Fetal cardiac abnormalities detected by transvaginal sonography at 12-16 weeks' gestation

The use of transvaginal ultrasound scanning has substantially improved early pregnancy imaging of fetal anatomy. We detected cardiac abnormalities in ten fetuses at 12-16 weeks' gestation using transvaginal ultrasound.

Three anomalies of the coronary arteries co-existing in a case of pulmonary atresia with intact ventricular septum

A female infant, who died 17 hours after spontaneous birth, was found to have three distinct coronary arterial anomalies in association with pulmonary atresia with intact ventricular septum. These anomalies were first, an aneurysmal left coronary artery with a fistulous communication into the right ventricle; second, an anomalous origin of the right coronary artery from the pulmonary artery; and third, a supernumerary coronary artery arising from the right ventricle. Although the coronary arterial system was entirely connected to the right ventricle, the perfusing blood originated from the left ventricle and there was no clinical or histological evidence of significant myocardial ischaemia.

Atrioventricular septal defect with intact septal structures in a 74-year-old

We report the incidental finding at post mortem of deficient atrioventricular septation in the heart of a 74-year-old woman. A review of her clinical history showed little indication of this lesion. The heart had intact septal structures but exhibited other features pathognomonic of atrioventricular septal defect.

Anomalous origin of the left coronary artery from the pulmonary trunk. Anatomic findings in relation to pathophysiology and surgical repair

Anomalous origin of the left coronary artery from the pulmonary trunk, though a discrete anatomic malformation, manifests a spectrum of clinical and pathologic consequences. The objectives of this study were to characterize the primary anatomic findings in a group of specimens with anomalous left coronary artery and the extent of secondary morphologic and pathologic changes. Although the cases studied probably represent the least favorable end of the spectrum, the observed pathogenesis and evolution of secondary changes suggest that reconstruction of a two-coronary arterial system supplied through two coronary arteries would be advantageous to most patients. A high origin of the right coronary artery or location of the left coronary artery adjacent to a pulmonary cusp or branch may complicate the tunnel-type repair. In these cases, transfer of the left coronary artery to the aorta may be preferable.

Anomalous subaortic position of the brachiocephalic (innominate) vein: a review of published reports and report of three new cases

Anomalous courses of the left innominate vein have rarely been described in anatomical specimens. Investigative techniques such as angiography and echocardiography have brought to light more instances of this anomaly. Three more cases identified by anatomical study are described. Earlier cases were reviewed to assess the type of associated cardiac malformations. Clinically, the abnormality is regarded as benign. When it is recognised during investigation it should alert the clinician to the possibility of associated malformations. Features commonly seen in tetralogy of Fallot--right aortic arch, ventricular septal defect, and right ventricular outflow obstruction--were common in patients with anomalous subaortic innominate veins.

Persistent 5th aortic arch--a great pretender: three new covert cases

Although persistence of the embryonic fifth aortic arch is considered a rare congenital malformation, analysis of the records of the cardiopathological collections of the Brompton and Killingbeck Hospitals reveals 6 examples in approximately 2000 specimens, an incidence amongst our material of 1 in 330. Since our review of the literature reveals only a further 13 described cases, we wonder if the condition may go unrecognized rather than being exceedingly rare. This possibility is further supported by the fact that 3 of our cases were incorrectly interpreted when initially described. In this report, we describe the details of 2 of these specimens and one other case that was not included in our earlier descriptions of this malformation. The first case had the persistent fifth arch as a conduit between the pulmonary and systemic circulations in the setting of aortic atresia with interruption of the aortic arch. The second case demonstrated a double lumen aortic arch, the fifth arch in this instance being an accessory systemic-to-systemic conduit. In the final case, the persistent arch was initially considered to represent an aorto-pulmonary window but review revealed an aortic to pulmonary conduit more in keeping with the presence of a fifth arch. We conclude that the powers of mimicry of this enigmatic structure may account for its apparent rarity.

Aortic root triangulation as a cause of sudden death

We have reviewed an autopsy series of thirty-six patients who died suddenly after receiving a Starr--Edwards aortic valve prosthesis. In fifteen of the thirty-six explanted valves, the aortic outlet was narrowed with the three-legged prosthetic cage causing a triangular distortion of the wall. In the remaining twenty-one patients, the cause of sudden death was not related to failure of the mechanical valve. Although aortic root triangulation would appear to be an uncommon complication with the Starr--Edwards prosthesis, these findings emphasise the need to carefully size the aortic root diameter at the time of surgery, whilst the known problems of morbidity and mortality with mechanical heart valves should continue to stimulate those developing conservative valve reconstruction.

Persistent fifth aortic arch. A report of two new cases and a review of the literature

Two new cases of persistent fifth aortic arch are described, one with a distal connexion to the pulmonary circulation and the other to the systemic circulation. The previously reported cases are reviewed and the advantages conferred clinically by persistence of this structure are noted.

Aortic valve damage caused by operative balloon dilatation of critical aortic valve stenosis

Operative balloon dilatation of the aortic valve was performed in seven neonates with critical stenosis of the aortic valve. The procedure was followed by the development of severe aortic regurgitation in four patients. Necropsy was performed in three and revealed partial detachment of the right coronary cusp of the aortic valve. Damage to the valve leaflet caused by balloon dilatation was probably the result of using a balloon with a diameter that was too large in relation to the aortic valve ring diameter and of shearing forces created in the aortic wall by the contracting ventricle. The diameter of the inflated balloon should not be larger than the diameter of the aortic valve ring.

Maternal antibodies against fetal cardiac antigens in congenital complete heart block

An immunologic basis for congenital heart block has been proposed previously. To investigate the association between congenital heart block and maternal antibodies capable of crossing the placenta, we used immunofluorescence to examine serum samples from 41 mothers and 8 affected children, together with serum from controls, for antibodies to fetal cardiac tissue. Twenty-one mothers (51 percent) had IgG antibody reactive with fetal heart tissue, as compared with only 9 of 94 controls (10 percent; P less than 0.001). Three of 8 affected babies, but none of 50 healthy babies, had similar antibodies. The antibodies reacted with all myocardial tissue and were not directed specifically to the conduction system. They also reacted with other fetal tissues and could be distinguished from nuclear and smooth-muscle autoantibodies. We also observed a higher occurrence of antibodies to cytomegalovirus, but not to Epstein-Barr virus, in these mothers. Autopsy specimens from babies with congenital heart block examined by immunoperoxidase staining showed deposition of immunoglobulin and complement components in all cardiac tissues. These findings strengthen the case implicating immune reactivity related to maternal antibody in the development of some but not all cases of congenital heart block.

Abnormalities of the mitral valve in congenitally corrected transposition (discordant atrioventricular and ventriculoarterial connections)

Abnormalities of the mitral valve were found in 16 (55%) of 29 necropsy specimens of hearts with congenitally corrected transposition of the great arteries (discordant atrioventricular and ventriculoarterial connections). These abnormalities were most commonly of cusp number (21%) and tension apparatus (21%). Dysplasia of the valve was less common (10%), and other abnormalities identified included common valve, stenosis, and cleft valve. Some of the cases showed more than one morphological abnormality. The median age at death in those cases with mitral valve abnormalities was significantly higher than those without. More females than males had valves affected (ratio 2:1). Malformations such as ventricular septal defect and tricuspid or pulmonary valve anomalies were represented in similar proportions in cases with and without mitral anomalies.

Persistent right umbilical vein--case report and review of literature

Persistence of the proximal portion of the right umbilical vein is described in a premature infant. Infracardiac total anomalous pulmonary venous connexion and unilateral renal agenesis with ipsilateral phocomelia and unicornuate uterus were associated anomalies. The mother had received carbamazepine therapy for epilepsy. Previously reported cases of persistent proximal right umbilical vein have shown a variety of other malformations but a single umbilical artery has been the most consistent.

Placental and fetal pathology in Coxsackie virus A9 infection: a case report

A 27-year-old patient contracted a Coxsackie virus A9 meningitis at 33 weeks gestational age. Two weeks later a macerated female stillborn infant was delivered. The placenta showed a diffuse perivillous fibrin deposition with villous necrosis and inflammatory cell infiltration and yielded Coxsackie virus A9 on culture. Post-mortem examination of the fetus showed only minimal inflammatory changes in the cardiac connective tissue and the subarachnoid space.

Mechanism of late failure of the Alvarez disc valve prosthesis

An Alvarez disc valve prosthesis had been implanted in the mitral and tricuspid positions in 15 patients between 1964 and 1967 in this hospital. Of these 15 patients, only three survived longer than 10 years, all three dying unexpectedly between 16 and 18 years postoperatively. Two deaths were a direct result of disruption of the Alvarez prosthesis. The third patient was not examined at necropsy, but in retrospect the history was highly suggestive of valve malfunction. Cross sectional and pulsed Doppler echocardiography made valuable contributions to the diagnosis in both cases of valve disruption and, when available, should be part of the primary investigation of suspected prosthetic heart valve failure. The Alvarez valve prosthesis is liable to erosive wear which may cause late detachment of the disc from the valve ring with abrupt and catastrophic haemodynamic consequences.

An unusual type of anomalous pulmonary venous drainage associated with a complex left heart hypoplasia and a variety of divided left atrium ("cor triatriatum")

A previously unreported complex congenital cardiac malformation was noted in which a vestigial left atrium consisted of two completely separate portions, one of which was connected to the pulmonary veins but had no outlet orifice. The pulmonary venous drainage was through an anomalous intrapulmonary vein within the displaced right lung into the inferior caval vein above a deformed diaphragm. The left atrioventricular connexion was absent. Some points of terminology are considered.

Pre-excitation due to accessory sinoventricular connexions associated with coronary sinus aneurysms. A report of two cases

Ventricular pre-excitation occurred in two cases in which the accessory pathways between the atria and the ventricles were histologically identified as being associated with aneurysmal malformations of the coronary sinus. In one case the connexions were in the posterior wall of the coronary sinus aneurysm and were not related to the atrioventricular annulus; in the other, a connexion was situated in the anterior wall of the aneurysm in close apposition to the annulus and superficially resembled a Kent fibre. These connexions were considered to be of sinus venosus origin and to represent a modification of the muscular sheath that normally surrounds the coronary sinus but does not continue along the coronary veins. One of the posterior wall connecting bundles was composed of abnormally large Purkinje-like fibres; this may have played some role in the manifestation of the pre-excitation by reducing any mismatch impedance.

Cardiac malformations in spontaneous abortions

A detailed examination of 247 spontaneously aborted foetuses, under the age of 24 weeks gestation, showed 38 instances of cardiac malformation (15.4%). Very early specimens were not included. There was a bimodal relationship with maternal age and parity and a higher incidence in summer conceptions, but there was no apparent association with maternal blood groups. There were more male foetuses and they had proportionately more malformed hearts than the females. There was a marked inverse relationship with foetal age; in early foetuses, less than 25 mm, cardiac malformations were present in 68%. A wide variety of morphological abnormalities was encountered; these are listed. No cardiac malformations occurred in 72 threatened abortions which went to full-term delivery.

Left ventricular bands. A normal anatomical feature

Discrete delicate fibromuscular structures crossing the cavity of the left ventricle were identified on morphological examination in 329 (48%) of 686 hearts from patients of all ages with congenital heart disease, acquired heart disease, or normal hearts. These structures were also present in 151 (95%) of 159 hearts from animals of six species. Cross sectional echocardiographic findings compatible with these structures were obtained in 39 (21.7%) of 179 children reviewed retrospectively and in three of 800 (0.4%) adults studied prospectively. These structures appear to be a normal anatomical finding.

Coronary sinus orifice atresia and persistent left superior vena cava. A report of two cases, one associated with atypical coronary artery thrombosis

Fourteen previously reported cases of atresia of the coronary sinus ostium, in which the coronary venous flow entered the right atrium by a persistent left superior vena cava, the innominate vein, and the right superior vena cava, are reviewed and two new cases reported. The first new case was in a 43 year old woman with atypical chest pains in whom investigations for suspected ischaemic heart disease, including coronary arteriography, yielded normal results. She died suddenly from massive myocardial infarction due to extensive old thrombotic occlusion of a major coronary artery without any appreciable underlying disease of the vessel wall. Exercise testing is considered to be advisable in symptomatic patients with normal coronary angiograms and attention to the venous phase might be informative. The second new case occurred in a child with an atrial septal defect and complete transposition of the great arteries, who died aged 1 month.

Valvar stenosis in truncus arteriosus

Twenty three morphological specimens of truncus arteriosus were examined for evidence of stenosis of the semilunar valve. One third showed good evidence of stenosis as judged by careful measurement of the valve orifice, the valve ring, and the maximum diameter of the truncus. Correlation with measured pressure gradients was poor, but angiography and cross sectional echocardiography were better predictors of stenosis. Stenosis was invariably associated with cusp dysplasia and was more common in valves with two or four cusps.

Duplication of the left atrioventricular valve in double inlet left ventricle: a triple inlet ventricle?

A heart is described with double inlet left ventricle, rudimentary right ventricle and ventriculo-arterio discordance. The lesion was complicated by a malformation of the left atrioventricular valve. The valve was divided into two distinct orifices. The major orifice connected to the morphologically left ventricle along with the right atrioventricular valve. The minor orifice opened predominantly into the rudimentary right ventricle but in part to the dominant left ventricle. The problems such a lesion produces in terms of nomenclature are discussed with regard to sequential segmental analysis.

Atrioventricular valve diverticulum--an unusual congenital malformation

A previously unreported congenital malformation was noted in an infant with right atrial isomerism ("asplenia syndrome"). The superior bridging leaflet of a common atrioventricular valve was attached to a band of muscular tissue spanning the atrioventricular junction. A large ventricular diverticulum extended into the substance of this band, possibly due to traction during fetal life.