Tricuspid atresia with prolonged survival. A report of two cases with a review of the world literature

Type Ia tricuspid atresia with extensive coronary artery abnormalities in a living 22 year old woman

Type Ia tricuspid atresia, with extensive coronary artery abnormalities, is identified in the oldest living patient with this condition, a 22 year old woman. Clinical characteristics include severe cyanosis, effort dyspnea, myocardial infarction in the past and persistent angina pectoris. "Ideal" pulmonary flow and adequate left ventricular function, despite an akinetic apical segment, are substantive factors for this exceptional longevity. Coronary abnormalities consist of: 1) total proximal occlusion of the left anterior descending coronary artery; and 2) partial diversion of coronary artery flow to a segmental pulmonary artery branch. Nonvisualization of the coronary sinus is also noted. Factors other than atherosclerosis may account for total proximal occlusion of the left anterior descending coronary artery. Survival is threatened by adverse effects of ongoing ischemic coronary events.

Surgical repair of univentricular heart (double inlet left ventricle) with obstructed anterior subaortic outlet chamber

The results of operation in all patients with univentricular heart and an obstructed anterior subaortic outlet chamber who were operated on utilizing extracorporeal circulation at the Mayo Clinic from 1973 through 1983 were reviewed. Ten of the 18 patients died during the immediate postoperative period and there was one late death. Factors significantly related to operative and immediate postoperative mortality were age at operation, cardiothoracic ratio on X-ray examination, degree of ST depression on electrocardiogram and pressure gradient across the outlet foramen at catheterization. Autopsy in eight cases revealed significant hypertrophy of ventricular myocardium and a small outlet foramen that was considered stenotic relative to either body surface area or aortic root area. The ventricular myocardium showed histologic changes of chronic ischemia that predated the surgical procedure.

Prolonged survival in tricuspid atresia with Eisenmenger's physiology

Survival to adulthood is very rare in tricuspid atresia, particularly in certain subtypes and in the presence of Eisenmenger's physiology. We report a 32-year-old woman who has the type IC variant of tricuspid atresia and who has had documented Eisenmenger's physiology for over 10 years.

Tricuspid atresia in adults

Congenital atresia of the tricuspid valve is still uncommon in adult patients. However, increasingly successful palliative surgery in children now has increased its incidence after age 15 years. This investigation updates the clinical features of this disease in adults in light of modern diagnostic and surgical techniques. The data on all 18 adults with tricuspid atresia having angiography after age 15 years at this institution since 1970 were reviewed. The patients' ages ranged up to 45 years; 12 had had previous palliative surgery. Left cineventriculography, particularly biplane, with the long axial view (60 degrees left anterior oblique with cranial angulation) is the most important diagnostic mode and reveals the ventricular and great vessel relations. According to standard classification, 11 patients had type I anatomy (normal great arterial relations), 4 type II (transposed great arteries) and 2 type III ("corrected transposition of the great arteries"). One patient with inverted ventricles could not be classified. Associated additional congenital defects were uncommon. On the basis of these data, a new anatomic classification of tricuspid atresia is given which encompasses all possible atrial-ventricular-great arterial combinations. Seven patients had further surgery after study, including two procedures of the Fontan type (right atrium to pulmonary arterial conduit). Follow-up data on all 18 patients revealed two deaths (one early after operation, one late after study without further surgery). The remaining 16 patients survive 2 to 120 months after study. Four patients had naturally balanced pulmonary and systemic circulations and have survived to ages 21 to 41 years without surgery. Prudent surgical decision based on accurate anatomic diagnosis and the need for optimal effective pulmonary blood flow may result in a relatively optimistic prognosis in adults with this disease.

Tricuspid atresia. A review of 68 cases

Sixty-eight patients with tricuspid atresia were seen at Indiana University during the past 30 years. Long term survivors treated without operation emerged from our review. In these, there was a combination of tricuspid atresia and transposition of the great vessels.

Left ventricular function in tricuspid atresia. Angiographic analysis in 28 patients

Thirty-one left ventricular (LV) biplane angiograms were performed in 28 patients with tricuspid atresia. Measurements of left ventricular end-diastolic volume (LVEDV) and left ventricular end-systolic volume were obtained by the modified Simpson's rule and systolic ejection fraction (EF) calculated. Left ventricular volumes and ejection fractions were also obtained in 19 control patients with no significant heart disease. The patients with tricuspid atresia were classified according to the appearance of the pulmonary vascularity on initial radiologic examination: Group A, decreased pulmonary vascularity; Group B, increased pulmonary vascularity. In the 13 group A infants who were unoperated, LVEDV was increased and EF mildly diminished. In the group B patients LVEDV was increased and EF normal. In the 12 group A patients with surgical shunts LVEDV was elevated. The five group A patients with long-standing systemic artery to pulmonary artery anastomoses (greater than 10 years) showed the largest LVEDV and the poorest EF. The angiographic data indicate that patients with tricuspid atresia experience significant LV dysfunction as a consequence of longstanding LV volume overload. The early detection of LV dysfunction may be an indication for a right ventricular bypass procedure in these patients.

Tricuspid atresia: clinical course in 101 patients

The clinical profile and course of 101 patients with tricuspid atresia seen at the Children's Hospital Medical Center, Boston, were reviewed; the electrocardiograms, hemodynamic data, associated anomalies, complications of the malformation and surgical results were outlined and a definition of anatomic types and radiologic groups formed in order to facilitate therapeutic decisions. Overall survival to 15 years of age was approximately 50 percent. Tricuspid atresia type 1 (normally related great arteries), group A (decreased pulmonary vascularity) was the most frequent category (54 percent); without surgery, these patients had only a 10 percent chance of survival beyond the 1st year of life. Surgical intervention improved chance of survival to 15 years of age to 50 percent. Overall surgical mortality was 23 percent. The Waterston shunt is the procedure of choice in symptomatic small infants with diminished pulmonary flow (group A). Type II patients with increased pulmonary blood flow (group B) would benefit from a pulmonary arterial band. In contrast, patients with group B, type I atresia would rarely need a pulmonary arterial band. Patients with spontaneously changing hemodynamics (group C) usually require a shunt later in life than those in group A, with more favorable operative results. Our experience indicates the continued need of early surgical palliation. New surgical approaches, such as the right atrial-pulmonary arterial anastomosis, may result in a more prolonged survival.