Pediatric Department of CHU-Tokoin, at Lomé (Togo)]

Currently, echography coupled with Doppler is a primary technique in the diagnosis of congenital heart disease. Since September 1993, the pediatric ward of the Tokoin teaching hospital of Lome has been equipped with this technology. During the following 23 months, there were 299 examinations with Doppler-echocardiography among the consultations of 15,082 children. Eighty-two cases of congenital heart defects were detected in 73 children, aged between 3 days and 13 years, of whom 79.4% were between 7 days and 30 months old. In all cases, either pulsed or continuous Doppler-echocardiography was performed at the request of doctors treating symptoms suggestive of cardiac disease, such as heart murmur (67%) and cyanopathy (22%). The noncyanotic cardiopathies found were ventricular septal defects (24%), patent ductus arteriosus (21%), interatrial septal defects (18%) and atrioventricular canal defects (9%). The most frequent cyanotic cardiopathy detected was Fallot's tetralogy (19.5%). Thus, early diagnosis and management of congenital heart disease is facilitated by systematic examination of newborns and sustained collaboration between pediatricians, obstetricians and cardiologists.

Complete atrioventricular septal defect and Ebstein anomaly

The newborn reported here presented with congestive heart failure and cyanosis on the first day of life. Echocardiographic examination revealed complete atrioventricular septal defect and Ebstein anomaly, a rare combination that has not been previously reported in the literature.

Polysplenia syndrome with common atrioventricular canal and persistent truncus arteriosus

A case of an infant with a rare combination of polysplenia syndrome with common atrioventricular canal and persistent truncus arteriosus is presented. In our present case, severe common atrioventricular valve regurgitation was identified, as in previous cases. To our knowledge, echocardiographic and autopsy findings of this association has not been previously reported. The persistent truncus arteriosus is extremely rare in the setting of the polysplenia syndrome, but the present case report demonstrates that these anomalies may, at times, occur.

Repair of complete atrioventricular canal defects: results with the two-patch technique

BACKGROUND

Between 1983 and 1994, 115 infants and children underwent repair of a complete atrioventricular canal defect with the two-patch technique and routine mitral valve "cleft" closure.

METHODS

A retrospective review of these 115 patients was performed. Age at the time of repair ranged from 1 month to 108 months (mean age, 14.2 +/- 16.5 months; median age, 8 months). Preoperative cardiac catheterization in 113 patients revealed a mean pulmonary to systemic flow ratio of 3.37 +/- 1.8, a mean pulmonary artery systolic pressure of 71.1 +/- 15.7 mm Hg, and a mean pulmonary vascular resistance of 4.9 +/- 3.3 units. Associated anomalies included Down's syndrome (99 patients), patent ductus arteriosus (47), and coarctation of the aorta (4). Rastelli classification was A (76 patients), B (10), C (24), and unknown (5). Twenty-four patients had intraoperative epicardial or transesophageal echocardiography.

RESULTS

Although there was a trend toward increasing mean preoperative pulmonary vascular resistance with age from 2.1 +/- 0.9 units (0 to 3 months) to 4.0 +/- 2.6 units (4 to 6 months) to 5.7 +/- 3.0 units (7 to 12 months), the mean pulmonary vascular resistance of each age group was not significantly different from that of the main group. The operative survival rate was 94% (seven early deaths) and the overall survival rate, 91% (three late deaths). Intraoperative echocardiography altered the surgical therapy for 1 patient. No patient has required reoperation for a residual ventricular septal defect. Four patients (3.5%) had heart block requiring permanent pacemakers. Eight patients (7%) required reoperation for mitral insufficiency; 6 of whom had successful repair of a residual cleft.

CONCLUSIONS

For infants with complete atrioventricular canal defect, repair using the two-patch technique with routine mitral valve cleft closure at 4 to 6 months of age results in a low operative mortality, a low incidence of permanent heart block, and a low reoperation rate for mitral insufficiency.

[Hypertrophic myocardiopathy and ostium primum]

A 45-year-old male with palpitations and a heart murmur was investigated. Echocardiography and haemodynamic study revealed the presence of a ostium primum type interatrial communication with left-right shunting and asymmetric hypertrophic heart disease. There was no subaortic obstruction, but anterior systolic movement of the mitral valve was detected that did not contact with the interventricular septum--in part due to the paradoxical motion of the latter. The possible benefit of surgery in this infrequent association is discussed, and a review is made of the literature.

[A successful surgical correction of the intermediate type of common atrioventricular orifice--report of an adult case]

A 42-year-old female was admitted to our hospital because of exertional dyspnea. Preoperative color Doppler echocardiogram revealed massive left to right shunt through the ostium primum defect, moderate mitral and tricuspid regurgitation, and trivial shunt via the small ventricular septal defect. Preoperative cardioangiogram also demonstrated goose neck deformity of the left ventricle. At the operation, the piece of atrioventricular valve fused on the summit of the small scooped ventricular defect was detected, and the total correction consisted of patch closure of the ostium primum defect and mitral and tricuspid valvuloplasty was performed. Postoperative course was uneventful. This is the first adult case reported in Japan who was operated on for the intermediate type of common atrioventricular orifice.

Surgical repair of aorto-right ventricular tunnel in an infant

A rare case of aorta to right ventricle tunnel with associated pulmonary stenosis was corrected on cardiopulmonary bypass in a 3-month-old infant. Both the aortic and ventricular openings were closed with a patch. Although the repair was successful and the child was discharged from the hospital, septicemia developed and she died later. Early repair of this defect is recommended.

[Late surgical results of operation in partial atrioventricular canal defect]

Twenty-three patients underwent repair of a partial atrioventricular canal defect and have been followed for a mean of 9.4 years. The patients were divided into two groups according to the management of mitral cleft. Mitral cleft was not repaired in seven patients and directly sutured or repaired by valvuloplasty using pericardium in sixteen patients. In seven patients untreated mitral cleft left, two patients have required mitral valve replacement because of progressive severe mitral regurgitation. In sixteen patients mitral cleft repaired, no patients have required re-operation. However, one patient using pericardium in valvuloplasty, mitral regurgitation was in progress recently due to calcification and degeneration of the pericardium. The peak flow velocity, pressure gradient, pressure half time, and valve area in the mitral valve were measured by echo-doppler study. We recognized no statistical difference among two groups about hemodynamic performance in the mitral valve.

IN CONCLUSION

1) As concerns post-operative mitral regurgitation, the mitral cleft should be repaired. 2) After mitral cleft closure, the mitral flow pattern was not disturbed. 3) Autologous pericardium should not be adapted for valvuloplasty, because calcification and degeneration of the pericardium may cause progressive incompetency of the mitral valve.

Fixed subaortic stenosis in atrioventricular canal defect: a Doppler echocardiographic study

OBJECTIVES

The objectives of this retrospective study were to describe the Doppler and echocardiographic features of fixed subaortic stenosis in the setting of atrioventricular (AV) canal defect and to document the de novo occurrence of subaortic stenosis and progression of this lesion over time on the basis of sequential echocardiographic studies.

BACKGROUND

The coexistence of fixed subaortic and AV canal defect has been sporadically noted, but no single or multicenter experience with this constellation of abnormalities has been previously described.

METHODS

All patients with a diagnosis of subaortic stenosis and complete or partial AV canal defect who had one or more Doppler echocardiographic examinations were identified from a computer data bank. Retrospective analysis was performed, including review of patients' charts, operative notes, recorded videotapes and hard copy recordings when available.

RESULTS

Twenty-one patients with both subaortic stenosis and AV canal defect were identified over a 13-year period. Fifteen were female and the mean age at diagnosis of subaortic stenosis was 16 years. Fifteen patients had partial AV canal defect with prior repair in 10; 6 patients had complete AV canal defect with prior repair in 4. The mean interval from prior repair to recognition of subaortic stenosis was 6.8 years. In six patients, serial examinations demonstrated the de novo occurrence of subaortic obstruction over a period of 10 to 87 months. In five patients, progression of known subaortic stenosis was documented over a 10- to 59-month period. Surgical resection of subaortic stenosis was performed in 16 patients; the echocardiographic diagnosis was confirmed in 15 of the 16.

CONCLUSIONS

In the largest reported echocardiographic series of this lesion complex, it is concluded that subaortic stenosis can occur de novo, is often recognized only after repair of the canal defect and is progressive. Doppler echocardiography is the method of choice for diagnosis and serial follow-up of these patients.

[Successful intrauterine digoxin therapy for fetal complete atrioventricular block with endocardial cushion defect: a case report]

We report herein a case of fetal complete atrioventricular block accompanied with endocardial cushion defect, successfully diagnosed and treated, in utero, with transplacental digitalization. A 23-year-old Japanese woman, at 20 weeks of gestation, was referred to the Maternity and Perinatal Care Unit of Kyushu University Hospital because of fetal continuous bradycardia. B-mode scanning and dual M-mode echocardiography revealed that the fetus had complete atrioventricular block with endocardial cushion defect with a ventricular rate of 60 beats per minute. At 23 weeks of gestation, it was found that the fractional shortenings (FSs) in both ventricles and the ventricular rate had decreased, with an increase in pericardial effusion. Thus, we diagnosed the fetus as having cardiac failure. Transplacental digoxin treatment was started and continued for 10 weeks, after which fetal pericardial effusion, as well as FSs ameliorated. The pregnancy was interrupted by cesarean section at 33 weeks of gestation due to a decrease in FSs with an accumulation of fetal ascites. A 1780g female infant was delivered and a pacemaker was implanted surgically, immediately after birth. She is alive and well at the time of writing.

[An autopsy case of endocardial cushion defect (ECD) in an 82-year-old female]

In an 82-year-old female case of endocardial cushion defect (ECD), a systolic regurgitant murmur was heard at the apex, and her ECG showed atrial fibrillation without right bundle branch block or left axis deviation. An echocardiogram demonstrated atrial septal defect (ASD) and a cleft of the anterior mitral leaflet with calcification. She died of refractory congestive heart failure. Autopsy revealed ECD (intermediate type) with mitral and tricuspid cleft, and ASD (ostium primum type, 2.0 x 1.0 cm in diameter). In addition, mitral ring calcification and calcification of the cleft mitral valve was disclosed, causing mitral stenosis in addition to mitral regurgitation due to the cleft mitral valve. This was the second oldest Japanese autopsy case of ECD. We concluded that echocardiographic examinations, including color flow imaging, in aged patients with heart murmur are necessary to confirm the diagnosis of congenital heart disease in the aged.

[Combined heart defects: tetralogy of Fallot, common atrium and a single atrioventricular valve diagnosed by echocardiography]

We present a case of the rare coincidence of three mechanisms leading to development of congenital heart disease in intrauterine life: intrinsic defect of the development of the cardiac loop (dextrocardia), failure of normal expansion of the subpulmonary infundibulum (Fallot syndrome) and endocardial cushion defect (common atrium and common atrioventricular valve ). It was associated with partial viscera inversion. A 31-year old man with congenital cyanotic heart disease, and Blalock-Taussig anastomosis was admitted to the hospital due to symptoms of severe cardiac failure. On physical examination: systolic murmur, hepatomegaly, ascites, leg's edema and cyanosis were found. In ECG--atrial fibrillation with 3-d degree a-v block. Standard echocardiography revealed: dextrocardia, a large single atrium with ostia of pulmonary and systemic veins, single atrio-ventricular valve , large ventricular, Fallot-like septal defect. The papillary muscles were not visible in the left ventricle. Aorta and pulmonary trunk arose from morphological right ventricle. The patient died on the 3-rd day of hospitalization in the course of cardiac and respiratory insufficiency. Postmorten examination confirmed the diagnosis.

Transesophageal echocardiography and the intraoperative management of pediatric congenital heart disease: initial experience with a pediatric esophageal 2D color flow echocardiographic probe

Intraoperative color Doppler transesophageal echocardiography (TEE) was performed in 26 patients undergoing corrective or palliative surgery for congenital heart disease. Age ranged from 1 day to 15 years, and body weight ranged from 2.9 to 42 kg. Objectives of the study were to determine the smallest infant in whom the pediatric probe could be used safely, additional diagnostic value, and it role in the intraoperative assessment of the surgical repair. The insertion of the pediatric probe was possible in all 26 patients. The smallest infant in this series was a newborn weighing 2.9 kg. Excellent correlation was obtained with preoperative transthoracic echocardiographic findings and operative findings. Assessment of the surgical repair was obtained in the immediate postcardiopulmonary bypass period. No short-term complications occurred in this series. Intraoperative color Doppler TEE provided a detailed and accurate assessment of the morphology, the function of the heart, and altered the management of at least two patients.

Congenital heart disease

The clinical usefulness of M-mode and two-dimensional echocardiography has been proven over the years. M-mode echocardiography allows an 'ice-pick' sampling of the heart, but in conjunction with two-dimensional echocardiography, assessments of cardiac structure and, to some extent, myocardial function can be appreciated. The limitations of these techniques include difficulty in 1) diagnosing subtle congenital heart disease and 2) estimating the severity of valvular lesions (stenosis and regurgitation). Doppler echocardiography overcomes these limitations by detecting abnormal direction, velocity, and turbulence of the blood flow (Chapter 2). This chapter will focus mainly on the two-dimensional and M-mode echocardiographic features of common congenital heart disease.

Prenatal diagnosis of atrioventricular canal malformations with up-to-date echocardiographic technology: report of 14 cases

Fourteen fetuses with atrioventricular canal malformations were examined by two-dimensional echocardiography, pulsed-wave Doppler echocardiography, and color Doppler flow mapping. Eleven fetuses had complete and three fetuses had partial atrioventricular canal malformations. Nonimmune hydrops fetalis was associated with six cases, and fetal arrhythmia was seen in three cases. With two-dimensional echocardiography, the atrioventricular canal malformations could be diagnosed accurately. The inclusion of color Doppler flow mapping, however, provided additional hemodynamic information that was important from the prognostic point of view. Incompetence of atrioventricular valves could be demonstrated in 10 of 14 cases by Doppler echocardiography. In nine cases, detailed Doppler echocardiographic evaluation of the regurgitation jet was possible. The proportion of systolic time during which atrioventricular valve insufficiency was demonstrated was related to the occurrence of nonimmune hydrops fetalis. When insufficiency of atrioventricular valves was associated with hydrops (four cases), a pansystolic insufficiency was always present. In cases without hydrops (five), regurgitation was confined to early systole. Thus a reliable method for semiquantitative evaluation of the degree of insufficiency seems to have been found. Moreover, an association appeared to exist between the occurrence of hydrops fetalis and the proportion of atrial area that was taken up by regurgitant jet area, as determined by planimetry in the four-chamber view. Prenatal diagnosis was confirmed by autopsy or neonatal cardiac evaluation. Only one neonate survived in our series. Two were stillborn, four died during the neonatal period, two died during infancy, and pregnancy was electively terminated prematurely in five cases. Eight fetuses were found to have a karyotypic abnormality.

[Results of surgical treatment of incomplete forms of atrioventricular septal defects in adults]

At a cardiosurgical department in Brno in 1978-1987 244 patients above 15 years of age were operated for the first ++time on account of inborn heart disease. This number comprised 21 patients (8.6%) with incomplete defects of the atrioventricular septum. Two patients died in the early postoperative period, two patients were lost from the records and 17 patients were subjected to clinical and echocardiographic examination two to 11 years after operation. All patients were in the 1st or 2nd functional class of the NYHA classification, signs of recanalization were found in one patient and progressing mitral regurgitation in two patients. Consistent with data in the literature, the authors consider it important, to check the patients regularly, incl. clinical and echocardiographic examination, after operations of incomplete defects of the atrioventricular septum and to focus special attention of progressing mitral regurgitation.

[Hydrops and common atrioventricular canal in a fetus of karyotype 47(XY)+21. Ultrasonic diagnosis at twenty weeks]

The Authors report a case of fetal ascites and hydrothorax with common atrioventricular canal diagnosed by ultrasound. They suspect a Down's syndrome confirmed by amniocentesis for fetal caryotype. They attach importance to the early diagnosis and to the cytogenetic research for therapeutic trend.

[Morphological and angiocardiographic study of atrioventricular septal defects]

A group of post-mortem specimens of 82 hearts with a defect of the atrioventricular septum (atrioventricular canal) was retrospectively examined with special attention to the morphology of the defect in relation to the left atrioventricular anastomosis. In 42 preparations the finding was compared with previous angiocardiography and post-mortally with X-ray pictures of the specimens. Correlation of the findings revealed malformation of the left atrioventricular orifice as part of a complex malformation affecting the valvular apparatus in conjunction with the atrioventricular septal defect. In the very variable anatomical morphology a major part is played by the superior cusp of the left atrioventricular anastomosis. The relationship of the superior cusp to the outflow tract of the left ventricle and to the atrioventricular septal defect has an impact on the variability of the angiocardiographic picture, and last but not least, also on the results of surgical treatment. The anteroposterior, left oblique and hepatoclavicular projections are optimal for visualization of the anomaly.

[Complete atrioventricular canal and tetralogy of Fallot: surgical considerations]

Nine patients with complete atrioventricular canal and tetralogy of Fallot underwent intracardiac repair of both anomalies between 1982 and 1989. The ages of the patients ranged from 6 months to 7 years. Six of the 9 had one or more previous systemic-pulmonary artery shunts. Two-dimensional echocardiography showed diagnostic characteristics of both malformations in all patients. The diagnosis was confirmed by cardiac catheterization and cineangiography. The ventricular septal defect was repaired by a combined right atrial and ventricular approach in every patient. Outflow tract reconstruction was performed with the use of a transannular patch (4), infundibular patch (4), and a valved conduit (1). There were no hospital deaths. Meningitis was responsible for the death of a patient 2 years after repair. We recommend early palliation, complete repair in those older than 4 or 5 years, surgical technique depending on the anatomical findings, combined atrial and ventricular approach, 2 separate patches to close the ventricular septal defect in required cases, adjusted correction of the right ventricular outflow tract, and careful postoperative care.

Skull erosion and bony changes in a child with endocardial cushion defect

A 9-year-old boy with an endocardial cushion defect who had skull erosion as well as widening of the diploe is described. This was accompanied by thickening of the tables, "hair-on-end" striations in the skull, and cortical thinning and medullary cavity expansion in the femora. The skull erosion is attributed to venous distension and increased blood volume. The finding of skull erosion in cyanotic congenital heart disease has not been reported before.

Double orifice mitral valve associated with endocardial cushion defect

Duplication of the mitral valve is a rare congenital cardiac anomaly. We encountered a case of duplication of the mitral valve associated with a partial form of endocardial cushion defect in a 6-year-old girl. The mitral orifice was separated by a fibrous tissue and each orifice provided papillary muscle and complete subvalvular mechanisms except for the cleft region. The fibrous tissue also provided a subvalvular apparatus. The cleft was repaired without complication. The short axis view of the two-dimensional echocardiogram demonstrated two separate holes in the mitral valve, which constituted the most obvious diagnostic sign prior to surgery.

Secondary left atrioventricular valve replacement in atrioventricular septal (AV canal) defect: a method to avoid left ventricular outflow tract obstruction

Patients with atrioventricular septal defects are morphologically predisposed to subaortic obstruction. Some individuals require secondary left atrioventricular valve replacement for severe incompetence persisting after repair, and they are especially susceptible to left ventricular outflow tract obstruction. A surgical technique is described for replacement of the atrioventricular valve which seems to avoid the complication of left ventricular outflow tract obstruction by the prosthesis.