Congenital corrected transposition of the great vessels without cardiac anomalies

Coronary artery anatomy in corrected transposition of the great arteries

Congenitally corrected transposition of the great arteries is an unusual cardiac malformation with discordant atrioventricular and ventriculoarterial alignments. Because knowledge of the coronary artery anatomy is a prerequisite for successful repair of this cardiac anomaly, selective coronary arteriography was performed in 13 children (4 male and 9 female; age range 18 months to 16 years) and 1 adult (aged 59 years) with congenitally corrected transposition of the great arteries and associated intracardiac defects. The typical coronary distribution of corrected transposition (that is, coronary artery-ventricular concordance) was found in 11 patients. In one patient, a single coronary ostium was observed; the right sinus of Valsalva gave rise to a short common branch that divided into three arteries: a left circumflex artery going to the right, a well developed left anterior descending artery running into the anterior interventricular groove and a third vessel that continued on the normal course of the right coronary artery directed posteriorly. In one patient, the left circumflex artery was particularly small. In another patient, with severe hypoplasia of the left anterior descending coronary artery, the anterior ventricular wall of the heart was supplied by three small branches that ended a short distance from their origins. The adult patient had a large anterior ventricular branch arising from the morphologic left coronary ventricular as well as a large acute marginal branch, with a wide distribution, from the morphologic right coronary artery. Presurgical coronary angiographic documentation is helpful because, in congenitally corrected transposition as well as in complex congenital heart disease, coronary anomalies (in origin, course and distribution) are occasionally present and knowledge of their presence can help determine the most appropriate surgical approach.

The cardiac malformations. Double inlet left ventricle and corrected transposition explained as deviations in the normal development of the interventricular septum

To examine the hypothesis that malpositions of cardiac ventricles could be explained by altered development of the interventricular septum, we studied hearts from the Johns Hopkins Hospital autopsy files with double inlet left ventricle (16 cases) or corrected transposition (nine cases). In double inlet left ventricle (16 cases) or corrected transposition (nine cases). In double inlet ventricle both atrioventricular valves connect normally developed and positioned right and left atria to a posterior morphologic left ventricle. In hearts with corrected transposition the atria are normally positioned and the morphologic right ventricle is on the left and is continuous with the anteriorly positioned aorta. The morphologic left ventricle is on the right, connected to the posteriorly positioned pulmonary trunk. Normal ventricular septation may be understood as arising from the mechanics of a spiral fold in the primary heart tube produced by the left interventricular sulcus. The ventral limb of the spiral induces the muscular interventricular septum while the dorsal limb becomes a component of the crista supraventricularis. We propose that double inlet left ventricle and corrected transposition are the result of minor deviations in the position of the interventricular sulcus on the primary heart tube. Double inlet left ventricle may develop from the formation of a closed unspiraled ring around the interventricular canal. Corrected transposition may result from a left interventricular sulcus whose ventral limb gives rise to a left sided crista supraventricularis, which determines in part the right ventricular morphology of the left sided ventricle. The dorsal limb spirals toward th atrioventricular canal, gives rise to a malpositioned interventricular septum, and displaces the embryonic trabeculated right ventricle to the left. The concept presented accounts for the morphologic findings characteristic of double inlet left ventricle and corrected transposition.

Systemic atrioventricular valve regurgitation in corrected transpositon of the great vessels. Angiographic differentiation of operable and nonoperable valve deformities

Abnormalities of the systemic atrioventricular (A-V) valve are frequently present in patients with corrected transposition. Systemic A-V valve regurgitation is usually present and may be amenable to operative correction with valve replacement if the regurgitation is caused by normally positioned but deformed valve leaflets or a dilated valve ring, or both. Systemic A-V valve regurgitation secondary to the more common Ebstein-type malformation of the inverted tricuspid valve is an inoperable conditon at present. Displacement of the valve leaflets below the level of the valve ring may be seen in the angiocardiograms of patients with this finding and is the differentiating feature between the two lesions. Ten cases of systemic A-V valve regurgitation in patients with corrected transposition are reviewed to illustrate these features.

Pediatric congenital cardiac becomes a postoperative adult. The changing population of congenital heart disease

The following commentary on the changing population of congenital heart disease will deal with: incidence and survival patterns—an overview; effects of diagnostic and surgical interventions on survival patterns—changing population; ultimate goals and aspirations—what are we trying to accomplish?; types of surgical intervention—desirability of primary anatomic repair in infancy; and the problem of residua—setting the stage for future research.