Morphologic Spectrum of Ventriculoarterial Connection in Hearts With Double Inlet Left Ventricle: Implications for Surgical Procedures

Deferred Norwood in the setting of airway compression in double-inlet left ventricle with dextro-transposition of the great arteries

A 4.1 kg male neonate with a diagnosis of double-inlet left ventricle with dextro-transposition of the great arteries was intubated shortly after birth due to respiratory insufficiency. The initial management consisted of a successful Stage I hybrid procedure. Persistent respiratory insufficiency led to cross-sectional imaging and bronchoscopy that demonstrated severe airway compression from a dilated main pulmonary artery. A Norwood procedure with Blalock-Thomas-Taussig shunt was performed at 1 month of age to relieve the airway obstruction. The patient was discharged home on room air at 2 months of age. This case highlights a unique single-ventricle anatomic variant with airway compression, which was successfully managed with deferred Norwood palliation.

A "holistic" sonographic view on congenital heart disease: How automatic reconstruction using fetal intelligent navigation echocardiography eases unveiling of abnormal cardiac anatomy part II-Left heart anomalies

Volume ultrasound has been shown to provide valid complementary information on fetal anatomy. Four-dimensional assessment (4D) of the fetal cardiovascular system using spatial-temporal image correlation (STIC) allows for detailed examination of a highly complex organ from the early second trimester onward. There is compelling evidence that this technique harbors quite a number of diagnostic opportunities, but manual navigation through STIC volume datasets is highly operator dependent. In fact, STIC is not incorporated yet into daily practice. Application of the novel fetal intelligent navigation echocardiography (FINE) considerably simplifies fetal cardiac volumetric examinations. This automatic technique applied on cardiac volume datasets reportedly has both high sensitivity and specificity for the detection of congenital heart defects (CHDs). Part I reviewed current data regarding detection rates of CHDs and illustrated the additional value of an automatic approach in delineating cardiac anatomy exemplified by congenital lesions of the right heart. In part II of this pictorial essay, we focused on left heart anomalies and aimed to tabulate recent findings on the quantification of normal and abnormal cardiac anatomy.

Bulboventricular foramen enlargement: an alternative surgical approach

Bulboventricular foramen (BVF) enlargement is often required to enlarge a restrictive interventricular communication in patients with univentricular hearts (UVH) to prevent the development of systemic ventricular outflow tract obstruction (SVOTO). We describe an alternative surgical technique through the transected pulmonary artery without an atriotomy, ventriculotomy or aortotomy that was successfully performed in a patient with double inlet left ventricle (DILV) with malposed great arteries (MPGA) and a restrictive BVF.

201Tl Myocardial Perfusion Imaging in a Case of Double-Inlet Left Ventricle: Correlate Anatomic Information of SPECT With MRI

Double-inlet left ventricle (DILV) is a congenital heart disease that only a single left ventricle and a rudimentary right ventricle are developed. Because of lack of anatomic landmark, interpretation of Tl myocardial perfusion imaging in DILV is essentially challenging for unusual anomaly. We report the case of a 44-year-old woman with DILV who presented exertional dyspnea and tachycardia and underwent Tl SPECT. The anatomic characteristics of cardiac Tl SPECT are correlated with MRI. To obtain accurate interpretation in DILV, it is absolutely necessary to realize the anatomy relationship between perfusion imaging and anatomic imaging such as CT or MRI.

Intracardiac anatomical relationships and potential for streaming in double inlet left ventricles

The aim of this study was to gain better understanding of the variable anatomical features of double inlet left ventricle hearts without cavopulmonary connection that would potentially facilitate favorable streaming. Thirty-nine post-mortem specimens of double inlet left ventricle without cavopulmonary connection were investigated. The focus was on anatomical characteristics that could influence the flow and separation of deoxygenated and oxygenated blood in the ventricles. Elements of interest were the ventriculoarterial connection, the spatial relationship of the ventricles, the position and size of the great arteries, the ventricular septal defect, the presence of relative outflow tract stenosis and the relationship of the inflow and outflow tracts. The most common anatomy was a discordant ventriculoarterial connection with an anatomically left-sided morphologically right ventricle (n = 12, 31%). When looking at the pulmonary trunk/aorta ratio, 21 (72%) hearts showed no pulmonary stenosis relative to the aorta. The ventricular septal defect created a relative subpulmonary or subaortic stenosis in 13 (41%) cases. Sixteen (41%) hearts had a parallel relationship of the inflow and outflow tracts, facilitating separation of deoxygenated and oxygenated blood streams. On the other end of the spectrum were 10 (25%) hearts with a perpendicular relationship, which might lead to maximum mixing of the blood streams. The relationship of the inflow and outflow tracts as well as the presence of (sub-) pulmonary stenosis might play a crucial role in the distribution of blood in double inlet left ventricle hearts. Additional in vivo studies will be necessary to confirm this postulation.

Management of the single ventricle and potentially obstructive systemic ventricular outflow tract

Multi-stage palliation is the current management strategy for the treatment of children with various single ventricle (SV) cardiac malformations. The success of this strategy depends on the presence of favorable anatomic and hemodynamic criteria. Several SV anomalies have the potential of developing systemic ventricular outflow tract obstruction (SVOTO) that might be evident early on or progress later after palliative surgeries. SVOTO could result in ventricular hypertrophy, impaired diastolic function and subendocardial ischemia with subsequent deleterious effects on the SV and disturbance of some of those criteria for a successful multi-stage palliation strategy. Careful identification of SV patients at risk of developing SVOTO and proper planning of the optimal palliation sequence beginning at the 1st stage procedure are vital factors that would affect long-term outcomes in those patients. In the current review, we describe the morphology of SV patients with potential SVOTO risk, surgical procedures that address potential or present SVOTO, and optimal timing of those procedures within the multi-stage palliation chain. We attempt to provide a treatment algorithm for various patients taking into consideration their unique anatomic and physiologic characteristics.

Prenatal diagnosis and outcome of fetuses with double-inlet left ventricle

The aim of this study is to characterize the in utero presentation of the subtype of double-inlet left ventricle (DILV), a rare congenital heart disease, and assess the postnatal outcome. We retrospectively studied fetuses diagnosed prenatally with DILV between 2007 and 2011. We reviewed the prenatal and postnatal echocardiograms, clinical presentations, karyotypes, and the postnatal outcomes. There were eight fetuses diagnosed with DILV with L-transposition of the great vessels (S, L, L). Mean gestational age at diagnosis was 24.7 weeks. Of these, four fetuses (50%) had pulmonary atresia. One fetus (12.5%) also had tricuspid atresia and coarctation of the aorta and died at 17 months of age. Complete heart block and long QT syndrome was present in one fetus (12.5%), who died shortly after birth. There were no extracardiac or karyotypic abnormalities. Six (75%) infants are alive and doing well. Double-inlet left ventricle with varied presentation can be accurately diagnosed prenatally. The outcome of fetuses is good in the absence of associated rhythm abnormalities with surgically staged procedures leading to a Fontan circulation.

Doppler echocardiographic description of double-inlet left ventricle in an Arabian horse

Univentricular atrioventricular (AV) connections are rare and complex congenital cardiac anomalies in which both AV valves communicate into a large, common (single) receiving chamber. The common chamber can be of left, right, or mixed ventricular morphology. Although well documented in people, reports of the double-inlet ventricle malformation are rare in the veterinary literature. This report provides description of an Arabian horse with a double-inlet univentricular connection of left ventricular type, a hypoplastic subpulmonary right ventricle, two muscular ventricular septal defects, and a stenotic mitral valve. Transthoracic Doppler echocardiography enabled antemortem diagnosis, and provided an assessment of intracardiac hemodynamics. The findings indicate that Doppler echocardiography is a useful, noninvasive tool for evaluating equine patients with congenital univentricular AV connections, such as a double-inlet left ventricle.