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Scognamiglio R, Daliento L, Razzolini R, Boffa GM, Pellegrino PA, Chioin R, Dalla Volta S. Pulmonary atresia with intact ventricular septum: a quantitative cineventriculographic study of the right and left ventricular function. Pediatr Cardiol 1986; 7:183-7. [PMID: 2950381 DOI: 10.1007/bf02093176] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Quantitative cineventriculographic measurements (ventricular volumes, ejection fraction, and myocardial mass) were obtained in 15 neonates with pulmonary atresia and intact ventricular septum. There was a wide dimensional range for the right ventricle, from a reduced through normal to enlarged. A restrictive tricuspid valve (less than 12 mm) was associated with a small or diminutive right ventricle. A normal function of the right ventricle was present only in those cases with normal-sized chambers. The left ventricular end-diastolic volume was always greater than normal. The ejection fraction was normal only if a normal myocardial mass was present. Additional abnormalities were frequent in the myocardium of both ventricles, such as extreme thinning of the wall of the right ventricle and hypoplasia or fibroelastosis of the left ventricle. All these factors can lead to a poor surgical prognosis despite good anatomical correction.
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Abstract
The prognosis for patients with pulmonary atresia with intact ventricular septum is poor with or without conventional surgical intervention. Therefore, a comprehensive program of medical and surgical treatment is necessary to improve long-term outlook for these infants. Such a program consists of management of the neonate at initial presentation with prompt administration of prostaglandins and institution of a combination of surgical procedures (isolated pulmonary valvotomy, valvotomy plus modified Blalock-Taussig shunt, Blalock-Taussig shunt plus balloon atrial septostomy, or Blalock-Taussig shunt alone) depending on the results of morphological analysis of the right ventricle; this treatment regimen is designed to relieve hypoxemia, encourage right ventricular growth, and provide adequate egress of blood from the right atrium. Another important element of management is to perform follow-up hemodynamic and angiographic studies when the patient is between 6 and 12 months old to ensure that the objectives of the comprehensive program are being met. Finally, a definitive repair should be offered. This can be done by using or bypassing the right ventricle, depending on whether it can support the pulmonary circuit.
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Weldon CS, Hartmann AF, McKnight RC. Surgical management of hypoplastic right ventricle with pulmonary atresia or critical pulmonary stenosis and intact ventricular septum. Ann Thorac Surg 1984; 37:12-24. [PMID: 6691736 DOI: 10.1016/s0003-4975(10)60702-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Our experience with the surgical management of hypoplastic right ventricle with intact ventricular septum includes 26 patients with pulmonary atresia and 4 with critical pulmonary stenosis. Group 1 consisted of 8 neonates managed initially by transventricular valvotomy; 6 later required a secondary procedure, with 100% survival. Group 2 had 11 neonates managed by aorta-pulmonary artery shunting without operative death. However, only 3 have survived over the long term and 1 has required an additional shunt procedure. Group 3 had 9 infants who underwent concomitant valvotomy and shunting. There were 4 operative deaths and 1 late death. Finally, Group 4 included 2 infants managed by primary repair at 3 days and 6 days old with prosthetic enlargement of the right ventricle; 1 required the addition of a shunt. Both are alive. Seven of the 15 patients in Groups 1, 2, and 3 who survived neonatal palliative procedures have undergone reparative operations. Two had no growth of the right ventricle and underwent repair after conversion to tricuspid atresia, by a Fontan procedure. Five had prosthetic enlargement of the right ventricle in childhood with 1 late death. Findings of this review were as follows: (1) effective palliation of pulmonary atresia and intact ventricular septum or critical pulmonary stenosis with cavitary hypoplasia of the right ventricle is rare unless transventricular flow can be established; (2) establishment of transventricular flow produces a high incidence of cavitary "growth," which permits later repair; (3) the Fontan operation is available for repair in patients who have no cavitary growth; and (4) when all three portions of the right ventricular cavity can be identified by angiography, a primary repair can be performed in the neonatal period with a good long-term prognosis.
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Hubbard JF, Girod DA, Caldwell RL, Hurwitz RA, Mahony LA, Waller BF. Right ventricular infarction with cardiac rupture in an infant with pulmonary valve atresia with intact ventricular septum. J Am Coll Cardiol 1983; 2:363-8. [PMID: 6863769 DOI: 10.1016/s0735-1097(83)80176-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This report describes an 8 day old infant with pulmonary valve atresia, hypoplastic and hypertensive right ventricle and myocardial sinusoid-left anterior descending coronary artery connections. A large right ventricular sinusoid complex developed that was associated with transmural right ventricular necrosis and cardiac rupture. This is the first report to document transmural myocardial infarction and rupture in pulmonary valve atresia with intact septum, and this condition should be added to the causes of myocardial infarction in infancy. A reduced number of caliber of sinusoid-coronary artery channels may be responsible for right ventricular damage in this condition.
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Kutsche LM, Van Mierop LH. Pulmonary atresia with and without ventricular septal defect: a different etiology and pathogenesis for the atresia in the 2 types? Am J Cardiol 1983; 51:932-5. [PMID: 6829467 DOI: 10.1016/s0002-9149(83)80168-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
In 15 of 20 hearts of neonates with pulmonary atresia and intact septum (PA-IVS) and in 4 with critical pulmonary stenosis, the pulmonary valve consisted of 3 fused cusps. One of the 11 patients with a ventricular septal defect (PA-VSD) had a well-developed pulmonary root; in 8 the pulmonary trunk arose from a dimple. Two had a bicuspid valve. In 10 of the 20 patients with PA-IVS and in those with critical stenosis, the diameter of the pulmonary trunk was normal or larger than normal. The authors believe that this is related to flow through an initially patent pulmonary valve and, perhaps more importantly, to poststenotic dilatation. In all hearts with PA-VSD, the pulmonary trunk was very small. In the patients with PA-IVS and a normal-sized pulmonary trunk and in 3 with critical pulmonary stenosis, the morphology of the ductus arteriosus was normal, suggesting that even in the former the valve was patent before birth, allowing forward flow. In all patients with small pulmonary trunk, the ductus was long, tortuous, and originated from the aortic arch in a proximal position, suggesting that reversal of flow had occurred early in development. The authors postulate that in patients with ventricular septal defect (VSD), the pulmonary ostium becomes atretic early in development, at or shortly after partitioning of the truncoconal part of the heart has taken place but before closure of the ventricular septum. In patients with intact ventricular septum, on the other hand, atresia very likely occurs sometime after cardiac septation has been completed. In these cases the pulmonary atresia may be due to a prenatal inflammatory process, rather than representing a true congenital malformation.
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O'Connor WN, Cottrill CM, Johnson GL, Noonan JA, Todd EP. Pulmonary atresia with intact ventricular septum and ventriculocoronary communications: surgical significance. Circulation 1982; 65:805-9. [PMID: 7060260 DOI: 10.1161/01.cir.65.4.805] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The first stage of a repair of pulmonary atresia with intact ventricular septum (type I) was attempted in a 2-day-old infant. At surgery, decompression of the hypertensive small right ventricle was followed by a sudden loss of myocardial contractility and death. Postmortem examination revealed a fistula with a large orifice in the right ventricular infundibulum that communicated directly with the left main coronary artery. Severe hypertensive changes indicative of abnormally high perfusion pressure were noted in the distal left coronary artery branches. The clinical course suggests that the effect of relieving right ventricular outflow obstruction was a reduction of left main coronary artery blood flow, resulting in fatal intraoperative myocardial ischemia. This unusual case draws attention to the anomalous ventriculocoronary communications often present in pulmonary atresia and their potential for limiting a successful surgical repair.
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Patel RG, Freedom RM, Moes CA, Bloom KR, Olley PM, Williams WG, Trusler GA, Rowe RD. Right ventricular volume determinations in 18 patients with pulmonary atresia and intact ventricular septum. Analysis of factors influencing right ventricular growth. Circulation 1980; 61:428-40. [PMID: 7351069 DOI: 10.1161/01.cir.61.2.428] [Citation(s) in RCA: 80] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Right ventricular growth was assessed angiocardiographically in 18 patients with pulmonary atresia, intact ventricular septum, and hypoplastic and hypertensive right ventricle. A variety of surgical procedures were performed. In only 12 patients (66.7%) was right ventricular-pulmonary artery continuity achieved (group 1). Nine of these 12 patients persisted with systemic or suprasystemic right ventricular pressures. Among the six patients in whom right ventricular-pulmonary artery continuity was not achieved (group 2), all maintained suprasystemic right ventricular pressures. Right ventricular growth was assessed in groups 1 and 2. The patients were also subdivided according to the qualitative degree of tricuspid regurgitation as determined angiocardiographically on right ventricular cineangiocardiograms at the preoperative catheter study. Right ventricular growth to normal levels as evidenced by change in right ventricular end-diastolic volume was rarely observed in group 2 patients. Among the four patients with severe tricuspid regurgitation and a large tricuspid valve, right ventricular growth to normal levels was achieved whether they were in group 1 or group 2. Right ventricular growth is thus predicated on numerous morphologic factors in these patients. However, reconstitution of right ventricular-pulmonary artery continuity and a nonobstructive tricuspid valve are probably two of the more important factors.
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Abstract
The morphological features of a series of 37 specimens of pulmonary atresia with intact ventricular septum were reviewed with particular emphasis on features which might influence the results of pulmonary valvotomy. The degree of right heart hypoplasia was quantified by measuring right and left heart dimensions and comparing them with 20 normal infant hearts. Right ventricular cavity size was usually smaller than normal but constituted a spectrum ranging from tiny to a dilated ventricle larger than normal. There was a positive correlation between triscuspid annular size and right ventricular size but no correlation between the size of the pulmonary artery and the right ventricle. Successful pulmonary valvotomy with subsequent adequate right ventricular function would have been precluded by a tiny right ventricular cavity or infundibular atresia in 14 specimens and by severe tricuspid stenosis or regurgitation in an additional 4. Severe right or left ventricular endocardial fibroelastosis may have adversely affected ventricular function in several others. Ten specimens displayed convex bulging of the left ventricular septal surface. If these these anatomical findings are representative for the condition as a whole, they provide a good explanation for its disastrous prognosis.
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Bharati S, McAllister HA, Chiemmongkoltip P, Lev M. Congenital pulmonary atresia with tricuspid insufficiency: morphologic study. Am J Cardiol 1977; 40:70-5. [PMID: 879017 DOI: 10.1016/0002-9149(77)90103-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In an anatomic study of 21 cases of pulmonary atresia with tricuspid insufficiency (pulmonary atresia with intact ventricular septum, type II), the morphologic features of the tricuspid valve and the right ventricle were found to differ greatly from those seen in pulmonary atresia with tricuspid stenosis (pulmonary atresia with intact ventricular septum, type I). Morphologically, pulmonary atresia with tricuspid insufficiency (type II) has a greater resemblance to Ebstein's disease with pulmonary atresia than to type I pulmonary atresia. The anomaly may be more amenable to surgery than pulmonary atresia with tricuspid stenosis because the right ventricle in the former may be converted into a functional chamber by a valvotomy combined with a shunting procedure and atrial septostomy.
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Rigby ML, Silove ED, Astley R, Abrams LD. Pulmonary atrsia with intact ventricular septum. Open heart surgical correction at 32 hours. Heart 1977; 39:573-6. [PMID: 861102 PMCID: PMC483278 DOI: 10.1136/hrt.39.5.573] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A case of pulmonary atresia with intact ventricular septum is reported in which total surgical correction was carried out successfully at 32 hours of age. Cardiac catheterisation at 17 months has revealed virtually normal haemodynamic and angiographic findings. Surgical correction of this condition in the neonatal period is discussed.
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Rao PS, Liebman J, Borkat G. Right ventricular growth in a case of pulmonic stenosis with intact ventricular septum and hypoplastic right ventricle. Circulation 1976; 53:389-94. [PMID: 1245047 DOI: 10.1161/01.cir.53.2.389] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Adequate growth of the hypoplastic right ventricle in a patient with severe pulmonary stenosis with an intact ventricular septum was documented after pulmonary valvotomy in infancy. It is postulated that the growth of the ventricular chamber is largely the result of pulmonary regurgitation resulting from successful pulmonary valvotomy. Based on this and the observations of others on the growth of the hypoplastic right ventricle in pulmonary atresia (with intact septum) cases, an organized approach to eventual total surgical correction is recommended.
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Freedom RM, Harrington DP. Contributions of intramyocardial sinusoids in pulmonary atresia and intact ventricular septum to a right-sided circular shunt. Heart 1974; 36:1061-5. [PMID: 4451584 PMCID: PMC458920 DOI: 10.1136/hrt.36.11.1061] [Citation(s) in RCA: 64] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Freedom RM, White RI, Ho CS, Gingell RL, Hawker RE, Rowe RD. Evaluation of patients with pulmonary atresia and intact ventricular septum by double catheter technique. Am J Cardiol 1974; 33:892-5. [PMID: 4829372 DOI: 10.1016/0002-9149(74)90637-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
Five neonates with congenital tricuspid incompetence due to severe tethering of the tricuspid valve to the right ventricle by abnormal chordal and papillary muscle attachments are described. The abnormality was called tricuspid valvular dysplasia (TVD) if the basal insertion of the valve was normal and the Ebstein malformation if it was displaced into the sinus portion of the ventricle.
In the two infants with isolated TVD and severe tricuspid regurgitation the functional obstruction to right ventricular outflow (ORVO) produced by the high perinatal pulmonary vascular resistance (PVR) made the exclusion of pulmonary atresia difficult, despite selective right ventricular angiocardiography.
In three infants the tricuspid valvular abnormality was associated with organic ORVO; pulmonary atresia in two and critical pulmonary valve stenosis in one. In the two infants with pulmonary atresia and intact ventricular septum (IVS) the severe tricuspid incompetence produced a clinical, radiological and hemodynamic profile which was clearly different from that usually seen in infants with pulmonary atresia and IVS and a normal right ventricular cavity (type 2 of Greenwold).
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Singer H, Bayer W, Reither M, von Hinüber G. [Coronary vessel anomalies and persisting myocardial sinusoids in pulmonary atresia with intact ventricular septum]. Basic Res Cardiol 1973; 68:153-76. [PMID: 4577012 DOI: 10.1007/bf01906422] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Miller GA, Restifo M, Shinebourne EA, Paneth M, Joseph MC, Lennox SC, Kerr IH. Pulmonary atresia with intact ventricular septum and critical pulmonary stenosis presenting in first month of life. Investigation and surgical results. Heart 1973; 35:9-16. [PMID: 4265486 PMCID: PMC458557 DOI: 10.1136/hrt.35.1.9] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Luckstead EF, Mattioli L, Crosby IK, Reed WA, Diehl AM. Two-stage palliative surgical approach for pulmonary atresia with intact ventricular septum (type I). Am J Cardiol 1972; 29:490-6. [PMID: 4111637 DOI: 10.1016/0002-9149(72)90438-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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McArthur JD, Munsi SC, Sukumar IP, Cherian G. Pulmonary valve atresia with intact ventricular septum. Report of a case with long survival and pulmonary blood supply from an anomalous coronary artery. Circulation 1971; 44:740-5. [PMID: 5094154 DOI: 10.1161/01.cir.44.4.740] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
A case of pulmonary valve atresia with intact ventricular septum' with long survival in the absence of a patent ductus arteriosus, is presented. The patient, alive at 21 years of age, has the anterior descending branch of the left coronary artery originating from the pulmonary artery. Thus, the pulmonary blood supply is obtained from the right coronary artery via intercoronary anastomoses. No similar case has been reported previously.
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MESH Headings
- Cyanosis/etiology
- Diagnosis, Differential
- Female
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/mortality
- Heart Defects, Congenital/prevention & control
- Heart Defects, Congenital/surgery
- Heart Defects, Congenital/therapy
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/complications
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/mortality
- Infant, Newborn, Diseases/prevention & control
- Infant, Newborn, Diseases/surgery
- Infant, Newborn, Diseases/therapy
- Pregnancy
- Time Factors
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