Morphologic Analysis of Congenital Heart Disease With Anomalous Tracheobronchial Arborization

Treatment of long-segment congenital tracheal stenosis with congenital cardiovascular defects in infancy

OBJECTIVES

This study aims to evaluate the outcomes of simultaneous repair for infants with long-segment congenital tracheal stenosis (LSCTS) with congenital cardiovascular defects (CCD).

METHODS

We retrospectively reviewed the clinical data of infants aged less than 1 year with LSCTS and CCD who underwent simultaneous repair at Children's Hospital of Chongqing Medical University from January 2020 to March 2023. A systematic search of PubMed, Embase, and Cochrane Library for the relevant published studies that reported the simultaneous repair of CTS and CCD in infancy was conducted in March 2023. The inverse variance method of DerSimonian-Laird (D + L) was used for estimate synthesis.

RESULTS

A total of thirteen infants with a mean age of 5.6 ± 3.1 months and a mean weight of 6.4 ± 0.9 Kg underwent slide tracheoplasty with modified procedures and cardiovascular operations. LSCTS was diagnosed in all thirteen patients. Nine infants were ventilator dependent, and four patients were operated on due to persistent wheezing and recurrent respiratory infections. Seven patients underwent pulmonary artery sling repair, and six underwent atrial septal defect repair. All infants were repaired utilizing cardiopulmonary bypass (CPB) support. Significant complications were recorded in three patients. In-hospital deaths were seen in one case. The median tracheal minimum diameter of hospital survivors was significantly larger than the preoperative minimum diameter (p < 0.001). The mean follow-up duration was 17.1 ± 7.1 months. There was no late mortality during the follow-up. Twelve studies were included based on our search strategy. The pooled estimate of mortality in the literature was 10.9% (95%CI, 5.3%-17.7%, I2 = 0). The pooled estimate of airway re-interventions was 28.8% (95%CI, 14.5%-43.2%, I2 = 74%).

CONCLUSIONS

Simultaneous repair of LSCTS and CCD in infancy is safe and effective. Slide tracheoplasty with appropriate technical modifications may be valid for LSCTS repair without significant restenosis and reinterventions.

Surgical management of long-segment congenital tracheal stenosis with tracheobronchial malacia

OBJECTIVES

Slide tracheoplasty has become the mainstream treatment for long-segment congenital tracheal stenosis (LSCTS). However, technical improvements are still needed to improve the clinical outcomes of patients exhibiting LSCTS with tracheobronchial malacia.

METHODS

LSCTS patients who underwent tracheoplasty from January 2010 to December 2020 were reviewed. According to the time of surgical technique modifications for reconstructing a supportive carina, the patients were divided into 2 groups: group A (2010-2018) and group B (2019-2020). We identified a well-balanced cohort matched by propensity score to evaluate the differences in surgical outcomes between the 2 groups.

RESULTS

There were no significant differences between group A and group B in any of the 8 characteristics before and after propensity score matching. In the propensity score-matched cohort, the number of patients who accepted anterior carina tracheopexy (75/77 vs 4/77, P < 0.001) and in situ pericardium insertion (75/77 vs 14/77, P < 0.001) in group B was significantly greater than that in group A. The mechanical ventilation time [48.3 (interquartile range: 29.6, 116.3) h vs 73.3 (interquartile range: 47.9, 111.6) h, P = 0.009] and cumulative mortality (P = 0.023) were significantly lower in Group B than Group A.

CONCLUSIONS

Reconstructing a supportive, stable carina of the neotrachea and tracheobronchopexy are helpful to improve the outcomes of slide tracheoplasty.

Tracheal trifurcation: new cases and review of the literature

BACKGROUND

Tracheal trifurcation is an uncommon and often unknown type of anomalous tracheobronchial arborization, characterized by three main bronchi originating at the level of the carina. Diagnosis is important due to its clinical implications.

OBJECTIVE

To highlight the anatomical, clinical and diagnostic aspects of tracheal trifurcation by reporting our experience and reviewing the literature.

MATERIALS AND METHODS

We retrospectively evaluated pediatric patients referred to our institution from January 2018 to May 2020 with a diagnosis of tracheal trifurcation. All patients underwent chest radiographs, computed tomography (CT) (with/without dynamic airway scanning) and bronchoscopy. Clinical and anatomical data were collected.

RESULTS

Three patients with tracheal trifurcation were identified (1 female, median age: 7.6±0.4 months). All had associated anomalies: two had tetralogy of Fallot, one with esophageal atresia/tracheoesophageal fistula and one with an atrioventricular septal defect, and the other had skeletal ciliopathy. Chest radiographs were not diagnostic for tracheal trifurcation. Bronchoscopy could not fully evaluate the trachea and main bronchi in two cases. CT detected tracheal trifurcation in all of the patients and also demonstrated other lung parenchymal and congenital anomalies. Two of the three main bronchi were directed to the right lung in all cases. Ostial stenosis of either the central (two patients) or right upper bronchus (one patient) was present. No signs of tracheobronchomalacia were found.

CONCLUSION

Tracheal trifurcation is rare and often associated with additional disorders, such as other tracheobronchial anomalies, cardiovascular defects or esophageal malformations, responsible for clinical manifestations and earlier detection. Bronchoscopy is often used for diagnosis, but is invasive and may be incomplete or inconclusive, while CT allows for a noninvasive and correct diagnosis, while also highlighting additional findings in the thorax.

The prevalence of the azygos lobe: A meta-analysis of 1,033,083 subjects

The azygos lobe (AL) is an accessory lobe of the right lung with prevalence between 0.4 and 1.2%. The aim of the present review is to provide a better estimate of the frequency of the AL and to examine its relationships with other variables such as population, diagnostic methods, and co-occurring illnesses. Studies published between 1899 and October 2020 were searched through three electronic databases; Google Scholar, PubMed, and JSTOR. Titles, abstracts, and full texts of the retrieved entries were screened to determine their appropriateness for inclusion. A total of 88 studies relating to 1,033,083 subjects met the inclusion criteria. A random-effects meta-analysis yielded an overall prevalence of 0.30% (95% CI: 0.0024-0.0035, I²  = 97.9%). Linear regression and subgroup analysis revealed a negative correlation (ρ = -0.540, p <0.001) between AL prevalence and sample size; studies with smaller sample sizes had higher prevalences. The AL prevalence in individuals with congenital pulmonary defects, 5.2% (95% CI: 0.0018-0.0086, I²  = 0%), was 17 times higher than the overall prevalence (z = 6.65, p <0.001), suggesting associations with other abnormalities and possibly a genetic predisposition. In addition to an evidence-based synthesis of AL prevalence, this study demonstrates publication bias and small-study effects in the anatomy literature. Awareness of the AL is crucial for radiologists when they interpret unusual radiological findings and for surgeons when they operate in the region.