Patterns of anomalous pulmonary venous connection/drainage in hypoplastic left heart syndrome: diagnostic role of Doppler color flow mapping and surgical implications

Hybrid Palliation for Hypoplastic Left Heart Syndrome: Role of Echocardiography

Hypoplastic left heart syndrome is a spectrum of complex congenital cardiac defects. Although in borderline cases, biventricular repair is a viable option, in the majority of cases, univentricular palliation is the treatment of choice. Hybrid palliation can be a valid alternative to classic Norwood operation in the neonatal period, especially in selected cases such as high-risk patients or borderline left ventricles. Echocardiography is the main diagnostic modality in this pediatric population, from the fetal diagnosis to the subsequent surgical steps of palliative treatment. Hybrid palliation is performed after birth and is characterized by surgical banding of the pulmonary arteries along with transcatheter stenting of the ductus arteriosus. There are some peculiar aspects of cardiac imaging that characterize this type of palliation, and that should be considered in the different phases before and after the procedure. We aimed to review the current literature about the role of echocardiography in the management of patients with hypoplastic left heart undergoing hybrid palliation.

Fetal case of rare association of hypoplastic left heart syndrome and absent atrial septum accompanied by mixed form of supracardiac total anomalous pulmonary venous connection

Abnormal pulmonary venous flow patterns on fetal echocardiography and a nutmeg lung pattern on fetal magnetic resonance imaging are seen in patients with pulmonary venous stenosis. The association between these findings and the degree of pulmonary venous stenosis remains unknown. We report an extremely rare case of a fetus diagnosed with hypoplastic left heart syndrome complicated by an absent atrial septum and supracardiac total anomalous pulmonary venous connection with left pulmonary venous congestion. This case suggests that compared to non-pulsatile continuous pulmonary venous flow, the nutmeg lung pattern can only be observed with severe pulmonary congestion and advanced pulmonary lymphangiectasia.

Outcome of Single Ventricle and Total Anomalous Pulmonary Venous Connection

Management of patients with single-ventricle physiology is significantly affected by anomalies of pulmonary venous return at all stages, whether primary palliation, bidirectional Glenn shunt, or completion of Fontan circulation. We treated 25 patients with pulmonary venous anomalies and single ventricle by staged palliation, from June 1996 to May 2005. Visceral heterotaxy with atrial isomerism was present in 19 of them. Primary palliation with a systemic-to-pulmonary artery shunt was undertaken in 15 patients. There were 5 early deaths, of which 4 were due to obstruction of pulmonary venous return. A bidirectional Glenn shunt was constructed in 17 patients including 10 who had it as a primary palliative procedure. There were 7 early deaths after the bidirectional Glenn procedure; only one was due to pulmonary venous obstruction. Five patients attained completion of the Fontan procedure. There was one early death after the Fontan operation. Anomalous pulmonary venous return can significantly complicate the management of patients with single ventricle, with an impact on survival in early infancy. Palliation with the aim of instituting extracardiac conduit Fontan circulation allows greater latitude and more streamlined management.

Management of partial anomalous pulmonary venous connection in single ventricle

We herein report a case of a hypoplastic left heart syndrome variant complicated with partial anomalous pulmonary venous connection to the left innominate vein. We left the vertical vein at the time of the bidirectional Glenn procedure, and ligated the vertical vein at the time of the total cavopulmonary connection procedure, without reconnecting the vertical vein to the left atrium. Because of the development of an interlobar vein draining from the left upper lung into the lower lung after the bidirectional Glenn procedure, the circulation of the left upper lung was preserved after the total cavopulmonary connection procedure.

Perioperative Imaging in Hypoplastic Left Heart Syndrome

Hypoplastic left heart syndrome is a constellation of left-sided congenital heart defects that result in variable hypoplasia of the left ventricle, left ventricular outflow tract, and aorta. Perioperative imaging with echocardiography, cardiac magnetic resonance imaging, and cardiac catheterization is vital for diagnosis, surgical planning, prognosis, and postoperative management.

Hypoplastic left heart syndrome, cor triatriatum and partial anomalous pulmonary venous connection: Imaging of a very rare association

A newborn is presented with an association of hypoplastic left heart syndrome, cor triatriatum and partial anomalous pulmonary venous connection. The diagnosis was established with echocardiography and further confirmed with computed tomography. To our knowledge the images of such an association have never been reported before.

Total anomalous pulmonary venous drainage to coronary sinus combined with left-sided obstructive lesions: a previously unreported association

We present a very rare cardiac lesion where we found a combination of abnormal pulmonary venous drainage and left-sided obstructive lesions. This case gives new insight into the complex malformation of the heart, raising questions about cardiac embryology and timing of interfering events. Here we describe the lesion for the first time and review the related literature. To the best of our knowledge, this combination has never been reported.

Hypoplastic left heart associated with scimitar syndrome

A child with the unique combination of hypoplastic left heart syndrome (HLHS) and scimitar syndrome is presented. Her HLHS was diagnosed in utero, and her scimitar syndrome was discovered during her immediate newborn period. She underwent a successful Norwood operation complicated by supraventricular tachycardia given her Wolf-Parkinson-White syndrome. She has also undergone successful Glenn shunt and at this writing is thriving.

Divided left atrium with obstruction of pulmonary venous return in the setting of hypoplasia of the left heart

We describe an infant with hypoplasia of the left heart diagnosed prenatally who, at birth, had signs of severe pulmonary venous obstruction. Echocardiography indicated normally connecting pulmonary veins, and showed a paradoxical right-to-left shunt across a patent oval foramen. Postmortem examination revealed that the obstruction was due to a divided left atrium, or cor triatriatum sinister, with an imperforate muscular diaphragm separating completely the two components of the divided atrium.

Partially anomalous pulmonary venous connection treated by interventional catheterization

A young man had anomalous connection of the veins draining the upper lobe of the left lung to both a left-sided vertical vein and the left atrium. The ratio of pulmonary to systemic flows was 1.7 : 1, and he was symptomatic with evidence of volume overload of the right heart. He was successfully treated by percutaneous placement of an Amplatzer ductal occlusion device into the vertical vein.

Normally connected anomalously draining obstructed pulmonary veins in an infant with mitral atresia: clinical presentation and catheter management

A patient with hypoplastic left ventricle and double outlet right ventricle underwent pulmonary artery band as a newborn. At age 3 months, cardiac catheterization demonstrated complete closure of his atrial septal defect with decompression of the left atrium via a small levo-cardinal vein. Thus, he had normally connected, anomalously draining obstructed pulmonary veins. He underwent successful catheter intervention with excellent release of the obstruction. This rare finding and technical aspects of catheter intervention are discussed.

Hypoplastic left heart syndrome with intact atrial septum: levoatriocardinal vein stent placement as a bridge to surgery

Infants with hypoplastic left heart syndrome, an intact atrial septum and pulmonary venous hypertension, are critically ill and have a poor prognosis. This case describes relief of severe pulmonary edema in such a patient by stent placement in a stenotic levoatriocardinal vein, with subsequent successful surgical palliation.

The hypoplastic left heart syndrome with intact atrial septum: atrial morphology, pulmonary vascular histopathology and outcome

OBJECTIVES

The purpose of this study was to investigate the outcome in infants with hypoplastic left heart syndrome and intact atrial septum and to evaluate the relationship of atrial morphology, left atrial decompression pathway and lung histopathology to outcome.

BACKGROUND

In the hypoplastic left heart syndrome, severe restriction at the atrial level results in marked systemic hypoxemia after birth. Infants with intact atrial septum may be at high risk for mortality after Norwood operation.

METHODS

Of 316 infants with hypoplastic left heart syndrome seen at our center over a 6.5-year period, 18 (5.7%) had intact atrial septum. Medical records and echocardiograms were reviewed.

RESULTS

On echocardiography, three types of intact atrial septal morphology were identified: 1) large left atrium, thick prominent septum secondary with thin septum primary adherent (type A, n = 12); 2) small left atrium with thick, muscular atrial septum (type B, n = 4), and 3) giant left atrium, thin atrial septum with severe mitral regurgitation (type C, n = 2). Seven infants had left atrial decompression pathways that were severely obstructed (3/12 type A, 4/4 type B). Norwood operation was performed in 17 infants; one underwent emergency balloon atrial septostomy and died. Of six early survivors, all with type A atrial morphology and unobstructed decompression pathway, three died after subsequent cavopulmonary surgery. Lung histopathology revealed severely dilated lymphatics and "arterialization" of the pulmonary veins in those with the severest degree of obstruction to left atrial egress (type B atrial morphology).

CONCLUSIONS

Despite aggressive intervention, outcome for infants born with hypoplastic left heart syndrome and intact atrial septum is poor. Maldevelopment of the pulmonary vasculature contributes to the high mortality seen. Atrial morphology can be used as a marker for the severity of pulmonary vascular disease.

Anomalous pulmonary venous return in the staged palliation of functional univentricular heart defects

BACKGROUND

Bidirectional cavopulmonary shunt and Fontan repair are now commonly performed in patients with a variety of forms of complex single ventricle, including those with anomalies of systemic, pulmonary, or systemic and pulmonary venous return. These anomalies are ideally dealt with during bidirectional cavopulmonary shunt, thereby minimizing the complexity of the eventual Fontan procedure.

METHODS AND RESULTS

Between March 1990 and March 1997, 32 patients with functional single ventricle and anomalous pulmonary venous return underwent operation at our institution. Five of 25 patients who underwent neonatal palliation died in the early postoperative period, all of whom had obstructed anomalous pulmonary venous return. Twenty-one patients have undergone bidirectional cavopulmonary shunt, including 7 in whom this was the primary palliative procedure. There was one early and two late deaths after the bidirectional Glenn procedure, two in patients with asplenia syndrome and none in patients with previously obstructed pulmonary venous return. Seven patients have undergone Fontan completion, 5 with an extracardiac conduit. There was one early death and one take-down to a classic Glenn shunt, both in patients who did not undergo the extracardiac conduit Fontan operation.

CONCLUSIONS

Anomalous pulmonary venous return can significantly complicate the management of the single-ventricle patient, with the major impact on survival coming in the neonatal period. Palliation with the aim of performing an extracardiac conduit Fontan procedure allows greater latitude and more streamlined management in this group of patients.

Aortic Stenosis or Atresia with Associated Hypoplasia of the Left Ventricle: Imaging Before and After Reconstructive Surgery

Aortic atresia or stenosis, when associated with hypoplasia of the left ventricle, presents the cardiac surgeon with a challenging reconstruction. Many preoperative and intraoperative decisions are now made on the basis of ultrasound data. Furthermore, echocardiography provides the most convenient way to time the stages of the reconstructive sequence and assess the hemodynamic result. (ECHOCARDIOGRAPHY, Volume 13, May 1996)

Doppler color flow echocardiography: indispensable application to congenital heart disease

Doppler color flow imaging has become indispensable in the diagnosis and management of patients with congenital heart disease. Certain defects may not be possible, or may be very difficult to diagnose by two-dimensional echocardiography alone. Such examples include multiple ventricular septal defects, anomalous pulmonary venous connection, coronary artery malformations, and the hypertensive patent ductus arteriosus. Additionally, color flow Doppler echocardiography significantly provides additional information, and reduces the time for fetal and transesophageal echocardiographic studies. Doppler color flow imaging has become an essential part of the echocardiographic examination. Experience has broadened the use of this important technological advance, with anticipation of an ever expanding future for its clinical application.

Partial or total direct pulmonary venous drainage to right atrium due to malposition of septum primum. Anatomic and echocardiographic findings and surgical treatment: a study based on 36 cases

The clinical and anatomic findings in 36 patients (21 postmortem cases and 15 living patients) with partially anomalous (16 [44%]) or totally anomalous (20 [56%]) pulmonary venous drainage directly to the right atrium constitute the material basis of this report. Displacement of septum primum--leftward in atrial situs solitus or rightward in atrial situs inversus--was present in all and appeared responsible for the anomalous pulmonary venous drainage. The pulmonary veins were connected with what normally constitutes the posterior wall of the left atrium, which became incorporated into the right atrium because of atrial septal displacement. This abnormality occurred predominantly in patients with visceral heterotaxy, usually with polysplenia, or rarely with asplenia or a normally formed spleen. Poor development or absence of septum secundum appeared responsible for the malposition of septum primum. Echocardiographic recognition of the displacement of septum primum facilitated surgical management.

Morphological features of the levoatriocardinal (or pulmonary-to-systemic collateral) vein

Three cases with an anomalous pulmonary-to-systemic collateral vein (levoatriocardinal vein) connecting the left atrium or one of the pulmonary veins to a systemic vein are described. In two of these cases the atrial septum is intact, the left atrioventricular connection is absent (mitral atresia), and the anomalous vein is the escape channel for pulmonary venous return. In the remaining case, a muscular membrane divides the left atrium, separating the pulmonary venous component from the distal component. The collateral vein may be mistaken for the vertical vein that is associated with totally anomalous pulmonary venous connections, but in all our cases the pulmonary veins inserted normally into the left atrium. Cross-sectional echocardiography, including conventional and color flow Doppler mapping, should overcome potential difficulties in diagnosis.

Noninvasive evaluation of newborns with congenital heart disease

Over the last decade, diagnosis and management of neonates with congenital heart disease have been greatly influenced by the constant expansion of noninvasive methods. We classify the most common congenital defects presenting in the first 2 weeks of life, based on clinical presentation and hemodynamic characteristics, followed by a discussion of echocardiographic findings in the most common congenital heart lesions and how ultrasound techniques can help solve problems frequently encountered during the early postoperative period.

Continuous cardiac output monitoring by the Fick method

Current methods for longitudinal assessment of cardiac output in severely ill patients are intermittent only and in many respects appear unsatisfactory. We have developed a computerized on-line system for continuous Fick cardiac output monitoring, utilizing fiberoptic arterial and pulmonary arterial probes with a metabolic analyzer for VO2. In 15 patients, cardiac output ranged 1.9-6.8 L/min and 12 were within 5% of thermodilution values. Continuous output monitoring during interventions in two patients (saline infusion and coronary angioplasty) illustrate the utility of the technique. Two additional patients had unsatisfactory VO2 data due to low airflow velocity. The results of this pilot study suggest that cardiac output monitoring by the Fick method may have clinical and investigational uses in intensive care units and during cardiac catheterization or surgical procedures.

Echocardiographic demonstration of an unusual pulmonary venous pathway in a patient with left ventricular inflow obstruction

A newborn infant with mitral atresia and a restrictive patent foramen ovale had normal pulmonary venous connection to the left atrium demonstrated by echocardiography. However, pulmonary venous blood then coursed through an unusual pathway in the roof of the left atrium into the right atrium. This case illustrates the need for the echocardiographer to be reminded of and then search for unusual drainage pathways in cases of left ventricular inflow obstruction, even when the pulmonary veins connect normally.