Angiography for delineation of systemic-to-pulmonary shunts in congenital pulmonary atresia: evaluation with the dynamic spatial reconstructor

In patients with pulmonary valve atresia, the arterial supply to the lungs is derived entirely from the aorta or its major branches. The anatomic detail of this arterial supply is usually identified by obtaining multiple selective arteriograms involving numerous injections of contrast material and x-ray exposures. In this study, we demonstrated that the information obtained from conventional diagnostic angiography in two patients with congenital pulmonary atresia was also clearly evident on scans from the dynamic spatial reconstructor (DSR), a high-speed three-dimensional computed tomographic system. Thus, numerous shunts, stenoses, and systemic collateral arteries were demonstrated by DSR scanning, which involved only one or two nonselective injections of a contrast agent and less x-ray exposure than that normally necessitated by angiographic study.

Aortico-left ventricular tunnel: diagnosis based on two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging

Aortico-left ventricular tunnel is a rare congenital cardiac lesion that often results in severe aortic insufficiency in infancy. In previously reported cases, the diagnosis has often been missed initially despite use of cardiac catheterization and angiography. We describe a patient who underwent successful surgical correction of this malformation at 10 months of age after the diagnosis had been established by use of two-dimensional echocardiography, color flow Doppler imaging, and magnetic resonance imaging. Aortico-left ventricular tunnel can be diagnosed by use of these noninvasive means without cardiac catheterization.

Prognostic factors and surgical treatment of partial atrioventricular canal

In this study we sought to determine the prognostic factors that influence early and late survival after repair of partial atrioventricular canal and the need for reoperation. From January 1962 to January 1984, 199 patients underwent correction of partial atrioventricular canal. There were 73 male and 126 female patients, ranging in age from 5 months to 71 years (mean 11.2 years). Total 30 day operative mortality was 5.5%. Since 1980, the mortality has declined to 3%. Significant determinants of operative mortality were congestive heart failure, cyanosis, failure to thrive, age less than 4 years, and moderate-to-severe mitral valve insufficiency (p less than .01). Sex, cardiomegaly, radiographically increased pulmonary vasculature, intraoperative postrepair right ventricular-to-left ventricular pressure ratio, and pulmonary-to-systemic flow ratio were not significant in determining early mortality. Follow-up ranged from 1 to 21.4 years (mean 15.2). There were seven late deaths, primarily in older patients from atherosclerotic disease or malignancy. Late survival was 98% at 1 year and 96% at 20 years. Reoperation was performed on 18 patients, 15 for mitral incompetence, and three for subaortic stenosis. The need for reoperation correlated with severity of postrepair mitral insufficiency. Longterm survival is excellent after repair of the partial form of atrioventricular canal.

Staged surgical repair of pulmonary atresia, ventricular septal defect, and hypoplastic, confluent pulmonary arteries

In patients with pulmonary atresia and ventricular septal defect, hypoplasia of the central pulmonary arteries prevents single-stage complete repair. Over an interval of 8 1/2 years, 105 patients underwent establishment of continuity between the right ventricle and a hypoplastic central pulmonary arterial confluence (first stage). There were 12 hospital deaths (11%) and 11 late deaths before second-stage (complete) repair. Twenty-five patients await late evaluation. The remaining 57 individuals have had follow-up cardiac catheterization a mean of 33 months postoperatively. In 31 of these, final repair was deferred because of insufficient pulmonary arterial enlargement (14), restricted peripheral arborization (nine), or both (eight). The final 26 patients were accepted for second-stage repair, which has been performed in 24. Complete repair included ventricular septal defect closure (24), right ventricular outflow tract reconstruction (18), relief of central pulmonary arterial stenosis (14), and ligation of systemic-pulmonary collateral arteries (10). The mean postrepair peak systolic right ventricular-left ventricular pressure ratio was 0.67 (range 0.32 to 1.0). One of these patients (4%) died in the hospital and there was one late death (4%) from sepsis after tricuspid valve replacement. Three patients were lost to follow-up; the remaining 19 patients are in functional Class I or II. A two-stage surgical approach is highly successful in those patients whose pulmonary arteries are too hypoplastic to allow a single-stage repair.

Magnetic resonance imaging of vascular rings

This case report illustrates the ability of magnetic resonance imaging (MRI) to define the abnormal aortic anatomy associated with a vascular ring malformation. After a brief review of the clinical and pathologic aspects of vascular rings, the unique characteristics of MRI that make it particularly well suited for cardiovascular imaging are discussed. A comparison between MRI and other currently used imaging modalities emphasizes their differences and indicates some of the advantages of MRI of the cardiovascular system. We recommend MRI as the technique of choice for patients suspected of having a vascular ring and predict that MRI will play an important role in the diagnosis of cardiovascular abnormalities in the future.

The "broken ring" sign in magnetic resonance imaging of partial anomalous pulmonary venous connection to the superior vena cava

In two patients with partial anomalous pulmonary venous connection to the superior vena cava, we attempted to demonstrate the pertinent anatomic abnormalities by using magnetic resonance imaging. The results show that magnetic resonance imaging is an ideal cardiovascular imaging modality. The observation of a "broken ring" structure in the magnetic resonance image of the superior vena cava is proposed as a diagnostic sign of partial anomalous pulmonary venous connection to the superior vena cava.

Pulmonary blood supply in patients with pulmonary atresia and ventricular septal defect

The heart and lung specimens in 31 cases of pulmonary value atresia and ventricular septal defect were studied at autopsy. Three types of natural arterial blood supply to the lungs were identified: 1) ductus arteriosus (patient or ligamentous) (12 cases); 2) major collateral arteries (20 cases); and 3) diffuse small pleural arterial plexus coexisting with either ductus arteriosus or major collateral arteries (17 cases). The ductus arteriosus and major collateral arteries did not coexist in the same lung in these cases. Confluent central pulmonary arteries were present in 22 (71%) of the 31 cases, involving 7 (58%) of the 12 cases of ductus arteriosus, 14 (70%) of the 20 cases with major collateral arteries and 1 case with an aorticopulmonary window. The pulmonary trunk (atretic or patent) was identifiable in 24 (77%) of the 31 cases. A lung or lungs that connected to a ductus (or ligamentum) had a complete and unifocal intrapulmonary arterial distribution (without arborization abnormalities). Major collateral blood supply was frequently multifocal and associated with arborization abnormalities. The size of the central pulmonary arteries was not related to the type of arterial blood source but seemed to be related to the amount of blood flow actually reaching the vessels, This study demonstrated a complex systemic arterial system supplying the lungs in these cases. The size, sources and relation among the ductus, the pulmonary artery confluence, the large and small collateral vessels and the intrapulmonary system are far more varied than has ever been reported previously. Careful and thorough premortem studies are crucial if surgical intervention is contemplated.

Pulmonary artery thrombosis associated with anomalous pulmonary venous connection: an unusual complication following the modified Fontan procedure

The presence of unrecognized partial anomalous pulmonary venous connection may cause complications of pulmonary infarction and right-to-left shunting in patients undergoing the modified Fontan procedure. These complications can be prevented by identification of any anomalous pulmonary venous connection at preoperative cardiac catheterization.

Relationship of pulmonary artery size to mortality in patients undergoing the Fontan operation

The size of the pulmonary arteries, measured intraoperatively, was correlated with operative mortality in 90 patients who underwent the Fontan operation. There was no significant difference in the cross-sectional area of the right and left pulmonary arteries/body surface area (PA index) between survivors and nonsurvivors. There was no significant difference in mortality rates between patients with a PA index greater than 250 and those with a PA index less than 250 mm2/m2. Survival was observed with cross-sectional area as low as 188 mm2/m2.

Detection of intrapericardial hematoma after open heart surgery: the roles of echocardiography and computed tomography

Two patients who had right atrial compression caused by intrapericardial hematomas after coronary artery bypass grafting and aortic valve replacement are described. During the course of postoperative evaluation, each patient underwent an echocardiographic examination followed by computed tomography of the chest. Two-dimensional echocardiography visualized the hematomas in both cases. Computed tomography played a useful adjunctive role by further clarifying their nature, location and extent.

Anatomy and function of the heart and intrathoracic vessels in congenital heart disease: evaluation with the Dynamic Spatial Reconstructor

The Dynamic Spatial Reconstructor is a unique high speed volume imaging X-ray scanner based on computed tomographic principles. It has several potential advantages over conventional angiographic methods, including reduced invasion, reduced rate of false negative results and increased accuracy of measurements of structure and function. To evaluate the utility of the Dynamic Spatial Reconstructor in the investigation of congenital heart disease, scanning was performed in several pediatric patients with pulmonary valve atresia. Early results show that three-dimensional images of the cardiac chambers and intrathoracic vessels can be acquired and displayed with the system. All the information necessary for quantitative analysis of the pulmonary arteries can be obtained with a single scan involving injection of 0.6 to 2.0 cc/kg of contrast agent and radiation exposure of 0.54 to 0.95 rad/s over 5 to 8 seconds.

Left ventricle-aortic conduits in pediatric patients

From August, 1974, to January, 1982, left ventricle-aortic porcine valved conduits were inserted in three patients less than 2 years old (Group 1) and in 10 patients between 2 and 14 years of age (Group 2) for relief of severe left ventricular outflow tract obstruction. The distal anastomosis was made to the ascending aorta in seven patients and to the supraceliac abdominal aorta in six patients. In six patients, the conduit was sutured directly to the left ventricle, and in seven a stented right-angle connector was employed. The left ventricle-aortic gradients were relieved in all cases (mean residual gradient = 4.3 mm Hg). All three patients in Group 1 had associated endocardial fibroelastosis and all died. There was one early death in Group 2 (10% mortality). Reoperation was required in seven of nine survivors (78%) 2.7 to 5.2 years postoperatively for conduit valve failure (five patients), progression of mild native aortic valve insufficiency (one patient), or both (one patient). One of the seven required another reoperation for re-replacement of the conduit valve. There was one late death associated with reoperation. At follow-up 3.4 to 7.5 years postoperatively, four patients are in Functional Class I, two are in Class II, and two are convalescing from reoperation. Left ventricle-aortic conduits provide excellent relief of left ventricular outflow tract obstruction. However, the high incidence of late complications suggests better results might be anticipated with aortoventriculoplasty (Konno).

The Dynamic Spatial Reconstructor: investigating congenital heart disease in four dimensions

The Dynamic Spatial Reconstructor (DSR) is a high-temporal resolution, three-dimensional (3-D) X-ray scanning device based on computed tomography (CT) principles. It was designed for investigation of some problems inherent in current diagnostic imaging techniques, and to allow quantitative studies of cardiovascular structure and function. One of the research protocols in which DSR is currently used involves studying selected pediatric patients with complex congenital heart disease. Initial results show that 3-D dynamic images can be obtained from these patients with minimal invasiveness and that these images may provide useful diagnostic information.

Complete atrioventricular canal associated with tetralogy of Fallot. Morphologic and surgical considerations

Between 1962 and 1979, 14 patients with complete atrioventricular canal and tetralogy of Fallot underwent repair of both anomalies. The ages of the patients ranged from 1 to 12 years. Six patients had Down's syndrome. Five of the 14 had one or more previous systemic-pulmonary artery shunts. The correct diagnosis was established preoperatively in 11 of the patients. The ventricular septal defect, with its large anterior subaortic extension, was repaired by a combined atrial and right ventricular approach in five patients and by an atrial approach alone in nine. Outflow tract reconstruction (transannular patch) was performed in seven patients, without affecting the surgical mortality. Mortality was higher with associated Down's syndrome, but not significantly so (p = 0.1), and was related to age less than 4 years (p = 0.04). The presence of complete atrioventricular canal should be considered in patients with tetralogy of Fallot, especially those having Down's syndrome, electrocardiographic superior-axis deviation, and vectorcardiographic counterclockwise frontal QRS loop. This diagnosis can be confirmed preoperatively by right and left ventricular angiocardiography and two-dimensional echocardiography. The overall risk of repair has been high (29% early, 14% late mortality), but the mortality has been reduced to 17% during the last 10 years. No deaths have occurred in five recent patients who underwent closure of the ventricular septal defect by a combined atrial and ventricular approach.

Left juxtaposed atrial appendages: diagnostic two-dimensional echocardiographic features

Left juxtaposition of the atrial appendages is usually associated with cyanotic congenital heart disease. Recognition of this rare anomaly is important before therapeutic or surgical procedures that involve the atrial septum can be undertaken (for example, septostomy, the Mustard or Senning operation and the Fontan anastomosis). The diagnosis of left juxtaposition of the atrial appendages is most commonly an incidental finding at the time of surgery or autopsy. This report describes the two-dimensional echocardiographic visualization of left juxtaposed atrial appendages. The diagnostic echocardiographic features are based on characteristic alterations of the plane of the atrial septum and visualization of the malpositioned right atrial appendage. On the basis of these observations, a noninvasive diagnosis of left juxtaposed atrial appendages is now possible by means of two-dimensional echocardiography.

Complete repair of pulmonary atresia with nonconfluent pulmonary arteries

From 1973 through 1979, 16 patients with pulmonary atresia, two normal-sized ventricles, and bilateral but nonconfluent pulmonary arteries underwent complete repair at the Mayo Clinic. Mean age at operation was 9.1 years (standard deviation [SD] 5.2 years). Sources of pulmonary flow were previous surgical shunts, patent ductus arteriosus, and discrete systemic-pulmonary arterial collaterals. The complete surgical repair included interruption of extracardiac shunts, closure of ventricular septal defect (15 patients), closure of atrial septal defect (3 patients), and establishment of right ventricular-pulmonary arterial continuity with a porcine-valved extracardiac conduit anastomosed to a transverse limb (T graft in 12 patients) or to a side-limb (Y graft in 4 patients). There were no operative deaths. Morbidity included reoperation for bleeding in 3 patients and compression of the prosthetic graft by the sternal closure in 1. The mean postrepair ratio of right ventricular peak systolic pressure to left ventricular peak systolic pressure (pRV/pLV) was 0.64 (SD, 0.23). Follow-up ranged from 12 to 72 months (means, 34.6 months; SD, 20.7 months). One patient died 12 months after operation (postrepair pRV/pLV, 1.3). Conduit obstruction has been proved in 4 patients, of whom 3 underwent reoperation for extracardiac conduit obstruction at 46, 47, and 48 months. The remaining 11 patients are alive and free of major symptoms.

Two-dimensional echocardiographic assessment of dextrocardia: a segmental approach

Two-dimensional echocardiography was used in the prospective evaluation of 40 patients with the clinical diagnosis of dextrocardia. A segmental analysis of the situs, connections, ventricular anatomy, and chamber positions was utilized for a complete diagnostic assessment. An adequate examination was possible in 33 of these patients; the findings were confirmed by cardiac catheterization and angiography in 31 patients and at operation in 26. Use of the location of the liver and the drainage of the hepatic veins and inferior vena cava allowed atrial visceral situs to be defined in 33 patients (solitus 21, inversus 9, and ambiguous 3). Pulmonary venous connections were correctly identified in 27. In 33 patients, atrioventricular (AV) and ventriculoarterial connections and ventricular anatomy were correctly predicted. Twenty patients had 2 separate well-developed ventricles. Ventriculoarterial connections were determined correctly in all 20 patients: concordant in 5, discordant in 6, double-outlet right ventricle in 5, and single-outlet right ventricle (pulmonary atresia) in 4. In 16 patients a ventricular septal defect was correctly identified. In the remainder the ventricular septum was intact. Thirteen patients had univentricular heart: 8 had 2 AV valves (double-inlet ventricle) 3 had common AV inlet, and 2 had atresia of 1 AV connection. Two-dimensional echocardiography allowed the accurate assessment of complex congenital heart defects associated with dextrocardia. Utilizing a segmental approach, one can correctly predict atrial-visceral situs, ventricular morphology and situs, and AV and ventriculoarterial connections.

Two dimensional echocardiographic detection and measurement of the right pulmonary artery in pulmonary atresia-ventricular septal defect: angiographic and surgical correlation

This study assessed the value of two dimensional echocardiography in patients with pulmonary atresia-ventricular septal defect in order to detect the presence of true pulmonary arteries, measure the dimension of the visible proximal right pulmonary artery and correlate these echocardiographic observations with angiographic and surgical findings. The data from 65 patients (age range 16 months to 54 years) with pulmonary atresia-ventricular septal defect who had both two dimensional echocardiographic and angiographic evaluation to determine the presence of pulmonary arteries were reviewed. Echocardiography allowed visualization of a right pulmonary artery in 55 (85 percent) of the 65 patients. Echocardiography detected a measurable proximal right pulmonary artery in 52 (98 percent) of 53 patients who had confluent pulmonary arteries confirmed with angiography. In three patients without confluence, a large systemic to pulmonary collateral artery was misinterpreted as the right pulmonary artery on two dimensional echocardiography. Right pulmonary arterial measurements on echocardiography (range 3 to 21 mm) showed excellent correlation with angiographic (r = 0.95) and surgical (r = 0.84) measurements. These data indicate that two dimensional echocardiography can be used to visualize proximal true pulmonary arteries (specifically, a right pulmonary artery) in a large proportion of patients with pulmonary atresia-ventricular septal defect; this finding usually denotes the presence of confluent pulmonary arteries. The data also suggest that this method can be reliably used for serial follow-up studies with noninvasive measurement of proximal right pulmonary arterial growth.

Pulmonary processes of mature-appearing lymphocytes: pseudolymphoma, well-differentiated lymphocytic lymphoma, and lymphocytic interstitial pneumonitis

Patients with pseudolymphoma, well-differentiated lymphocytic lymphoma, and lymphocytic interstitial pneumonitis were studied. Diagnoses were confirmed by recently developed immunochemical staining techniques. Radiographic findings in pseudolymphoma were different from those in well-differentiated lymphocytic lymphoma, and clinical findings in lymphocytic interstitial pneumonitis were different from those in the other two types of lesions. The interstitial infiltrate of lymphocytic interstitial pneumonitis had two patterns: basilar with an alveolar component and diffuse with associated honeycombing. Pseudolymphoma and lymphocytic interstitial pneumonitis are being polyclonal inflammatory processes without malignant potential. Well-differentiated lymphocytic lymphoma, a monoclonal neoplasm, often has an indolent course.