Pulmonary venous and systemic ventricular inflow obstruction in patients with congenital heart disease: detection by combined two-dimensional and Doppler echocardiography

Total anomalous pulmonary venous connection in 80 patients: Primary sutureless repair and outcomes

Introduction

Total anomalous pulmonary venous connection (TAPVC) is a rare but critical cardiac anomaly, in which pulmonary veins are connected to an abnormal location rather than the left atrium. The prognosis can be extremely poor without intervention, with a mortality of 80% during infancy. The purpose of this research is to summarize the outcomes and relevant risk factors of 80 total anomalous pulmonary venous connection (TAPVC) patients who underwent primary TAPVC sutureless repair and discuss the indications and benefits of primary sutureless repair.

Methods

This retrospective review included 80 patients with TAPVC who underwent primary sutureless repair at a single institution between January 2015 and December 2020. Patients were subdivided into 4 groups according to Darling's classification. Risk factors that increase the postoperative pulmonary vein flow velocity were explored by Multiple Linear regression.

Results

Anatomic TAPVC subtypes included supracardiac 35 (43.8%), cardiac 24 (30%), infracardiac 17 (21.2%), and mixed 4 (5%). Median age at repair was 16.5 days and median weight was 3.5 kg. Preoperative pulmonary venous obstruction (PVO)was presented in 20 (25%) patients. There were 2 early deaths and 1 late death. 2 patients developed postoperative PVO and none required reintervention. Prolonged cardiopulmonary bypass time (CPB) (p = 0.009), preoperative pneumonia (p = 0.022) and gender (p = 0.041) were found to be associated with the increase of postoperative pulmonary vein flow velocity.

Discussion

Under the primary sutureless technique, no statistical difference was observed among the 4 subgroups in terms of postoperative pulmonary vein flow velocity (p = 0.589). The primary sutureless technique may eliminate the differences between subtypes while decrease the postoperative PVO rate, which makes it applicable in any subtypes of TAPVC. Following the favorable outcomes in preventing postoperative PVO in all subtypes in this study, we advocate the indications for primary sutureless repair may expand further to all the TAPVC patients.

Large Atrial Septal Aneurysm Associated with Secundum Atrial Septal Defect

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A structured multimodality approach is imperative in evaluating interatrial anatomy.

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Secundum ASDs may be associated with ASA.

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Interatrial shunts may be missed, especially when aneurysms are large.

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Three-dimensional TEE allows careful interrogation of concomitant septal defects.

Congenital pulmonary vein stenosis and bronchopulmonary vascular malformation

The objective is demonstrate the diagnostic process and evolution of a patient with a diagnosis of congenital pulmonary vein stenosis and broncho-pulmonary vascular malformation. One year old female patient with repeated bronchopneumonia, acrocyanosis, split S2, cardiomegaly, pulmonary hypertension, with a clinical diagnosis of atrial septal defect. The echocardiogram demonstrated left sided vein pulmonary stenosis. The cardiac catheterization demonstrated arterial-venous fistulas apical on the right lung. Magnetic Resonance image and angiography showed an aberrant arterial vessel parallel to the abdominal aorta which flow the right pulmonary lobe. The cardiac tomography angiography reported confluence of right-sided pulmonary veins. A lobectomy is performed. Patient died in post-operative due to massive pulmonary hemorrhaging. This is the first patient mentioned in written literature with pulmonary vein stenosis associated with pulmonary sequestration, with normal venous connection. Echocardiography represents the specific standard study ideal for initial diagnostic for patients with pulmonary vein stenosis.

Pulmonary vein stenosis of ex-premature infants with pulmonary hypertension and bronchopulmonary dysplasia, epidemiology, and survival from a multicenter cohort

BACKGROUND

Pulmonary vein stenosis is emerging as an important clinical problem in ex-premature infants.

METHODS

We sought to describe the epidemiology of pulmonary vein stenosis affecting ex-premature infants by a multicenter retrospective cohort study of patients from seven children's hospitals diagnosed between 2000-2014.

RESULTS

We identified 39 ex-premature patients (26 males, median gestational age 28 weeks range 22-36 weeks, birth weight 1.1 kg range 433-2645-g) with pulmonary vein stenosis. Median age at diagnosis was 6.5 months (1 month-6 years). Presentation with pulmonary hypertension occurred in 26/39 (67%) and 29/39 (74%) had bronchopulmonary dysplasia, 15 (39%) were born of twin pregnancies with unaffected twin siblings. A median of 5 (range 1-25) echocardiograms was performed prior to diagnosis. The diagnosis was made using echocardiography in 22/39 (56%), by multi-detector contrast computed tomography scan (CT) in 8/39 (21%), cardiac catheterization in 6/39 (15%) patients, magnetic resonance imaging in 3/39 (8%). Freedom from death or re-stenosis was 73% at 1-year, 55% at 2, 5, and 10 years. Factors associated with shorter survival or re-stenosis were stenosis of  ≥3 pulmonary veins (P < 0.01), bilateral pulmonary vein stenosis (P < 0.01) small for gestational age (P = 0.05), aged <6 months at diagnosis (P < 0.01).

CONCLUSION

Pulmonary vein stenosis of ex-premature infants is a complex problem with poor survival, delayed diagnosis, and unsatisfactory treatment. The lack of concordance in twins suggests epigenetic or environmental factors may play a role in the development of pulmonary vein stenosis. In ex-premature infants with pulmonary hypertension and bronchopulmonary dysplasia a focused echocardiographic assessment of the pulmonary veins is required with further imaging if the echocardiogram is inconclusive.

Atrial septal defects - clinical manifestations, echo assessment, and intervention

Atrial septal defect (ASD) is a common congenital abnormality that occurs in the form of ostium secundum, ostium primum, sinus venosus, and rarely, coronary sinus defects. Pathophysiologic consequences of ASDs typically begin in adulthood, and include arrhythmia, paradoxical embolism, cerebral abscess, pulmonary hypertension, and right ventricular failure. Two-dimensional (2D) transthoracic echocardiography with Doppler is a central aspect of the evaluation. This noninvasive imaging modality often establishes the diagnosis and provides critical information guiding intervention. A comprehensive echocardiogram includes evaluation of anatomical ASD characteristics, flow direction, associated abnormalities (eg, anomalous pulmonary veins), right ventricular anatomy and function, pulmonary pressures, and the pulmonary/systemic flow ratio. The primary indication for ASD closure is right heart volume overload, whether symptoms are present or not. ASD closure may also be reasonable in other contexts, such as paradoxical embolism. ASD type and local clinical expertise guide choice of a percutaneous versus surgical approach to ASD closure.

Wheezing as a sign of cor triatriatum sinister culminating in multiple organ failure

Cardiac asthma or cardiac wheezing (CW) refers to a syndrome of dyspnea and wheezing that mimicks asthma clinically. Reported herein is the case of a 2-month-old boy who presented with refractory wheezing as a sign of cor triatriatum sinister (CTS) that culminated in overwhelming multiple organ failure in a short time. On the day of admission, oxygen saturation (SpO2 ) was <80%. Heart rate was 198 beats/min and respiratory rate 58 breaths/min. Chest radiogram showed pulmonary edema. Electrocardiogram showed right atrial enlargement and right ventricular hypertrophy. N-terminal pro-brain natriuretic peptide (NTproBNP) was very high at >20,000 pg/mL. Two-dimensional echocardiography with Doppler showed CTS, which was complicated with severe pulmonary arterial hypertension due to flagrant pulmonary venous obstruction. Cardiac surgery was undertaken, after which pulmonary edema subsided, SpO2 increased to ≥96%, and NTproBNP dropped to normal. He was discharged 11 days later, and was free of cardiac, pulmonary, renal, and neurological sequelae at 24 month follow up.

Total anomalous pulmonary venous connection: 15 years' experience of a tertiary care center in Taiwan

BACKGROUND

Total anomalous pulmonary venous connection (TAPVC) is a rare congenital heart disease in which the connection between the pulmonary vein (PV) and left atrium needs to be surgically created. This study investigated the spectrum and outcome of a Taiwanese cohort.

METHODS

Isolated TAPVC cases were identified from our institutional database between 1995 and 2009. We reviewed the medical chart and conducted telephone interviews with those lost to follow-up.

RESULTS

There were 78 patients (52% male). The anomalous drainage sites were mainly supracardiac type (42.3%) and cardiac type (39.8%). Before operation, PV stenosis was found in 100% of infracardiac type, and in 69.7% of supracardiac type. Among the 75 patients undergoing operation, the surgical mortality was 9% (7/75). Perioperative arrhythmias (mainly of atrial origin) occurred in 35% of the patients. Of the 68 patients who survived the first operation, 28 (41%) developed pulmonary vein restenosis. Half of them progressed to severe PV stenosis, which required reintervention or resulted in mortality. Preoperative PV stenosis was the most significant predictor for postoperative PV restenosis and PV re-intervention. For the cohort, the 1-year and 5-year survivals were 78.9% and 74.2%, respectively, and the predictor for survival was again preoperative PV stenosis.

CONCLUSION

The surgical mortality of isolated TAPVC is now low. Preoperative PV stenosis not only increased the risk of late PV restenosis and its reintervention, but also the overall mortality. The spectrum of PV drainage, per se, was not associated with worse outcome. PV restenosis remained the most important issue after correction of TAPVC.

Acquired pulmonary vein stenosis: one problem, two mechanisms

Until the last decade, acquired pulmonary vein (PV) stenosis in the adult population was a rare finding, caused by neoplasm or inflammatory conditions such as sarcoidosis or fibrosing mediastinitis. With the increased use of catheter-based ablation for the treatment of atrial fibrillation, PV stenosis is increasingly recognized as a complication of this procedure. Additionally, PV stenosis has been described as a rare complication of cardiac surgery. This report describes two cases of PV stenosis, one acquired as a result of multiple left atrial ablation procedures and the other after surgical cannulation of the right upper PV.

Primary pulmonary vein stenosis

Primary pulmonary vein stenosis (PVS) is a rare entity with a high mortality rate. Relatively little is known regarding predictors of outcome or the appropriate timing of intervention. The Pediatric Cardiac Care Consortium database (n = 98,126) was searched for patients who had undergone cardiac catheterization or surgical procedures with primary diagnoses of PVS or atresia from 1982 to 2002. Patients with total or partial anomalous pulmonary venous return, cor triatriatum, previous atrial switch, or previous lung transplantation were excluded. Additional data were obtained through questionnaires sent to each Pediatric Cardiac Care Consortium institution. A total of 31 patients were identified with primary PVS. Excluding lung transplantation, 16 of 31 patients underwent intervention to relieve PVS. Univariate predictors of lung death, defined as death or lung transplantation, included younger age at diagnosis (16.2 vs 52.5 months, p = 0.0221), higher initial mean pulmonary arterial pressure (46.4 vs 26.8 mm Hg, p = 0.0003), and bilateral vessel involvement (lung death in 17 of 19 vs 0 of 9 patients, p <0.0001). Patients diagnosed at 18 months of age and those with initial mean pulmonary arterial pressures >33 mm Hg had incidences of lung death of 76% and 88%, respectively. In conclusion, primary PVS carries a high mortality rate despite attempts at palliation. Patients diagnosed at 18 months of age, having initial mean pulmonary arterial pressures >33 mm Hg, or with bilateral vessel involvement are at significantly increased risk for death or lung transplantation. In these high-risk groups, death occurs rapidly despite intervention, and lung transplantation should be an early consideration.

Transposition of the great arteries

Many patients with ventriculoarterial discordance have survived to adulthood. Those with complete transposition of the great arteries have often had an atrial switch procedure (Mustard or Senning operation) performed, which leaves the morphological right ventricle (RV) supporting the systemic circulation. RV failure and tricuspid regurgitation are common. Some patients may ultimately require cardiac transplantation. Sinus node dysfunction is increasingly common with longer follow-up, and some patients need pacemaker implantation. Atrial arrhythmias are frequent, and atrial flutter may be a marker for sudden death. Patients with an arterial switch procedure are also surviving to adulthood. Long-term problems include coronary stenoses, distortion of the pulmonary arteries, dilatation of the neoaortic root, and aortic regurgitation. Patients with congenitally corrected transposition have both atrioventricular and ventriculoarterial discordance and therefore also have a morphological RV and delicate tricuspid valve in the systemic circulation. Associated defects, such as abnormalities of the tricuspid valve, ventricular septal defect, and pulmonary stenosis, occur in the majority of patients. Heart block occurs with increasing age. Atrial arrhythmias occur frequently, and their occurrence should prompt a search for a hemodynamic problem. Progressive tricuspid regurgitation occurs with age and is associated with deterioration of RV function. Surgical treatment should be considered at the earliest sign of RV dilatation or dysfunction. All patients should be seen periodically in a center where expertise in the clinical evaluation, imaging, and hemodynamic assessment of adult congenital heart disease is available.

Transesophageal echocardiography in comparison with magnetic resonance imaging in the diagnosis of pulmonary vein stenosis after radiofrequency ablation therapy

OBJECTIVE

Doppler-derived flow velocity measured by transesophageal echocardiography (TEE) may overestimate pulmonary vein stenosis. We hypothesized that combining peak velocity with a stenotic flow pattern improves diagnosis compared with magnetic resonance imaging (MRI).

METHODS

TEE and MRI were performed in 44 patients 19 +/- 11 months after radiofrequency catheter ablation. Pulmonary vein stenosis was defined by a peak velocity of 110 cm/s or more plus a stenotic flow pattern (turbulence and reduced flow variation) on TEE and a lumen reduction of more than 50% on MRI.

RESULTS

In all, 175 pulmonary veins were studied. MRI showed 7 cases of pulmonary vein stenosis that were correctly identified by TEE. In addition, TEE criteria for pulmonary vein stenosis were met in 4 pulmonary veins that did not show obstruction on MRI. In all, 5 pulmonary veins with normal appearance on MRI had peak velocity of 110 cm/s or more with normal flow pattern.

CONCLUSIONS

TEE Doppler measurements can be reliably used to detect or exclude significant pulmonary vein stenosis if the diagnosis is restricted to a combination of elevated peak velocity (> or = 110 cm/s) with turbulence and little flow variation.

Validation of pulmonary venous obstruction by electron beam computed tomography in children with congenital heart disease

The purpose of this study was to explore the useful imaging findings of electron beam computed tomography (EBCT) for diagnosing pulmonary venous obstruction (PVO) in children with congenital heart disease. From July 1995 to March 1998, 17 children (9 girls and 8 boys, aged 7 days to 14 years and 9 months [median 3 months]) with the diagnosis of PVO were enrolled in this study. All images were obtained by EBCT at the end-diastolic phase of the cardiac cycle after administration of intravenous iodinated contrast medium. The findings of 25 EBCT studies were retrospectively analyzed by 2 radiologists and were correlated with echocardiography, angiocardiography, and surgical findings. Main findings on EBCT for PVO were (1) structural narrowing, (2) thickened interlobular septa, (3) peribronchovascular cuffing, and (4) ground-glass opacity of the alveoli. Structural narrowing along the course of the pulmonary venous drainage was the most important finding in all examinations (25 of 25). Lung parenchymal changes secondary to PVO included thickened interlobular septa (17 of 25), peribronchovascular cuffing (15 of 25), and ground-glass opacity of the alveoli (8 of 25). Thus, the combination of these findings provides very useful data for the definitive diagnosis of PVO. Characteristic electron beam computed tomographic findings can validate suspected PVO noninvasively.

Pulmonary vein stenosis with normal connection: associated cardiac abnormalities and variable outcome

BACKGROUND

Pulmonary vein (PV) stenosis with anatomically normal connection is considered rare, unresponsive to treatment, progressive, and usually fatal.

METHODS

We reviewed the records of 13 children with this diagnosis at our center since 1990.

RESULTS

The number of stenosed PVs ranged from all PVs (n = 5); three PVs (n = 1); two PVs (n = 5); and one PV (n = 2). All patients had associated congenital cardiac abnormalities. Operation on PV stenosis was attempted in 7 patients (54%), 2 of whom have done well and 5 of whom have not. Two patients underwent heart transplantation for inoperable associated cardiac lesions. Significantly more patients with three or four stenosed PVs died (83%) compared with patients with one or two stenosed PVs (0%).

CONCLUSIONS

(1) Pulmonary vein stenosis with anatomically normal connection is associated with other congenital cardiac abnormalities, (2) presentation and outcome are contingent on the number of stenosed PVs, (3) surgical palliation may be helpful in some patients, and (4) heart transplantation for inoperable associated cardiac abnormalities may be an option in patients with only one or two stenosed PVs.

Thoracic Aortic Aneurysm Presenting as Pulmonary Vein Stenosis: A Case Presentation and Review of the Literature

We present the case of a 66-year-old woman presenting with pulmonary vein stenosis with a large descending thoracic aortic aneurysm. Pulmonary vein stenosis is a rare condition and can be caused by extrinsic compression, as well as by inflammatory diseases, congenital anomalies and related surgical repair, tuberculosis, and pulmonary veno-occlusive disease. With obstruction to pulmonary vein flow, the velocity increases and becomes continuous. The finding of turbulent antegrade flow in the left atrium through the use of transthoracic color flow Doppler and pulsed-Doppler warrants further investigation to evaluate known causes of pulmonary vein stenosis. We believe this is the first reported case of a patient with an aortic aneurysm causing pulmonary vein stenosis.

Spontaneous Obstruction of Interatrial Communication in Infants with Atrioventricular Valve Atresia or Stenosis in the Neonatal Period: Serial Echocardiographic-Doppler Study

BACKGROUND AND METHODS: The objective of this serial echocardiographic study was to document the critical size of the interatrial communication in infants with atrioventricular valve atresia, with which spontaneous obstruction is most likely to occur. Spontaneous obstruction of interatrial communication (patent foramen ovale) has been reported to occur in infants with atrioventricular valve atresia or severe stenosis. Atrial septostomy or septectomy therefore may be considered during initial palliation of these infants. Serial two-dimensional Doppler echocardiographic examinations were performed on 11 newborn infants with complex cyanotic congenital cardiac lesions for whom Fontan procedure was contemplated. These newborn infants had either mitral or tricuspid valve atresia or severe stenosis other than hypoplastic left heart syndrome. The size of the foramen ovale was measured from the subcostal frontal, long-axis oblique, and parasagittal views. Conventional Doppler and color flow mapping of the interatrial shunt also was obtained on each patient. RESULTS: The size of the foramen ovale was 5 mm in nine patients at birth. Five of these patients underwent Blalock-Taussig shunt in the neonatal period for severely restricted pulmonary blood flow. In three patients, surgery was postponed due to severe systemic (noncardiac) disease. One patient underwent the hemi-Fontan procedure without a previous shunt. In all nine patients, the foramen ovale remained the same size or became progressively smaller beyond the neonatal period, and atrial septectomy was performed in five patients after initial palliation. In the remaining two patients (who underwent Blalock-Taussig shunt as initial palliation), the foramen ovale measured >/=10 mm at birth and became progressively larger on subsequent follow-up studies. Atrial septectomy was not necessary in these patients. In the first nine patients, Doppler technique did not detect any obstructive pattern during the first 2-4 weeks of life, after which it became progressively obstructive (i.e., >2 m/sec and nonphasic). CONCLUSIONS: In newborn infants with either atrioventricular valve atresia or severe stenosis, the interatrial communication, which may not appear restrictive by Doppler at birth, becomes progressively obstructed beyond the neonatal period. If the size of the communication is <10 mm in diameter, as measured by two-dimensional echocardiography, atrial septectomy should be performed as an integral part of any initial palliation to protect the pulmonary vascular bed for subsequent successful Fontan repair.

Echocardiographic spectrum of supracardiac total anomalous pulmonary venous connection

Although infracardiac total anomalous pulmonary venous connection (TAPVC) is almost always associated with venous obstruction, the incidence and location of obstruction in supracardiac TAPVC has not been completely delineated. This report summarizes our experience with 20 cases of supracardiac TAPVC diagnosed by transthoracic echocardiography from Jan. 1989 to Mar. 1997. Fifty percent were obstructed, and five different sites of narrowing were found. The most common sites of obstruction were at the level of the left pulmonary artery (left vertical vein) and at the insertion into the superior vena cava (right vertical vein). Because nonobstructed Doppler flow patterns are present proximal to the actual site of obstruction in the anomalous pathway, a thorough interrogation of the entire venous channel with two-dimensional and Doppler echocardiography is essential to provide complete preoperative anatomic and hemodynamic details to determine the nature and timing of surgery in this condition.

Importance of Recording Pulmonary Venous Flow Velocities With Transthoracic or Transesophagea1 Echocartiography

The recording of pulmonary venous flow velocities during Doppler ecgicardiography has not received sufficient attention. This review emphasizes the importance of recording pulmonary venous flow velocities (systolic, diastolic, and atrial reversal components) during transthoracic or transesophageal echocardiography. Clinical conditions that increase left atrial pressure, such as congestive heart failure, or that alter left atrial contraction (i.e., atrial fibrillation) result in diminished systolic pulmonary venous inflow and relatively increased diastolic pulmonary venous inflow. When moderate or severe mitral regurgitation is present or suspected by color Doppler imaging, pulmonary venous systolic flow will be blunted or exhibit systolic revetrsal. Distinctive patterns of respiratory variation in systolic and diastolic pulmonary venous velocities can be observed in patients with constrictive heart failure and elevated left ventricular end diastolic pressures but with normal mitral inflow patterns have abnormal pulmonary venous flow characteristics. Stenosis of the pulmonary may demonsterate increased pulmonary venous velocities or flow disturbances after postoperative repair. Pulmonary venous flow characteristics provide hemodynamic infomation not provided by other Doppler monalities or echocardiographic imaging.

Evaluation of pulmonary vein stenosis by transesophageal echocardiography

Pulmonary vein stenosis was diagnosed by transesophageal echocardiography in five patients who underwent the study for different clinical indications. Stenosis was encountered in the right upper pulmonary vein in two patients, the right lower pulmonary vein in two patients, and at the confluence of the left pulmonary veins in one patient. In only one patient was the diagnosis suspected on transthoracic echocardiography. Contralateral normal veins from the same patient served as the control. Vessel diameter and peak flow velocity were measured and compared. The diameter of the stenosed veins ranged from 0.3 to 0.8 cm (mean 0.4 +/- 0.09 cm [SEM]), whereas for normal veins the diameter was 0.9 to 1.2 cm (mean 1.0 +/- 0.05 cm [SEM]; p < 0.001). Peak flow velocity in the stenosed veins ranged from 1.1 to 1.6 m/sec (mean 1.4 +/- 0.1 m/sec [SEM]), whereas in normal veins peak flow velocity ranged from 0.4 to 0.7 m/sec (mean 0.6 +/- 0.04 m/sec [SEM]; p < 0.001). There was a strong negative correlation between vessel diameter and peak flow velocity (R = 0.89; p < 0.001). Peak flow velocity of 0.8 m/sec appears to provide the best separation between normal and stenosed pulmonary veins. We conclude that pulmonary vein stenosis is associated with increased flow velocity and turbulence and deformity of the flow signal. Transesophageal echocardiography is a powerful tool in the study of pulmonary vein stenosis.

Pulmonary venous flow as assessed by Doppler echocardiography: potential clinical applications

During the past few years Doppler assessment of pulmonary venous flow has gained increasing interest. The growing experience with the use of transesophageal echocardiography, the approach that nearly always yields registrations adequate for quantitative analysis, has markedly contributed in this respect. The Doppler-derived pulmonary venous flow pattern can be regarded as a measure of left atrial inflow and it augments the clinical significance of Doppler transmitral flow in the evaluation of diastolic left ventricular function. This article summarizes physiological background, possible applications, and limitations of Doppler echocardiography of pulmonary venous flow in clinical cardiology.

Abnormal Doppler pulmonary venous flow patterns in children after repaired total anomalous pulmonary venous connection

Doppler echocardiography was used to evaluate pulmonary venous flow patterns in 16 children with repaired total anomalous pulmonary venous connection and in 16 age-matched normal controls. Using right upper pulmonary venous pulsed Doppler tracings, peak velocities and velocity time integrals were determined for ventricular systole, ventricular diastole, and atrial systole. Mitral inflow indexes and cardiac outputs were obtained. Patients with repaired total anomalous pulmonary venous connection and controls were similar in weight, heart rate, mitral inflow indexes, and cardiac output. In normal children, peak velocities were greater during ventricular diastole than systole, but velocity time integrals were greater during ventricular systole than diastole. Compared with normals, repaired patients had unobstructed flow patterns with increased peak velocities during ventricular diastole (0.92 +/- 0.35 vs 0.62 +/- 0.12 m/s) and atrial systole (0.27 +/- 0.12 vs 0.17 +/- 0.04 m/s). Velocity time integrals of repaired patients were increased during atrial systole (0.02 +/- 0.01 vs 0.01 +/- 0.03 m) but decreased during ventricular systole (0.08 +/- 0.03 vs 0.12 +/- 0.03 m). Systolic-to-diastolic ratios were decreased in repaired patients for peak velocity (0.56 +/- 0.20 vs 0.79 +/- 0.12) and velocity time integral (0.6 +/- 0.18 vs 1.48 +/- 0.35). Thus, pulmonary venous flow in normal children is greater during ventricular systole than during ventricular diastole. Repaired patients show a shift in forward flow from ventricular systole to diastole, with greater reversed flow during atrial systole.

Obstructed total anomalous pulmonary venous connection

With the advent of echocardiography, total anomalous pulmonary venous connection (TAPVC) can be readily diagnosed without much difficulty. However, noninvasive detection of the presence of pulmonary venous obstruction in TAPVC remains a difficult issue. During a 5.5-year period, 42 patients were found to have TAPVC by catheterization, surgery, and/or autopsy: 17 had supracardiac drainage, 13 paracardiac drainage, nine infracardiac drainage, and three mixed drainage. Obstruction to pulmonary venous drainage was found in 24 patients (57%). Patients with right isomerism tended to have a higher incidence of pulmonary venous obstruction than those with the usual atrial arrangement (80% vs. 44%, p < 0.05). Color Doppler combined with cross-sectional echocardiography provided accurate delineation of drainage sites in 93% cases (39 of 42). Among the 39 cases with correct echocardiographic delineation of the drainage site, obstruction was detected by echocardiography in 22 cases with a sensitivity of 100% (22 of 22) and a specificity of 85% (17 of 20). Therefore, complete echocardiography, including cross-sectional images and color Doppler proved to be a reliable tool in the detection of drainage sites and pulmonary venous obstruction in TAPVC.

Role of transesophageal echocardiography in evaluation of pulmonary venous obstruction by paracardiac neoplastic masses

From 71 consecutive patients with paracardiac neoplastic masses who underwent transesophageal echocardiography (TEE), obstruction of individual right upper pulmonary venous flow by compression by contiguous mass was detected by TEE in 4 patients before and disappeared after anti-neoplastic treatments. Pulmonary vein, contiguous neoplastic mass and their relation could be clearly visualized and assessed by TEE. Pulmonary venous obstruction was assessed as moderate degree by combination of Doppler flow characteristics and diameter of pulmonary vein. Before therapy, peak velocities and time-velocity integrals in obstructed right upper pulmonary venous flow were increased, whereas deceleration times of systolic flow were prolonged. After therapy, peak velocities and time-velocity integrals were reduced and deceleration times of systolic flow were shortened, with normalization of the diameter of the right upper pulmonary veins. Thus, TEE may be used to detect and evaluate pulmonary venous obstruction by neoplastic masses and its changes after antineoplastic treatments.

A characteristic continuous wave Doppler signal in cor triatriatum?

Continuous wave Doppler recordings of the turbulent jet through the restrictive orifice of a left atrial partition in a patient with corrected transposition of the great arteries and cor triatriatum showed alternate bands of high intensity diastolic and low intensity systolic signals with preservation of the normal configuration of the diastolic E and A peaks. It is thought that Doppler studies in cor triatriatum will provide useful complementary haemodynamic information in the echocardiographic diagnosis of this anomaly.

Imaging of pulmonary venous pathway obstruction in patients after the modified Fontan procedure

To evaluate the efficacy of chest roentgenograms and echocardiograms in identifying pulmonary venous pathway obstruction in patients after the modified Fontan procedure, the records of 297 patients who underwent 307 Fontan procedures between 1984 and 1990 were reviewed. Twelve cases of pulmonary venous pathway obstruction documented by autopsy (3 cases) or cardiac catheterization (9 cases with an A wave gradient greater than or equal to 4 mm Hg) were found in 10 patients (mean age 43 +/- 28 months). The mechanisms of obstruction included narrow pulmonary vein ostia in six cases, narrow left atrial outlet in four and atrial baffle obstruction in three. Two causes of obstruction were present in one case. No patient had pulmonary venous congestion on chest roentgenograms. Pathway diameters indexed to 3 square root of body surface area with two-dimensional echocardiography were found to be 6.8 +/- 1.2 mm/3 square root of m2 in the subcostal frontal view, 7.9 +/- 0.6 mm/3 square root of m2 in the subcostal sagittal view and 6.5 +/- 1.7 mm/3 square root of m2 in the apical "four-chamber" view. These values differed significantly from those in 11 age-matched patients undergoing the Fontan procedure without pulmonary venous pathway obstruction documented by catheterization (p = 0.001). With pulsed Doppler ultrasound, there was a relatively narrow range of velocities distal to the obstruction (1.3 to 2.5 m/s). In five of the seven cases with pulsed Doppler measurements, flow was continuous and the Doppler spectral recordings were not phasic. Thus, in patients who have undergone the Fontan procedure and have pulmonary venous pathway obstruction 1) chest roentgenography cannot be used as a screening tool; 2) distal velocities as low as 1.3 m/s occur, usually with nonphasic, continuous forward flow; and 3) pathway diameters indexed to 3 square root of body surface area may be used as an output-independent parameter to cross-check Doppler data.

Pulsed wave and color Doppler findings in congenital pulmonary vein stenosis

A premature infant presented at 8 weeks of age with respiratory failure and pulmonary hypertension. Two-dimensional echocardiography was not diagnostic but color flow imaging and pulsed Doppler examination revealed turbulent and continuous pulmonary venous flow. Differing patterns of disturbed flow suggested varying severity of obstruction in individual pulmonary veins. The Doppler findings are compared to the angiographic and autopsy data.

Pulmonary venous flow in cardiac tamponade: influence of left ventricular dysfunction and the relation to pulsus paradoxus

The pattern of left atrial filling was studied in nine closed-chest dogs during cardiac tamponade before and after production of microembolic left ventricular dysfunction produced by intracoronary injection of 54 +/- 4 microns (SD) microspheres. With cardiac tamponade, a significant increase in the ratio of systolic/diastolic pulmonary venous flow velocity integral both before (1.65 +/- 0.24 versus 2.77 +/- 0.43 [SE], p less than 0.05) and after production of left ventricular dysfunction (0.57 +/- 0.12 versus 1.77 +/- 0.44, p less than 0.05) was seen. Compared with baseline, cardiac tamponade caused a significant inspiratory decrease in systolic pulmonary venous velocity both before (7.3 +/- 2.0 versus 1.2 +/- 1.4 cm/sec) and after left ventricular dysfunction (3.4 +/- 0.4 versus 1.0 +/- 0.9 cm/sec, both p less than 0.05). The magnitude of respiratory variation (expiration-inspiration) of the pulmonary venous flow velocity integral with tamponade was significantly greater before than after left ventricular dysfunction (1.6 +/- 0.2 cm versus 0.8 +/- 0.2 cm, p less than 0.05). A significant correlation was found between the inspiratory fall in aortic systolic pressure and the flow velocity integral of pulmonary venous flow before left ventricular dysfunction (r = 0.58, p less than 0.05). After coronary embolization, neither pulsus paradoxus nor significant respiratory variation (expiration-inspiration) of the pulmonary venous flow integral was observed with cardiac tamponade. In this model of cardiac tamponade and left ventricular dysfunction, left atrial filling occurs predominantly during ventricular systole. These changes may be helpful in recognizing hemodynamically significant pericardial effusion and have implications for the pathophysiology of cardiac tamponade.

Pulmonary venous flow velocity: relation to hemodynamics, mitral flow velocity and left atrial volume, and ejection fraction

Abnormal pulmonary venous flow velocity patterns are present in multiple cardiac disease states, but the determinants of pulmonary venous flow velocity have not been fully elucidated. To determine the relative importance of several proposed factors that could influence pulmonary venous flow, anatomic, hemodynamic, and Doppler mitral and pulmonary venous flow velocity data were compared in 50 consecutive patients undergoing cardiac catheterization for clinical reasons. Pulmonary venous diastolic flow velocity was most strongly related to left ventricular isovolumetric relaxation time (r = -0.59), left ventricular end-diastolic pressure (LVEDP, r = 0.50), left atrial minimum volume (r = 0.50), mitral deceleration time (r = -0.50), and early diastolic mitral flow velocity (r = 0.45). Pulmonary venous systolic flow velocity related best with left atrial minimum volume (r = -0.45) and left atrial ejection fraction (r = 0.44). Pulmonary venous systolic flow velocity integral also showed the strongest relation with left atrial minimum volume (r = -0.48). Relations between pulmonary venous flow velocity and velocity time integrals and other variables were sometimes significantly different, apparently caused in part to differences in heart rate. These results suggest that pulmonary venous diastolic flow velocity is influenced by the same factors that influence early left ventricular diastolic filling; pulmonary venous systolic flow velocity relates best to left atrial volume and atrial ejection fraction and does not relate to left ventricular ejection fraction. Future studies analyzing pulmonary venous flow velocity variables should include data on both peak velocities and velocity time integrals as well as left atrial size and function.

Transesophageal Doppler echocardiography of pulmonary venous flow: a new marker of mitral regurgitation severity

Pulmonary venous flow varies with different cardiac conditions. Flow patterns in response to mitral regurgitation have not been well studied, but flows may vary enough to differentiate among different grades of regurgitation. Accordingly, pulmonary venous flow velocities were recorded in 50 consecutive patients referred for outpatient (n = 26) or intraoperative (mitral valve repair; n = 24) echocardiographic examination for mitral regurgitation. Recordings were made of right and left upper pulmonary veins with pulsed wave Doppler transesophageal echocardiography. Mitral regurgitation was graded from 1+ to 4+ by an independent observer using transesophageal color flow mapping. The results of cardiac catheterization performed 5 weeks earlier in 43 of the patients were also graded for mitral regurgitation by an independent observer. Pulmonary venous flow patterns, the presence of reversed systolic flow and peak systolic and diastolic flow velocities were compared with the severity of mitral regurgitation indicated by each technique. Of the 28 patients with 4+ regurgitation by transesophageal color flow mapping, 26 (93%) had reversed systolic flow. The sensitivity of reversed systolic flow in detecting 4+ mitral regurgitation by transesophageal color flow mapping was 93% and the specificity was 100%. The sensitivity and specificity of reversed systolic flow in detecting 4+ mitral regurgitation by cardiac catheterization were 86% and 81%, respectively. Discordant flows were observed in 9 (24%) of 38 patients; the left vein usually showed blunted systolic flow and the right showed reversed systolic flow. In 22 intraoperative patients, there was "normalization" of pulmonary venous systolic flow after mitral valve repair in the postcardiopulmonary bypass study compared with the prebypass study after the mitral regurgitant leak was corrected.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic and color flow Doppler assessment of systemic and pulmonary venous connection and drainage in the neonate with congenital heart disease

Systemic and pulmonary venous anomalies are frequently encountered either as isolated lesions or as a significant component of a more complex lesion in the newborn infant with congenital heart disease. Two-dimensional echocardiography and Doppler techniques (conventional and color flow) have become the primary diagnostic imaging modality in this setting. Precise pre-operative definition of these variable venous connection and drainage patterns is critical as the required surgical procedure may solely be based on exact understanding of the veins' anatomy and physiology. On the systemic venous site, anomalies of superior and inferior venae cavae, innominate vein, and coronary sinus can be equally well imaged with either echocardiography or angiography. However, on the pulmonary venous site, echocardiography and Doppler techniques including color flow mapping are superior to angiography for precise definition of the connection and drainage sites of the individual pulmonary veins.

Doppler assessment of pulmonary venous flow in healthy subjects and in patients with heart disease

Pulmonary venous flow as assessed by Doppler echocardiography is a current topic of investigation. Pulmonary venous flow has been used recently as part of a comprehensive assessment of left ventricular diastolic filling dynamics in restrictive myocardial diseases and constrictive pericarditis. Abnormalities of flow have been described in dilated cardiomyopathy, congenital heart disease, and arrhythmias. With the advent of transesophageal echocardiography, pulmonary venous flow can be readily obtained in all patients by pulsed-wave Doppler echocardiography. Recently, it has been used to assess the severity of mitral regurgitation and to estimate mean left atrial pressure. This article emphasizes the utility, physiology, and technique of measuring pulmonary venous flow with Doppler echocardiography in health and in disease.

Two-dimensional, spectral Doppler, and color flow imaging in adults with acquired and congenital cor triatriatum

Four adult patients ranging in age from 37 to 72 years with cor triatriatum diagnosed by two-dimensional, spectral Doppler, and color flow imaging are presented, including a previously undescribed "acquired" form after orthotopic heart transplantation and the oldest documented patient with cor triatriatum. The echocardiographic features of cor triatriatum with use of surface and transesophageal imaging are reviewed, with particular emphasis on the color flow findings. Color flow imaging has simplified the diagnosis and assessment of cor triatriatum, including the demonstration of other often-associated congenital cardiac anomalies.

Cor triatriatum with isolated pulmonary venous stenosis in an adult: diagnosis with transesophageal two-dimensional echocardiography

The diagnosis of cor triatriatum in an adult was made from routine two-dimensional transthoracic echocardiography. The findings of aliasing and turbulence in the roof of the left atrium suggested pulmonary venous stenosis. A transesophageal echocardiogram defined both the hemodynamic features of nonobstructing cor triatriatum and the presence of isolated pulmonary venous stenosis. The clinical use of transesophageal echocardiography with color flow Doppler in the elucidation of complex anatomic substrate is demonstrated.

Comparative values of the precordial and transesophageal approaches in the echocardiographic evaluation of atrial baffle function after an atrial correction procedure

Previous methods used to assess atrial baffle function after correction of transposition of the great arteries have included precordial echocardiography and cardiac catheterization. To evaluate whether single plane transesophageal echocardiography might provide additional information, its findings were correlated with information derived from both precordial echocardiography and cardiac catheterization in 15 patients (14 Mustard procedures, 1 Senning procedure) aged 4.2 to 33 years (mean 16.3). Precordial ultrasound with combined imaging, color flow mapping and pulsed Doppler ultrasound visualized the supramitral portion of the common systemic venous atrium in every case but could identify only superior limb obstruction in three of six patients, mid-baffle obstruction in zero of two and inferior limb obstruction in zero of two patients. Transesophageal studies with use of the same range of ultrasound methods demonstrated superior limb obstruction (severe in four, mild in two) in six of six patients, mid-baffle obstruction in two of two and inferior limb obstruction in two of two patients. The entire pulmonary venous atrium was equally well interrogated by either ultrasound approach, with both identifying three cases (two mild, one moderate) of mid-pulmonary venous atrium obstruction. However, individual pulmonary vein velocity profiles could only be recorded by transesophageal pulsed Doppler ultrasound. Precordial studies identified baffle leaks (1 large, 2 small) in only three patients, whereas transesophageal studies identified 11 such baffle leaks (1 large, 10 small), which were multiple in two patients. It is concluded that transesophageal echocardiography provides a more detailed and accurate assessment of atrial baffle morphology and function than is provided by either precordial ultrasound or cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

The potential value of transoesophageal evaluation of individual pulmonary venous flow after an atrial baffle procedure

Following a Mustard's procedure, transoesophageal echocardiography allowed the visualization of all 4 pulmonary veins in 7/12 patients (mean age 14.8 years) and of three veins in a further 2 patients. Both upper pulmonary veins could be visualized consistently. No patient had an isolated pulmonary venous stenosis. In 9 patients in sinus rhythm, computer analysis of Doppler tracings from the left upper pulmonary vein showed significantly lower systolic peak velocities (mean 0.39 +/- 0.10 m/s) and time velocity integrals (mean 6.9 +/- 1.66 cm) than in normal subjects (mean 0.6 +/- 0.09 m/s and 14.4 +/- 2.97 cm respectively; P less than 0.001). We postulate that this is due to compromised atrial relaxation and compliance. In contrast, patients in junctional rhythm (mean 10.7 vs. 7.7 cm in normal subjects). Flow reversal during early ventricular systole (due to tricuspid regurgitation or atrial contraction after retrograde conduction during junctional rhythm) was detected in 6/12 patients. These results confirm that the transoesophageal approach should allow the identification of isolated pulmonary venous obstruction after a Mustard procedure. In addition. detailed analysis of tracings of flow in the pulmonary veins can document the presence of compromised atrial relaxation and help to evaluate the severity of tricuspid regurgitation. It may provide a new index with which to assess impaired systemic ventricular function.

Perioperative echocardiographic evaluation

The integration of pre-, intra- and postoperative echo-cardiography has advanced the health of patients with congenital heart disease by providing an accurate initial evaluation, improving the timing and choice of intervention and detecting residual abnormalities in a timely fashion.

Doppler echocardiography in the diagnosis of divided left atrium (cor triatriatum sinister)

A case of congenitally divided left atrium detected on cross-sectional echocardiography is described. Simultaneous Doppler examination helped to diagnose the obstructive nature of the partition within the left atrium by locating a turbulent high velocity (2.2 meters/second) diastolic signal. The diagnosis was confirmed on cardiac catheterization and surgery.