Echocardiographic diagnosis of right aortic arch with a retroesophageal segment and left descending aorta

Follow-up of surgical correction of aortic arch anomalies causing tracheoesophageal compression: a 38-year single institution experience

OBJECTIVE

Anomalies of the aortic arch (vascular rings) are uncommon anomalies in which preferred strategies for diagnosis and treatment may vary among institutions. In this study, we report a description of our approach and review of our 38-year experience in patients surgically treated for vascular rings.

METHODS

A retrospective review was conducted of all patients with/without symptomatic tracheoesophageal compression secondary to anomalies of the aortic arch and great vessels diagnosed from 1970 to 2008. A total of 183 patients underwent surgical repair. Median age at the time of the operation was 5 months (range, 3 days to 30 years). Patients were classified into 5 major subtypes based on their surgical anatomy as follows: right aortic arch-left ligamentum (n = 77), double aortic arch (n = 67), aberrant (retroesophageal) right subclavian artery (n = 30), pulmonary sling (n = 8), and innominate artery compression (n = 1). Six patients (3%) had an associated Kommerell diverticulum. In patients with a double aortic arch, 82% had a dominant right arch and 18% had a dominant left arch. Preoperatively, 80 patients (44%) had stridor, and 86 patients (47%) had recurrent upper respiratory tract infection.

RESULTS

Associated cardiac diagnosis were present in 54 (30%) of 183 of all patients with vascular rings. Left thoracotomy was a common operative approach in all patients except pulmonary artery sling patients where a median sternotomy was the preferred approach. There were 3 early and 5 late deaths (all patients had complex cardiac anomalies) with a median follow-up of 6 years. Overall survival was 96% at 35 years. Postoperative complication occurred in 3 patients (2%) as follows: tracheostomy because of severe distal tracheal compression (n = 2) and left true vocal cord paralysis (n = 1). None of the patients showed any evidence of recurrent vascular ring anomalies at last follow-up. Of the children, 75% (135/180) were free from compressive symptoms within 1 year of the operation.

CONCLUSIONS

Vascular anomalies with/without tracheoesophageal compression present symptomatically in a variety of ways, and noninvasive methods are used to identify the specific lesion and associated cardiac defects. Surgical repair is associated with low or no mortality in patients with uncomplicated complex of vascular anomalies.

Three-dimensional imaging of aortic arch anomalies in infants and children with intravascular ultrasound catheters from a transesophageal approach

Aortic arch anomalies usually require surgical intervention preceded by precise anatomic definition. We studied 20 patients to evaluate the feasibility and accuracy of using intravascular ultrasound catheters from a transesophageal approach with 3-dimensional image reconstruction for the diagnosis of aortic arch anomalies in infants and children. All patients had transthoracic echocardiograms and/or angiograms or magnetic resonance imaging. A 12.5-MHz intravascular ultrasound catheter was positioned in the esophagus and withdrawn by using an electrocardiogram and a respiratory gated pullback device to acquire the mediastinal images. All patients with arch anomalies underwent surgical repair. Reconstructed images were analyzed in the "anyplane" mode and with surface rendering. Intravascular ultrasound 3-dimensional imaging was successfully accomplished without complications. Anatomy was correctly identified in all patients by both blinded and unblinded observers, thus confirming the sensitivity and accuracy of the technique. We foresee this new technique to be useful as an adjunctive imaging modality applicable at the bedside or in the cardiac imaging laboratory.

Ultrasonic Imaging of Vascular Rings and Other Anomalies Causing Tracheobronchial Compression

Display of aortic arch anatomy using single plane views does not readily allow for a three-dimensional interpretation of structural relationships. A method that includes a sweep consisting of multiple contiguous frontal planes has been developed for the evaluation of the arch sidedness and number, brachiocephalic vessel pattern, upper descending thoracic aorta sidedness, ductus arteriosi site(s), and proximal pulmonary arteries. The addition of Doppler color flow mapping aids in the tracing of multiple vascular structures in complex cases, and in assessing ductus arteriosi and arch patency. Posterior angulation can display encirclement of the air-filled trachea in cases of double aortic arch. Vascular ring segments without lumens cannot be displayed. (ECHOCARDIOGRAPHY, Volume 13, May 1996)

Congenital Anomalies of the Aortic Arch

Congenital anomalies of the aortic arch can occur either in isolation or in conjunction with other intracardiac defects. This review will examine congenital aortic arch anomalies as if they occur in isolation, with the awareness that intracardiac defects often coexist. The three general classes of abnormalities to be reviewed are: (1) abnormal connections between the aorta and pulmonary arterial system; (2) aortic arch obstructions; and (3) defects in the formation of the aortic arch typified by right aortic arches, vascular rings, and cervical aortic arches. (ECHOCARDIOGRAPHY, Volume 13, March 1996)

Rings, slings and such things: diagnosis and management with special emphasis on the role of echocardiography

Vascular anomalies of the aorta and pulmonary artery that cause tracheal, esophageal, or tracheoesophageal compression form an important group of congenital cardiovascular malformations. The diagnostic approach to the patient with possible vascular ring is variable. This article presents a systematic approach to the evaluation and management of this fascinating group of malformations, with special emphasis on the role and limitations of echocardiography. Using this approach between September 1990 and March 1992, we identified and defined vascular anomalies of aorta and pulmonary artery in eight children.

Right aortic arch with aberrant left subclavian artery. Report of two cases

Two cases of adult asymptomatic right aortic arch with an aberrant subclavian artery are reported. They were discovered at time of coronary surgery. Preoperative coronary arteriography failed to demonstrate the anomalies. In one case, the right arch was suspected on chest x-ray and preoperative barium oesophagography. In one case, the proximal suture of one saphenous bypass graft was performed on the left common carotid artery. Right aortic arch is a malformation rarely discovered in adults. It generally produces no symptoms when not associated with cardiac disease.

Central nervous system malformations in the CHARGE association

Of 144 patients with the CHARGE association (literature 136, new patients 8), 47 (33%) had either a postmortem examination (30) or computerized axial tomography scan (17) of the head. Twenty-six of 47 (55%) had definite central nervous system (CNS) malformations; arhinencephaly, with or without other defects (11), holoprosencephaly (2), holoprosencephaly with arhinencephaly (1), other forebrain defects (3), hindbrain defects (3), or other defects (6). The presence of CNS malformation was most strongly associated with choanal atresia. This review demonstrates a predominance of forebrain anomalies, particularly arhinencephaly and holoprosencephaly, which may provide a clue to the mechanism of abnormal morphogenesis involved in CHARGE association.

Ultrasonographic display of complex vascular rings

Ultrasonographic display of vascular ring anatomy has been limited to single-plane views. This does not readily allow for a three-dimensional interpretation of structural relations. A method that included a sweep consisting of multiple contiguous frontal planes was used in 12 patients with a vascular ring before repair for the evaluation of the arch sidedness and number, brachiocephalic vessel pattern, upper descending thoracic aorta sidedness, ductus arteriosus site or sites and proximal pulmonary arteries; 7 patients had Doppler color flow imaging. Complete imaging of the luminal vascular components was possible in all but one patient. In four other patients, atretic segments of the vascular ring could not be displayed. The addition of Doppler color flow imaging especially aided in the tracing of multiple vascular structures in complex cases and in assessing ductus arteriosus and arch patency. The use of a suprasternal frontal sweep with posterior angulation could display encirclement of the air-filled trachea. Vascular ring segments without lumens could not be displayed.

Hypoplastic right retro-oesophageal aortic arch: similarities to interrupted aortic arch

At echocardiography a dysmorphic neonate was found to have a hypoplastic mitral valve, left ventricle, and ascending aorta with interruption of the aortic arch between the left common carotid and the left subclavian arteries--the left subclavian artery arose from a normal sized left descending aorta. Cardiac catheterisation and subsequent necropsy confirmed this arrangement but also showed a tortuous right retro-oesophageal aortic arch. This arch was severely hypoplastic distal to the right subclavian artery. These cardiovascular anomalies occurred in the child of a family in which other members showed the velo-cardio-facial syndrome, a condition known to be associated with right aortic arch. This aortic arch arrangement may be impossible to distinguish from simple aortic interruption by echocardiography alone.