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Alemany VS, Crawford A, Gauvreau K, Bucholz EM, del Nido PJ, Schidlow DN, Nathan M. Early and long-term outcomes following cardiac surgery for patients with heterotaxy syndrome. JTCVS OPEN 2024; 18:167-179. [PMID: 38690436 PMCID: PMC11056491 DOI: 10.1016/j.xjon.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 12/17/2023] [Accepted: 02/06/2024] [Indexed: 05/02/2024]
Abstract
Objective Heterotaxy syndrome is a complex multisystem abnormality historically associated with high morbidity and mortality. We sought to evaluate the early and long-term outcomes after cardiac surgery in heterotaxy syndrome. Methods This is a single-center retrospective review of patients with heterotaxy syndrome undergoing single-ventricle palliation or primary or staged biventricular repair from 1998 to 2018. Patients were stratified by single ventricle versus biventricular physiology, and the severity of atrioventricular valve regurgitation. Demographics, anatomic characteristics, and early and late outcomes, including the length of stay, mortality, and surgical or catheter reinterventions, were analyzed. Results Among 250 patients, 150 (60%) underwent biventricular repair. In-hospital mortality was 7.6% (n = 19). Median follow-up was 5.2 (range, 0-16) years. Among survivors to discharge, mortality was 19% (n = 44) and reintervention was 52% (n = 120). Patients with moderate/severe atrioventricular valve regurgitation were older (32 vs 16 months, P = .02), were more likely to experience adverse events during their index surgical admission (72% vs 46%, P < .001), and had longer in-hospital length of stay (20 vs 12 days, P = .009). Among patients with moderate to severe atrioventricular valve regurgitation, single-ventricle palliation is associated with a greater risk of unplanned reintervention compared with patients undergoing biventricular repair (hazard ratio, 2.13; CI, 1.10-4.12; P = .025). Conclusions There was no significant difference in early or late outcomes in single-ventricle versus biventricular repair strategies in heterotaxy. In the subgroup of patients with moderate/severe atrioventricular valve regurgitation, patients who underwent single-ventricle palliation were 2.5 times more likely to need a late reintervention compared with those undergoing biventricular repair.
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Affiliation(s)
- Victor S. Alemany
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Alexis Crawford
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
- Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | - Emily M. Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Pedro J. del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Surgery, Harvard Medical School, Boston, Mass
| | - David N. Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
- Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Surgery, Harvard Medical School, Boston, Mass
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2
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So K, Shinagawa T, Yoshizato T, Fukahori S, Asagiri K, Maeno Y, Hayashida S, Ushijima K. Difficulty in the Diagnosis of Biliary Atresia Splenic Malformation Syndrome In Utero. Kurume Med J 2023; 68:265-268. [PMID: 37380446 DOI: 10.2739/kurumemedj.ms6834011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The fetus of a 30-year-old pregnant Japanese woman was diagnosed with absence of inferior vena cava (IVC) and azygos continuation of interrupted IVC without cardiac anomalies at 34 weeks of gestation, and a healthy male neonate weighing 2,910 g was delivered at 37 weeks of gestation. On day 42 after birth, direct bilirubin predominant hyperbilirubinemia and high serum gamma-GTP levels were detected. Computed tomography revealed the presence of a lobulated and accessory spleen, and laparotomy demonstrated type III biliary atresia (BA), confirming the final diagnosis of BA splenic malformation (BASM) syndrome. In retrospect, non-visualization of the gallbladder was missed in utero. The combination of the absence of IVC and BA without cardiac anomalies is far less likely to occur in left isomerism. Although BA remains difficult to detect in utero, special attention should be paid to cases of BA associated with findings of left isomerism, including the absence of IVC, to enable early diagnosis and treatment of BASM.
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Affiliation(s)
- Kunio So
- Department of Obstetrics and Gynecology, Kurume University School of Medicine
| | - Takaaki Shinagawa
- Department of Obstetrics and Gynecology, National Hospital Organization Saga Hospital
| | - Toshiyuki Yoshizato
- Department of Obstetrics and Gynecology, Kurume University School of Medicine
| | - Suguru Fukahori
- Department of Pediatric Surgery, Kurume University School of Medicine
| | - Kimio Asagiri
- Department of Pediatric Surgery, Kurume University School of Medicine
| | - Yasuki Maeno
- Department of Pediatrics, Kurume University School of Medicine
| | - Shintaro Hayashida
- Department of Pediatric Surgery and Transplantation, Graduate School of Medical Sciences, Kumamoto University
| | - Kimio Ushijima
- Department of Obstetrics and Gynecology, Kurume University School of Medicine
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He F, Feng S, Xiu Y, Zhang Y, Wang Y, Zhang Z, Chen L. Dysmorphic Gallbladder Found on Prenatal Ultrasound as a Hint for Biliary Atresia. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1345-1351. [PMID: 36485004 DOI: 10.1002/jum.16145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/02/2022] [Accepted: 11/24/2022] [Indexed: 05/18/2023]
Abstract
Biliary atresia (BA) is a rare but devastating cholangiopathy. We report a case series of dysmorphic gallbladders detected during prenatal ultrasound, which were confirmed as BA after birth. We present the prenatal ultrasound findings as well as integral follow-up, with an aim to raise awareness regarding the association between BA and dysmorphic gallbladder. Although this dysmorphic gallbladder is a strong hint for BA, it is also important to search for other related sonographic features, such as the presence of microcysts at the hepatic hilum, dilated right hepatic artery, and seroperitoneum, which may provide more evidence for the diagnosis of BA.
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Affiliation(s)
- Fujiao He
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Shu Feng
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yun Xiu
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yixin Zhang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yuntong Wang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhibo Zhang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Lizhu Chen
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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4
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Saba TG, Geddes GC, Ware SM, Schidlow DN, Del Nido PJ, Rubalcava NS, Gadepalli SK, Stillwell T, Griffiths A, Bennett Murphy LM, Barber AT, Leigh MW, Sabin N, Shapiro AJ. A multi-disciplinary, comprehensive approach to management of children with heterotaxy. Orphanet J Rare Dis 2022; 17:351. [PMID: 36085154 PMCID: PMC9463860 DOI: 10.1186/s13023-022-02515-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Heterotaxy (HTX) is a rare condition of abnormal thoraco-abdominal organ arrangement across the left-right axis of the body. The pathogenesis of HTX includes a derangement of the complex signaling at the left-right organizer early in embryogenesis involving motile and non-motile cilia. It can be inherited as a single-gene disorder, a phenotypic feature of a known genetic syndrome or without any clear genetic etiology. Most patients with HTX have complex cardiovascular malformations requiring surgical intervention. Surgical risks are relatively high due to several serious comorbidities often seen in patients with HTX. Asplenia or functional hyposplenism significantly increase the risk for sepsis and therefore require antimicrobial prophylaxis and immediate medical attention with fever. Intestinal rotation abnormalities are common among patients with HTX, although volvulus is rare and surgical correction carries substantial risk. While routine screening for intestinal malrotation is not recommended, providers and families should promptly address symptoms concerning for volvulus and biliary atresia, another serious morbidity more common among patients with HTX. Many patients with HTX have chronic lung disease and should be screened for primary ciliary dyskinesia, a condition of respiratory cilia impairment leading to bronchiectasis. Mental health and neurodevelopmental conditions need to be carefully considered among this population of patients living with a substantial medical burden. Optimal care of children with HTX requires a cohesive team of primary care providers and experienced subspecialists collaborating to provide compassionate, standardized and evidence-based care. In this statement, subspecialty experts experienced in HTX care and research collaborated to provide expert- and evidence-based suggestions addressing the numerous medical issues affecting children living with HTX.
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Affiliation(s)
- Thomas G Saba
- Department of Pediatrics, Pulmonary Division, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, USA.
| | - Gabrielle C Geddes
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stephanie M Ware
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nathan S Rubalcava
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Terri Stillwell
- Department of Pediatrics, Infectious Disease Division, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne Griffiths
- Department of Pediatrics, Pulmonary/Critical Care Division, Children's Minnesota and Children's Respiratory and Critical Care Specialists, Minneapolis, MN, USA
| | - Laura M Bennett Murphy
- Department of Pediatrics, Division of Pediatric Psychiatry and Behavioral Health, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Andrew T Barber
- Department of Pediatrics, Division of Pulmonology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Margaret W Leigh
- Department of Pediatrics, Division of Pulmonology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Necia Sabin
- Heterotaxy Connection, Eagle Mountain, UT, USA
| | - Adam J Shapiro
- Department of Pediatrics, McGill University Health Centre Research Institute, Montreal, QC, Canada
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Wang CC, Wu MH, Wu ET, Lu F, Chen SJ. Clinical implications of airway anomalies and stenosis in patients with heterotaxy syndrome. Pediatr Pulmonol 2022; 57:2074-2081. [PMID: 35582940 DOI: 10.1002/ppul.25981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/28/2022] [Accepted: 05/07/2022] [Indexed: 11/12/2022]
Abstract
In heterotaxy syndrome, bronchopulmonary situs usually reflects atrial situs, resulting in either right (RAI) or left atrial isomerism (LAI). This study determines airway anomalies and its implications in patients with heterotaxy. This retrospective study included 223 patients with heterotaxy syndrome who received an integrated cardiac computed tomography evaluation. Patient database from 1995 to 2020 was reviewed. The patients were examined by a congenital heart disease team comprising pediatric cardiologists, radiologists, pulmonologists, and cardiovascular surgeons. Among the 223 patients, 189 (84.8%, M/F = 1.66) had RAI and 29 had LAI (13.0%, M/F = 0.71). Five patients had indeterminate isomerism (2.2%, M/F = 1.5). Discordant bronchopulmonary and atrial situs occurred in 4% patients, while discordant bronchopulmonary, atrial, and splenic situs occurred in 23.2% patients. Lower airway stenosis was observed in 61 patients (27.4%), including 27.5%, 20.7%, and 60% RAI, LAI, and indeterminate isomerism patients, respectively (p = 0.189). One patient had an intrinsic long segment lower tracheal stenosis and received slide tracheoplasty. Initial cardiac operation was performed in 213 patients. Higher surgical mortality occurred in patients with RAI (19.5% vs. none for LAI and indeterminate isomerism, p = 0.038). In patients with RAI, lower airway anomaly/stenosis increased the duration of ventilator usage (p = 0.030) but did not affect surgical mortality. Total anomalous pulmonary venous return to systemic veins and pulmonary venous stenosis were major surgical risk factors. Bronchopulmonary isomerism shares a similar isomeric pattern to cardiac atrial appendage. Lower airway anomalies/stenosis was common in patients with heterotaxy, resulting in prolonged ventilator therapy in patients with RAI.
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Affiliation(s)
- Ching-Chia Wang
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - En-Ting Wu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Frank Lu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Shyh-Jye Chen
- Department of Radiology, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
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Babaoğlu K, Doğan Y, Başar EZ, Usta E. Prenatal diagnosis of hepatic interruption of the inferior vena cava with azygos/hemiazygos continuation without structural heart defects: A case series. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:795-802. [PMID: 35355279 DOI: 10.1002/jcu.23209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/02/2022] [Accepted: 02/15/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To describe fetal spectrum and echocardiographic characteristics of interrupted inferior vena cava (IIVC) with azygos/hemiazygous continuation without other structural heart defects and to evaluate its association with visceral heterotaxy and isomerism, extracardiac and genetic anomalies, and to review neonatal outcome. METHODS This was a retrospective study of 14 fetuses with a confirmed diagnosis of IIVC with normal intracardiac anatomy. The following variables were collected; indication for referral, gestational age at diagnosis; associated isomerism and visceral heterotaxy, heart rhythm, genetic and extracardiac abnormalities, and fetal/neonatal outcome. RESULTS Among 36 fetuses with IIVC, 14 cases (38.8%) had normal intracardiac anatomy. These IIVC cases correspond to 0.19% (14/7250) of all fetal cardiac examinations, and to 1.5% (14/922) of all cardiac abnormalities. Six patients had visceral abnormalities. Atrial appendage morphology was clearly depicted in three fetuses, both appendages were left. One fetus had bradyarrhythmia revealing atrial ectopic rhythm. Six fetuses did not have any concomitant cardiac or visceral abnormalities, therefore regarded as isolated. All babies were delivered at term with a good prognosis. CONCLUSION Our study has shown that almost half of the IIVC cases without intracardiac structural anomalies displayed other findings of isomerism while the other half was isolated benign vascular variant. Therefore, prenatal diagnosis of IIVC should prompt a comprehensive evaluation for cardiac, situs, and visceral anomalies. The outcome is favorable.
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Affiliation(s)
- Kadir Babaoğlu
- Department of Pediatric Cardiology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Yasemin Doğan
- Department of Perinatology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Eviç Zeynep Başar
- Department of Pediatric Cardiology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Emre Usta
- Department of Pediatric Cardiology, Kocaeli University School of Medicine, Kocaeli, Turkey
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7
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Akalın M, Demirci O, Kumru P, Yücel İK. Heterotaxy syndrome: Prenatal diagnosis, concomitant malformations and outcomes. Prenat Diagn 2022; 42:435-446. [PMID: 35102577 DOI: 10.1002/pd.6110] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/15/2022] [Accepted: 01/27/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of this study is to define cardiac and extracardiac malformations in fetuses with heterotaxy syndrome and to determine perinatal and childhood prognosis. METHODS In this retrospective study, fetuses diagnosed with heterotaxy syndrome on antenatal ultrasonography in a tertiary center between January 2014 and January 2021 were analyzed. Fetuses with heterotaxy syndrome were grouped as right atrial isomerism (RAI) and left atrial isomerism (LAI). RESULTS A total of 62 fetuses, 32 (51.6%) with RAI and 30 (48.4%) with LAI, were included in the study. Extracardiac anomaly was detected in 25% of fetuses with RAI and 44% of fetuses with LAI (p = 0.13). Patients with univentricular repair had a higher childhood mortality than patients with biventricular repair (p = 0.031). The presence of conotruncal anomaly was an independent factor affecting mortality (HR = 5.09, CI 95% 1.09-23.71, p = 0.039). CONCLUSION Hydrops fetalis, univentricular physiology and conotruncal anomalies are associated with poor outcomes in heterotaxy syndrome. The severity of the cardiac malformation is the main determinant of the outcomes. The presence of extracardiac malformations is associated with increased morbidity and mortality.
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Affiliation(s)
- Münip Akalın
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Oya Demirci
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Pınar Kumru
- Department of Obstetrics and Gynaecology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - İlker Kemal Yücel
- Department of Pediatric Cardiology, University of Health Sciences Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training & Research Hospital, Istanbul, Turkey
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Seidl-Mlczoch E, Kasprian G, Kitzmueller E, Zimpfer D, Steiner I, Jowett V, Stuempflen M, Wielandner A, Ulm B, Michel-Behnke I. Discordant Post-natal Patterns in Fetuses With Heterotaxy Syndrome: A Retrospective Single-Centre Series on Outcome After Fetal Diagnosis. Front Pediatr 2022; 10:908505. [PMID: 35911827 PMCID: PMC9329514 DOI: 10.3389/fped.2022.908505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Cardiac and extra-cardiac anomalies in 46 pre-natally diagnosed cases of heterotaxy were compared to post-natal anatomical patterns in order to reveal discordant findings. Second, the outcome of these fetuses was evaluated. METHODS Fetuses with heterotaxy, diagnosed in a tertiary referral centre, were analysed retrospectively. Based on the foetal abdominal situs view, right atrial isomerism (RAI) and left atrial isomerism (LAI) were defined as foetal sub-types. Post-natally, discordant anatomical patterns for broncho-pulmonary branching, atrial appendage morphology, and splenic status were further clarified with CT scans. In summary, the spectrum of pre-natally and post-natally detected cardiac and extra-cardiac anomalies is systematically reviewed. Necessary surgical interventions and mid-long-term outcomes were compared between the two sub-types in surviving infants. RESULTS A total of 46 fetuses with heterotaxy were included; LAI was diagnosed in 29 (63%) fetuses and RAI was diagnosed in 17 (37%) fetuses. Extra-cardiac anomalies were noted in 35% of fetuses. Seven out of the 29 fetuses (24%) with LAI had atrio-ventricular block (AVB) and four of these cases presented with hydrops. Twenty nine out of the 46 participating fetuses (63%) were live births, with 62% in the LAI group and 65% in the RAI group. Five fetuses were lost to follow-up. At the age of 1 year, the overall survival of live births [estimate (95% CI)] was 67% (48; 92%) in patients with LAI and 55% (32; 94%) in patients with RAI. At the age of 5 years, the estimates were 67% (48; 92%) in the LAI group and 46% (24-87%) in the RAI group. The median survival (first quartile; third quartile) was 11.1 (0.1; 14) years for patients with LAI and 1.3 (0.09; NA) years for patients with RAI. Of 17 children who had undergone cardiac surgery, five (29%) children achieved a bi-ventricular repair and 12 (70%) children achieved a uni-ventricular palliation. Three were primarily palliated, but converted to bi-ventricular thereafter. Foetal subtype definition of heterotaxy based on the abdominal situs and post-natal thoracic imaging studies showed a discordant pattern of broncho-pulmonary branching and atrial appendage anatomy in 40% of our live-born children. CONCLUSION Heterotaxy is a rare and complex condition with significant morbidity and mortality related to severe cardiac and extra-cardiac associations. Accurate pre-natal diagnosis can help identify the fetuses at risk and allow for timely intervention in a multi-disciplinary setting. Further studies are warranted to shed light on the exact sub-type definition in fetuses with heterotaxy and the presence of discordant post-natal patterns.
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Affiliation(s)
- Elisabeth Seidl-Mlczoch
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center, Medical University of Vienna, Vienna, Austria
| | - Gregor Kasprian
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Erwin Kitzmueller
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Pediatric Heart Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Irene Steiner
- Section for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Victoria Jowett
- Department of Fetal Cardiology, Great Ormond Street Hospital, London, United Kingdom
| | - Marlene Stuempflen
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center, Medical University of Vienna, Vienna, Austria
| | - Alice Wielandner
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center, Medical University of Vienna, Vienna, Austria
| | - Barbara Ulm
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Ina Michel-Behnke
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center, Medical University of Vienna, Vienna, Austria
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Seidl‐Mlczoch E, Kasprian G, Ba‐ssalamah A, Stuempflen M, Kitzmueller E, Muin DA, Zimpfer D, Prayer D, Michel‐behnke I, Ulm B. Characterization of phenotypic spectrum of fetal heterotaxy syndrome by combining ultrasound and magnetic resonance imaging. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:837-845. [PMID: 34097330 PMCID: PMC9299896 DOI: 10.1002/uog.23705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/27/2021] [Accepted: 05/28/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Heterotaxy or isomerism of the atrial appendages is a congenital disorder with variable presentation, associated with both cardiac and non-cardiac anomalies, which may have a serious impact on fetal outcome. The aim of this exploratory study was to assess the value of fetal magnetic resonance imaging (MRI), as a complementary tool to ultrasound, for describing the morphological spectrum encountered in heterotaxy. METHODS This retrospective study included 27 fetuses that underwent fetal MRI following prenatal suspicion of heterotaxy on ultrasound from 1998 to 2019 in a tertiary referral center. Heterotaxy was classified as left atrial isomerism (LAI) or right atrial isomerism (RAI) based on fetal echocardiography (FE) examination. In addition to routine prenatal ultrasound, fetal MRI was offered routinely to enhance the diagnosis of non-cardiac anomalies, which might have been missed on ultrasound. Prenatal findings on ultrasound, FE and MRI were reviewed systematically and compared with those of postnatal imaging and autopsy reports. RESULTS Twenty-seven fetuses with heterotaxy and cardiovascular pathology, of which 19 (70%) had LAI and eight (30%) had RAI, were included. Seven (7/19 (37%)) fetuses with LAI had normal intracardiac anatomy, whereas all fetuses with RAI had a cardiac malformation. All 27 fetuses had non-cardiac anomalies on fetal MRI, including situs and splenic anomalies. In 12/19 (63%) fetuses with LAI, a specific abnormal configuration of the liver was observed on MRI. In three fetuses, fetal MRI revealed signs of total anomalous pulmonary venous connection obstruction. An abnormal bronchial tree pattern was suspected on prenatal MRI in 6/19 (32%) fetuses with LAI and 3/8 (38%) fetuses with RAI. CONCLUSIONS Visualization on MRI of non-cardiac anomalies in fetuses with suspected heterotaxy is feasible and can assist the complex diagnosis of this condition, despite its limitations. This modality potentially enables differentiation of less severe cases from more complex ones, which may have a poorer prognosis. Fetal MRI can assist in prenatal counseling and planning postnatal management. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E. Seidl‐Mlczoch
- Pediatric Heart Center, Department of Pediatrics and Adolescent Medicine, Division of Pediatric CardiologyMedical University of ViennaViennaAustria
| | - G. Kasprian
- Department of Biomedical Imaging and Image‐guided Therapy, Division of Neuroradiology and Musculoskeletal RadiologyMedical University of Vienna, ViennaAustria
| | - A. Ba‐ssalamah
- Department of Biomedical Imaging and Image‐guided Therapy, Division of Neuroradiology and Musculoskeletal RadiologyMedical University of Vienna, ViennaAustria
| | - M. Stuempflen
- Department of Biomedical Imaging and Image‐guided Therapy, Division of Neuroradiology and Musculoskeletal RadiologyMedical University of Vienna, ViennaAustria
| | - E. Kitzmueller
- Pediatric Heart Center, Department of Pediatrics and Adolescent Medicine, Division of Pediatric CardiologyMedical University of ViennaViennaAustria
| | - D. A. Muin
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetomaternal MedicineMedical University of Vienna, ViennaAustria
| | - D. Zimpfer
- Department of Cardiac Surgery, Pediatric Heart Center ViennaMedical University of Vienna, ViennaAustria
| | - D. Prayer
- Department of Biomedical Imaging and Image‐guided Therapy, Division of Neuroradiology and Musculoskeletal RadiologyMedical University of Vienna, ViennaAustria
| | - I. Michel‐behnke
- Pediatric Heart Center, Department of Pediatrics and Adolescent Medicine, Division of Pediatric CardiologyMedical University of ViennaViennaAustria
| | - B. Ulm
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetomaternal MedicineMedical University of Vienna, ViennaAustria
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10
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Wang X, Chen S, Tu P, Liu X, Zhang X, Han J, Dong H, Ran S, He Y. Fetal Ultrasonic Evaluation of Bronchial Morphology in Fetuses with Isomerism. Fetal Diagn Ther 2021; 48:641-650. [PMID: 34510037 DOI: 10.1159/000515250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 02/15/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate whether fetal ultrasound could determine bronchial isomerism and distinguish left isomerism from right isomerism. METHODS We identified 110 healthy fetuses and 28 fetuses with isomerism. The outer angle between the tracheal midline and the inner margin of the bronchus is measured. The bronchial angles and the ratio of left/right bronchial angle were used to differentiate bronchial morphology and confirm the presence of bronchial isomerism in pathological cases. RESULTS The normal angles of the left and right bronchi were 146.98° (95% CI, 145.15-147.81°) and 167.37° (95% CI, 166.30-168.44°), separately. The cutoff bronchial angle of 156.5° was used to distinguish left bronchus from right bronchus. The bronchial isomerism could be identified in all pathological cases by autopsy and bronchial-atrial concordance occurred in 27 pathological cases (96.4%). In 21 pathological cases, the bilateral bronchial angle was <156.5 versus >156.5 differentiated left from right isomerism, respectively. The ratio of the left/right bronchial angle of >0.935 identified 92.9% (26/28) of all pathological cases, with a sensitivity of 89.7%. CONCLUSIONS Fetal ultrasound can detect the bronchial morphology and the presence of bronchial isomerism in fetuses with isomerism according to bronchial angles and the ratio of left/right bronchial angle.
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Affiliation(s)
- Xin Wang
- Maternal-Fetal Consultation Center of Congenital Heart Disease, Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Song Chen
- Department of Ultrasound Diagnosis, Chongqing Health Center for Women and Children, Chongqing, China
| | - Peng Tu
- Department of Ultrasound Diagnosis, Chongqing Health Center for Women and Children, Chongqing, China
| | - Xiaowei Liu
- Maternal-Fetal Consultation Center of Congenital Heart Disease, Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaohang Zhang
- Department of Ultrasound Diagnosis, Chongqing Health Center for Women and Children, Chongqing, China
| | - Jiancheng Han
- Maternal-Fetal Consultation Center of Congenital Heart Disease, Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongmei Dong
- Department of Ultrasound Diagnosis, Chongqing Health Center for Women and Children, Chongqing, China
| | - Suzhen Ran
- Department of Ultrasound Diagnosis, Chongqing Health Center for Women and Children, Chongqing, China
| | - Yihua He
- Maternal-Fetal Consultation Center of Congenital Heart Disease, Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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11
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Romanowicz J, Sinha P, Donofrio MT, Schidlow DN. Predicting Cardiac Anatomy, Physiology, and Surgical Management Based on Fetal Echocardiography in Heterotaxy Syndrome. Am J Perinatol 2021. [PMID: 34282574 DOI: 10.1055/s-0041-1732457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Heterotaxy syndrome (HS) is often associated with complex congenital heart disease (CHD). While fetal echocardiography (FE) permits accurate prenatal identification of most CHD, the high level of disease complexity in HS may pose challenges in predicting postnatal findings and outcomes. This study aimed to define the accuracy of FE in predicting postnatal anatomy, physiology, and surgical management of CHD in the setting of HS. STUDY DESIGN Retrospective single-center cohort study including all patients with a prenatal diagnosis of HS from 2003 to 2018. Anatomic diagnoses from FE reports were compared with postnatal echocardiogram, catheterization, and operative reports. Prenatal predictions were compared with postnatal outcomes with a focus on ductal dependence, time to first intervention (immediate, neonatal period, 1-6 months, or older than 6 months), and surgical approach (single or biventricular). RESULTS There were 102 pregnancies with fetal HS resulting in 21 terminations, 5 fetal losses, and 76 live births. Of the live births, 55 had significant CHD and available postnatal data for review. Among this group, survival to 1 year was 62% and was no different comparing single versus biventricular surgical approach. FE diagnostic accuracy varied by anatomic feature and was the lowest for diagnosis of venous anatomy. Determination of postnatal care was most accurate for predicting single versus biventricular surgical approach (91%), followed by ductal dependence (75%). Accuracy for predicting time to first intervention was the lowest at 69%. The most common reason for an incorrect prediction was difficulty in assessing the severity of pulmonary stenosis. CONCLUSION FE permits accurate predictions regarding surgical approach. Characterizing systemic and pulmonary veins is challenging, as is predicting ductal dependence and time to first intervention. These data suggest that despite the high diagnostic accuracy of CHD in HS, a circumspect approach may be reasonable with regard to predicting some anatomic details and postnatal management decisions. KEY POINTS · In HS, FE was most accurate for intracardiac anatomy.. · Diagnostic accuracy of venous anatomy was less reliable.. · Predicting surgical approach (single ventricle vs. biventricular) was highly accurate.. · Predicting ductal dependence and time-to-intervention were more challenging in some instances..
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Affiliation(s)
- Jennifer Romanowicz
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia
| | - Pranava Sinha
- Division of Cardiac Surgery, Children's National Hospital, Washington, District of Columbia
| | - Mary T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
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12
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Wu MH, Wang JK, Chiu SN, Tseng WC, Lu CW, Lin HC, Lin MT, Chen CA. Twin atrioventricular nodes, arrhythmias, and survival in pediatric and adult patients with heterotaxy syndrome. Heart Rhythm 2020; 18:605-612. [PMID: 33321198 DOI: 10.1016/j.hrthm.2020.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Heterotaxy syndrome is likely to involve arrhythmias from associated conduction system abnormalities, which are distinct in different subtypes of isomerism and may change further after interventions and remodeling. OBJECTIVE The purpose of this study was to understand the risk of arrhythmias and its relation to isomerism subtypes. METHODS Patients diagnosed between 1980 and 2019 as having heterotaxy syndrome were enrolled and grouped as right atrial isomerism (RAI), left atrial isomerism (LAI), or indeterminate isomerism. RESULTS Of the 366 patients enrolled, 326 (89.1%) had RAI, 35 (9.6%) LAI, and 5 (1.4%) indeterminate isomerism; 71 (19.4%) patients were adults. Arrhythmias occurred in 37.2% of patients (109 supraventricular tachycardia [SVT], 8 atrial fibrillation/flutter, 12 ventricular tachycardia, and 14 paced bradycardia). Freedom from arrhythmias by the age of 1, 5, 10, 20, and 40 years was 0.849, 0.680, 0.550, 0.413, and 0.053, respectively. Twin atrioventricular nodes were identified in 51.5% of patients with RAI, 8.7% of patients with LAI, and 40.0% of patients with indeterminate isomerism and were the key predictors of SVT. Indeterminate isomerism was also a risk factor for SVT. Other forms of tachycardia appeared relatively late. Sinus bradycardia with junctional rhythm was common in LAI (48.7%) and less in indeterminate isomerism (20.0%), with none occurring in RAI. Only in patients with RAI who showed the poorest survival, ventricular tachycardia worsened the long-term survival. CONCLUSION RAI was the predominant subtype of heterotaxy in this cohort. Collectively, the median RAI/LAI ratio was 0.731 and 5.450 in Western and East Asian studies, respectively. Arrhythmias, tachycardia, or paced bradycardia were common, but the spectrum was distinct among subtypes.
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Affiliation(s)
- Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan.
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Sheunn-Nan Chiu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Wei-Chieh Tseng
- Department of Pediatrics, Yuan-Lin Branch, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Hsin-Chia Lin
- Department of Pediatrics, Yuan-Lin Branch, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
| | - Chun-An Chen
- Department of Pediatrics, National Taiwan University Hospital and Medical College, National Taiwan University, Taipei, Taiwan
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13
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Namavarian A, Eid A, Goh ESY, Thakur V. A novel DNAH11 variant segregating in a sibship with heterotaxy and implications for genetic counseling. Mol Genet Genomic Med 2020; 8:e1358. [PMID: 32633470 PMCID: PMC7507105 DOI: 10.1002/mgg3.1358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 01/28/2023] Open
Abstract
Background Isomerism or heterotaxy syndrome is the loss of normal asymmetry of the internal thoraco‐abdominal organs in the left‐right axis and is associated with cardiovascular malformations. Mutations within DNAH11 can be associated with primary ciliary dyskinesia and heterotaxy syndromes. Methods We report a family of healthy, nonconsanguinous parents with subsequent pregnancies demonstrating a novel likely pathogenic variant in DNAH11 segregating in a sibship with varied presentations. Result The first affected pregnancy presented with right atrial isomerism. Further DNA testing identified three variants in DNAH11 related to primary ciliary dyskinesia: a maternally inherited heterozygous variant of unknown significance (VUS) c.2772G>A (p.Met924Ile), a maternally inherited novel likely pathogenic variant c.11662C>T (p.Arg3888Cys) as well as a paternally inherited pathogenic c.1648delA variant (p.Arg550GlyfsX16). The second pregnancy inherited the same variants including the pathogenic and likely pathogenic DNAH11 variants and presented with left isomerism and extracardiac abnormalities. Conclusion We present a novel likely pathogenic variant (c.11662C>T) in DNAH11 that has manifested in heterotaxy with variability in phenotypes for subsequent pregnancies of common parents. This report demonstrates that sibship illustrates potential variability in phenotypes associated with the same pathogenic variants within a family and highlights the difficulty in genetic counseling due to the variation in clinical presentation.
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Affiliation(s)
| | - Anas Eid
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elaine Suk-Ying Goh
- Laboratory Medicine and Genetics, Trillium Health Partners, Mississauga, ON, Canada
| | - Varsha Thakur
- Division of Cardiology, Hospital for Sick Children, Toronto, ON, Canada
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14
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Kostouros A, Koliarakis I, Natsis K, Spandidos DA, Tsatsakis A, Tsiaoussis J. Large intestine embryogenesis: Molecular pathways and related disorders (Review). Int J Mol Med 2020; 46:27-57. [PMID: 32319546 PMCID: PMC7255481 DOI: 10.3892/ijmm.2020.4583] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/08/2020] [Indexed: 02/07/2023] Open
Abstract
The large intestine, part of the gastrointestinal tract (GI), is composed of all three germ layers, namely the endoderm, the mesoderm and the ectoderm, forming the epithelium, the smooth muscle layers and the enteric nervous system, respectively. Since gastrulation, these layers develop simultaneously during embryogenesis, signaling to each other continuously until adult age. Two invaginations, the anterior intestinal portal (AIP) and the caudal/posterior intestinal portal (CIP), elongate and fuse, creating the primitive gut tube, which is then patterned along the antero‑posterior (AP) axis and the radial (RAD) axis in the context of left‑right (LR) asymmetry. These events lead to the formation of three distinct regions, the foregut, midgut and hindgut. All the above‑mentioned phenomena are under strict control from various molecular pathways, which are critical for the normal intestinal development and function. Specifically, the intestinal epithelium constitutes a constantly developing tissue, deriving from the progenitor stem cells at the bottom of the intestinal crypt. Epithelial differentiation strongly depends on the crosstalk with the adjacent mesoderm. Major molecular pathways that are implicated in the embryogenesis of the large intestine include the canonical and non‑canonical wingless‑related integration site (Wnt), bone morphogenetic protein (BMP), Notch and hedgehog systems. The aberrant regulation of these pathways inevitably leads to several intestinal malformation syndromes, such as atresia, stenosis, or agangliosis. Novel theories, involving the regulation and homeostasis of intestinal stem cells, suggest an embryological basis for the pathogenesis of colorectal cancer (CRC). Thus, the present review article summarizes the diverse roles of these molecular factors in intestinal embryogenesis and related disorders.
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Affiliation(s)
- Antonios Kostouros
- Laboratory of Anatomy-Histology-Embryology, Medical School, University of Crete, 71110 Heraklion
| | - Ioannis Koliarakis
- Laboratory of Anatomy-Histology-Embryology, Medical School, University of Crete, 71110 Heraklion
| | - Konstantinos Natsis
- Department of Anatomy and Surgical Anatomy, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki
| | | | - Aristidis Tsatsakis
- Laboratory of Toxicology, Medical School, University of Crete, 71409 Heraklion, Greece
| | - John Tsiaoussis
- Laboratory of Anatomy-Histology-Embryology, Medical School, University of Crete, 71110 Heraklion
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15
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Karmegaraj B, Deol SK, Krishnan V, Vaidyanathan B. Prenatal diagnosis of asplenia syndrome with sliding hiatus hernia in a fetus. Ann Pediatr Cardiol 2020; 13:167-170. [PMID: 32641894 PMCID: PMC7331833 DOI: 10.4103/apc.apc_34_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/05/2019] [Accepted: 12/05/2019] [Indexed: 11/04/2022] Open
Abstract
We report a case of right isomerism with a complex congenital heart disease associated with hiatus hernia in a 19-week-old fetus with relevant review of literature. This report highlights the importance of having a proper checklist for prenatal identification of extracardiac manifestations of isomerism syndromes. This will enable us to provide an effective family-centered counseling for perinatal management of these complex lesions. To our knowledge, prenatal sonographic detection of a sliding hiatal hernia in a fetus with right isomerism has not been reported previously.
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Affiliation(s)
- Balaganesh Karmegaraj
- Departmentof Fetal Cardiology, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Satjeet Kaur Deol
- Department of Fetal Medicine, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Vivek Krishnan
- Department of Fetal Medicine, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Balu Vaidyanathan
- Departmentof Fetal Cardiology, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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16
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Chen W, Guo Z, Qian L, Wang L. Comorbidities in situs inversus totalis: A hospital-based study. Birth Defects Res 2020; 112:418-426. [PMID: 31994846 DOI: 10.1002/bdr2.1652] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/03/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Few studies have assessed the comorbid diseases in situs inversus totalis (SIT) comprehensively. The aim of this study was to provide insight into the spectrum and prevalence of comorbidities in SIT. METHODS Children ≤18 years of age with SIT were enrolled in this retrospective observational study. Situs status and comorbidities were independently confirmed by two physicians, based on review of radiologic, ultrasonic examination, operative records, and case notes. RESULTS A total of 155 children (median age: 1.24 years; range: 1 day-17.8 years) confirmed to have SIT were recruited between January 2008 and December 2018. Associated conditions were diagnosed in 114 children (73.5%). Among them, 25 children (16.1%) had multiple anomalies affecting two or more organ systems. The most commonly associated conditions were congenital heart defects (n = 72, 46.5%) followed by primary ciliary dyskinesia (n = 19, 12.3%), renal disorders (n = 12, 7.7%), biliary atresia (n = 7, 4.5%), skeletal dysplasia (n = 8, 5.2%), and mental retardation (n = 4, 2.6%). CONCLUSION A substantial proportion of children with SIT have comorbidities affecting multiple systems, especially cardiovascular and respiratory abnormalities. Children with SIT warrant careful examination for the presence of congenital and acquired abnormalities.
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Affiliation(s)
- Weicheng Chen
- Cardiothoracic Surgery Department, Children's Hospital of Fudan University, Shanghai, China
| | - Zhuoyao Guo
- Respirology Department, Children's Hospital of Fudan University, Shanghai, China
| | - Liling Qian
- Respirology Department, Children's Hospital of Fudan University, Shanghai, China
| | - Libo Wang
- Respirology Department, Children's Hospital of Fudan University, Shanghai, China
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17
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Agarwal P, Agarwal RK. Left atrial isomerism associated with aneurysmal enlargement of right atrial appendage: A case report with literature review. Indian J Radiol Imaging 2019; 29:318-323. [PMID: 31741603 PMCID: PMC6857260 DOI: 10.4103/ijri.ijri_341_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/07/2019] [Accepted: 09/10/2019] [Indexed: 11/21/2022] Open
Abstract
We present a prenatally diagnosed case of heterotaxy syndrome (HS) in which left atrial isomerism (LAI) was associated with an aneurysmal enlargement of the right atrial appendage (RAA). Although LAI is usually associated with complex cardiac and extracardiac anomalies, the association of LAI and right atrial appendage aneurysm (RAAA) is exceptional. Congenital RAAA itself is an idiopathic, very rare cardiac anomaly characterized by the enlargement of the appendage in the absence of any other cardiac or extra-cardiac defect. The prognosis of the heterotaxy is poor with associated major cardiac malformations and even cases with minor cardiac anomalies are at risk postnatally for complications like biliary atresia, intestinal rotational abnormalities, and immune disorders. In this case, the prenatal diagnosis of the isomerism was mainly based on the abnormalities of caval veins. Although no typical complex cardiac anomaly was present, the HS was associated with biliary atresia, polysplenia, and malrotation of the gut. Associated RAAA further imposed an additional risk of complications such as tachyarrhythmias, thromboembolic events, and aneurysmal rupture.
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Affiliation(s)
- Prateek Agarwal
- Department of Radiodiagnosis, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka
| | - Rajesh Kumar Agarwal
- Department of Ultrasound, Meera Hospital, Shiv Marg, Bani Park, Jaipur, Rajasthan, India
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18
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Duong SQ, Godown J, Soslow JH, Thurm C, Hall M, Sainathan S, Morell VO, Dodd DA, Feingold B. Increased mortality, morbidities, and costs after heart transplantation in heterotaxy syndrome and other complex situs arrangements. J Thorac Cardiovasc Surg 2019; 157:730-740.e11. [PMID: 30669235 PMCID: PMC6865268 DOI: 10.1016/j.jtcvs.2018.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/22/2018] [Accepted: 11/04/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Identify pediatric heart transplant (HT) recipients with heterotaxy and other complex arrangements of cardiac situs (heterotaxy/situs anomaly) and compare mortality, morbidities, length of stay (LOS), and costs to recipients with congenital heart disease without heterotaxy/situs anomaly. METHODS Using linked registry data (2001-2016), we identified 186 HT recipients with heterotaxy/situs anomaly and 1254 with congenital heart disease without heterotaxy/situs anomaly. We compared post-HT outcomes in univariable and multivariable time-to-event analyses. LOS and cost from HT to discharge were compared using Wilcoxon rank-sum tests. Sensitivity analyses were performed using stricter heterotaxy/situs anomaly group inclusion criteria and through propensity matching. RESULTS HT recipients with heterotaxy/situs anomaly were older (median age, 5.1 vs 1.6 years; P < .001) and more often black, Asian, Hispanic, or "other" nonwhite (54% vs 32%; P < .001). Heterotaxy/situs anomaly was independently associated with increased mortality (hazard ratio, 1.58; 95% confidence interval, 1.19-2.09; P = .002), even among 6-month survivors (hazard ratio, 1.86; 95% confidence interval, 1.09-3.16; P = .021). Heterotaxy/situs anomaly recipients more commonly required dialysis (odds ratio, 2.58; 95% confidence interval, 1.51-4.42; P = .001) and cardiac reoperation (odds ratio, 1.91; 95% confidence interval, 1.17-3.11; P = .010) before discharge. They had longer ischemic times (19.2 additional minutes [range, 10.9-27.5 minutes]; P < .001), post-HT intensive care unit LOS (16 vs 13 days; P = .012), and hospital LOS (26 vs 23 days; P = .005). Post-HT hospitalization costs were also greater ($447,604 vs $379,357; P = .001). CONCLUSIONS Heterotaxy and other complex arrangements of cardiac situs are associated with increased mortality, postoperative complications, LOS, and costs after HT. Although increased surgical complexity can account for many of these differences, inferior late survival is not well explained and deserves further study.
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Affiliation(s)
- Son Q Duong
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Jonathan H Soslow
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kan
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kan
| | - Sandeep Sainathan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Victor O Morell
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Debra A Dodd
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Brian Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
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Baban A, Cantarutti N, Adorisio R, Lombardi R, Calcagni G, Piano Mortari E, Dallapiccola B, Marino B, Iorio FS, Carsetti R, Digilio MC, Giannico S, Drago F, Carotti A. Long-term survival and phenotypic spectrum in heterotaxy syndrome: A 25-year follow-up experience. Int J Cardiol 2018; 268:100-105. [DOI: 10.1016/j.ijcard.2018.02.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 02/03/2018] [Accepted: 02/13/2018] [Indexed: 11/29/2022]
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20
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Womble M, Amin NM, Nascone-Yoder N. The left-right asymmetry of liver lobation is generated by Pitx2c-mediated asymmetries in the hepatic diverticulum. Dev Biol 2018; 439:80-91. [PMID: 29709601 PMCID: PMC5988353 DOI: 10.1016/j.ydbio.2018.04.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/26/2018] [Accepted: 04/24/2018] [Indexed: 12/17/2022]
Abstract
Internal organs exhibit left-right asymmetric sizes, shapes and anatomical positions, but how these different lateralities develop is poorly understood. Here we use the experimentally tractable Xenopus model to uncover the morphogenetic events that drive the left-right asymmetrical lobation of the liver. On the right side of the early hepatic diverticulum, endoderm cells become columnar and apically constricted, forming an expanded epithelial surface and, ultimately, an enlarged right liver lobe. In contrast, the cells on the left side become rounder, and rearrange into a compact, stratified architecture that produces a smaller left lobe. Side-specific gain- and loss-of-function studies reveal that asymmetric expression of the left-right determinant Pitx2c elicits distinct epithelial morphogenesis events in the left side of the diverticulum. Surprisingly, the cellular events induced by Pitx2c during liver development are opposite those induced in other digestive organs, suggesting divergent cellular mechanisms underlie the formation of different lateralities.
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Affiliation(s)
- Mandy Womble
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Dr., Raleigh, NC 27607, USA
| | - Nirav M Amin
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Dr., Raleigh, NC 27607, USA
| | - Nanette Nascone-Yoder
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Dr., Raleigh, NC 27607, USA.
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Buca DIP, Khalil A, Rizzo G, Familiari A, Di Giovanni S, Liberati M, Murgano D, Ricciardulli A, Fanfani F, Scambia G, D'Antonio F. Outcome of prenatally diagnosed fetal heterotaxy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:323-330. [PMID: 28603940 DOI: 10.1002/uog.17546] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/22/2017] [Accepted: 06/02/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The main aim of this systematic review was to evaluate the prevalence and type of associated anomalies in fetuses with heterotaxy diagnosed prenatally on ultrasound; the perinatal outcome of these fetuses was also studied. METHODS An electronic search of MEDLINE, EMBASE and CINAHL databases was performed. Only studies reporting the prenatal diagnosis of isomerism were included. Outcomes observed included associated cardiac and extracardiac anomalies, fetal arrhythmia, abnormal karyotype, type of surgical repair and perinatal mortality. The analysis was stratified according to the type of heterotaxy syndrome (left (LAI) or right (RAI) atrial isomerism). Meta-analyses of proportions were used to combine data. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for cohort studies. RESULTS Sixteen studies (647 fetuses) were included in the analysis. Atrioventricular septal defect was the most common associated major cardiac anomaly found both in fetuses with LAI (pooled proportion (PP), 59.3% (95% CI, 44.0-73.7%)), with obstructive lesions of the right outflow tract occurring in 35.5% of these cases, and in fetuses with RAI (PP, 72.9% (95% CI, 60.4-83.7%)). Fetal arrhythmias occurred in 36.7% (95% CI, 26.9-47.2%) of cases with LAI and were mainly represented by complete atrioventricular block, while this finding was uncommon in cases with RAI (PP, 1.3% (95% CI, 0.2-3.2%)). Abnormal stomach and liver position were found, respectively, in 59.4% (95% CI, 38.1-79.0%) and 32.5% (95% CI, 11.9-57.6%) of cases with LAI, and in 54.5% (95% CI, 38.5-70.1%) and 45.9% (95% CI, 11.3-83.0%) of cases with RAI, while intestinal malrotation was detected in 14.2% (95% CI, 2.5-33.1%) of LAI and 27.1% (95% CI, 7.9-52.0%) of RAI cases. Hydrops developed in 11.8% (95% CI, 2.9-25.6%) of fetuses diagnosed prenatally with LAI. Biventricular repair was accomplished in 78.2% (95% CI, 64.3-89.4%) of cases with LAI, while univentricular repair or palliation was needed in 17.0% (95% CI, 9.7-25.9%); death during or after surgery occurred in 26.8% (95% CI, 4.6-58.7%) of LAI cases. Most children with RAI had univentricular repair and 27.8% (95% CI, 15.5-42.1%) died during or after surgery. CONCLUSIONS Fetal heterotaxy is associated with a high prevalence of cardiac and extracardiac anomalies. Approximately one quarter of fetuses with heterotaxy died during or after surgery. Abnormal heart rhythm, especially heart block, is common in fetuses with LAI, while this finding is uncommon in RAI. Biventricular repair was common in LAI while univentricular repair was required in the majority of children affected by RAI. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D I P Buca
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - A Khalil
- St George's, University of London & St George's University Hospitals NHS Foundation Trust Molecular and Clinical Sciences Research Institute, London, UK
| | - G Rizzo
- Department of Obstetrics and Gynaecology, Università di Roma Tor Vergata, Rome, Italy
| | - A Familiari
- Department of Obstetrics and Gynaecology, Catholic University of the Sacred Heart, Rome, Italy
| | - S Di Giovanni
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - M Liberati
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - D Murgano
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - A Ricciardulli
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - F Fanfani
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - G Scambia
- Department of Obstetrics and Gynaecology, Catholic University of the Sacred Heart, Rome, Italy
| | - F D'Antonio
- Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
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22
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Cupers S, Linthout CV, Desprechins B, Rausin L, Demarche M, Seghaye MC. Heterotaxy syndrome with intestinal malrotation, polysplenia and azygos continuity. Clin Pract 2018; 8:1004. [PMID: 29383228 PMCID: PMC5768155 DOI: 10.4081/cp.2018.1004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/01/2017] [Indexed: 12/11/2022] Open
Affiliation(s)
| | | | | | - Léon Rausin
- Department of Medical Imaging, Regional Hospital Center La Citadelle
| | - Martine Demarche
- Department of Surgery, Regional Hospital Center La Citadelle, Liège,Belgium
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23
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Wang X, Shi Y, Zeng S, Zhou J, Zhou J, Yuan H, Wang L, Shi W, Zhou Q. Comparing levocardia and dextrocardia in fetuses with heterotaxy syndrome: prenatal features, clinical significance and outcomes. BMC Pregnancy Childbirth 2017; 17:393. [PMID: 29169330 PMCID: PMC5701355 DOI: 10.1186/s12884-017-1579-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/15/2017] [Indexed: 01/01/2023] Open
Abstract
Background To investigate the differences in cardiovascular disease, extracardiac anomalies and outcomes between fetuses with levocardia and dextrocardia. Methods Clinical demographics, prenatal features, postnatal characteristics and the outcomes of fetuses with levocardia or dextrocardia were recorded and analyzed. Results Sixty-five fetuses with dextrocardia and thirty-eight fetuses with levocardia were enrolled. Right ventricle outlet obstruction, atrioventricular septal defect and intestinal malrotation were common in both groups. Univentricular physiology, transposition of the great arteries and esophageal atresia were more frequent in fetuses with levocardia, whereas abnormal pulmonary venous connection, double outlet of right ventricle, left ventricle outlet obstruction and brain abnormalities were more frequent in the dextrocardia group. The accuracy of evaluating cardiac malformations was high, but the sensitivity in assessing extracardiac abnormalities was low. Conclusions Although the disorders have certain overlapping features, there are several differences between fetuses with levocardia and dextrocardia. These findings might improve patient counseling and perinatal management.
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Affiliation(s)
- Xiaofang Wang
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, Hunan, 410011, China
| | - Yifan Shi
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, Hunan, 410011, China.,Department of Ultrasonography, Chenzhou No.1 People's hospital, Chenzhou, Hunan, 423000, China
| | - Shi Zeng
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, Hunan, 410011, China
| | - Jiawei Zhou
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, Hunan, 410011, China
| | - Jia Zhou
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, Hunan, 410011, China.,Department of Ultrasonography, The first affiliated hospital of University of South China, Hengyang, Hunan, 421001, China
| | - Hongxia Yuan
- Department of Ultrasonography, Maternal & Child Health Center of Changsha, Changsha, Hunan, 410011, China
| | - Lin Wang
- Department of Ultrasonography, Maternal & Child Health Center of Zhuzhou, Zhuzhou, Hunan, 412000, China
| | - Weiyuan Shi
- Department of Ultrasonography, Chenzhou No.1 People's hospital, Chenzhou, Hunan, 423000, China
| | - Qichang Zhou
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, Hunan, 410011, China.
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24
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Moradi B, Moosavi NS, Kazemi MA. Fetal echocardiographic evaluation in cases of heterotaxy syndrome. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:436-437. [PMID: 28594083 DOI: 10.1002/jcu.22508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/07/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Behnaz Moradi
- Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Najme-Sadat Moosavi
- Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Ali Kazemi
- Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran
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25
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Moradi B, Moosavi NS, Kazemi MA, Tahmasebpour AR, Fattahi Masrour F. A case of prenatally detected left isomerism and hemiazygos continuation of inferior vena cava. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:430-433. [PMID: 28256002 DOI: 10.1002/jcu.22464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 01/06/2017] [Accepted: 01/22/2017] [Indexed: 06/06/2023]
Abstract
Heterotaxy syndromes are defined as the disorders that involve abnormal arrangement of viscera. We present a case of prenatally diagnosed left isomerism in a 30-year-old primigravida woman referred to our hospital for complex cardiac abnormality. Sonographic findings included heart block, unbalanced atrioventricular septal defect, interruption of the inferior vena cava with hemiazygos continuation, double superior vena cava, a right-sided stomach, and biliary atresia. The hemiazygos vein drained into the right atrium by the persistent left superior vena cava. This type of inferior vena cava interruption and continuation is rarely reported in prenatally detected cases of left isomerism. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:430-433, 2017.
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Affiliation(s)
- Behnaz Moradi
- Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Najme-Sadat Moosavi
- Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Ali Kazemi
- Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran
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26
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Prenatal diagnosis of biliary atresia: A case series. Early Hum Dev 2017; 111:16-19. [PMID: 28531808 DOI: 10.1016/j.earlhumdev.2017.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 05/08/2017] [Accepted: 05/13/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Biliary atresia is a progressive disease presenting with jaundice, and is the most common indication for liver transplantation in the pediatric population. Prenatal series have yielded conflicting results concerning a possible association between BA and prenatal nonvisualization of the gallbladder. AIMS This retrospective case series was performed to assess the association between biliary atresia, prenatal nonvisualization of the gallbladder and other sonographic signs. STUDY DESIGN/SUBJECTS We identified biliary atresia patients who underwent a Kasai procedure by a single pediatric surgeon and/or follow up by a single pediatric gastroenterologist. Axial plane images and/or video recordings were scrutinized for sonographic signs of biliary atresia on the second trimester anomaly scan. OUTCOME MEASURES Proportion of biliary atresia cases with prenatal sonographic signs. RESULTS Twenty five charts of children with biliary and high quality prenatal images were retrieved. 6/25 (24%) of cases analyzed had prenatal nonvisualization of the gallbladder or a small gallbladder on the prenatal scan. Two cases had biliary atresia splenic malformation syndrome. None of the cases had additional sonographic markers of biliary atresia. CONCLUSIONS Our study suggests that in addition to the well-established embryonic and cystic forms, an additional type can be suspected prenatally, which is characterized by prenatal nonvisualization of the gallbladder in the second trimester. This provides additional evidence that some cases of BA are of fetal rather than perinatal onset and may have important implications for prenatal diagnosis, for counseling and for research of the disease's etiology and pathophysiology.
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