Pulmonary valvular atresia with intact ventricular septum: problems in diagnosis and results of treatment

Surgical management of hypoplastic right ventricle with pulmonary atresia or critical pulmonary stenosis and intact ventricular septum

Our experience with the surgical management of hypoplastic right ventricle with intact ventricular septum includes 26 patients with pulmonary atresia and 4 with critical pulmonary stenosis. Group 1 consisted of 8 neonates managed initially by transventricular valvotomy; 6 later required a secondary procedure, with 100% survival. Group 2 had 11 neonates managed by aorta-pulmonary artery shunting without operative death. However, only 3 have survived over the long term and 1 has required an additional shunt procedure. Group 3 had 9 infants who underwent concomitant valvotomy and shunting. There were 4 operative deaths and 1 late death. Finally, Group 4 included 2 infants managed by primary repair at 3 days and 6 days old with prosthetic enlargement of the right ventricle; 1 required the addition of a shunt. Both are alive. Seven of the 15 patients in Groups 1, 2, and 3 who survived neonatal palliative procedures have undergone reparative operations. Two had no growth of the right ventricle and underwent repair after conversion to tricuspid atresia, by a Fontan procedure. Five had prosthetic enlargement of the right ventricle in childhood with 1 late death. Findings of this review were as follows: (1) effective palliation of pulmonary atresia and intact ventricular septum or critical pulmonary stenosis with cavitary hypoplasia of the right ventricle is rare unless transventricular flow can be established; (2) establishment of transventricular flow produces a high incidence of cavitary "growth," which permits later repair; (3) the Fontan operation is available for repair in patients who have no cavitary growth; and (4) when all three portions of the right ventricular cavity can be identified by angiography, a primary repair can be performed in the neonatal period with a good long-term prognosis.

Evaluation and surgical treatment of pulmonary atresia and intact ventricular septum in infancy

The initial surgical approach to the infant with pulmonary atresia and intact ventricular (PA-IVS) is to establish an adequate source of pulmonary blood flow and, when possible, relieve right ventricular (RV) outflow obstruction. The selection of patients for pulmonary valvotomy, alone or in combination with a systemic-pulmonary arterial shunt, depends on the presence of an RV outflow tract and the adequacy of the RV chamber. To evaluate the size of the RV cavity in PA-IVS, an RV index (RVI) was developed using biplane angiographic measurements of the sum of the tricuspid valve annulus and the RV inflow and the RV outflow tracts. The RVI was normalized by relating it to the aortic diameter (Ao) at the diaphragm (RVI/Ao). The RVI/Ao was 13.5 +/- 1.4 in 20 control subjects and only 7.3 +/- 2.6 in 26 PA-IVS patients (p less than 0.001), and was within the normal range in only two of the 26. Since 1976, pulmonary valvotomy plus a Blalock-Taussig shunt has been performed in 10 infants, with one death. Serial cardiac catheterizations in five of nine survivors demonstrated substantial RV growth in all, with the RVI/Ao increasing from an average of 8.0 to 12.5. In contrast, patients who underwent a shunt alone had no change in RV cavity size. We conclude that pulmonary valvotomy may be performed successfully in most PA-IVS patients, but usually must be combined with a systemic-pulmonary shunt. In a small minority of patients, a normal RV cavity, as evidenced by an RVI/Ao greater than or equal to 11, appears to be sufficient to sustain adequate pulmonary blood flow after valvotomy alone. The RVI/Ao ratio is a simple method of quantitatively evaluating RV cavity size and is helpful in planning the initial surgical approach for these infants.

Angio-pathological appearances of pulmonary valve in pulmonary atresia with intact ventricular septum. Interpretation of nature of right ventricle from pulmonary angiography

Correlative angiographic-anatomical studies in 19 cases of pulmonary atresia with infarct ventricular septum showed the following relations between the angiographic appearance of the pulmonary valve and the morphology of the right ventricle. (1) Doming of the pulmonary valve was associated with a nearly normal-sized right ventricle and a wide infundibulum patent to the level of the pulmonary valve. (2) A fixed valve was associated either with (a) pronounced hypoplasia of the ventricular changer and stenosis of the infundibulum or (b) less commonly, a massive right ventricle and Ebstein's malformation of the tricuspid valve. (3) An intermediate type valve was associated with a small right ventricle and a small infundibulum which was, however, patent to the level of the pulmonary valve. It is suggested that the configuration of the pulmonary valve is a result of haemodynamic stresses placed upon it. These stresses, in turn, are determined by the morphological nature of the right ventricle. Thus, the nature of the pulmonary valve as seen angiographically may ve used as an index of right ventricular morphology.

Side effects of therapy with prostaglandin E1 in infants with critical congenital heart disease

The case reports of 492 infants with critical congenital cardiac disease treated with prostaglandin E1 (PGE1) were reviewed to determine the nature and incidence of intercurrent medical events. Forty-three percent of the infants had at least one such event, but only half of these were related to PGE1 and the majority required only minor changes in management. Cardiovascular events were the most common (18% incidence), with cutaneous vasodilation and edema occurring more frequently during intraaortic infusion than during i.v. infusion. Central nervous system events were reported in 16% of the patients. Respiratory depression was reported in 12%, and was particularly common in infants weighing less than 2.0 kg at birth (42%). Hematologic, infectious and renal events appeared for the most part to be unrelated to PGE1. The overall mortality (excluding 19 patients with hypoplastic left-heart syndrome) was 31%; the mortality for the patients with critical coarctation or interruption of the aortic arch was nearly twice that for the cyanotic infants (50% vs 27%). No death was attributed to PGE1 administration. During infusion of PGE1, arterial blood pressure and respiratory activity should be monitored carefully and appropriate supportive steps taken if hypotension or respiratory depression occurs. The development of fever or jitteriness may require reduction of the infusion rate and, in view of the possible increased incidence of infections, the prophylactic use of antibiotics is recommended.

Development of the ductus arteriosus in right ventricular outflow tract obstruction

We studied the morphology of the ductus arteriosus in 14 infants, ages 2--90 days. Eight (group 1) had pulmonary atresia (structural and functional) with an intact interventricular septum; six (group 2) had pulmonary atresia with a ventricular septal defect. The inferior angle of the ductus arteriosus at the aortic junction was measured in each patient. In group 1, this angle was obtuse in all but one patient. In group 2, the angle was acute in all. Further study of intracardiac anatomy suggested that in group 1, the obtuse inferior angle of the ductus arteriosus was the result of a late and progressive obstructive phenomenon that allowed normal right-to-left flow through the ductus arteriosus during much of fetal life. In group 2, the direction of ductus arteriosus flow (normally from the pulmonary trunk to the aorta) was reversed, and flowed from the aorta to the pulmonary trunk. This reversal of flow was probably of early onset in the fetus, the aorta receiving the total combined ventricular output, and produced a small ductus arteriosus with an acute inferior angle. It is extremely important not to rule out pulmonary atresia with an intact interventricular septum when aortography in the newborn shows a normal-sized ductus arteriosus with an obtuse inferior angle. Despite existing pulmonary atresia, these patients have neither a hypoplastic right ventricle nor discontinuity of the right ventricle with the pulmonary artery.

Right ventricular volume determinations in 18 patients with pulmonary atresia and intact ventricular septum. Analysis of factors influencing right ventricular growth

Right ventricular growth was assessed angiocardiographically in 18 patients with pulmonary atresia, intact ventricular septum, and hypoplastic and hypertensive right ventricle. A variety of surgical procedures were performed. In only 12 patients (66.7%) was right ventricular-pulmonary artery continuity achieved (group 1). Nine of these 12 patients persisted with systemic or suprasystemic right ventricular pressures. Among the six patients in whom right ventricular-pulmonary artery continuity was not achieved (group 2), all maintained suprasystemic right ventricular pressures. Right ventricular growth was assessed in groups 1 and 2. The patients were also subdivided according to the qualitative degree of tricuspid regurgitation as determined angiocardiographically on right ventricular cineangiocardiograms at the preoperative catheter study. Right ventricular growth to normal levels as evidenced by change in right ventricular end-diastolic volume was rarely observed in group 2 patients. Among the four patients with severe tricuspid regurgitation and a large tricuspid valve, right ventricular growth to normal levels was achieved whether they were in group 1 or group 2. Right ventricular growth is thus predicated on numerous morphologic factors in these patients. However, reconstitution of right ventricular-pulmonary artery continuity and a nonobstructive tricuspid valve are probably two of the more important factors.

Echocardiographic diagnosis of atrial septal aneurysm in an infant with hypoplastic right heart syndrome

Echocardiographic findings are described in a patient with hypoplastic right heart syndrome (pulmonary atresia type with intact ventricular septum and small right ventricular cavity) who had an associated atrial septal aneurysm. An unusual appearance of echoes behind the aorta bulging into the left atrium in diastole on both the M-mode and cross-sectional echo suggested this diagnosis prior to cardiac catheterization. The angiographic findings confirmed the diagnosis of right ventricular hypoplasia, pulmonary atresia and the large atrial septal aneurysm. The infant died after surgery and the atrial septal aneurysm was observed at autopsy. The importance of the diagnosis of the atrial septal aneurysm and its association with restriction of right-to-left atrial shunting prompts this report.

Congenital pulmonary atresia with tricuspid insufficiency: morphologic study

In an anatomic study of 21 cases of pulmonary atresia with tricuspid insufficiency (pulmonary atresia with intact ventricular septum, type II), the morphologic features of the tricuspid valve and the right ventricle were found to differ greatly from those seen in pulmonary atresia with tricuspid stenosis (pulmonary atresia with intact ventricular septum, type I). Morphologically, pulmonary atresia with tricuspid insufficiency (type II) has a greater resemblance to Ebstein's disease with pulmonary atresia than to type I pulmonary atresia. The anomaly may be more amenable to surgery than pulmonary atresia with tricuspid stenosis because the right ventricle in the former may be converted into a functional chamber by a valvotomy combined with a shunting procedure and atrial septostomy.

Pulmonary atrsia with intact ventricular septum. Open heart surgical correction at 32 hours

A case of pulmonary atresia with intact ventricular septum is reported in which total surgical correction was carried out successfully at 32 hours of age. Cardiac catheterisation at 17 months has revealed virtually normal haemodynamic and angiographic findings. Surgical correction of this condition in the neonatal period is discussed.

Severe congenital tricuspid incompetence in the neonate

Five neonates with congenital tricuspid incompetence due to severe tethering of the tricuspid valve to the right ventricle by abnormal chordal and papillary muscle attachments are described. The abnormality was called tricuspid valvular dysplasia (TVD) if the basal insertion of the valve was normal and the Ebstein malformation if it was displaced into the sinus portion of the ventricle.

In the two infants with isolated TVD and severe tricuspid regurgitation the functional obstruction to right ventricular outflow (ORVO) produced by the high perinatal pulmonary vascular resistance (PVR) made the exclusion of pulmonary atresia difficult, despite selective right ventricular angiocardiography.

In three infants the tricuspid valvular abnormality was associated with organic ORVO; pulmonary atresia in two and critical pulmonary valve stenosis in one. In the two infants with pulmonary atresia and intact ventricular septum (IVS) the severe tricuspid incompetence produced a clinical, radiological and hemodynamic profile which was clearly different from that usually seen in infants with pulmonary atresia and IVS and a normal right ventricular cavity (type 2 of Greenwold).