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Oliver JM, Gallego P, Gonzalez A, Dominguez FJ, Aroca A, Mesa JM. Sinus venosus syndrome: atrial septal defect or anomalous venous connection? A multiplane transoesophageal approach. Heart 2002; 88:634-8. [PMID: 12433899 PMCID: PMC1767459 DOI: 10.1136/heart.88.6.634] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To discuss the anatomical features of sinus venosus atrial defect on the basis of a comprehensive transoesophageal echocardiography (TOE) examination and its relation to surgical data. METHODS 24 patients (13 men, 11 women, mean (SD) age 37 (17) years, range 17-73 years) with a posterior interatrial communication closely related to the entrance of the superior (SVC) or inferior vena cava (IVC) who underwent TOE before surgical repair. Records of these patients were retrospectively reviewed and compared with surgical assessments. RESULTS In 13 patients, TOE showed a deficiency in the extraseptal wall that normally separates the left atrium and right upper pulmonary vein from the SVC and right atrium. This deficiency unroofed the right upper pulmonary vein, compelling it to drain into the SVC, which overrode the intact atrial septum. In three patients, TOE examination showed a defect in the wall of the IVC, which continued directly into the posterior border of the left atrium. Thus, the intact muscular border of the atrial septum was overridden by the mouth of the IVC, which presented a biatrial connection. In the remaining eight patients, the defect was located in the muscular posterior border of the fossa ovalis. A residuum of atrial septum was visualised in the superior margin of the defect. Neither caval vein overriding nor anomalous pulmonary vein drainage was present. CONCLUSIONS Sinus venosus syndrome should be regarded as an anomalous venous connection with an interatrial communication outside the confines of the atrial septum, in the unfolding wall that normally separates the left atrium from either caval vein. It results in overriding of the caval veins across the intact atrial septum and partial pulmonary vein anomalous drainage. It should be differentiated from posterior atrial septal defect without overriding or anomalous venous connections.
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Affiliation(s)
- J M Oliver
- Adult Congenital Heart Disease Unit, La Paz Hospital, Madrid, Spain
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Fagan S, Veinot JP, Chan KL. Residual sinus venosus atrial septal defect after surgical closure of atrial septal defect. J Am Soc Echocardiogr 2001; 14:738-41. [PMID: 11447421 DOI: 10.1067/mje.2001.111005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We describe residual atrial septal defects in 3 patients who had previous surgical repair. The residual defects were the sinus venosus type near the orifice of the inferior vena cava. Preoperative and intraoperative transesophageal echocardiography may aid in the detection and facilitate the successful repair of these defects.
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Affiliation(s)
- S Fagan
- University of Ottawa Heart Institute, Ontario, Canada
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Ferrari VA, Scott CH, Holland GA, Axel L, Sutton MS. Ultrafast three-dimensional contrast-enhanced magnetic resonance angiography and imaging in the diagnosis of partial anomalous pulmonary venous drainage. J Am Coll Cardiol 2001; 37:1120-8. [PMID: 11263618 DOI: 10.1016/s0735-1097(01)01148-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The purpose of our study was to evaluate patients with suspected anomalous pulmonary veins (APVs) and atrial septal defects (ASDs) using fast cine magnetic resonance imaging (MRI) and ultrafast three-dimensional magnetic resonance angiography (MRA). BACKGROUND Precise anatomic definition of anomalous pulmonary and systemic veins, and the atrial septum are prerequisites for surgical correction of ASDs. Cardiac catheterization and transesophageal echocardiography (TEE) are currently used to diagnose APVs, but did not provide complete information in our patients. METHODS Twenty consecutive patients with suspected APVs were studied by MRA after inconclusive assessment by catheterization, TEE or both. The MRI images were acquired with a fast cine sequence and a novel ultrafast three-dimensional sequence before and after contrast injection. RESULTS Partial anomalous pulmonary venous drainage was demonstrated in 16 of 20 patients and was excluded in four patients. Magnetic resonance imaging correctly diagnosed APVs and ASDs in all patients (100%) who underwent surgery. For the diagnosis of APVs, the MRI and catheterization results agreed in 74% of patients and the MRI and TEE agreed in 75% of patients. For ASDs, MRI agreed with catheterization and TEE in 53% and 83% of patients, respectively. CONCLUSIONS Fast cine MRI with three-dimensional contrast-enhanced MRA provides rapid and comprehensive anatomic definition of APVs and ASDs in patients with adult congenital heart disease in a single examination.
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Affiliation(s)
- V A Ferrari
- Adult Congenital Heart Disease Department of Medicine, University of Pennsylvania Medical Center, Philadelphia 19104, USA.
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Pfammatter JP, Berdat P, Hämmerli M, Carrel T. Pediatric cardiac surgery after exclusively echocardiography-based diagnostic work-up. Int J Cardiol 2000; 74:185-90. [PMID: 10962120 DOI: 10.1016/s0167-5273(00)00278-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This study was performed to evaluate the accuracy of exclusively non-invasive preoperative diagnostic work-up based on echocardiography and to assess the safety of cardiac surgery using this diagnostic approach in children with heart disease. During a 3. 5-year period, accuracy of preoperative (invasive and non-invasive) diagnostic work-up was prospectively tested by comparison with the intraoperative findings obtained by surgical inspection and transoesophageal echocardiography. Included were all consecutive 358 children undergoing cardiac surgery (except pulmonary artery bandings and ductus ligations) during the study period at our institution. Of the patients, 44% were operated on in infancy, 84% of procedures were on cardiopulmonary bypass. Echocardiography as the only preoperative imaging modality was used in 231 patients (65%), in the other children, a diagnostic catheter was done. Diagnostic errors occurred in 3.9% (n=5) of patients after diagnostic catheter and in 6.9% (n=16) of patients with echocardiography only. Major diagnostic errors (resulting in prolongation of cardiac bypass time) were observed at equal frequency in both groups (1.7% or four children in the echo-only group and 1.6% or two patients in the catheter group). In no case was the outcome affected by the previously unrecognized findings. It was shown that diagnostic cardiac catheterization could be avoided in a majority of pediatric patients prior to surgical palliation or correction of cardiac defects, without increasing the risk of complications or the overall outcome.
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Affiliation(s)
- J P Pfammatter
- Pediatric Cardiology, University Children's Hospital, CH 3010, Berne, Switzerland.
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Abstract
The location, and morphology, of the superior sinus venosus interatrial communication remains contentious. As part of a clinical study, we examined anatomic specimens and echocardiograms so as to clarify the arrangement of the normal atrial septal structures, and compared them with the arrangement found in the superior sinus venosus defect. The pathognomonic diagnostic criterion in the abnormal hearts was overriding of the intact muscular rim of the oval fossa by the mouth of the superior caval vein. This muscular rim is, in reality, a tube of myocardium which encloses a core of extracardiac adipose tissue. Understanding of this anatomic conundrum clarifies the understanding of the structures of both the normal atrial septum and sinus venosus defects.
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Affiliation(s)
- J Li
- Paediatrics, Imperial College School of Medicine at National Heart and Lung Institute, London, United Kingdom
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56
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Nanda NC, Ansingkar K, Espinal M, Jindal A, Puri V, Aaluri S, Mukhtar O, Lee TY, Samal AK, Bhambore MM, Pacifico AD. Transesophageal Three-Dimensional Echo Assessment of Sinus Venosus Atrial Septal Defect. Echocardiography 1999; 16:835-837. [PMID: 11175230 DOI: 10.1111/j.1540-8175.1999.tb00138.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The incremental value of three-dimensional echocardiography over transesophageal multiplane two-dimensional imaging in the assessment of sinus venosus atrial septal defect is demonstrated in the present study.
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Affiliation(s)
- Navin C. Nanda
- University of Alabama at Birmingham, Heart Station SW/S102, Birmingham, AL 35233
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Abstract
Echo and Doppler echocardiographic procedures have gained special importance in the diagnostics of congenital diseases in adults. These procedures permit detailed visualization of the pathomorphology of the heart as well as reliable evaluation of the hemodynamic changes. There are differentiated indications for the various procedures, such as transthoracic and transesophageal echocardiography, Doppler and color-Doppler echocardiography, contrast echocardiography and 3-dimensional echocardiography. This article discusses the opposition of the various echo and Doppler echocardiographic procedures with respect to the diagnostics of the most frequent non-operated congenital diseases in adults. The pathomorphology of the various congenital diseases will be summarized and then the important echocardiographic criteria presented which are decisive for the diagnostic procedure. In simple congenital malformation of cardiac valves, such as bicuspid aortic valve (Figure 1: aortic ring abscess), pulmonary valve stenosis (Figure 2), Ebstein's anomaly (Figure 3) or malformations of the mitral valve (Figure 4: cleft in the anterior mitral cusp), the diagnosis can often be made using transthoracic echo and Doppler echocardiography, and the severity of the defect determined. However, the sonographic conditions, especially in adults, are frequently too limited to permit recognition of detailed smaller changes, so that transesophageal examination is required to finally confirm the diagnosis in these patients. In the diagnostics of diseases of the left ventricular outflow tract and the thoracic aorta, such as subvalvular aortic valve stenosis (Figure 5), the sinus of Valsalva aneurysm or the coarctation of the aorta (Figure 6), the left ventricular outflow tract can be evaluated morphologically from a transthoracic procedure and the accelerations of flow can be recorded by continuous wave Doppler. If there is no sclerosis of the fibrous membrane, these can often not be depicted by transthoracic procedures, so that a supplementary transesophageal examination is meaningful. This is required in any case for diseases of the descending thoracic aorta. In the case of congenital lesions, such as atrial septal defects (Figure 7: anomalous pulmonary venous return, Figure 8: 3-dimensional visualization of an atrial septal defect, Figure 9: sinus venosus defect), ventricular septal defect or a patent ductus arteriosus Botalli (Figure 10), color-Doppler and contrast echocardiography have become especially important. Transesophageal examination is also indicated for these congenital diseases for direct depiction of the defect as well as for precise evaluation of the shunt. Moreover, in atrial septal defects, it has been shown that a 3-dimensional echocardiography provides additional advantage with respect to spatial relationship of the defect to the other cardiac structures, as well as presenting dynamic changes during a heart cycle. Extensive knowledge of complex congenital heart disease, such as tetralogy of Fallot (Figure 11), complete transposition of the great arteries, congenitally corrected transposition of the great arteries (Figure 12), the double-outlet right ventricle, truncus arteriosus communis, the cor triatriatum, tricuspid atresia (Figure 13) or the univentricular heart (Figure 14) usually requires performance of a transthoracic echo- and Doppler echocardiographic examination to assess the pathomorphological changes and to examine hemodynamics. In the majority of patients, supplementary transesophageal echocardiography and an echo contrast examination are important. Initial examinations using 3-dimensional echocardiography are very promising in this connection and with respect to the exact spatial presentation of pathoanatomical structures.
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Affiliation(s)
- A Geibel
- Abteilung Innere Medizin III-Kardiologie-Angiologie, Universitätsklinik Freiburg.
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Tighe DA, Thomas NV, Hafer JG, Rousou JA, Engelman RM, Anene CA, Fernandez E, Rifkin RD. Diagnosis of Partial Anomalous Pulmonary Venous Connection with Intact Interatrial Septum by Echocardiography. Echocardiography 1998; 15:405-408. [PMID: 11175057 DOI: 10.1111/j.1540-8175.1998.tb00625.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
This case illustrates the complementary use of transthoracic echocardiography and transesophageal echocardiography in the diagnosis of partial anomalous pulmonary venous connection. The transthoracic echocardiogram suggested the presence of anomalous pulmonary venous return by demonstrating right heart volume overload and evidence of an intact atrial septum. Transesophageal echocardiography was required to confirm these findings and provide a firm anatomic diagnosis before surgery. This case also emphasizes that a high degree of clinical suspicion for this condition should occur in situations in which apparent right heart volume overload is otherwise unexplained.
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Affiliation(s)
- Dennis A. Tighe
- Division of Cardiology, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199
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Miller-Hance WC, Russell IAM. Sinus Venosus Atrial Septal Defect? Anesth Analg 1997. [DOI: 10.1213/00000539-199712000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Miller-Hance WC, Russell IA. Sinus venosus atrial septal defect? Anesth Analg 1997; 85:1214-7. [PMID: 9390582 DOI: 10.1097/00000539-199712000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- W C Miller-Hance
- Department of Anesthesia, University of California-San Francisco, 94143-0648, USA
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al Zaghal AM, Li J, Anderson RH, Lincoln C, Shore D, Rigby ML. Anatomical criteria for the diagnosis of sinus venosus defects. Heart 1997; 78:298-304. [PMID: 9391294 PMCID: PMC484934 DOI: 10.1136/hrt.78.3.298] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The diagnosis of sinus venosus defects remains a matter of debate. It is crucial to provide solid anatomical criteria, by identifying the very nature of the atrial septum relative to sinus venosus defects, to diagnose and differentiate them from other interatrial communications. OBJECTIVE This study was designed to reestablish the anatomical criteria for the diagnosis of sinus venosus defects. METHODS Five specimens with sinus venosus defects from the cardiopathological museum were examined. Study of the abnormal hearts was supplemented by examining the extent and structure of the atrial septum in 10 normal hearts. The echocardiograms and surgical notes were reviewed from 18 patients seen between July 1991 and August 1996 at the Royal Brompton Hospital in London diagnosed preoperatively to have a sinus venosus defect. RESULTS The nature of the oval fossa and its muscular borders were identified in the normal hearts. In all three autopsied specimens of the superior variety of sinus venosus defect, the mouth of the superior caval vein was overriding the intact muscular anterosuperior border of the oval fossa. Two specimens thought initially to have the inferior variety of sinus venosus defect were re-classified as having defects within the oval fossa as it was the deficient oval fossa itself, rather than its intact muscular border, that was overridden by the mouth of the inferior caval vein. Sixteen patients had been diagnosed echocardiographically as exhibiting the superior variant of the defect. Retrospective review showed overriding of the superior caval vein across the upper rim of the oval fossa in 12 patients. These findings were confirmed by surgery in 11 patients with the 12th awaiting operation. Overriding of the fossa by the caval vein was not found in the other four patients. Surgery in all of these showed the defect to be within the oval fossa. In two patients diagnosed echocardiographically as having inferior defects, the surgical findings confirmed a biatrial connection of the inferior caval vein in one patient, the findings in the second were equivocal. CONCLUSIONS The key anatomical criterion for the diagnosis of sinus venosus defects is overriding of the mouth of the superior or inferior caval vein across the intact muscular border of the oval fossa. The interatrial communication is then formed within the mouth of the overriding vein, and is outside the confines of the oval fossa.
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62
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Ammash NM, Seward JB, Warnes CA, Connolly HM, O'Leary PW, Danielson GK. Partial anomalous pulmonary venous connection: diagnosis by transesophageal echocardiography. J Am Coll Cardiol 1997; 29:1351-8. [PMID: 9137235 DOI: 10.1016/s0735-1097(97)82758-1] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study sought to demonstrate that with proper technique, identification of the normal and abnormal pulmonary venous connection can be made with confidence using transesophageal echocardiography (TEE). BACKGROUND Partial anomalous pulmonary venous connection (PAPVC) is an uncommon congenital anomaly whose diagnosis has classically been made using angiography. METHODS We performed a retrospective review of all patients of all ages with PAPVC diagnosed at the Mayo Clinic who had undergone TEE because of either right ventricular volume overload or suspected intracardiac shunting by transthoracic echocardiography or intraoperatively. RESULTS A total of 66 PAPVCs were detected in 43 patients (1.5/patient); in 2 additional patients, TEE suggested, but did not diagnose, PAPVCs. Shortness of breath was the most common presenting symptom (42.2%), followed by heart murmur and supraventricular tachycardia. Right-sided anomalous veins were identified in 35 patients (81.4%), left-sided in 7 (16.3%) and bilateral in 1 (2.3%). There was a single anomalous connecting vein in 23 patients (53.5%), two in 18 (41.9%), three in 1 (2.3%) and four in 1 (2.3%). The connecting site was the superior vena cava (SVC) in 39 veins (59.1%), right atrial-SVC junction in 6 (9.1%), right atrium in 8 (12.1%), inferior vena cava in 1 (1.5%) and the coronary sinus in 2 (3.0%). Ten anomalous left pulmonary veins were connected by a vertical vein to the innominate vein (15.1%). Sinus venosus atrial septal defect (ASD) was the most common associated anomaly in 22 patients (49%), followed by ostium secundum ASD in 6 and patent foramen ovale in 4. Fifteen patients had an intact atrial septum. Thirty-one patients (68.8%) underwent surgical repair. PAPVC was confirmed in all patients, including the two whose TEE results were suggestive of PAPVC. All 49 PAPVCs detected by TEE preoperatively were confirmed at the time of operation. CONCLUSIONS TEE is highly diagnostic for PAPVC and can obviate angiography. Accurate anatomic diagnosis may influence the need for medical and surgical management. TEE should be performed in patients with right ventricular volume overload when the precordial examination is inconclusive.
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Affiliation(s)
- N M Ammash
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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