Sequential diagnosis of coronary arterial anatomy in congenitally corrected transposition of the great arteries

The Leiden Convention coronary coding system: translation from the surgical to the universal view

AIMS

The Leiden Convention coronary coding system structures the large variety of coronary anatomical patterns; isolated and in congenital heart disease. It is widely used by surgeons but not by cardiologists as the system uses a surgeons' cranial view. Since thoracic surgeons and cardiologists work closely together, a coronary coding system practical for both disciplines is mandatory. To this purpose, the 'surgical' coronary coding system was adapted to an 'imaging' system, extending its applicability to different cardiac imaging techniques.

METHODS AND RESULTS

The physician takes place in the non-facing sinus of the aortic valve, oriented with the back towards the pulmonary valve, looking outward from the sinus. From this position, the right-hand sinus is sinus 1, and the left-hand sinus is sinus 2. Next, a clockwise rotation is adopted starting at sinus 1 and the encountered coronary branches described. Annotation of the normal anatomical pattern is 1R-2LCx, corresponding to the 'surgical' coding system. The 'imaging' coding system was made applicable for Computed Tomography (CT), Magnetic Resonance Imaging (MRI), echocardiography, and coronary angiography, thus facilitating interdisciplinary use. To assess applicability in daily clinical practice, images from different imaging modalities were annotated by cardiologists and cardiology residents and results scored. The average score upon evaluation was 87.5%, with the highest scores for CT and MRI images (average 90%).

CONCLUSION

The imaging Leiden Convention is a coronary coding system that unifies the annotation of coronary anatomy for thoracic surgeons, cardiologists, and radiologists. Validation of the coding system shows it can be easily and reliably applied in clinical practice.

Incidental congenitally corrected transposition of the great arteries (ccTGA) in an adult with suspected coronary artery disease: review on radiological features and pathophysiology

We report a case of a 46-year-old woman who has presented to a peripheral hospital with progressive exertional dyspnoea and chest discomfort. The resting ECG showed features of left-sided ventricular hypertrophy. The initial chest radiograph was reported as cardiomegaly. Initial echocardiography revealed left atrial dilatation and ‘left ventricular’ hypertrophy with normal ejection fraction. She was treated as possible coronary artery disease and was subsequently referred to our centre for CT coronary angiography. Findings from the CT scan were consistent with congenitally corrected transposition of the great arteries (ccTGA). This report describes the radiological features of ccTGA, its associated cardiovascular anomalies, pathophysiology and potential complications.

Influence of apical position on the left ventricular outflow tract obstruction in congenitally corrected transposition

BACKGROUND

The right ventricle has a proclivity to wrap around the left ventricle outflow tract (LVOT) in congenitally corrected transposition (CCT) patients with apicocaval ipsilaterality, which may influence the outcome of the double switch operation (DSO). The goal of this study was to determine if the LVOT is compressed by the right ventricle in this setting.

METHODS

A total of 103 patients with CCT were divided into four groups according to ventricular looping and apical position, including Group A (D-loop and levocardia), Group B (L-loop and dextrocardia), Group C (D-loop and dextrocardia), and Group D (L-loop and levocardia). Computed tomography was used to define left-right laterality and ventro-dorsal relationship of the LVOT.

RESULTS

Apicocaval ipsilaterality was found in 57 patients (Group A, n=25; Group B, n=32), in whom the right ventricle was found to wrap around the LVOT. Among them, 49 (86%) had LVOT obstruction. In 46 patients without apicocaval ipsilaterality (Group C, n=10; Group D, n=36), 31 had LVOT obstruction (67.4%). LVOT obstruction was more prone to occur in patients with apicocaval ipsilaterality compared with those without (p=0.025), and was more significant in the situs solitus (p=0.058) than in situs inversus (p=0.547).

CONCLUSIONS

LVOT obstruction was prone to occur in CCT patients with situs solitus and apicocaval ipsilaterality (Group B). The ventricular outflow patency was influenced by apical position, which should be considered to avoid a posterior ventricular outflow tract from compression after DSO.

Understanding coronary arterial anatomy in the congenitally malformed heart

With the development of three-dimensional techniques for imaging, such as computed tomography and magnetic resonance imaging, it is now possible to demonstrate the precise sinusal origin and epicardial course of the coronary arteries with just as much accuracy as can be achieved by the morphologist holding the heart in his or her hands. At present, however, there is no universally accepted convention for categorising the various patterns found when the heart is congenitally malformed. In this review, we show how, to provide such a convention, it is necessary to take note not only of the sinusal origin of the three major coronary arteries, but also the relationship of the aortic root relative to the cardiac base. We summarise the evidence showing how the proximal portions of the developing coronary arteries grow into the aortic valvar sinuses subsequent to the separation of the aortic root from the subpulmonary infundibulum. We also discuss the evidence showing that the subpulmonary myocardium is impervious to the passage of epicardial coronary arteries, and suggest that the process of septation itself plays an integral role in guiding the arteries into the two aortic sinuses that are adjacent to the pulmonary root. We then show how marriage of convenience between the epicardial coronary arteries and the aortic valvar sinuses provides a good explanation for the known variations found in the setting of transposition. We point out that it is the absence of septation that likely governs the patterns seen in the setting of a common arterial trunk.

Can we better understand the known variations in coronary arterial anatomy?

Coronary arterial anatomy is remarkably diverse. Identification of surgical risk factors, however, requires description in a uniform fashion. Such description mandates that account be given of both aortic sinusal origin and variability in aortopulmonary relationships. Currently, however, it is rare to find all this information provided either in clinical reports or published reviews. In this review, therefore, we summarize why both these features are important, emphasizing the marriage of convenience between the aortic root position within the cardiac base and the arrangement of the epicardial coronary arteries. The inductive approach accounts for all potential variations.

Restoration of Transposed Great Arteries to Nature

Surgical correction of transposition of the great arteries was proposed by many in the past half-century and was claimed as the anatomical correction, but the treatment of choice was ever changing. The current technique usually includes the Lecompte maneuver to bring the pulmonary bifurcation in front of the aorta. Although the ventricular–arterial connection is corrected, it is not “normal.” This review describes an innovative technique to reconstruct the great arteries in spiral fashion, which is the natural relationship of the aorta and pulmonary artery. The surgical principles of nature and even distribution using autologous tissues are emphasized. The structural and functional studies of the spiral great arteries in the last 2 decades are also presented.

Long term follow up after surgery in congenitally corrected transposition of the great arteries with a right ventricle in the systemic circulation

Aim of the study

To investigate the long-term outcome of surgical treatment for congenitally corrected transposition of the great arteries (CCTGA), in patients with biventricular repair with the right ventricle as systemic ventricle.

Methods

A total of 32 patients with CCTGA were operated between January 1972 and October 2008. These operations comprised 18 patients with a repair with a normal left ventricular outflow tract, 11 patients with a Rastelli repair of the left ventricle to the pulmonary artery and 3 patients with a cardiac transplantation.

Results

Excluding the cardiac transplantation patients, mean age at operation was 16 years (sd 15 years, range 1 week - 49 years). Median follow-up was 12 years (sd 10 years, range 7 days - 32 years). Survival obtained from Kaplan-Meier analysis at 20 years after surgery was 63% (CI 53-73%). For the non-Rastelli group these data at 20 years were 62% (CI 48-76%) and for the Rastelli group 67% (CI 51-83%). Freedom of reoperation at 20 years was 32% (CI 19-45%) in the overall group. In the non-Rastelli group the data at 20 years were 47% (CI 11-83%) and for the Rastelli group 21% (CI 0-54%) after almost 19 years.

Conclusions

Long term follow up confirms that surgery in CCTGA with the right ventricle as systemic ventricle has a suboptimal survival and limited freedom of reoperation. Death occurred mostly as a result of cardiac failure.

Coronary artery anatomy in complete transposition with situs solitus and dextrocardia

The coronary artery anatomy of complete transposition with situs solitus/levocardia (CTSSL) has been well elucidated in the current era of arterial switch operation. However, coronary artery for complete transposition with situs solitus/dextrocardia (CTSSD) has never been documented. Coronary anatomy of transposition and aortopulmonary rotation were identified by angiography or surgical intervention from 1988 to 2007 at our hospital. The degree of aortopulmonary rotation was defined by the aortic sinus pattern on lateral angiogram. Apicocaval ipsilaterality was defined as situs solitus/dextrocardia or situs inversus/levocardia. The coronary artery anatomy in 3 cases of CTSSD was analyzed and correlated with those patients having transposition with the same coronary pattern but without apicocaval ipsilaterality, i.e., 276 cases with CTSSL and 8 cases with complete transposition with situs inversus/dextrocardia (CTSID). Fisher's exact test was used to determine statistical significance. All three cases with CTSSD (with apicocaval ipsilaterality) had a single coronary artery piercing into the left-hand sinus with a right coronary artery in the posterior atrioventricular groove, whereas all 284 cases without apicocaval ipsilaterality (CTSSL or CTSID) had the left circumflex artery in the posterior atrioventricular groove. The aorta was significantly less left laterally rotated in CTSSD than the other 2 cases of CTSSL and 3 cases of CTSSD with a similar coronary pattern (p < 0.05). One may anticipate coronary artery anatomy in the posterior atrioventricular groove based on apicocaval ipsilaterality, which in turn decreases aortopulmonary rotation to predict the central coronary pattern.

Coronary artery anatomy in children with congenital heart disease by computed tomography

AIMS

To evaluate electron beam computed tomography (EBCT) for recognition of coronary artery patterns in children with congenital heart diseases.

METHODS

Institutional review board approval was obtained; informed consents were not required. A total of 226 children diagnosed with Tetralogy of Fallot (n=122), double outlet right ventricle (n=52), transposition of the great arteries (n=34), and congenitally corrected transposition (n=18) who had undergone cardiac EBCT at our institution between 1995 and 2002 were identified. Iodinated contrast medium was injected with arterial phase acquisition. The two radiologists and one pediatric cardiologist that interpreted the EBCT images and cardiac angiograms, respectively, were blinded to each other's results. Surgical and cardiac angiogram findings were compared to the EBCT results. Descriptive statistics were used to compare efficacy.

RESULTS

Numerous aberrant patterns were clearly identified on the EBCT images. Pattern IX occurred in most patients with Tetralogy of Fallot or double outlet right ventricle. Patterns I and 0 are the most common coronary artery types in transposition of the great arteries and congenitally corrected transposition, respectively. Overall diagnostic accuracy for all disease groups was 82.7%. The diagnostic accuracy of the coronary arterial anatomy by EBCT increased with older age, and was more than 90% in individuals aged over 3 months.

CONCLUSION

EBCT is effective for identification of the coronary anatomy of children with specific congenital heart diseases, except for neonates and small infants less than 3 months of age.

Congenitally corrected transposition of the great arteries: MDCT angiography findings and interpretation of complex coronary anatomy

A 56-year-old male patient was admitted to our hospital because of dyspne and chest pain. A chest radiograph showed mild cardiomegaly. Echocardiography revealed unusual chamber in the heart. The chamber beneath the left atrium was morphologically right ventricle. To evaluate the precise complex anatomy of this abnormality, multidetector computed tomography (MDCT) angiography was performed. MDCT clearly revealed complex intracardiac and vascular anatomy, including typical imaging findings of a patient with congenitally corrected transposition of the great arteries (CCTGA). We described both imaging findings of MDCT angiography and interpretation of complex vascular anatomy in a patient with CCTGA.

Electrocardiographic-Gated Multislice Computed Tomography for Visualization of Cardiac Morphology in Congenitally Corrected Transposition of the Great Arteries

A case of congenitally corrected transposition of the great arteries in a 64-old-woman is presented. Diagnosis was missed by invasive angiocardiography. Electrocardiographic-gated multislice computed tomography not only demonstrated switching of the aortic root and pulmonary trunk but clearly identified fine morphologic details of the cardiac chambers, including the atypical coronary artery pattern.

Chest pain in adult congenital heart disease: where does it come from?

Chest pain is common in adolescents and in young adults and usually not associated with a severe underlying cardiovascular disorder. However, in adults with congenital heart disease, residua or sequellae of previous interventions may provoke potential complications. Moreover, chest pain may be the first sign of a life-threatening condition. Basic knowledge is mandatory and will lead to the correct diagnosis and treatment. Data in literature, which focus on this issue, are scarce and motivated to summarize the experience of daily practice from the eye point of the clinician.