Two-stage palliative surgical approach for pulmonary atresia with intact ventricular septum (type I)

Simultaneous patency of ductus arteriosus and surgical shunt in pulmonary atresia with intact ventricular septum. A cause of acute myocardial failure?

Twenty-seven patients with pulmonary atresia and intact interventricular septum were treated with prostaglandin E1 infusion, followed by standard or modified Blalock-Taussig shunt. Three infants died. In all three there was anatomic and functional patency of the ductus arteriosus and the surgical systemic-pulmonary shunt. The unusual clinical course in these cases suggests that in the clinical management of patients with pulmonary atresia and intact interventricular septum after a shunt operation, particular attention must be paid to the problems associated with persistent ductal patency.

Pulmonary atresia with intact ventricular septum: a quantitative cineventriculographic study of the right and left ventricular function

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.

Comprehensive management of pulmonary atresia with intact ventricular septum

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.

Pulmonary atresia with intact ventricular septum and ventriculocoronary communications: surgical significance

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.

Angio-pathological appearances of pulmonary valve in pulmonary atresia with intact ventricular septum. Interpretation of nature of right ventricle from pulmonary angiography

Correlative angiographic-anatomical studies in 19 cases of pulmonary atresia with infarct ventricular septum showed the following relations between the angiographic appearance of the pulmonary valve and the morphology of the right ventricle. (1) Doming of the pulmonary valve was associated with a nearly normal-sized right ventricle and a wide infundibulum patent to the level of the pulmonary valve. (2) A fixed valve was associated either with (a) pronounced hypoplasia of the ventricular changer and stenosis of the infundibulum or (b) less commonly, a massive right ventricle and Ebstein's malformation of the tricuspid valve. (3) An intermediate type valve was associated with a small right ventricle and a small infundibulum which was, however, patent to the level of the pulmonary valve. It is suggested that the configuration of the pulmonary valve is a result of haemodynamic stresses placed upon it. These stresses, in turn, are determined by the morphological nature of the right ventricle. Thus, the nature of the pulmonary valve as seen angiographically may ve used as an index of right ventricular morphology.

Right ventricular volume determinations in 18 patients with pulmonary atresia and intact ventricular septum. Analysis of factors influencing right ventricular growth

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.

Morphological variations in pulmonary atresia with intact ventricular septum

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.

Early and late results in pulmonary atresia

The early and long-term results following surgical treatment of 24 infants with pulmonary atresia with an intact ventricular septum were reviewed. Pulmonary valvotomy was the operation most often performed, and we came to realize that this was effective when the preoperative right ventricular angiogram had shown an open conus up to the atretic valve. By contrast, no infant without a patent conus survived pulmonary valvotomy. We suggest that this subgroup of patients (8 of the 24 in this series) should have a systemic-pulmonary shunt followed later by reconstruction of the right ventricular outflow tract. Diminutive right ventricles will grow and dilate if a reasonable passageway is formed from right ventricle to pulmonary artery. Thus the long-term results have been excellent when this has been carried out, with normal right ventricular pressures and appearance on angiography in 7 patients followed up to 13 years.

Right ventricular growth in a case of pulmonic stenosis with intact ventricular septum and hypoplastic right ventricle

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.

Survival after systemic to pulmonary arterial shunts in infants less than 30 days old with obstructive lesions of the right heart chambers

Ninety-seven infants less than 30 days old with obstructive lesions of the right heart chambers underwent palliative surgery from 1950 through 1972. The diagnosis was made at cardiac catheterization and confirmed at operation or subsequent autopsy. Because of unavailability of complete preoperative studies and sufficient blood gas data, 36 patients presenting between 1950 and 1965 (Group I) were analyzed for surgical risk only. In 61 patients who underwent palliative procedures between 1966 and 1972 (Group II) a more detailed analysis was done. In this group, 31 had a Potts shunt, 29 a Waterston shunt and 1 a Blalock-Taussig shunt. The most frequently encountered malformation was severe tetralogy of Fallot (30 percent) with or without pulmonary atresia, followed by pulmonary atresia with intact ventricular septum (25 percent). The overall surgical mortality rate in patients seen after 1965 (Group II) was 34 percent compared with the 78 percent mortality rate in patients seen earlier (Group I). The surgical mortality in infants operated on during the 1st week of life was double that of those operated on in the 2nd through 4th weeks. Survivors were compared with nonsurvivors for timing of surgery, age at presentation and clinical profile. Only two significant differences were found. Preoperative continuous murmurs were more common in those who survived operation (13 of 40 patients) than in those who died (2 of 21). Arterial pH during cardiac catheterization was the best predictor of subsequent survival, nonsurvivors having significantly greater metabolic acidosis. Palliation of these severe lesions still carries a high mortality rate to which must be added the risk of subsequent repair. Our data suggest that primary repair is to be preferred if it can be undertaken with a risk approximating that of palliative procedures.