A case of COVID-19 in a patient with a univentricular heart post total cavopulmonary connection (Fontan) surgery

Coronavirus disease 2019 (COVID-19) has caused a global pandemic which has affected patients and healthcare systems around the world. Patients with underlying health conditions seem to be more severely affected. There are limited reports of patients with univentricular circulations and COVID 19; thus, we report a case of COVID-19 in a patient with a univentricular circulation.

Percutaneous Closure of a "Doughnut Leak" Around an Atrial Septal Occluder Device in a Patient With Recurrent Migraines

A 10-year-old girl with pulmonary atresia status post transannular patch repair and secundum atrial septal defect (ASD) underwent percutaneous ASD closure 5 years earlier. There was improvement in arterial saturation from 86% to 98% with minimal residual right-to-left shunt. Despite subsequent medical therapy, she developed recurrent migraines, which led us to pursue percutaneous closure of the shunt.

Unusual Case of Common Arterial Trunk With Atresia of the Right Pulmonary Artery and Aortopulmonary Collaterals

We describe a two-year-old African girl with late diagnosis of unusual case of common arterial trunk with two separate pulmonary artery branch origins from the ascending aorta, hypoplastic right pulmonary artery that becomes atretic and reconstitutes at hilum, and three aortopulmonary collaterals providing right lung blood supply. She underwent single-stage intracardiac repair and unifocalization of collaterals.

Fetal pulmonary atresia with ventricular septal defect: Features, associations, and outcome in fetuses with different pulmonary circulation supply types

OBJECTIVES

To assess features and outcome in fetuses with pulmonary atresia with ventricular septal defect (PA-VSD).

METHODS

Fetuses with PA-VSD were prospectively enrolled and grouped on the basis of the pulmonary blood supply, including type A (only arterial duct [DA]), type B (both DA and major aortopulmonary collateral arteries [MAPCAs] present), and type C (MAPCAs only). The echocardiography features, associated chromosomal/genetic malformations, and postnatal outcome were compared among the three groups.

RESULTS

Fifty-five fetuses with PA-VSD were enrolled. The presence of confluent PAs varied, with the highest displaying rate in type A and lowest rate in type C (100% vs 41.1%). The intrapericardial pulmonary arteries in all groups were hypoplastic but smaller in types B and C than in type A (P < .05). Deletion of 22q11.2 and right aortic arch were more frequently observed in types B and C than in type A. At the end of the study, overall survival rates in type C were lower than those in type A (22.1% vs 77.3%).

CONCLUSION

There are great differences in the size of pulmonary arteries, associated genetic malformations, and perinatal outcomes among fetuses with PA-VSD. These results could be used for family counseling and surgical planning.

MR imaging of subaortic and retroesophageal anomalous courses of the left brachiocephalic vein in the fetus

The purpose of this study was to report fetal cases of subaortic and retroesophageal anomalous courses of the left brachiocephalic vein (LBCV) evaluated by fetal cardiac magnetic resonance imaging (MRI). A retrospective review of 7282 fetal cardiac MRI from June 2006 to March 2017, nine cases of anomalous courses of the LBCV were correctly diagnosed by fetal cardiac MRI, one case of abnormal subaortic left brachiocephalic vein (ASLBV) missed by fetal MRI was identified postnatally during further imaging of the TOF. The diagnosis was confirmed postnatally by cardiac CT/MRI. An ASLBV was found in 8 cases, a retroesophageal LBCV was found in 2 additional cases with right aortic arch and aberrant left subclavian artery. 3 of 8 ASLBV cases were with a right aortic arch, 4 ASLBV cases had additional cardiovascular anomalies with one case isolated. 7 of 8 ASLBV and 2 retroesophageal LBCV were correctly diagnosed by fetal cardiac MRI; however fetal cardiac MRI missed 2 cases of associated pulmonary atresia (PA). Prenatal echocardiography (echo) correctly diagnosed five ASLBV and one retroesophageal LBCV as well as associated intracardiac anomalies. Fetal cardiac MRI can be a useful adjunct in the identification of subaortic and retroesophageal anomalous courses of the LBCV prenatally.

Prenatal diagnosis of absent pulmonary valve syndrome from first trimester onwards: novel insights into pathophysiology, associated conditions and outcome

OBJECTIVE

To assess the spectrum of associated anomalies, intrauterine course and outcome in fetuses with absent pulmonary valve syndrome (APVS).

METHODS

All cases with a prenatal diagnosis of APVS at two centers over a period of 13 years were analyzed retrospectively. APVS was diagnosed in the presence of rudimentary or dysplastic pulmonary valve leaflets with to-and-fro blood flow in the pulmonary trunk on color and pulsed-wave Doppler ultrasound. Data on demographic characteristics, presence of associated conditions, Doppler studies and pregnancy outcome were reviewed.

RESULTS

During the study period, 40 cases of APVS were diagnosed prenatally. Thirty-seven (92.5%) cases were associated with tetralogy of Fallot (TOF) and three (7.5%) had an intact ventricular septum. Patency of the ductus arteriosus (DA) was found in 17/37 (45.9%) TOF cases and in all three cases with an intact ventricular septum. Mean gestational age at diagnosis was 19.7 (range, 12-34) weeks with 10 (25.0%) cases (all with TOF) diagnosed in the first trimester. TOF was an isolated finding in 15 (37.5%) cases. Chromosomal anomalies, cardiac defects and extracardiac anomalies were present in 18 (45.0%), four (10.0%) and three (7.5%) cases, respectively. Among the 40 cases, there were 19 (47.5%) terminations of pregnancy, six (15.0%) intrauterine deaths, four (10.0%) neonatal deaths and 11 (27.5%) survivors. Patency of the DA, reversed flow during atrial contraction in the ductus venosus, umbilical artery or fetal middle cerebral artery, and hydrops/increased nuchal translucency thickness were significantly associated with non-survival. All 10 cases diagnosed in the first trimester had a patent DA and abnormal Doppler parameters, eight had hydrops and/or increased nuchal translucency, six were associated with trisomy 13 or 18 and none survived.

CONCLUSION

APVS diagnosed in the first trimester is significantly associated with TOF, patency of the DA, abnormal Doppler parameters, lethal trisomies and intrauterine mortality. Cases of APVS with isolated TOF and agenesis of the DA have a better outcome than those with additional anomalies, with > 80% survival. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Congenital pulmonary lymphangiectasia in patient with pulmonary vein stenosis/atresia

No abstract Keywords.

Pulmonary Valve Replacement With Balloon-Expandable Prosthesis Under Direct Vision: A Novel Therapeutic Approach

A 57-year-old woman with a history of pulmonary atresia with ventricular septal defect and hypoplastic pulmonary arteries was referred for a fifth redo sternotomy for right ventricular outflow conduit replacement. Traditional pulmonary valve replacement was aborted during the procedure because of heavy calcification, and the pulmonary valve was replaced with a SAPIEN XT stent valve under direct vision. We believe this is the first application of a balloon-expandable stent valve in the pulmonary valve position under direct vision. It provides a novel therapeutic approach to recurrent pulmonary valve dysfunction in adult congenital heart diseases.

Stenting of stenotic aortopulmonary collaterals in non-surgically treated adolescent or adult patients with pulmonary atresia, ventricular septal defect and multiple aortopulmonary collaterals

OBJECTIVES

To present our experience with stent implantations in non-surgically treated patients with pulmonary atresia, ventricular septal defect and stenotic aortopulmonary collaterals.

METHODS

Between April 2007 and June 2009, 6 stents in 4 patients were implanted into stenosed segments of MAPCAs. The median age and weight of patients at stent implantation were 24 years (range 13-34 years) and 58.5 kg (range 56-70 kg), respectively.

RESULTS

All implantations were successfully performed; there were no procedure associated complications. The median diameter increase of stenosed MAPCAs was 107%. The mean arterial blood saturation increased from mean 78% to 84%. An early increase in the median exercise duration measured by 6MWT was 36%. Neointimal in-stent fibroproliferation in 4/6 stents and stent fracture in 1/6 patients occured in mid-term follow-up.

CONCLUSION

Percutaneous catheterizational stent implantation into stenosed segments of MAPCAs is a palliative procedure, that might improve quality of life of non-surgically treated patients with PA, VSD, MAPCAs. Neointimal in-stent fibroproliferation and stent fracture can be expected as complications in mid-term follow-up. CT-angiography is recommended to confirm these complications in progressive satO2 decrease (Fig. 3, Ref. 12).

Complete Preoperative Evaluation of Pulmonary Atresia with Ventricular Septal Defect with Multi-Detector Computed Tomography

Objective

To compare multi-detector computed tomography (MDCT) with cardiac catheterization and transthoracic echocardiography (TTE) in comprehensive evaluation of the global cardiovascular anatomy in patients with pulmonary atresia with ventricular septal defect (PA-VSD).

Methods

The clinical and imaging data of 116 patients with PA-VSD confirmed by surgery were reviewed. Using findings at surgery as the reference standard, data from MDCT, TTE and catheterization were reviewed for assessment of native pulmonary vasculature and intracardiac defects.

Results

MDCT was more accurate than catheterization and TTE in identification of native pulmonary arteries. MDCT is also the most accurate test for delineation of the major aortopulmonary collateral arteries. The inter-modality agreement for evaluation of overriding aorta and VSD were both excellent. In the subgroup with surgical correlation, excellent agreement was found between TTE and surgery, and substantial agreement was also found at MDCT.

Conclusion

MDCT can correctly delineate the native pulmonary vasculatures and intracardiac defects and may be a reliable method for noninvasive assessment of global cardiovascular abnormalities in patients with PA-VSD.

Prenatal differentiation between truncus arteriosus (Types II and III) and pulmonary atresia with ventricular septal defect

OBJECTIVE

To describe antenatal sonographic signs that help in the differentiation of truncus arteriosus Types II and III (TA-II/III) from pulmonary atresia with ventricular septal defect (PA-VSD).

METHODS

From a database of fetal echocardiographic examinations, we identified fetuses with sonographic features of a single great artery with VSD and relatively normal four-chamber view. Records were reviewed, comparing fetuses with TA-II/III and those with PA-VSD, with particular focus on: 1) characteristics of the overriding vessel, 2) appearance of the semilunar valves, 3) competence of the semilunar valves, 4) presence of major aortopulmonary collateral arteries (MAPCA), 5) main pulmonary artery being without antegrade flow, 6) site of arterial branching from the great artery and 7) other minor features, such as cardiac axis or associated anomalies.

RESULTS

Seventeen fetuses were identified, eight with TA-II/III and nine with PA-VSD. Among the eight fetuses with TA-II/III, seven had abnormal valves and six had valve regurgitation, compared with none of the nine PA-VSD fetuses. Five TA-II/III fetuses had early branching to supply the lungs, whereas most fetuses with PA-VSD had more distal branching. Notably, in six of the TA-II/III fetuses, the root of the single great artery originated predominantly from the right ventricle, while all but one of the PA-VSD fetuses had typical equal overriding of the VSD. The main pulmonary artery was without antegrade flow in two cases with PA-VSD. Finally, four cases with PA-VSD had MAPCA, in two of which this was identified prenatally.

CONCLUSION

Identification of abnormal arterial valves or valve regurgitation, site of origin of branching, presence of overriding of the great artery, a main pulmonary artery without antegrade flow and MAPCA are helpful in differentiating between TA-II/III and PA-VSD.

[Pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries: diagnosis and treatment]

The basic principles of diagnosis and management of pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries are systematizes in this paper. The personal experience of surgical treatment of consecutive 66 patients with this disease is analyzed, including one-stage and multistage approaches.

[Results of surgical treatment of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries]

This article presents the 14-year experience of surgical treatment of pulmonary atresia with ventricular septal defect and pulmonary collateral blood bed. The surgery of defect was performed on 32 patients and they were followed up. The individual and differential approaches should be used in the choice of surgical strategy. This approach is based on the state of pulmonary arterial and collateral beds. An integral criterion of assessment was the common neo-pulmonary arterial index with boundary measure equal 150 mm2/m2. An application of given method allowed the performance of successful radical repair of defect in 15 patients, 4 patients having been operated in one stage. The rest of the patients had the appropriate staged interventions. The lethality consisted of 9.4%.

Tetralogy of Fallot variant with pulmonary atresia (pseudotruncus arteriosus) in a case of maternal PKU syndrome

The authors report on a child with a rare variant of the Tetralogy of Fallot with pulmonary atresia also known as Pseudotruncus arteriosus, who was born by a mother affected by classic phenylketonuria (PKU), diet free of phenylalanine until the age of seven years. According to the authors, this is the first example of such rare variant in an offspring of maternal PKU syndrome.

Prenatally diagnosed case of 22q11.2 deletion syndrome associated with pulmonary artery aneurysm

Here, we report a new case with chromosome 22q11 deletion and cardiac anomaly diagnosed prenatally by echocardiography. Fluorescence in situ hybridization (FISH) analysis demonstrated a heterozygous deletion at 22q11.2. Echocardiography revealed ventricular septal defect, pulmonary atresia, and aneurysm of the main pulmonary artery and its branches. Pulmonary artery aneurysm (PAA) is rarely seen in patients with 22q11.2 deletion syndrome (22qDS). In this case, PAA was found by prenatal echocardiographic examination at the 25th week of gestation. To date, no prenatally diagnosed case of 22qDS with PAA has been reported. This is the first 22qDS case with PAA that was detected prenatally by FISH analysis.

Late pulmonary valve replacement in patients with pulmonary atresia and intact ventricular septum: a case-matched study

BACKGROUND

Pulmonary valve replacement (PVR) is a common therapy for chronic pulmonary regurgitation. However, the use of this strategy is mostly based on the studies performed on patients with tetralogy of Fallot (TOF) and not in patients with pulmonary atresia/intact ventricular septum (PA/IVS). The aim of this study is to evaluate our experience with PVR in patients with PA/IVS and compare them with a matched cohort of TOF patients.

METHODS

Between 1995 and 2009, 13 patients with PA/IVS underwent a late PVR. Matched TOF control subjects were identified for 12 of these patients. Before and after PVR echocardiographic, magnetic resonance imaging, exercise test, Holter, and electrocardiographic data were compared between groups.

RESULTS

There was no mortality in either group. The PVR improved pulmonary regurgitant fraction and right ventricular volumes in all patients. Patients with PA/IVS had more significant tricuspid regurgitation (TR [at least moderate]) by echocardiography and magnetic resonance imaging before PVR (n = 11 [85%] versus n = 1 [8%]; p = 0.003) and had more tricuspid valve repairs than TOF patients (n = 9 [69%] versus n = 1 [8%]; p = 0.004). Repair was undertaken by a combination of techniques. Although TR was improved early postoperatively, only 2 of 9 patients (22%) were free from significant TR at most recent follow-up (median 2.5 years; range, 0.1 to 10.9). No patient underwent reoperation at latest follow-up.

CONCLUSIONS

Patients with PA/IVS can undergo a late PVR with excellent results. Significant TR and repair are more commonly observed among patients with PA/IVS compared with TOF patients. Although tricuspid valve repair improves regurgitation early, TR tends to recur, suggesting the need for further refinement of current surgical techniques.

[Pulmonary stenosis and atresia with intact ventricular septum]

Pulmonary atresia and critical pulmonary stenosis with intact ventricular septum includes a wide spectrum of cardiopathies with great morphological heterogeneity. The pulmonary valve may be completely atretic or may contain a puncture hole if stenosis is present. The obstruction may be membranous and/or muscular. All components of the right ventricle can be affected, even the coronary circulation with ventriculocoronary connections and stenosis or atresia of the pulmonary arteries. Prenatal diagnosis is made when the right ventricle is hypoplastic and hypertrophic. The pulmonary valve is thickened and the pulmonary artery is perfused retrogradely through the ductus arteriosus. Right ventriculocoronary connections may sometimes be seen with fetal echocardiography. Postnatal survival depends on the patency of the ductus arteriosus, requiring prostaglandin E1 infusion. When hypoplastic right ventricle and/or ventricle-dependent coronary circulation exists, biventricular circulation is not possible. In these cases, surgical treatment is palliative. In cases with well-developed right ventricle, transcatheter therapy is usually provided with perforation and balloon dilation of the pulmonary valve. In cases of muscular obstruction of the right ventricle outflow tract, surgery may be considered as first-line therapy. In case of prenatal diagnosis, the medical termination of pregnancy is possible when severe right ventricular hypoplasia exists, precluding biventricular circulation. Postnatally, the prognosis of the patients is highly variable, mainly related to the size of the right cavities and the presence of coronary anomalies.

Preoperative evaluation of pulmonary artery morphology and pulmonary circulation in neonates with pulmonary atresia--usefulness of MR angiography in clinical routine

BACKGROUND

To explore the role of contrast-enhanced magnetic resonance angiography (CE-MRA) in clinical routine for evaluating neonates with pulmonary atresia (PA) and to describe their pulmonary artery morphology and blood supply.CE-MRA studies of 15 neonates with PA (12 female; median weight: 2900 g) were retrospectively evaluated by two radiologists in consensus. Each study was judged to be either diagnostic or non-diagnostic depending on the potential to evaluate pulmonary artery morphology and pulmonary blood supply. In those cases where surgery or conventional angiocardiography was performed results were compared.

RESULTS

CE-MRA was considered diagnostic in 87%. Pulmonary artery morphology was classified as "confluent with (n = 1) and without (n = 1) main pulmonary artery", "non-confluent" (n = 6) or "absent" (n = 7). Source of pulmonary blood supply was "a persistent arterial duct" (n = 12), "a direct" (n = 22) or "indirect (n = 9) aortopulmonary collateral artery (APCA)" or "an APCA from the ascending aorta" (n = 2). In no patient were there any additional findings at surgery or conventional angiocardiography which would have changed the therapeutic or surgical approach.

CONCLUSIONS

CE-MRA is a useful diagnostic tool for the preoperative evaluation of the morphology of pulmonary arteries and blood supply in neonates with PA. In most cases diagnostic cardiac catheterization can be avoided.

Functional pulmonary atresia: in a critically ill premature infant

WEB SITE FEATURE

Pulmonary atresia with intact ventricular septum causing severe left ventricular outflow tract obstruction

We describe an infant with pulmonary atresia with intact ventricular septum (PAIVS) and severe left ventricular outflow tract (LVOT) obstruction secondary to a suprasystemic right ventricle causing leftward displacement of the interventricular septum. Imaging demonstrated an aneurysmal dilation at the base of the proximal main pulmonary artery (MPA) with no forward flow from the right ventricle. During transannular patch and central shunt placement, the communication between the pulmonary artery and the right ventricle was enlarged to ensure adequate decompression. We report this successful palliation and resulting complete elimination of the LVOT obstruction in a very unique presentation of PAIVS in a newborn.

Surgical management of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals: a protocol-based approach

Historically, outcomes of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals have been quite poor. Over the past 15 years, our group has strived to apply a consistent surgical strategy for this lesion based on two guiding principles: early unifocalization of all important collaterals; and the early establishment of a low-pressure pulmonary arterial bed, preferably using simultaneous intracardiac repair. We describe a management protocol that has been developed to handle the highly variable nature of pulmonary blood flow observed with this lesion.

How we manage patients with major aorta pulmonary collaterals

Patients with major aortopulmonary collateral arteries usually present in one of three ways: either with marked heart failure because of lung overflow, cyanotic because of reduced lung flow, or fairly well balanced with systemic oxygen saturations in the high 70s to low 80s. All patients require a planned cardiologic surgical approach, with careful investigation to delineate the collateral morphology. A carefully coordinated, combined approach between surgery and cardiology intervention is required throughout the treatment of these patients. The majority of these patients now enter a program of reconstruction of the collaterals to a valved right ventricular pulmonary artery conduit with or without ventricular septal defect closure. Further catheter intervention to stretch and enlarge the pulmonary arteries may be necessary, followed by staged ventricular septal defect closure. Other techniques to enlarge central pulmonary arteries or to recruit collaterals can be used. Outcomes over the last 20 years have been satisfactory, with survival of 80% over 10 years, which is a marked improvement on the natural survival in this group of patients.

[Coexistence of partial anomalous pulmonary venous drainage and pulmonary atresia with ventricular septal defect: a report of two cases]

Coexistence of partial anomalous pulmonary venous drainage (PVD) and pulmonary atresia with ventricular septal defect (PA-VSD) is very rare with the exception of heterotaxy syndromes. We presented two cases of PA-VSD in which partial anomalous PVD was detected during pulmonary artery angiography. One was a six-month-old girl who underwent cardiac catheterization to evaluate the chance of unifocalization. There were true pulmonary arteries and three major aortopulmonary collaterals. It was noted that the right upper pulmonary vein was in direct continuity with the right atrium. The second case was a 12-year-old girl who was previously diagnosed as having PA-VSD and absence of true pulmonary arteries, for which she had undergone two subsequent aortopulmonary shunt operations four years before. During cardiac catheterization, confluent but hypoplastic true pulmonary arteries and multiple minor aortopulmonary collaterals were detected. The right and left upper pulmonary veins were draining to the right atrium. It should be known that, albeit very rare, partial anomalous PVD may be present in PA-VSD cases, requiring careful evaluation of pulmonary venous drainage during echocardiographic and angiographic studies.

Pre-operative evaluation with magnetic resonance imaging in tetralogy of fallot and pulmonary atresia with ventricular septal defect

BACKGROUND

Preoperative evaluation of patients with pulmonary atresia and ventricular septal defect (PA/ VSD) are generally done by echocardiogram and cardiac catheterization. The authors' objective of the present study was to compare the findings of Gadolinium (Gd) enhanced cardiac magnetic resonance angiography (MRA) with cardiac catheterization.

MATERIAL AND METHOD

Patients who had PA/VSD were prospectively evaluated using cardiac catheterization and cardiac MRA. A branch of the pulmonary arteries was divided into: main pulmonary artery (MPA), left and right branch pulmonary artery (LPA & RPA), major aortopulmonary collateral arteries (MAPCA) and minor collaterals. Each study was interpreted blindly. The agreement of findings was compared using Kappa statistics.

RESULTS

There were 43 patients who received both cardiac catheterization and cardiac MRI within a 2 month period The average age was 13.8 +/- 8.4 (2-30) years-old. There was an agreement among measurement of both MPA and LPA & RPA with Kappa statistics of more than 0.8. Gd-enhanced MRA was able to identify more branches of MAPCA when compared to cardiac catheterization.

CONCLUSIONS

The results of the present study indicate that Gd-enhanced MRA is a feasible, fast and accurate technique for identification of all sources of pulmonary blood supply in patients with complex pulmonary atresia. The present study was a noninvasive alternative to cardiac catheterization. Gd-enhanced MRA can better delineate small (minor) branches of collateral.

[Congenitally absent pulmonary valve--analysis of ten prenatally diagnosed cases and review of the literature]

OBJECTIVES

To assess in a population of 10 fetuses diagnosed with absent pulmonary valve the incidence of associated cardiac extracardiac and chromosomal anomalies and the outcome of pregnancies.

METHOD

Retrospective analysis of data of prenatally diagnosed absent pulmonary valve cases between 1 January 1993 and 31 December 2005 in Fetal Echocardiography Laboratory of Ist Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary. The diagnosis was controlled with autopsy or postnatal examinations. The time of the prenatal diagnosis, indications, connected cardiac, extracardiac and chromosomal anomalies were studied.

RESULTS

Absent pulmonary valve was diagnosed prenatally in 10 pregnancies. The mean gestational age at the time of the diagnosis was 23.1 weeks (18-33 weeks). In 6 cases the malformation was diagnosed before the 24th gestational week, in 4 cases after the 24th gestational week. In 6 cases pregnancies were terminated. Fetal hydrops were found in 2 cases. Among 4 continued pregnancies one intrauterine fetal demise and two neonatal death occurred, one baby was successfully operated and survived. The Botallo duct was normally developed in five cases, in this group the absent pulmonary valve was isolated at 3 fetuses, at 1 fetus absent aortic valve and at 1 fetus tricuspid valve dysplasia were diagnosed. The Botallo duct was absent in five cases, in this group at 3 fetuses tetralogy of Fallot, at 1 fetus atrioventricular septal defect and at 1 fetus subaortic ventricular septal defect were diagnosed. Extracardiac malformations associated with cardiac abnormality at 3 fetuses. The indication for fetal echocardiography was positive family history in 3 cases, abnormal four chamber view in 2 cases, suspicion of thoracal cyst in 3 cases, fetal hydrops in 1 case, extracardiac malformation in 1 case.

CONCLUSION

The absent pulmonary valve is a severe malformation, the prognosis is poor and highly dependent on associated malformations. The correct early prenatal diagnosis is possible. The recurrence risk is higher than in multifactorial inheritance.

Prenatal diagnosis of pulmonary atresia: impact on clinical presentation and early outcome

AIM

The impact of prenatal diagnosis on morbidity and mortality for certain types of congenital heart disease (obstructive left heart lesions and transposition of the great arteries) is well established. No data are available for lesions with duct dependent pulmonary flow. We aimed to assess the impact of prenatal diagnosis of pulmonary atresia on clinical presentation and neonatal outcome.

METHOD

Fifty-eight newborns with pulmonary atresia presenting to our centre were identified retrospectively between 1997 and 2004 (prenatal diagnosis n = 37, postnatal n = 21). Anatomical sub-types included intact ventricular septum (PAIVS, n = 33) and ventricular septal defect (PAVSD, n = 25); those with more complex anatomy were excluded.

RESULTS

After adjusting for anatomical sub-type, postnatally diagnosed infants were significantly more hypoxic at presentation (mean oxygen saturation 65% vs 84%). However, they presented early (median age 1 day) and prostaglandin E was initiated promptly (median 3 hours) with rapid improvement of oxygen saturations (interaction p<0.001). This resulted in no appreciable differences in terms of pH, base deficit, blood pressure or heart rate between the groups by the time of the first catheter/surgical intervention. Postnatal infants did not differ in terms of length of intensive care unit (p = 0.18) or hospital stay (p = 0.86), incidence of complications (p = 0.72), or mortality (p = 0.77). Multivariable analysis revealed a positive association between occurrence of complications and both degree of cyanosis at presentation (rather than postnatal diagnosis per se) and anatomy (PAIVS).

CONCLUSION

Postnatal diagnosis of pulmonary atresia is associated with greater cyanosis at presentation. However this does not translate into greater neonatal morbidity or mortality provided that early recognition and prompt initiation of prostaglandin E therapy occur.

Postoperative coagulopathy in a pediatric patient after exposure to bovine topical thrombin

Severe postoperative coagulopathy developed in a child with congenital heart disease due to a factor V inhibitor from repetitive exposure to bovine topical thrombin. This case report alerts pediatric providers to consider these inhibitors when postoperative coagulopathy occurs. Potential treatment options are reviewed.

Double-barrelled aorta with tetralogy of Fallot and pulmonary atresia

We report the first case of double-barrelled aorta associated with tetralogy of Fallot and pulmonary atresia, and we discuss the difficulties in the terminology of this fascinating anomaly.

Management algorithm in pulmonary atresia with intact ventricular septum

Pulmonary atresia with intact ventricular septum (PAIVS) is a disease with remarkable morphologic variability, affecting not only the pulmonary valve but also the tricuspid valve, the RV cavity and coronary arteries. With advances in interventional techniques and congenital heart surgery, the management of PAIVS continues to evolve. This review is an attempt at providing a practical approach to the management of this disease. The basis of our approach is morphologic classification as derived from echocardiography and angiography. Group A, patients with good sized RV and membranous atresia, the primary procedure at presentation is radiofrequency (RF) valvotomy. Often it is the only procedure required in this group with the most favourable outcome. Patients with severely hypoplastic RV (Group C) are managed along the lines of hearts with single ventricle physiology. The treatment at presentation is patent ductus arteriosus (PDA) stenting with balloon atrial septostomy or conventional modified Blalock Taussig (BT) shunt. Bidirectional Glenn shunt may be done 6-12 months later followed by Fontan completion after a suitable interval. Patients in Group B, the intermediate group, are those with borderline RV size, usually with attenuated trabecular component but well developed infundibulum. The treatment at presentation is RF valvotomy and PDA stenting +/- balloon atrial septostomy. Surgical re-interventions are not uncommonly required viz. bidirectional Glenn shunt when the RV fails to grow adequately (11/2 - ventricle repair) and right ventricular outflow tract (RVOT) reconstruction for subvalvar obstruction or small pulmonary annulus. Catheter based interventions viz. repeat balloon dilatation or device closure of patent foramen ovale (PFO) may also be required in some patients.

Right ventricular outflow tract transannular patch placement without cardiopulmonary bypass

In children with pulmonary atresia not amenable to initial complete correction, antegrade pulmonary blood flow can be established with surgical right ventricular outflow tract (RVOT) patch enlargement. An 11-year experience with RVOT transannular patch (TAP) augmentation without the use of cardiopulmonary bypass (off-pump) is reported. From March 1993 to October 2004, off-pump surgical RVOT enlargement with a TAP was attempted in all patients in whom a concurrent procedure that required bypass was not required. The procedure was performed with cardiopulmonary bypass standby. Twenty-two consecutive patients in whom this procedure was attempted were reviewed. Twenty of 22 patients tolerated off-pump TAP placement. In 2 patients with ductal-dependent pulmonary blood flow, off-pump TAP placement was not tolerated. Adequate antegrade pulmonary blood flow was achieved in all patients without operative mortalities or complications. There was one death in the postoperative period from myocardial ischemia secondary to right ventricular-dependent coronary circulation. Transannular RVOT patch augmentation can be performed safely and effectively without cardiopulmonary bypass.

Congenital bronchial atresia in infants and children

BACKGROUND/PURPOSE

Congenital bronchial atresia (CBA) usually presents incidentally in asymptomatic young male adults but is rarely diagnosed in children. The aim of this study was to clarify the clinical characteristics of CBA in childhood and to describe the spectrum of this condition.

METHODS

The clinical features in 29 patients with CBA, aged from 1 day to 13 years (median, 4 years), were reviewed retrospectively. Diagnosis was confirmed by pathological findings of a blind-ending bronchus associated with distal mucous-filled bronchocele surrounded by hyperinflated lung parenchyma.

RESULTS

All but 1 patient were symptomatic. The most frequent symptom was productive cough and fever owing to recurrent pneumonia found in 26 children. Two infants suffered from respiratory distress. Chest x-ray showed various findings of infiltrative pneumonia, emphysema, and a large cyst. Computed tomography, bronchography, and bronchoscopy were useful modalities for demonstrating bronchocele associated with hyperinflated lung or proximal blind-ending bronchus even in infected cases. The right lower lobe was predominantly affected in 12 cases, followed by left or right upper lobe in 7 cases. Lobectomy or segmentectomy resulted in remarkable clinical improvement.

CONCLUSIONS

Congenital bronchial atresia presents differently in children than in young adults. Modern imaging techniques and careful pathological analyses lead to an accurate diagnosis of bronchial atresia, which may be misdiagnosed as intralobar sequestration or pulmonary bronchial cysts. Bronchial atresia is a distinct pathological entity that accounts for recurrent pneumonia or respiratory distress in childhood, requiring surgical treatment.

Cardiac MR Imaging and MR Angiography for Assessment of Complex Tetralogy of Fallot and Pulmonary Atresia

Breath-hold electrocardiographically gated cardiac magnetic resonance (MR) imaging and contrast material-enhanced MR angiography are emerging as ideal techniques for the evaluation of complex congenital heart disease. Tetralogy of Fallot is the most common cause of cyanotic congenital heart disease and, in its classic form, is associated with varying degrees of hypoplasia of the central and peripheral pulmonary arteries, with valvar pulmonary atresia and collateral aortopulmonary vessels occupying the extreme end of the spectrum. Accurate assessment of the size and anatomy of the pulmonary arteries is often difficult with echocardiography and conventional cineangiography. Compared with echocardiography in particular, cardiac MR imaging with three-dimensional reconstruction has distinct advantages for pre- or postoperative assessment of pulmonary anatomy in patients with tetralogy of Fallot and pulmonary atresia. MR imaging enables the clear and complete depiction of anatomy and thus can provide additional information about pulmonary artery abnormalities that are difficult to evaluate with conventional cardiac imaging techniques.

Successful dilatation of left pulmonary artery stenosis by stent implantation through a modified Blalock-Taussig shunt in an infant with pulmonary atresia and ventricular septal defect

We successfully implanted a coronary stent via a modified Blalock-Taussig shunt to relieve stenosis of the left pulmonary artery in an infant with pulmonary atresia and ventricular septal defect. The placement of a flexible coronary stent via a modified Blalock-Taussig shunt is a safe and feasible catheter intervention for the treatment of infants with hypoplastic pulmonary arteries.

Construction of a pulmonary artery pump for unifocalization and repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals

Single-stage repair has been presented as the treatment of choice for pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals. This surgical approach may result in the difficult decision of whether to close the ventricular septal defect. This decision may significantly affect the postoperative course of the patient. There are several diagnostic techniques clinicians may use to help them decide if closure is indicated. One technique is to modify an extracorporeal circuit to deliver precise flow rates of blood into the newly created pulmonary arterial system, at the same time supporting the patient during the operative procedure. While this technique is not novel, there is only a single published description of the circuit. This report is brief and does not discuss potential complications that these modifications may cause. Therefore, it is the purpose of this paper to describe a circuit modification to perform this diagnostic measurement as well as elucidating potential risks of this technique.

Bidirectional cavopulmonary shunt using the azygos vein

A case is described in which a two-year-old boy, diagnosed with common atrioventricular canal, pulmonary atresia, major aortopulmonary collateral artery, asplenia, and situs inversus, underwent palliative operations for the following: unifocalization of the right major aortopulmonary collateral artery, right ventricle-to-pulmonary artery shunt, and pulmonary artery plasty. Upon completion of the bidirectional cavopulmonary shunt operation, we addressed the stenotic lesions of the superior vena cava and left pulmonary artery, and a markedly expanded azygos vein. During this operation, the superior vena cava was divided and we performed cavopulmonary shunting with the azygos vein.

[22q11 deletion in conotruncal anomalies]

22q11 deletions in conotruncal anomalies. Two children are reported in whom conotruncal anomalies (truncus arteriosus communis, tetralogy of Fallot) were associated with chromosome 22q11 deletion. In both cases, which represent the first published cases in Hungary according to the knowledge of the author, deletions were suspected on the basis of phenotype termed Di George syndrome. Nowadays the role of molecular genetics is growing in the etiology of congenital heart defects and the chromosome 22q11 deletions constitute one of the most frequent genetic mutations associated with congenital heart defects. The author emphasizes that clinicians must know about this disease, and in case of suspicion they should request for molecular genetic investigation. 22q11 deletions have an important roles in the prognosis of congenital heart disease, in counseling and in the prenatal diagnosis as well.

Endoscopic Carbon Dioxide Laser Division of Congenital Complete Tracheal Rings: A New Operative Technique

A carbon dioxide laser was used through a bronchoscope to split the posterior aspect of complete tracheal rings in the distal trachea of a 16-month-old boy previously palliated for cyanotic congenital heart disease. After laser division of the complete tracheal rings, the patient was successfully extubated. Subsequently, the boy had granulation tissue develop, which required bronchoscopic resection, and then severe posterior tracheal impingement developed from the esophageal herniation, which required placement of a distal tracheal stent. Although unsuccessful in this case, carbon dioxide laser division of complete tracheal rings may be a safe and effective method of treating congenital tracheal stenosis in selected cases.

[Pulmonary atresia with intact ventricular septum]

It is important to employ a strategy for pulmonary atresia with intact ventricular septum (PAIVS) in collaboration with cardiology and cardiac surgery. We established our policy of treatment based on the right ventricular end diastolic volume. Sinusoidal communication should be carefully considered. Prognosis was poor in case of interruption of coronary arteries. Although catheter intervention is not fully established in initial treatment of PAIVS, it has a clinically significant roll in case of sufficient right ventricular end diastolic volume.

Unilateral pulmonary atresia with total sacral agenesis and other congenital defects

Is there a common aetiologic element in the VACTERL syndrome and the caudal regression syndrome? We report a boy who fulfilled three criteria of the VACTERL association (he had thoracic hemivertebra, high anal atresia and tracheo-oesophageal fistula) but also could be classified as caudal regression syndrome on the basis of the anal atresia and total sacral agenesis. We discuss the arguments in favour of both diagnosis.