Congenitally corrected transposition and Ebstein's anomaly of the systemic atrioventricular valve: association with aortic arch obstruction

Combined Norwood and Modified Left-Sided Starnes Procedures for Congenitally Corrected Transposition of the Great Arteries

The combination of congenitally corrected transposition of the great arteries (ccTGA), Ebstein anomaly of the systemic atrioventricular valve, and critical systemic ventricular outflow tract obstruction is extremely rare. Management of a neonate with these lesions in cardiogenic shock is quite challenging. Tricuspid valve exclusion has been increasingly and successfully used to manage neonatal Ebstein anomaly patients. We extended this idea of tricuspid valve exclusion (modified Starnes) combined with a Norwood Stage 1 operation with a modified systemic to pulmonary artery shunt to successfully manage a neonate with ccTGA, severe systemic atrioventricular valve regurgitation, and critical ventricular outflow tract obstruction.

Ebstein's anomaly with coarctation of the aorta and a bicuspid aortic valve: a case report of a rare association with unique prenatal findings

Ebstein's anomaly is rarely accompanied by coarctation of the aorta, although patients with Ebstein's anomaly have a relatively small left ventricle. Here, we report a rare case of Ebstein's anomaly with coarctation of the aorta and a bicuspid aortic valve. We compared the foetal echocardiographic parameters of five previous cases with Ebstein's anomaly without left heart obstruction to explore the association between left ventricular volume, Ebstein's anomaly severity, and left heart obstruction.

Atrioventricular, ventriculoarterial discordance and Ebstein malformation of the tricuspid valve with severe regurgitation resulting in aortic atresia in a neonate

Aortic atresia is uncommonly associated with atrioventricular and ventriculoarterial discordance. Presence of severe regurgitation of Ebstein malformation of the tricuspid valve in this subset results in reduced aortic blood flow in-utero. We report here a term neonate with this anomaly detected antenatally.

Perioperative Echocardiography in the Adult With Congenital Heart Disease

Survival of patients with congenital heart disease has significantly improved over the last 2 decades, confronting interventionalists, surgeons, anesthesiologists, cardiologists, and intensivists with often unfamiliar complex pathophysiology in the perioperative setting. Aside from cardiac catheterization, echocardiography has become the main imaging modality in the hospitalized adult with congenital heart disease. The great variety of congenital lesions and their prior surgical management challenges practitioners to generate optimal imaging, reporting, and interpretation of these complex anatomic structures. Standardization of echocardiographic studies can not only provide significant benefits in the surveillance of these patients, but also facilitate understanding of pathophysiologic mechanism and assist clinical management in the perioperative setting. Knowledge in obtaining and interpreting uniform imaging protocols is essential for the perioperative clinician. In this publication, the authors review current international consensus recommendations on echocardiographic imaging of adults with congenital heart disease and describe the fundamental components by specific lesion. The authors will emphasize key aspects pertinent to the clinical management when imaging these patients in the perioperative setting. The goal of this review is to familiarize the perioperative physician on how to structure and standardize echocardiographic image acquisition of congenital heart disease anatomy for optimal clinical management.

Surgical management of a neonate with congenitally corrected transposition of the great vessels, hypoplastic right aortic arch, and Ebstein anomaly

We report a neonate with a primary diagnosis of congenitally corrected transposition (ccTGA) of the great vessels, hypoplastic right aortic arch, and a severely regurgitant Ebstein tricuspid valve (TV). During the fetal period, she was listed for heart transplantation, and two weeks after birth due to a deterioration of her general condition, we performed a Norwood-Sano modified procedure. After 58 days a donor heart became available and the baby successfully received a orthotopic heart transplantation.

Anatomy of discordant atrioventricular connections

The term discordant atrioventricular connections refers to the situation in which the ventricles are connected inappropriately to the atrial chambers. In most instances, the connections of the great arteries are also abnormal, with the aorta and the pulmonary trunk arising from morphologically inappropriate ventricles. This combination results in the presence of so-called congenitally corrected transposition. Double-outlet right ventricle is occasionally present, while concordant ventriculoarterial connections may be seen rarely. Most such hearts have a range of additional abnormalities, including ventricular septal defects; outflow tract obstruction, usually of the morphologically left ventricle; anomalies of the morphologically tricuspid valve; and a highly abnormal location of the specialized atrioventricular conduction axis. Some examples exhibit bizarre abnormalities of ventricular relationships and topology, including criss-cross atrioventricular connections and superoinferior ventricular relations. In describing the anatomy of these malformations, it is important to use a step-by-step segmental approach to the documentation of the connections and associated defects in each case and to avoid potentially confusing shorthand terms.

Norwood procedure combined with the Starnes procedure

We describe the case of 6-day-old baby girl with congenitally corrected transposition of the great arteries, Ebstein anomaly with severe tricuspid valve regurgitation, aortic atresia, hypoplastic aortic arch, and patent ductus arteriosus. She underwent Starnes procedure combined with the Norwood procedure. Postoperative echocardiography demonstrated good left ventricular function, reduced size of the right ventricle, and an unobstructed aortic arch. She was discharged and is currently awaiting a bidirectional Glenn operation.

Physiologic versus anatomic repair of congenitally corrected transposition of the great arteries: meta-analysis of individual patient data

The objective of this meta-analysis of individual patients' data was to compare the immediate outcomes of anatomic and physiologic repair of congenitally corrected transposition of the great arteries. Eleven nonrandomized studies, involving 124 patients, met the inclusion criteria for this review. The Rastelli type anatomic repair and the era of surgery were significantly related to the outcome in different tested models. Entering all variables into the logistic regression model showed a significant protective effect of the Rastelli type anatomic repair (odds ratio = 0.05, 95% confidence interval: 0.01, 0.50, p = 0.02).

Management of the Failing Systemic Right Ventricle

Conditions in which the right ventricle serves as the systemic pumping chamber are frequently complicated by the development of right ventricular failure and tricuspid valve regurgitation. The right ventricle is the systemic ventricle in conditions of ventriculoarterial discordance with atrioventricular concordance (transposition of the great arteries) or with atrioventricular discordance (congenitally corrected transposition of the great arteries). Concerns regarding actual or potential systemic right ventricular failure in these cases may lead to surgical evaluation and treatment designed to reestablish the left ventricle as the systemic pump. In cases where the left ventricle has prolonged exposure to low pressures in the pulmonary circulation, the left ventricle must be "retrained" to assume a systemic pressure load. Anatomic repair, with or without a preparatory period of left ventricular retraining, is a consideration for three clinically relevant scenarios: (1) patients with transposition of the great arteries after an atrial level switch (Senning or Mustard procedure), (2) patients with congenitally corrected transposition who are unoperated or who have undergone physiologic ("classic") repair, and (3) unoperated patients with transposition who present after the neonatal period.

Congenitally corrected transposition of the great arteries with Ebstein malformation and hypoplasia of the aortic arch in a fetus

Congenitally corrected transposition of the great arteries is not uncommonly associated with Ebstein's malformation of its left-sided tricuspid valve. The recognition of this rare association in the fetus is important because its postnatal prognosis is guarded. The present case report illustrates fetal echocardiographic clues to the diagnosis that include mesocardia and apically displaced attachment of the left-sided atrioventricular valve to the ventricular septum at four-chamber view.

The prenatal diagnosis of, and short-term outcome for, patients with congenitally corrected transposition

Congenitally corrected transposition is a rare congenital anomaly, with only a few cases diagnosed and reported prenatally even in the largest fetal series. To determine the morphologic features and outcome for the lesion as recognized during fetal life, we reviewed the fetal and postnatal echocardiograms and medical records of 11 consecutive cases of congenitally corrected transposition. These were identified among 230 (4.7%) consecutive cases of structural cardiac disease referred to our fetal cardiology unit over a period of 4 years. The mean gestational age at diagnosis was 24.7 weeks. Reasons for referral were suspected complete transposition, abnormal position of the heart, and bradyarrhythmias. Associated cardiac lesions included an abnormal cardiac position in 6 cases, ventricular septal defect in 8, obstruction of the subpulmonary outflow tract in 6, tricuspid valvar displacement in 5, and complete atrioventricular block in 2. Only 3 of the cases had mild tricuspid regurgitation prior to birth. Termination was chosen in 4 cases with severe obstruction to pulmonary flow. Of the remaining cases, 2 patients died at 3 and 12 months after birth, respectively. Both developed significant tricuspid regurgitation associated with unexpected major arrhythmias. The remaining 5 patients are alive and relatively well at a mean follow-up of 25.4 months. An epicardial pacemaker was inserted in 1 because of complete atrioventricular block. We conclude that prenatal counseling must be guarded following the diagnosis of congenitally corrected transposition, even in fetuses with an apparently favorable state at initial examination. Some of these cases may undergo major and unexpected changes, particularly with regard to cardiac rhythm and tricuspid valvar function, with concomitant significant changes in prognosis.

Ebstein's anomaly associated with severe valvar pulmonary stenosis: successful palliation with balloon pulmonary valvuloplasty in an adult

We report a 52-year-old adult with Ebstein's anomaly associated with severe valvar pulmonary stenosis, secundum atrial septal defect, polycythemia, hypoxemia, and severe exertional limitations. Balloon pulmonary valvuloplasty relieved the valvar obstruction, reduced the degree of tricuspid regurgitation and polycythemia, and improved systemic oxygenation and exercise abilities. Use of this technique in patients with this combination of lesions can postpone the need for surgical intervention.

Serial echocardiographic assessment of left atrioventricular valve function in young children with ventricular inversion

BACKGROUND

Regurgitation of the morphologic tricuspid valve (mTV) adversely influences the clinical outcome of patients with ventricular inversion.

METHODS AND RESULTS

To evaluate the mTV regurgitation (TR), we reviewed serial echocardiograms for 25 children with ventricular inversion, with and without congenital heart surgery. Patient age was from 6 months to 19.0 (median 5.8) years. Follow-up was from 5 months to 15.0 (median 4.1) years. Initial assessment was at a median 65 days of age; only nine (36%) of 25 had TR. At follow-up, 16 (64%) of 25 had TR, with two requiring valve replacement. The mTV was abnormal in 16 (64%) of 25 patients and in 11 (69%) of 16 TR worsened compared with one (11%) of nine patients with "normal" mTVs. Nine (36%) of 25 had Ebstein's anomaly, three of whom had new TR develop. Of 17 patients who underwent cardiac surgery, 10 (59%) had new or increased TR compared with three (37%) of eight nonoperative patients. After intracardiac repairs, eight (73%) of 11 had increased TR develop compared with two (33%) of six patients after extracardiac surgery.

CONCLUSIONS

(1) Young patients with ventricular inversion had TR develop during follow-up, without cardiac surgery. (2) Surgical patients with intracardiac repairs had more TR develop than with extracardiac procedures. (3) Anatomic abnormalities of the mTV were associated with an increased risk of TR developing. These data help elucidate the factors that affect the development of TR in patients with ventricular inversion.

Flail Tricuspid Valve in an Adult Patient with Congenitally Corrected Transposition of the Great Arteries

We describe a case of a 50-year-old woman with congenitally corrected transposition of the great vessels, in whom severe left-sided tricuspid (systemic atrioventricular) valve insufficiency was the only associated anomaly. The tricuspid valve was dysplastic and abnormally oriented toward the interventricular septum, without the downward displacement of Ebstein's anomaly. The mechanism of atrioventricular regurgitation was unusual in that it consisted of the rupture of chordae tendineae of both the anterior and septal leaflets. The left-sided tricuspid valve was replaced with a St. Jude prosthesis and the postoperative course was uneventful.

Surgical Repair of Corrected Transposition of the Great Arteries with Cardiac Anomalies: A Report of Fifty-Three Cases

Between February 1964 and June 1994, we operated on 53 patients with corrected transposition of the great arteries associated with cardiac anomalies. Their ages ranged from 2.5 to 37 years (mean 15.9 years). There were 36 patients with type SLL and 17 with type IDD. Forty-three patients had ventricular septal defect with pulmonary stenosis, 7 had VSD with pulmonary hypertension and only 3 patients had atrioventricular valve incompetence without ventricular septal defect. Atrial septal defects were found in 13 cases and patent ductus arteriosus in 2. The main operative procedures were closure of ventricular septal defect (49), closure of atrial septal defect (13), resection of pulmonary stenosis (43) and pulmonary annulus enlargement (3). Additional procedures were bypass between the morphological left ventricle and the pulmonary artery using valved external conduit (4), tricuspid valve repair (4), tricuspid valve replacement (4) and one Fontan operation. Nine patients died (17%) within 30 days of operation. The mortality rate decreased from 29.2% to 6.9% after 1988. The main cause of early death was low cardiac output syndrome. The most common perioperative complications were complete heart block (5) and residual tricuspid valve incompetence (4). Forty of the 44 survivors were followed up from 2 months to 5 years. There were 2 late deaths due to tricuspid incompetence. Our surgical experience in the prevention of operative complications are discussed.

Pathologic elucidation of the echocardiographic features of Ebstein's malformation of the morphologically tricuspid valve in discordant atrioventricular connections

We defined the morphology of the left atrioventricular valve in Ebstein's malformation associated with congenitally corrected transposition to elucidate the approach to diagnosis by echocardiography. We found 14 unequivocal cases out of a total of 3,720 specimens. We noted the atrial arrangement, displacement, and nature of the tricuspid leaflets, and axis of the plane of the tricuspid orifice. We constructed ratios of volume of the atrialized to the functional right ventricle, and of the right to left ventricle, as well as distances of the septal attachments of the atrioventricular junctions to the respective ventricular apices. Three specimens had abnormalities of cardiac position, and 8 had ventricular septal defect. The tricuspid valve plane was rotated 47 +/- 21 degrees from its usual position into the ventricle. The tricuspid valvar tissue was variably attached to the underlying myocardium, with the most severely affected lesion being the mural leaflet followed by the septal leaflet, and the anterior leaflet attachment the least affected. Abnormalities of the tendinous cords and the effective valvar orifice occurred in 3 specimens. The ratio of the atrialized to the functional right ventricular volume was 0.74 +/- 0.49; the ratio of the fetal right to left ventricular volume was 1.18:1 +/- 0.70:1. These data suggest that plastic repairs of the right ventricle would leave a small functional right ventricle, but that valve replacement could restore the volume of the ventricle. Thus, the plane of displacement of the valve in corrected transposition appears less amenable to 4-chamber echocardiography than other forms of Ebstein's malformation. Changes in the echocardiographic planes should display the morphology and also provide some hemodynamic information.

Tricuspid valve abnormalities in patients with atrioventricular discordance: surgical implications

From 1975 to 1990, 90 patients (age, 6 months to 30 years; mean, 9.1 years) underwent operation for defects associated with atrioventricular discordance. Twenty-one had an anatomically abnormal tricuspid (systemic) atrioventricular valve (SAVV) of the following types: Ebstein, 11; straddling, 6; and dysplastic, 4. Sixteen valves were regurgitant: regurgitation was trivial to mild in nine and moderate to severe in seven. Two patients underwent a successful Fontan-type operation. None of the 5 patients with a competent SAVV underwent valve repair or replacement; 1 of these patients died. A ventricular septal defect was closed in 14 and an extracardiac valved conduit was placed in 7. Sixteen had a regurgitant valve: it was replaced in 10 and repaired in 2 (early mortality, 25%). All 4 patients who did not undergo repair or replacement of their regurgitant SAVV died. Two patients died late after repeat replacement. Four other reoperations (closure of a residual ventricular septal defect, SAVV replacement, left ventricle-to-pulmonary artery conduit replacement, and a redo Fontan procedure) were successful. Two patients are lost to follow-up, and 9 have been followed up for them 27 to 156 months (median, 117 months). All were well when last seen. We suggest that an abnormal regurgitant SAVV should be replaced. Alternatively, a "double-switch" procedure that leaves the tricuspid valve in the pulmonary circulation may be used.

Morbid anatomy in neonates with Ebstein's anomaly of the tricuspid valve: pathophysiologic and clinical implications

The hearts of six neonates with Ebstein's anomaly of the tricuspid valve who died in the 1st month of life were compared with hearts of six age- and size-matched control neonates. All six hearts had morphologically severe disease with gross right atrial dilation and marked apical displacement of the tricuspid valve. All had a secundum atrial septal defect and four had additional cardiac lesions (pulmonary atresia in two, ventricular septal defect in two). There was significant thinning of the right ventricular free wall distal to the tricuspid valve (3 +/- 0.2 mm vs. control 4.2 +/- 0.2, p less than 0.01) and right ventricular fiber diameter was reduced (7.2 +/- 0.3 microns vs. control 11.4 +/- 0.6, p less than 0.001). The fibrous tissue content of both right and left ventricular free walls was increased (right, 29.3 +/- 2.6% vs. control 8.7 +/- 1.1, p less than 0.001; left, 23.2 +/- 1.5% vs. control 8.5 +/- 0.7%, p less than 0.001). Although the right ventricular abnormalities might be explained by hemodynamic stress in utero, abnormalities of the left ventricular free wall suggest that either genetic or nonhemodynamic environmental factors are involved in the morphogenesis of this condition. Increased right and left ventricular fibrosis may contribute to the poor early outcome in this group and may predispose to late complications, such as subnormal exercise performance, hemodynamic deterioration or late sudden death that may occur in patients with Ebstein's anomaly who survive the neonatal period.