Computed tomography findings and preoperative risk factors for mortality of total anomalous pulmonary venous connection

Total Anomalous Pulmonary Venous Return in the Time of SARS-CoV-2-Case Report

The management of children with complex and life-threatening heart malformations became a clinical conundrum during the SARS-CoV-2 pandemic. The pathophysiological features of the new coronavirus infection have raised major dilemmas regarding the postoperative evolution of an infected patient, and the epidemiological limitations have tightened the criteria for selecting cases. We present the case of a newborn diagnosed with total anomalous pulmonary venous return (TAPVR) who underwent surgical repair of the defect with favorable outcome, despite a prior diagnosis of SARS-CoV-2 infection. We discuss the medical and surgical management of TAPVR, highlighting possible management difficulties brought by the SARS-CoV-2 pandemic.

Echocardiographic evaluation of supracardiac anomalous pulmonary venous connection in children: comparison with multilayer spiral CT

Objective To explore the clinical value of transthoracic echocardiography (TTE) in the differentiation of Supracardiac Anomalous Pulmonary Venous Connection (SAPVC) in children. Materials and methods A total of 118 children with concurrent TTE and CT databases of cases diagnosed with SAPVCs were included. We analyzed the consistency between the two for the ability to diagnose the classification of SAPVC, drainage sites, ectopic pulmonary veins and the segments of superior vena cava (SVC). Results The consistency between TTE and CT in diagnosing the existence of SAPVC and the classification were 88.1% (95% CI: 80.9-93.4%) and 91.0% (95% CI: 84.1-95.6%), respectively. The error rate of partial type diagnosed by TTE was significantly higher than that of total and mixed type (20.5% vs. 2.8%, P = 0.003). The consistency between TTE and CT to determine drainage sites was 91.9% (95% CI: 85.2-96.2%). TTE had a significantly higher error rate in determining pulmonary vein drainage to the SVC than in those draining into the left innominate vein (17.5 vs. 2.5%, P = 0.007). The consistency of TTE and CT in judging the number of veins was 87.4% (95% CI: 79.7-92.9%). The error rate in determining the presence of 2 and 5 ectopic pulmonary veins was significantly higher than those of 1 and 4 veins (P < 0.05). Conclusion TTE for diagnosing partial SAPVC and identifying the drainage site of SVC has a high error rate of misdiagnosis and missed diagnosis. The extra attention should be given to these factors in clinical practice to improve the accuracy of TTE in diagnosing SAPVC.

Computed tomography of pulmonary veins: review of congenital and acquired pathologies

Newer-generation CT scanners with ultrawide detectors or dual sources offer millisecond image acquisition times and significantly decreased radiation doses compared to historical cardiac CT and CT angiography. This technology is capable of nearly freezing cardiac and respiratory motion. As a result, CT is increasingly used for diagnosing and monitoring cardiac and vascular abnormalities in the pediatric population. CT is particularly useful in the setting of pulmonary vein evaluation because it offers evaluation of the entire pulmonary venous system and lung parenchyma. In this article we review a spectrum of congenital and acquired pulmonary venous abnormalities, including potential etiologies, CT imaging findings and important factors of preoperative planning. In addition, we discuss optimization of CT techniques for evaluating the pulmonary veins.

Emergency surgery without stabilization prior to surgical repair for total anomalous pulmonary venous connection reduces duration of mechanical ventilation without reducing survival

Background

To examine two different operation timing for treating patients with a total anomalous pulmonary venous connection (TAPVC) who need emergency surgery and to summarize the effects of the two operation strategies.

Methods

A retrospective review of 54 patients with TAPVC who underwent operations within 72 h of presentation between December 2010 and July 2019 at a single institution was conducted. All patients exhibited respiratory or hemodynamic instability that required mechanical ventilation and inotropic support. Forty-four patients received emergency operations between 24 to 72 h due to stabilization of the patient’s condition. Stable hemodynamics were achieved, and a stable internal milieu was maintained before the operation. These patients comprised the Stable group (SG). Rather than being subjected to efforts to obtain stable hemodynamics and maintain a stable internal milieu, ten patients received emergency operations immediately within 24 h of diagnosis or an emergency operation is performed immediately due to uncorrectable acidosis or progressive cardiovascular collapse. These patients comprised the Unstable group (UG). The hospital course, operative data, and outpatient records were reviewed.

Results

In SG group, there were 23 exhibited the supracardiac type, 15 exhibited the cardiac type, 4 exhibited the cardiac type, and 2 exhibited the mixed cardiac type,3 patients were premature, the rest was term infant, PDA was the most common comorbidities (28 patients), the next is severe tricuspid valve regurgitation (21 patients). In UG group, there were 3 exhibited the supracardiac type, 4 exhibited the cardiac type, 3 exhibited the cardiac type, and no patient exhibited the mixed cardiac type, only 1 patient was premature, the rest were term infant. PDA (6 patients) and severe tricuspid valve regurgitation (5 patients) were the top two comorbidities. The median weight, median age at surgery, mean cardiopulmonary bypass (CPB) duration and mean aortic cross-clamp (ACC) duration were not significantly different between the two groups. The median postoperation durations of ventilator support were 8.1 ± 4.6 (2–13) days in the SG group and 4.9 ± 2.1 (2–18) days in the UG group, resulting in a significant difference (p = 0.008), the Post-op days in ICU and Days of hospitalization were 8.64 ± 4.04 days and 19.9 ± 4.27 days in the SG group and 5.6 ± 2.01 days and 14.7 ± 1.75 days in the UG group (P = 0.026 and 0.002). There were 12 hospital mortalities (27.3%) in the SG group and 2 hospital mortalities (20%) in the UG group, resulting in no significant difference in mortality (p = 0.636). Postoperative complications, such as low cardiac output and arrhythmia, were not significantly different between the two groups. The survival rates in the UG and SG groups at 5 years were 87.5 and 89.9%, respectively. There was no difference in survival between the two groups at the latest follow-up (SG group 89.9% versus UG group 87.5%, p = 0.8115).

Conclusion

An emergency operation should be performed immediately without any delay, it can reduce duration of mechanical ventilation and Days of hospitalization without reducing mortality.

Total Anomalous Pulmonary Venous Connection with Lethal Pulmonary Venous Obstruction Managed by Multidisciplinary Cooperation

Background

Total anomalous pulmonary venous connection (TAPVC) is a critical congenital heart disease for which emergency surgery is required after birth. In cases of no intervention, TAPVC is associated with a high mortality rate in the first year of life. Although foetal echocardiographic techniques for diagnosing TAPVC have improved, TAPVC remains one of the most difficult congenital heart diseases to diagnose via foetal echocardiography. Here, we report a case of TAPVC with pulmonary venous obstruction (PVO), which was diagnosed via foetal echocardiography. Case Presentation. On foetal echocardiography at 32 weeks' gestation, a large atrial septal defect, enlarged superior vena cava, and continuous flow pattern in the vertical vein from the common chamber were observed in the foetus. Paediatric cardiologists and cardiac surgeons, neonatologists, and obstetricians planned to perform a caesarean section and emergency heart surgery. The male infant was born at 37 weeks' gestation via caesarean section, and postnatal echocardiography revealed PVO at the confluence of the superior vena cava and common chamber. Similarly, chest computed tomography confirmed the foetal diagnosis. The postnatal diagnoses were TAPVC type Ib, PVO, atrial septal defect, and patent ductus arteriosus. Surgical repair of the TAPVC was initiated within the first 3 hours of life. Screening brain echocardiography and head computed tomography revealed intracranial haemorrhage and hydrocephalus. Therefore, the patient underwent emergency bilateral external drainage on day 13. On day 48, a ventriculoperitoneal shunt was inserted owing to progressive brain ventricular dilatation. The patient was discharged home on postoperative day 68.

Conclusions

Although the prognosis of TAPVC with PVO remains poor, continuous observation through foetal echocardiography and early interdepartmental collaboration can result in good outcomes.