Anomalous left coronary artery from the right sinus of valsalva and noncompaction of the left ventricle

Anomalous origin of the left coronary artery is a well-known cause of sudden death. Noncompaction of the ventricular myocardium is a cardiomyopathy characterized by prominent trabeculae and deep intertrabecular recesses. Both anomalies are rare. We report the case of a child with both anomalous origin of the left coronary artery from the right sinus of Valsalva and noncompaction of the left ventricular myocardium found during an evaluation for Kawasaki's disease.

Double aortic arch and d-transposition of the great arteries

We present a rare case of D-transposition of the great arteries (D-TGA) and double aortic arch (DAA). The anatomy was prospectively and preoperatively diagnosed by echocardiography and confirmed by ultra-fast computed tomography. The patient underwent successful arterial switch operation and division of the vascular ring at a single procedure.

Annular and Septal Doppler Tissue Imaging in Children: Normal z-Score Tables and Effects of Age, Heart Rate, and Body Surface Area

The aim of this study was to construct normal z-score tables for longitudinal directed Doppler tissue imaging (DTI) systolic wave (S), DTI early diastolic wave (E'), and DTI late diastolic wave (A') at the mitral valve annulus (MV), superior ventricular septum (VS), and tricuspid valve annulus (TV) in pediatric patients. We analyzed normal echocardiograms from 634 children aged 1 day to 18 years, heart rate (HR) range of 50 to 194/min, and body surface area (BSA) range of 0.1 to 2.8 m2. First we determined the effects of age, HR, and BSA on the S, E', and A' at the MV, VS, and TV sampling sites by univariate analysis. Next we determined which of the 3 factors, age versus HR versus BSA, correlated best with the S, E', and A' at each of the 3 sampling sites by multivariate analysis. Finally, using the specific factor of age versus HR versus BSA that best predicted a particular DTI wave at a particular sampling site, we constructed z-score tables for each of the 3 DTI parameters at each of the 3 sampling sites. The S range was: MV = 2.2 to 23.2 cm/s; VS = 1.6 to 22.3 cm/s; and TV = 1.8 to 31.3 cm/s. By univariate analysis the S correlated negatively with HR and positively with age and BSA with strong correlations at all 3 sites. By multiple regression analysis the S correlated best with age at all 3 sites. The E' range was: MV = 2.4 to 37.1 cm/s; VS = 1.8 to 29.0 cm/s; and TV = 2.4 to 32.4 cm/s. The E' varied negatively with HR and positively with age and BSA with strong correlations by univariate analysis at all 3 sites. By multiple regression, the E' correlated best with age for the VS and TV sites, and correlated best with HR at the MV site. The E' at the MV site also strongly correlated with age by multivariate analysis. The A' range was: MV = 2.9 to 20.7 cm/s; VS = 2.7 to 18.2 cm/s; and TV = 1.1 to 29.3 cm/s. The A' had a strong positive correlation with HR at all 3 sites, a strong negative correlation with BSA and age at the TV site only, with no statistical significant correlation of the MV and VS site A' to BSA or age. Using multiple regression analysis the A' correlated best with HR at all 3 sites. Z-score tables developed from a large sample volume encompassing the entire spectrum of ages, HR, and BSA encountered in pediatric patients and developed using the strongest predicting factor serve as reference data for longitudinal directed DTI annular and septal S, E', and A' normal values in children.

Systolic and diastolic time intervals measured from Doppler tissue imaging: normal values and Z-score tables, and effects of age, heart rate, and body surface area

The aim of this study was to develop normal values, including Z-score tables when appropriate, for systolic time (St) and diastolic time (Dt) intervals measured by Doppler tissue imaging (DTI) and to determine the effects of age, heart rate (HR), and body surface area on DTI-derived time intervals in children. We studied 593 children with normal echocardiogram results. Developmental factors ranged from age 1 day to 18 years, HR 46 to 182/min, and body surface area 0.08 to 2.80 m(2). A total of 7 DTI-derived time interval parameters were studied. Five time interval parameters were measured from DTI: isovolumic contraction time (IVCT), isovolumic relaxation time (IVRT), ejection time, St, and Dt. In addition, we calculated the Tei index (TX) and St/Dt. We sampled longitudinal directed DTI waves from 3 sites: mitral annulus, basal interventricular septum, and tricuspid annulus from an apical 4-chamber view. Parameters were measured in each case from a single echocardiogram during times of hemodynamic stability. By univariate analysis all 7 time intervals at each of the 3 sampling sites correlated with age, HR, and body surface area (P < .001-P < .003), except the mitral annulus TX (P = .1). The following results are all based on multivariate analysis. IVCT, IVRT, and TX correlated best with age at all 3 sites (P < .001). However, when we corrected for HR by dividing by square root(R)-R interval, both corrected IVCT and corrected IVRT became constants at all 3 sites. The change in TX with age was very small and not clinically significant. Therefore, for practical clinical purposes, corrected IVCT, corrected IVRT, and TX were constant at all 3 sites. Ejection time, St, Dt, and St/Dt correlated best with HR at all 3 sites (P < .001). Ejection time, St, and Dt all decreased at faster HRs, whereas St/Dt increased at faster HRs.

Right Ventricular Tei Index in Children: Effect of Method, Age, Body Surface Area, and Heart Rate

The right ventricular (RV) Tei index (RVTX) has been used to analyze systolic and diastolic global RV function in various congenital and acquired cardiac abnormalities in children. We conducted a study to determine the effects of the methods of Doppler tissue imaging (DTI) versus pulse wave Doppler (PWD) and age, body surface area (BSA), and heart rate on the RVTX in a population of 308 children with normal echocardiogram findings. Participants ranged in age from 1 day to 18 years, with BSA from 0.08 to 2.4 m2 and heart rate from 46 to 182/min. The RVTX was calculated by both DTI and PWD in each patient during a single echocardiographic examination. RVTX-DTI = 0.37 +/- 0.05 (mean +/- SD) versus RVTX-PWD = 0.34 +/- 0.06 were slightly but statistically different (P < .001). Univariate linear regression analysis showed age and BSA both had small but significant positive effects on both the RVTX-DTI and RVTX-PWD, and heart rate had a small but significant negative effect on both techniques (all with P < .01). By multivariate regression analysis RVTX-DTI was significantly affected only by the BSA and the RVTX-PWD only by age (both with P < .05). Therefore, one must consider the method of RVTX measurement, the BSA for RVTX-DTI, and the age for RVTX-PWD to accurately assess RVTX values.

Unusual atrial septal anatomy resulting in an interatrial chamber: the true triatrial heart?

We report two patients who were found to have nearly identical, very peculiar atrial septal anatomy. The septum actually consisted of two distinct septa with discrete defects creating an interatrial chamber. The orifice from the left atrium was unrestrictive, but the orifice to the right atrium was restrictive. Overall, there was net left-to-right shunting. This finding represents a clinical dilemma: Left untreated, the interatrial chamber might be a nidus for thrombus formation, but attempting device closure might result in incomplete obliteration of the chamber, also resulting in potential locus for clot formation. Clot formation might lead to systemic embolization. Angiographic findings are correlated with echocardiographic findings. Embryology and treatment options are considered.

Left Ventricular Tei Index in Children: Comparison of Tissue Doppler Imaging, Pulsed Wave Doppler, and M-Mode Echocardiography Normal Values

The Tei index has been found to be useful for analyzing systolic and diastolic global ventricular function in a wide variety of congenital and acquired cardiac abnormalities. However, there are some discrepancies between reports as to the normal values for the Tei index obtained by the different echocardiographic techniques and by different investigators. We conducted a prospective study to determine the normal range of left ventricular Tei index (LVTX) values in a broad sample of children using tissue Doppler imaging, pulsed wave Doppler, and M-mode echocardiography. In all, 289 children with normal echocardiogram findings (age 1 day-18 years, body surface area 0.08-2.4 m(2), heart rate 46-182/min) were studied. The LVTX was calculated by all 3 methods in each patient during a single echocardiographic examination. The normal LVTX values (mean +/- SD) for the 3 techniques were: LVTX-Doppler tissue imaging = 0.38 +/- 0.06; LVTX-pulsed wave Doppler = 0.36 +/- 0.07; and LVTX-M-mode echocardiography = 0.29 +/- 0.08. LVTX-Doppler tissue imaging and LVTX-pulsed wave Doppler values were only slightly but statistically significantly different (P < .05). LVTX-M-mode echocardiography values were consistently and significantly less than those obtained by both of the other two methods (P < .01, respectively). The effects of age, body surface area, and heart rate were not clinically significant. These results are similar but not identical to those from prior studies.

Double Atrial Septum with Persistent Interatrial Space: Echocardiographic Features of a Rare Atrial Septal Malformation

We describe the echocardiographic features of 4 new cases of a rare atrial septal malformation consisting a double atrial septum with a midline chamber between the left and right atrium. Half of the cases had major left-sided obstructive lesions. Transthoracic, transesophageal, intracardiac, and fetal echocardiographic features of this anomaly are demonstrated. Previous descriptions, embryologic speculations, and clinical considerations are discussed.

Intermediate results of the anatomic repair for congenitally corrected transposition

BACKGROUND

Anatomic repair of congenitally corrected transposition of the great arteries has several advantages over the traditional approach but lacks long-term evaluation.

METHODS

The data on 12 patients who had the procedure between January 1989 and June 2000 were retrospectively reviewed. Associated lesions included ventricular septal defect in 12 patients, pulmonary stenosis in 10 patients, and moderate to severe tricuspid valve regurgitation in 4 patients. Mean age at operation was 9+/-3.6 months. All patients had venous switch Mustard procedure. Tunneling of the morphologic left ventricle through the ventricular septal defect to the aorta with insertion of right ventricular to pulmonary artery conduit was performed in 10 patients, and arterial switch operation in 2. Concomitant tricuspid valvuloplasty was done in 2 patients and ventricular septal defect enlargement in 1.

RESULTS

There was one hospital death (9%) in the patient who needed ventricular septal defect enlargement. Complications included atrioventricular block requiring pacemaker insertion in 1 patient (9%) and superior vena caval obstruction in 1 patient (9%). Follow-up is available on all patients 0.5 to 10 years (mean, 7.6+/-3.1 years). All patients are asymptomatic. Exercise test results on the three oldest patients were normal. Bradytachyarrhythmias developed in 4 patients (36%). Right ventricular to pulmonary artery conduit replacement was needed in 5 patients 2.2 to 7.1 years (mean 5.2+/-3.6 years) postoperatively. Mild to moderate tricuspid valve regurgitation persisted in 2 patients. Systemic left ventricular fractional shortening was 36% to 47% (mean, 39%+/-4.6%), and ejection fraction was 49% to 70% (mean, 60.8%+/-7.9%).

CONCLUSIONS

The double switch operation can be performed safely with minimal intermediate and long-term complications.

The effect on the hemodynamic stability of varying calcium chloride administration during protamine infusion in pediatric open-heart patients

IMPLICATIONS

We conducted a randomized study in 147 pediatric patients undergoing cardiopulmonary bypass to determine when there are any differences in hemodynamic effects if CaCl(2) 20 mg/kg and protamine 5mg/kg are mixed together and infused over 10 min versus administering half of the calcium dose (10 mg/kg) as a bolus followed by a 10-min infusion of protamine 5 mg/kg and CaCl(2) 10mg/kg.

Alternative techniques for surgical management of recoarctation

OBJECTIVE

To evaluate the different surgical options in patients with recoarctation and minimal collaterals.

METHODS

Thirty-three cases operated on between January 1980 and January 1995 were reviewed. Initial repair was end-to-end anastomosis in 16 patients, subclavian artery aortoplasty in 10, synthetic patch aortoplasty in 4 and bypass conduit in 3 patients. Age at reoperation was 7.5 +/- 5.2 years (1-17 years). Pressure gradient was 20-48 Torr (33 +/- 9). Upper extremity resting or exercise systemic hypertension was present in all. In 18 patients recoarctation was repaired using subclavian artery aortoplasty (n = 15) or synthetic patch aortoplasty (n = 3); alone in 9, with temporary heparinized bypass in 2, or in addition to placement of ascending aorta to descending aorta conduit as a permanent bypass through a left thoracotomy in 9. In 13 patients a conduit was interposed between ascending aorta and descending aorta through a right thoracotomy. In one patient recoarctation segment was patched on cardiopulmonary bypass through a midsternotomy.

RESULTS

There was no mortality or complications. All patients had no echocardiographic pressure gradients across recoarctation on 5 +/- 3.4 years follow-up. Persistent systemic hypertension following recoarctation repair was present in 3/8 patients (37%) operated on at age greater than 10 years, but has been resolved in all 25 patients less than 10 years of age (P = 0.02).

CONCLUSIONS

Use of ascending aorta to descending aorta conduit, either alone through a right thoracotomy, or as permanent bypass in combination with patching the recoarctation through a left thoracotomy provides safe and excellent relief of obstruction.

Color Doppler flow mapping of the patent ductus arteriosus in very low birthweight neonates: echocardiographic and clinical findings

Forty-eight preterm infants (mean birthweight 1.0 +/- 0.3 kg; mean gestational age 28 +/- 3 weeks) underwent serial echocardiograms and physical examinations in order to determine the correlation between color Doppler flow mapping (CDFM) results and physical findings of a patent ductus arteriosus (PDA), the predictive value of early CDFM as an indicator of subsequent requirement for treatment of a PDA, and to determine the direction and duration of ductal shunting and the rate of ductal closure and opening. CDFM analysis and cardiac physical examination of left-to-right ductal shunting were usually concordant in infants with a large PDA shunt, the most reliable physical finding being increased precordial activity. CDFM studies on day 2 or 3 of postnatal life had prognostic value with regard to subsequent need for closing the PDA. Additional findings included the absence of right-to-left PDA shunting in infants < 1 kg and < 28 weeks gestation and the absence of ductal reopening in infants in whom it had closed spontaneously. After complete PDA closure using indomethacin, subsequent ductal reopening is uncommon, except in infants < 25 weeks gestation and < 700 g bodyweight.

Extended aortic valvuloplasty for recurrent valvular stenosis and regurgitation in children

Recurrent significant aortic valvular stenosis or regurgitation, or both, after balloon or open valvotomy in pediatric patients often necessitates aortic valve replacement. In an attempt to preserve the aortic valve, we performed extended aortic valvuloplasty in 21 children with recurrent aortic valve stenosis or regurgitation from January 1989 to March 1993. Previous related procedures were one open aortic valvotomy or more (n = 15), balloon valvotomy (n = 4), balloon valvotomy after surgical valvotomy (n = 1), and repair of iatrogenic valve tear (n = 1). Mean age at the time of the extended aortic valvuloplasty was 6 +/- 3.4 years. Mean pressure gradient across the aortic valve was 56 +/- 12 torr. Regurgitation was moderate (grade 2 to 3) in nine and severe (grade 4) in 12 patients. Extended aortic valvuloplasty techniques consisted of thinning of valve leaflets (n = 15), augmentation of scarred and retracted leaflets with autologous pericardium (n = 11), resuspension of the augmented leaflet (n = 14), release of the rudimentary commissure from the aortic wall (n = 5), extension of the valvotomy incision into the aortic wall on both sides of the commissure (n = 20), patch repair of the sinus of Valsalva perforation (n = 1), reapproximation of tears (n = 5), and narrowing of the ventriculoaortic junction (n = 2). No operative deaths occurred. The postoperative mean pressure gradient, assessed by most recent Doppler echocardiography or cardiac catheterization at a follow-up of 18 +/- 6 months, was 19 +/- 6 torr (p < 0.01 versus the preoperative gradient). Aortic regurgitation was absent in 13, mild in 6, and moderate-to-severe, necessitating subsequent aortic valve replacement, in 2. This short-term experience indicates that extended aortic valvuloplasty is a safe and effective surgical approach that minimizes the need for aortic valve replacement in children with significant recurrent aortic valve stenosis or regurgitation.

Intraoperative echocardiography for evaluation of congenital heart defects in infants and children

To determine the accuracy, utility, and limitations of intraoperative transesophageal echocardiography (TEE) in infants and children, we performed prebypass and postbypass TEE in 90 children undergoing surgical repair of congenital heart lesions, comparing the results to those obtained using intraoperative epicardial echocardiography and pre- and postoperative precordial echocardiography. Patients ranged in age from 4 days to 21 yr (mean 4.1 yr) and in weight from 3 to 68 kg (mean 15.4 kg). Prebypass, we obtained high-quality, two-dimensional TEE images in 86 patients, with correction of the preoperative precordial diagnosis in 3 and confirmation of the preoperative diagnosis in the rest. Adequate epicardial images were obtained in 78 patients, with confirmation of the preoperative diagnosis in all. Shunt lesions that were well delineated prebypass by both TEE and epicardial imaging included interatrial, interventricular, and atrioventricular septal defect lesions. TEE failed to detect the exact size and location of lesions involving the right ventricular outflow tract, i.e., doubly committed subarterial (supracristal) ventricular septal defects. Regurgitant lesions (n = 30) were identified and their severity evaluated in all patients by both TEE and epicardial imaging. Obstructive lesions (n = 33), excluding those involving the right ventricular outflow tract, were well defined by both echocardiographic approaches. Postbypass, we obtained high-quality, two-dimensional, color and Doppler TEE images in 86 patients and epicardial images in 78 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Conal enlargement for diffuse subaortic stenosis

Twelve patients underwent conal enlargement for diffuse subaortic stenosis over a 3 1/2-year period. The subaortic stenosis was due to tunnel outflow in 11 and malattached mitral valve in one. Mean age was 4.4 +/- 4 years and mean subaortic gradient was 50 +/- 21 mm Hg. Three infants had a malalignment ventricular septal defect. In eight patients significant obstruction occurred 2 to 7 years (mean 4 +/- 2) after simple resection of subaortic stenosis (n = 2), ventricular septal defect closure (n = 2), ventricular septal defect closure and subaortic stenosis resection (n = 2), and canal repair (n = 2). In three infants the tunnel outflow distal to a malalignment ventricular septal defect was enlarged and closed with the defect. In three patients with subaortic stenosis proximal to a previously repaired ventricular septal defect, transatrial conal enlargement through the ventricular septal defect was performed. Another patient without a ventricular septal defect had transatrial conal enlargement. The remaining five patients had the modified Konno procedure. Two patients had postoperative complete heart block and one infant had insertion of an apicoaortic conduit for aortic anulus hypoplasia 9 months later. One patient died of pneumonia during the follow-up period. Postoperative echographic outflow gradients up to 3 1/2 years (mean 1.2 +/- 1) ranged up to 25 mm Hg (mean 7 +/- 11) and were mainly at the aortic level. The 11 surviving patients are doing well up to 3 1/2 years of follow-up (mean 1.5 +/- 1). We conclude that conal enlargement procedures with aortic valve preservation are preferable, effective, and can be safely performed for diffuse subaortic stenosis in infants and children.

Intraoperative transesophageal echocardiography of ventricular septal defect

The accuracy and limitations of intraoperative two-dimensional (2-D) and color Doppler flow mapping transesophageal echocardiography (TEE) of ventricular septal defect (VSD), before and after cardiopulmonary bypass, were analyzed in 62 children. Twenty-one patients had an isolated VSD, and 41 had a VSD plus additional cardiac anomalies. Two-dimensional and color Doppler flow mapping TEE were performed with a miniaturized 5-MHz single (transverse) plane transducer in the 51 of 62 patients weighing less than 20 kg. The remaining 11 were monitored using a single plane adult probe (n = 4) and a biplane (transverse plus longitudinal) probe (N = 7). Prebypass TEE provided a correct diagnosis in 57 of 62 cases (92%) and corrected an erroneous preoperative transthoracic echocardiographic diagnosis in three of 62 cases (5%). Single plane TEE diagnosis was erroneous in five patients: four with doubly-committed subarterial VSD and one with multiple small apical muscular defects and pulmonary hypertension. Biplane TEE (transverse longitudinal) provided clear and complete imaging of the right ventricular outflow tract in all seven cases in whom it was used. Postbypass TEE showed absence of a hemodynamically significant residual VSD in 30 of 40 patients (95%) who underwent VSD patch closure, prospectively identified two of 40 with significant residual VSD, and accurately measured the color Doppler jet width of all residual VSDs. We conclude that hemodynamically significant VSDs can be identified immediately after cardiopulmonary bypass based on the width of the residual VSD color Doppler flow map jet. Therefore, 2-D and color Doppler flow mapping TEE provide an accurate diagnosis in most cases of VSD but may miss doubly-committed subarterial and apical muscular VSD unless biplane TEE is used.

Advantages of early relief of subaortic stenosis in single ventricle equivalents

Thirteen patients with single ventricle equivalents and subaortic stenosis underwent relief of the stenosis and subsequent Fontan operation. Nine patients, group 1, had the obstruction relieved at 3.6 +/- 1.6 years of age whenever the pressure gradient became apparent. Four patients, group 2, had the subaortic stenosis operated on at the neonatal period, 10.5 +/- 10 days old, before hemodynamic evidence of obstruction. Preoperative pressure gradient across the outflow tract was 44.2 +/- 4.7 mm Hg in group 1 versus 4.7 +/- 5 mm Hg in group 2 (p = 0.002). Ventricular muscle mass was 186% +/- 18% in group 1 versus 114% +/- 5% of normal in group 2 (p = 0.0001), and mass/volume ratio was 1.12 +/- 0.62 in group 1 versus 0.62 +/- 0.16 in group 2 (p = 0.003). Relief of subaortic stenosis was achieved by proximal pulmonary artery to ascending aorta or aortic arch anastomosis and by systemic to distal pulmonary artery shunt. There was no hospital mortality or complication related to the procedure. At evaluation before Fontan operation, 4.3 +/- 1.6 years after relief of subaortic stenosis in group 1 and 3.2 +/- 0.9 years in group 2, the pressure gradient across the ventricular outflow tract was 4 +/- 3 mm Hg in group 1 versus 3 +/- 2 mm Hg in group 2 (p = not significant), ventricular muscle mass was 184% +/- 31% in group 1 versus 114% +/- 5% of normal in group 2 (p = 0.003), and the mass/volume ratio was 1.17 +/- 0.2 in group 1 versus 0.62 +/- 0.2 in group 2 (p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Extended aortic valvuloplasty: a new approach for the management of congenital valvar aortic stenosis

A new technique for the treatment of congenital valvar aortic stenosis is described. It consists of augmenting the aortic cusp by extending the commissurotomy incision into the aortic wall around the leaflet insertion, mobilizing the valve cusp attachment at the commissures, and freeing the aortic insertion of the rudimentary commissure. The results of standard valvotomy performed on 48 patients (group 1) were compared with those of the new extended valvuloplasty carried out on 16 patients (group 2). The two groups were comparable in age at operation (2.7 +/- 2.1 years for group 1 versus 2.1 +/- 1.7 years for group 2; p = not significant) and in preoperative pressure gradient (58 +/- 25 mm Hg for group 1 versus 61 +/- 36 mm Hg for group 2; p = not significant). There was no operative mortality in either group. Follow-up is available on all patients, with a mean of 4.3 +/- 2.6 years for group 1 versus 1.7 +/- 0.5 years for group 2 (p = 0.05). There was one late death in group 1. Postoperative gradient was 47 +/- 13 mm Hg in group 1 versus 19 +/- 13 mm Hg in group 2 (p = 0.05). Moderate or severe regurgitation was present in 18 patients (38%) in group 1 and 2 patients (13%) in group 2 (p = not significant). Reoperation was needed in 8 patients (17%) in group 1 versus 2 patients (13%) in group 2 (p = not significant). The described valvuloplasty procedure addresses the unique pathological features of valvar aortic stenosis and provides better relief of the obstruction than the presently available techniques. Longer follow-up is needed to determine the late results of this approach.