Distal ductal origin of the right pulmonary artery: prospective diagnosis and primary repair in infancy

Absence of the proximal segment of the right pulmonary artery was diagnosed by echocardiography in two neonates. In both a right-sided duct communicated with the right pulmonary artery at the hilum of the lung. Successful surgical repair was undertaken at seven months and 10 weeks, respectively

Balloon dilatation of the arterial duct in congenital heart disease

The systemic circulation of newborn infants with congenital left-heart obstruction is supplied from the right ventricle via a patent arterial duct between the pulmonary artery and descending aorta. The duct closes during the first few days of life, but infusion of prostaglandin E2 can prevent closure in some cases. We report four newborn infants (aged 3-8 days) with intractable heart failure due to severe obstruction of the left heart in the presence of a closing arterial duct. Infusion of prostaglandin E2 did not improve their clinical condition. Cardiac catheterisation and balloon dilatation of their arterial ducts resulted in a dramatic improvement in the babies' clinical condition; during subsequent surgical repair of the infants' hearts, the arterial ducts were found to be widely patent. Balloon dilatation gives immediate and sustained wide patency of the arterial duct in infants who do not respond adequately to prostaglandin E2.

Absent left-sided atrioventricular connexion, with right atrium connected to left ventricle: prospective diagnosis in infancy, and outcome

Prospective echocardiographic diagnosis of absence of the left atrioventricular connexion, with the right atrium connected to a morphologic left ventricle through a bileaflet morphologically mitral valve, was made in six infants. The rudimentary right ventricle was left-sided in all patients, and separated from the left atrium by sulcus tissue. The ventriculoarterial connexions were discordant. Associated defects included subpulmonary stenosis (2 patients), pulmonary atresia (1 patient), and a patent duct (4 patients). All patients developed early left atrial hypertension due to a restrictive interatrial septum, and required transcatheter septostomy (5 patients), or surgical septectomy (3 patients). One patient who had a severely restrictive ventricular septal defect died following cardiac catheterization. In three others the ventricular septal defect has become progressively restrictive on serial catheterization. Successful intermediate term palliation has been performed in two patients using a bidirectional Glenn anastomosis, together with enlargement of the ventricular septal defect and a Damus-Kay-Stansel procedure in one. It is possible to distinguish this malformation from "mitral atresia" using cross-sectional echocardiography. The long-term outlook is influenced by early relief of left atrial hypertension. Balloon atrial septostomy alone is usually inadequate, and either blade septostomy or surgical septectomy are required. Serial cardiac catheterization is mandatory for planning definitive palliation.

Traumatic ventricular septal defect: serial follow-up with Doppler ultrasound

A three-year-old girl presented with a gunshot wound of the chest. Cross-sectional and Doppler echocardiography enabled precise location of the bullet, and assessment of the haemodynamic effects of the traumatic ventricular septal defect. Serial ultrasound examination in the acute stage confirmed that the bullet was well embedded in the left ventricular myocardium, and the ventricular septal defect was restrictive, enabling conservative management.

Diaphragmatic hernia with extrathoracic heart

We report the cross sectional ultrasonic diagnosis of a rare form of central diaphragmatic hernia. The inferior portion of the parietal pericardium was also absent, with herniation of the heart through the defect. Surgical repair was successfully undertaken based on the ultrasonic findings.

Tricuspid atresia with common arterial trunk: surgical palliation in a neonate

A two-week-old asymptomatic baby was diagnosed by cross-sectional and Doppler ultrasound to have tricuspid atresia with a common arterial trunk. Successful surgical palliation was undertaken at 17 days of age, by disconnection of the pulmonary arteries from the trunk, and creation of an aortopulmonary shunt. There are no known previous reports of surgical palliation of this lesion.

Results of balloon pulmonary valvuloplasty as a palliative procedure in tetralogy of Fallot

Balloon pulmonary valvuloplasty was attempted in 67 patients with tetralogy of Fallot at a median age of 5 months (range 0.03 to 52 months) for relief of cyanosis. In three patients, the valve could not be crossed and an aortopulmonary shunt was performed. In 35 patients, follow-up angiography was performed 3 to 30 months (average 12) after valvuloplasty. In 24 of these 35 patients (group A), the stenosis had been adequately palliated by valvuloplasty; the other 11 patients (group B) had required an aortopulmonary shunt 1 month (range 0 to 3 months) after valvuloplasty. The two groups were similar (p greater than 0.1) with respect to age at valvuloplasty, pulmonary anulus diameter, ratio of pulmonary artery to descending aorta diameter before valvuloplasty and interval to follow-up angiography. In contrast to patients in group B, patients in group A had a significant immediate improvement in systemic arterial oxygen saturation (p less than 0.01) and a significant increase in pulmonary anulus diameter at follow-up angiography (p less than 0.001). The growth of the branch pulmonary arteries was similar (p greater than 0.1) in the two groups. Among 42 patients who have had surgical correction, a transannular patch for right ventricular outflow tract reconstruction was used in 27 (64%); there was no difference between groups A and B with respect to its use. Eight patients died (three after repair) and death could not be directly attributed to valvuloplasty in any. Balloon valvuloplasty promotes growth of the pulmonary valve anulus and pulmonary arteries and is a useful alternative to an aortopulmonary shunt in patients with small pulmonary arteries or associated complex intracardiac defects.

Aortopulmonary window with aortic origin of the right pulmonary artery

Cross-sectional Doppler echocardiographic diagnosis of an aortopulmonary window with type B interrupted aortic arch, and anomalous origin of the right pulmonary artery from the ascending aorta was made in a 15-day-old neonate. This is the first known reported case of surgical repair for this rare association based on prospective echocardiographic diagnosis alone.

Cerebral arteriovenous malformations in the neonate: clinical presentation, diagnosis and outcome

We reviewed the diagnostic features and clinical outcome of 7 consecutive neonates who were diagnosed to have cerebral arteriovenous malformations. All presented with cardiac failure, and a cranial bruit was heard in 6/7 patients. There was electrocardiographic evidence of myocardial ischemia in 6 patients. The diagnosis was established at cardiac catheterization, or by cardiac and cranial ultrasound. Three patients died of heart failure before definitive treatment. Despite early intervention, three of the remaining four patients died either during or immediately after embolization or ligation of the fistula. A cerebral arteriovenous malformation is a rare cause of neonatal heart failure. Despite prompt recognition and aggressive treatment, the outlook for symptomatic neonates is poor.

Role of intraoperative ultrasound examination in patients undergoing a Fontan-type procedure

To determine its potential impact on perioperative surgical management intraoperative ultrasound examination (cross sectional imaging, colour flow mapping, pulsed and continuous wave Doppler) was used in 16 consecutive patients undergoing a Fontan-type procedure. Epicardial cross sectional imaging before bypass defined the precise intracardiac morphology in 15 of 16 patients. The preoperative morphological diagnosis was refined in four patients (25%), and this influenced surgical management in two (12%). Epicardial studies after bypass identified seven residual haemodynamic lesions in five patients (three residual intercardiac shunts, one ventricular outflow obstruction, one pulmonary artery obstruction, two mitral valve regurgitation), and led to immediate revision during a second period of bypass in three (18%). In one patient who required early reoperation residual shunting was not detected after bypass by either colour flow mapping or a contrast study. Final intraoperative studies showed a good surgical result in 14 patients (87%). Flow characteristics and flow velocities within the Fontan circulation could be assessed immediately after the patient came off cardiopulmonary bypass by means of combined pulsed wave Doppler and colour flow mapping in 14 of the 16 patients. Cross sectional studies of the left heart after bypass showed no change in ventricular function and allowed monitoring of volume replacement and ventricular filling. Intraoperative ultrasound was a valuable monitoring technique in patients undergoing a Fontan-type procedure. It refined preoperative diagnosis, monitored ventricular function, and identified or excluded residual haemodynamic lesions in most patients.

Aortic-ventricular tunnel in a neonate: diagnosis and management based on cross sectional and colour Doppler ultrasonography

A five day old symptom free neonate was referred for assessment of a to and fro murmur associated with large volume pulses. Cross sectional echocardiography and colour flow mapping confirmed the diagnosis of an aortic-ventricular tunnel with forward flow into the aorta and regurgitant flow into the ventricle through both the tunnel and the dilated aortic valve ring. Surgical correction by patch closure of the aortic end of the tunnel was successfully undertaken two weeks later without any additional investigations. Postoperative echocardiography and colour flow imaging showed no aortic regurgitation and normal left ventricular dimensions and function.

Aortic atresia with normal left ventricle: one-stage repair in early infancy

Successful one-stage repair of aortic atresia with a left ventricle was performed in a 6-week-old infant using a new technique. After patch enhancement of the hypoplastic aortic arch, the transected proximal pulmonary artery was directly anastomosed to the aortic arch. An intraventricular baffle established continuity between the left ventricle and neoaortic valve, and a homograft conduit was inserted between the right ventricle and pulmonary artery bifurcation.

The role of transoesophageal echocardiography in adolescents and adults with congenital heart defects

Between April 1985 and December 1989, outpatient transoesophageal echocardiography was performed in 133 adolescent and adult patients (14% of all outpatient transoesophageal studies) (age range 11-78 years; weight 30-95 kg) to determine the value of this technique both in establishing the primary diagnosis (62 patients) and in the post-surgical follow up (71 patients) of congenital heart disease. The results were correlated with the findings of precordial echocardiography, catheterization and surgical inspection. Clear advantages of transoesophageal imaging over precordial imaging include: (1) direct identification of atrial appendage morphology in all patients; (2) delineation of systemic and pulmonary venous connections; (3) atrial baffle function (eight patients); (4) better evaluation of the Fontan-type circulation (five patients); (5) improved morphologic assessment of the atrioventricular junction and valves (29 patients); (6) definition of subaortic obstruction (18 patients); and (7) definition of ascending aortic morphology in Marfan's syndrome and supravalvar aortic stenosis (13 patients). The problems encountered with transoesophageal imaging include: (1) limited imaging planes; (2) poor visualization of specific intracardiac regions (antero-apical trabecular septum, right ventricular outflow tract); (3) flow masking behind implanted intracardiac prosthetic material.

Cardiovascular effects of acute bronchiolitis

Twenty-one children with normal hearts were studied during acute bronchiolitis. Doppler echocardiography showed tricuspid valve regurgitation in 11 patients, many of whom had evidence of raised pulmonary artery systolic pressure. Serial studies in those with severe infection showed that tricuspid regurgitation disappears with clinical improvement.

Comparative value of transthoracic and transesophageal echocardiography in the assessment of congenital abnormalities of the atrioventricular junction

Information obtained from transthoracic and transesophageal echocardiography (two-dimensional echocardiography with spectral Doppler and color flow imaging) was compared in 17 patients with major congenital abnormalities of the atrioventricular (AV) junction (10 discordant AV connections, 1 criss-cross connection, 5 absent right connections and 1 absent left connection). The findings by either technique were correlated with findings at cardiac catheterization (12 patients) and at surgery (5 patients). In two of six patients with an absent AV connection as defined by transthoracic echocardiography, transesophageal imaging demonstrated an imperforate AV valve. In 11 of 11 patients with a discordant or criss-cross connection, assessment of AV valve and ventricular morphology (by defining the chordal attachments of both AV valves) was possible with transesophageal echocardiography (3 of 11 patients by transthoracic echocardiography); chordal straddling was detected in 1 patient and excluded in 3 others with an associated inlet ventricular septal defect. Anomalous pulmonary venous connection (one patient), atrial septal defect (three patients) and subpulmonary stenosis (five patients) were better assessed by transesophageal imaging, and atrial appendage morphology could be demonstrated in all. The transesophageal technique was less useful in demonstrating the anterior subaortic infundibulum or aortopulmonary shunt (two patients). Although systemic ventricular function could be assessed by either method with use of short-axis M-mode scans, transesophageal pulsed Doppler interrogation of AV valve and pulmonary venous flow patterns provided clues to diastolic dysfunction of the systemic ventricle.

Subaortic obstruction: intraoperative echocardiography as an adjunct to operation

Fourteen patients undergoing operation for subaortic obstruction (membranous obstruction in 11 patients, tunnel obstruction in 2 patients, obstruction due to reduplicated mitral valve tissue in 1 patient) were evaluated by intraoperative epicardial echocardiography. In all 9 patients with "discrete" obstruction who underwent prebypass epicardial echocardiography, the septal and lateral attachments of the lesion were correctly demonstrated. The precise extent of tunnel stenosis was seen in both patients. The lateral attachment of the membrane in 4 patients and multiple extensions in another 2 were identified by the epicardial study (having been missed on precordial echocardiography). The discrete membrane was enucleated in 10 of the 11 patients and was partially resected in 1. One tunnel obstruction was completely relieved; the other was partially relieved. Reduplicated mitral valve tissue in the remaining patient was completely resected. Epicardial imaging after bypass showed remnants of the membrane in 2 patients. Intraoperative Doppler echocardiography and color flow imaging confirmed the absence of clinically significant residual gradients (less than 20 mm Hg) in all but 1 patient with tunnel obstruction. Epicardial imaging provided excellent morphological information about obstructive lesions of the left ventricular outflow tract and enabled immediate assessment of surgical repair.

Comparative roles of intraoperative epicardial and early postoperative transthoracic echocardiography in the assessment of surgical repair of congenital heart defects

In 94 consecutive patients undergoing surgical repair of congenital heart defects the results of intraoperative (after cardiopulmonary bypass) epicardial two-dimensional and Doppler color flow imaging were compared with those of sequential transthoracic echocardiography performed within 24 h of surgery and again before hospital discharge to define the precise role of intraoperative imaging. In 6 of 7 patients with a residual defect requiring immediate surgical revision, intraoperative imaging correctly identified the defect; spectral Doppler imaging underestimated or did not identify a residual outflow tract gradient in 17 patients. Left atrioventricular (AV) valve regurgitation after repair of complete AV septal defect was underestimated in three patients. Although intraoperative documentation of good ventricular function was usually associated with a good outcome, in three patients poor systemic ventricular function after cardiopulmonary bypass was not associated with early mortality. A minor degree of shunting around the patch was a common finding on epicardial and early postoperative imaging and persisted at the time of hospital discharge in 17 of 46 patients who had undergone patch closure of a ventricular septal defect as part of the surgical procedure. Additional trabecular septal defects were missed on color flow imaging after cardiopulmonary bypass in three patients, one of whom required subsequent reoperation. Although intraoperative two-dimensional and color flow imaging permitted the recognition of the majority of residual defects requiring immediate revision, residual outflow obstruction or AV valve regurgitation was usually underestimated.

Comparative values of the precordial and transesophageal approaches in the echocardiographic evaluation of atrial baffle function after an atrial correction procedure

Previous methods used to assess atrial baffle function after correction of transposition of the great arteries have included precordial echocardiography and cardiac catheterization. To evaluate whether single plane transesophageal echocardiography might provide additional information, its findings were correlated with information derived from both precordial echocardiography and cardiac catheterization in 15 patients (14 Mustard procedures, 1 Senning procedure) aged 4.2 to 33 years (mean 16.3). Precordial ultrasound with combined imaging, color flow mapping and pulsed Doppler ultrasound visualized the supramitral portion of the common systemic venous atrium in every case but could identify only superior limb obstruction in three of six patients, mid-baffle obstruction in zero of two and inferior limb obstruction in zero of two patients. Transesophageal studies with use of the same range of ultrasound methods demonstrated superior limb obstruction (severe in four, mild in two) in six of six patients, mid-baffle obstruction in two of two and inferior limb obstruction in two of two patients. The entire pulmonary venous atrium was equally well interrogated by either ultrasound approach, with both identifying three cases (two mild, one moderate) of mid-pulmonary venous atrium obstruction. However, individual pulmonary vein velocity profiles could only be recorded by transesophageal pulsed Doppler ultrasound. Precordial studies identified baffle leaks (1 large, 2 small) in only three patients, whereas transesophageal studies identified 11 such baffle leaks (1 large, 10 small), which were multiple in two patients. It is concluded that transesophageal echocardiography provides a more detailed and accurate assessment of atrial baffle morphology and function than is provided by either precordial ultrasound or cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative transesophageal versus epicardial ultrasound in surgery for congenital heart disease

Twenty-eight patients (age range, 0.7 to 65 years; median age, 6.1 years) who were undergoing correction for congenital heart disease were entered into a prospective study with both intraoperative transesophageal and epicardial ultrasound to determine the relative values of these techniques before and after bypass surgery. Introduction of the transesophageal probe was successful in 26 patients (93%); children were studied with use of dedicated pediatric transducers. Epicardial studies were performed in all 28 patients. Epicardial studies allowed for higher resolution imaging and a more complete assessment before bypass surgery of the intracardiac morphological condition (ventricular septum and right ventricular outflow tract) than the assessment that was obtained by the transesophageal approach. In the period immediately after bypass surgery, the transesophageal technique allowed a more detailed insight into atrioventricular valve function (valvar regurgitation [five patients] and ventricular inflow patterns) and the continuous monitoring of left ventricular function and volume. Residual interventricular shunting (three patients) or residual outflow tract obstruction (four patients) could not be reliably documented by transesophageal studies. It is concluded that intraoperative transesophageal and epicardial ultrasound in surgery for congenital heart disease are complementary rather than alternative techniques.

Diagnosis of atrial situs by transesophageal echocardiography

In a prospective investigation, direct visualization of both atrial appendages was attempted during transesophageal echocardiographic studies in 132 patients with congenital heart disease. High quality cross-sectional images delineating the unique morphologic details of both atrial appendages were obtained in every patient. Abnormal cardiac position such as dextrocardia (four patients) or mesocardia (two patients) did not pose any problems for transesophageal assessment of both atrial appendages. Thus, direct diagnosis of atrial situs was possible in every patient. Atrial situs solitus was present in 127 patients studied. Three patients were found to have situs inversus, one had left atrial isomerism and one had right atrial isomerism. No patient with juxtaposed atrial appendages was encountered. All patients had prior subcostal ultrasound scans for assessment of the morphology and relation of the suprarenal abdominal great vessels and the related patterns of hepatic venous drainage. Patients with abnormal atrial situs had correlative high kilovoltage filter beam radiography for assessment of bronchus morphology. The results of situs determination obtained by either method were in agreement. In this series, transesophageal echocardiography allowed the direct and accurate visualization of both atrial appendages and the determination of atrial situs in all patients studied. Transesophageal echocardiography may prove to be the most reliable in vivo technique for determination of atrial situs.

Changing role of non-invasive investigation in the preoperative assessment of congenital heart disease: a nine year experience

The total surgical experience of a supraregional paediatric cardiology unit over a nine year period (January 1980 to December 1988) was reviewed to assess the effect of the introduction of the full range of ultrasound techniques. A total of 1517 patients underwent cardiac surgery (955 cardiopulmonary bypass, 562 closed procedures). Of these, 485 patients (32%) did not undergo cardiac catheterisation before operation: 217 bypass (23% of all procedures under cardiopulmonary bypass) and 268 closed procedures (48%). The overall ratio of catheterisations to operations for patients undergoing palliative or corrective surgery fell from 0.97 (1980) to 0.38 (1988). The patients were classified as (a) neonates (0-28 days), (b) infants (one to 12 months), and (c) children (one to 14 years). The main impact of non-invasive surgical referral was in neonates (total catheter:operation ratio 0.38; neonates 0.2 for 1988). The surgical population was further divided according to the principal echocardiographic technique available: (a) 1980-4 cross sectional imaging; (b) 1985-6; imaging plus spectral Doppler ultrasound; (c) 1987-8; imaging plus spectral Doppler ultrasound and colour flow mapping. A fall in the catheter:operation ratio for all age groups was most pronounced in the last four years. This reflects increased familiarity and surgical confidence with non-invasive diagnostic assessment. The introduction of each new echocardiographic technique was associated with a significant fall in the total catheter:operation ratio compared with the preceding period. Six incorrect ultrasound diagnoses were made during the entire period; one of these patients died in the early postoperative period. The integration of Doppler ultrasound with cross sectional imaging has made non-invasive assessment an increasingly practical alternative to preoperative cardiac catheterization.

Pseudoaneurysm of the right ventricular outflow tract: diagnosis by colour flow mapping

Eleven years after surgical repair of pulmonary atresia with a ventricular septal defect with a valved conduit, a 20 year old patient was diagnosed on follow up echocardiography to have a right ventricular pseudoaneurysm related to the conduit. The echocardiographic findings were confirmed at reoperation and the pseudoaneurysm was excised.

Supraventricular tachycardia in infants: response to initial treatment

All patients with supraventricular tachycardia during the first 12 months of life who presented between 1977 and 1988 were identified by a retrospective survey of records in this hospital and by a questionnaire sent to paediatricians in the Northern region. Twenty two of 29 patients (76%) were in heart failure and seven (24%) had cardiogenic shock. Seven patients (24%) were free of symptoms. All had narrow QRS tachycardia at 215-315 beats/minute (mean (SD) 292 (21)). Initial treatment included digoxin (effective in seven of 14 patients, with overdose in three), verapamil (effective in three of three but fatal in one), cardioversion (effective in all 10 who were treated in this way), iced water applied to the face (effective in all 16 patients on 53 of 59 occasions, 90%). Initial treatment in local hospitals was less effective and associated with more complications than that given in the regional referral centre. Digoxin is often ineffective, return to sinus rhythm is delayed, and overdosing is common. Cardioversion is effective but tachycardia often recurs. Iced water is safe and effective, and should become the treatment of choice for termination of supraventricular tachycardia in neonates and young infants.