Echocardiographic assessment of neonates with pulmonary atresia and intact ventricular septum

Transcatheter pulmonary valvuloplasty in neonates with pulmonary atresia and intact ventricular septum

BACKGROUND

Transcatheter pulmonary valvuloplasty in neonates with pulmonary atresia and intact ventricular septum (PA-IVS) or duct-dependent pulmonary valve stenosis (DD-PVS) has become a reasonable alternative to surgical right ventricle decompression.

AIM

To investigate mid-term outcomes following pulmonary valvuloplasty.

METHODS

Sixty-five neonates with PA-IVS (n=29) or DD-PVS (n=36) (median age 4 days; mean weight 3.0kg) undergoing pulmonary valvuloplasty were reviewed retrospectively. Procedural data and clinical outcomes were assessed.

RESULTS

Pulmonary valvuloplasty was successful in 59 patients (90.8%). Preterm birth, larger tricuspid valve annulus diameter and PA-IVS correlated with procedural failure. Eleven patients (18.6%) required a Blalock-Taussig shunt during early follow-up, despite valvuloplasty. These neonates had smaller tricuspid and pulmonary valve annulus Z-scores (-1.9 vs. -0.8 [p=0.04] and -2.5 vs. -0.9 [P=0.005], respectively) and a higher incidence of "bipartite" right ventricle (P=0.02). Mean follow-up was 5.4±3.3 years. Mortality after successful valvuloplasty was 8.5% (n=5). Among the 54 survivors, biventricular repair was achieved in 52 patients (96.3%), including nine with a previous Blalock-Taussig shunt. The cumulative rate of subsequent surgery (excluding Blalock-Taussig shunt) was 13.7% (95% confidence interval 6.8-26.7%) and 16.4% (95% confidence interval 8.5-30.4%) at 2 and 4 years, respectively. Secondary surgery was significantly more frequent in PA-IVS compared with DD-PVS, and in neonates with a Blalock-Taussig shunt (P=0.003 and 0.01, respectively).

CONCLUSIONS

Selected neonates with DD-PVS or PA-IVS managed by transcatheter pulmonary valvuloplasty had a good mid-term outcome. In neonates with a borderline small right ventricle, a hybrid strategy with a supplementary source of pulmonary blood flow can be efficient to achieve biventricular repair.

Transthoracic Echocardiographic Assessment of Coronary Flow in the Diagnosis of Right Ventricular-Dependent Coronary Circulation in Pulmonary Atresia with Intact Ventricular Septum

Right ventricular-dependent coronary circulation (RVDCC) is associated with pulmonary atresia with intact ventricular septum and is defined by two or more epicardial coronary arteries with atresia or severe stenosis resulting in the dependency of coronary supply by retrograde flow. The hypothesis of this study is that coronary Doppler flow patterns on echocardiography can be used to distinguish patients with RVDCC. Between 2007 and 2016, we reviewed 16 patients with pulmonary atresia or critical pulmonary stenosis. Patients were divided into two groups, those with RVDCC (determined by angiography or pathology evaluation) and those without. Echocardiographic evaluation of the coronary arteries included 2-dimensional measurements and pulse wave Doppler flow pattern in 3 epicardial coronary arteries. Velocity-time integral (VTI) and maximal velocity (V_max) were measured and compared between the two groups. Three coronary flow patterns were demonstrated: (1) all antegrade flow, (2) antegrade to retrograde VTI flow ratio > 1, and (3) antegrade to retrograde VTI flow ratio ≤ 1. Of the 7 patients with RVDCC, 6 (86%) had evidence of flow pattern 3 in ≥ 2 of the 3 coronary arteries in contrast to 0 (0%) of the non-RVDCC patients (p = 0.001). Higher retrograde V_max was associated with RVDCC (p < 0.001) and coronary artery dilatation with Z-score ≥ + 3 was also associated with RVDCC (p = 0.02). Echocardiographic evaluation of the coronaries can be useful in identifying RVDCC. More retrograde flow in at least two coronary arteries is strongly suggestive of RVDCC. Dilatation of the coronary arteries is also supportive evidence.

Echocardiographic Diagnosis and Management of Bilateral Coronary Ostial Atresia in a Patient with Pulmonary Atresia and Intact Ventricular Septum

Bilateral atresia of the coronary artery ostia in patients with pulmonary atresia and intact ventricular septum is a rare condition with no reported survivors beyond early infancy. We report the first case of diagnosis by echocardiography followed by successful cardiac transplantation.

Regression of cardiac enzyme and ventriculocoronary communication in an infant with pulmonary atresia and intact ventricular septum after radiofrequency valvulotomy and valvuloplasty

I report on a 3-month-old infant with pulmonary atresia-intact ventricular septum and ventriculocoronary communication (VCC) who underwent percutaneous radiofrequency valvulotomy and valvuloplasty (RFVV). The patient's cardiac troponin-I, creatine kinase (CK), and myocardial fraction of (CK-MB) were elevated before RFVV and were gradually regressed to normal levels 12 days after RFVV. The VCC disappeared after RFVV. The transvalvular pressure gradients across the pulmonary valve were less than 30 mmHg in the follow-up echocardiography at 4-12 months of age. Oxygen saturation was approximately 90% in room air. Dipyridamole-thallium myocardial scintigraphy showed positive reperfusion over the apex and interventricular septum.

Echocardiographic predictors of coronary artery pathology in pulmonary atresia with intact ventricular septum

Coronary artery pathology is a major determinant of treatment strategy and outcome in patients with pulmonary atresia and intact ventricular septum (PA/IVS). For this reason, infants with PA/IVS routinely undergo preoperative cardiac catheterization. The goal of this study was to identify echocardiographic predictors of coronary artery pathology in infants with PA/IVS. The initial preoperative echocardiograms of 30 consecutive infants with PA/IVS (median age at diagnosis 1 day) were reviewed for indexes predicting the degree of coronary pathology. The tricuspid valve (TV) annulus diameter Z- score was determined and evidence of abnormal flow in the coronary arteries by Doppler was evaluated. Coronary pathology was defined by angiography and graded as: 0 = no fistulae; 1 = fistulae/no right ventricular (RV)-dependent coronary arteries; 2 = fistulae with 1 RV-dependent coronary; 3 = fistulae with >/=2- vessel RV-dependent coronary arteries. Outcome was classified as: 2 ventricles, "1.5" ventricles, and 1 ventricle. By angiography, 30% of the patients had grade 0 coronary pathology, 30% had grade 1, 20% had grade 2, and 20% had grade 3. There was 1 death in a patient with grade 3 coronary pathology. Among the survivors (median age at follow-up 28. 6 months), biventricular circulation existed in 12 patients (41%), 7 patients (24%) were 1.5, and 10 (34%) were 1 ventricle. All patients with TV Z-score </=-2 had coronary fistulae by angiography and 35% had grade 3 coronary pathology. None of the patients with grade 2 or 3 coronary artery pathology had a TV Z-score >-2.5. The sensitivity, specificity, positive, and negative predictive values of TV Z-score </=-2.5 in predicting RV dependent coronary arteries were 100%, 83%, 80%, and 100%, respectively. Thus, in newborns with PA/IVS the echocardiographically derived TV Z-score predicts the likelihood of coronary artery fistulae and RV-dependent coronary arteries and can be used to rationalize the need for preoperative diagnostic catheterization.

Outcomes of transcatheter valvotomy in patients with pulmonary atresia and intact ventricular septum

The results of transcatheter valvotomy in pulmonary atresia with intact ventricular septum (PA-IVS) patients are presented with an attempt to identify the predictive factors for pulmonary valvotomy alone as definitive treatment. Between June 1995 and December 1997, 14 PA-IVS neonates with tripartite right ventricle underwent an attempted pulmonary valvotomy. For perforation of the pulmonary valve, a guidewire was used in 4, and a radiofrequency guidewire in 10 patients. Two outcome groups were identified. Group I included those in whom transcatheter treatment achieved a definitive success; group II patients required surgery despite an initial successful valvotomy. The attempt failed in 3 patients, 1 of whom had pericardial effusion. Perforation of the pulmonary valve was achieved in 11 patients: 2 with a guidewire and 9 with a radiofrequency guidewire. A subsequent balloon valvuloplasty was performed in these 11 patients. After valvuloplasty, mean right ventricular pressure decreased from 124 +/- 24 to 60 +/- 15 mm Hg (p <0.01). One died of heart failure and infection 10 days later, despite successful weaning from prostaglandin E1. Group I patients (n = 6) were treated with transcatheter valvotomy alone. Group II patients (n = 4) required right ventricular outflow patch. Significant differences between the 2 groups (group I vs II) were identified in tricuspid valve Z value (0.52 +/- 0.37 vs -1.25 +/- 0.48, p <0.05), pulmonary valve Z value (-3.47 +/- 0.59 vs -5.43 +/- 0.94, p <0.05), and ratio of right-to-left ventricular area on the apical 4-chamber view (0.73 +/- 0.06 vs 0.49 +/- 0.03, p <0.05). There were no significant differences in hemodynamic characteristics between the 2 groups. After a follow-up period ranging from 7 to 35 months (mean 18 +/- 10.3), the most recent echocardiograms in the 10 patients showed a mean pressure gradient across the pulmonary valve of 17 +/- 15 mm Hg. All 10 patients had an oxygen saturation of >92%. Transcatheter valvotomy using a radiofrequency guidewire is a safe and effective treatment in selected patients with PA-IVS. Transcatheter valvotomy can be a definitive treatment in PA-IVS patients with a tricuspid valve Z value > or = -0.1, pulmonary valve Z value > or = -4.1 and ratio of right-to-left ventricular area > or = 0.65.

Usefulness of Doppler echocardiography in diagnosing right ventricular coronary arterial communications in patients with pulmonary atresia and intact ventricular septum and comparison with angiography

Direct and indirect evidence of right ventricular coronary arterial communications has been detected by use of 2-dimensional and Doppler echocardiography in patients with pulmonary atresia and intact ventricular septum. We describe additional consistent and reproducible Doppler echocardiographic findings that were useful for identifying patients in whom abnormal coronary arterial flow patterns were detected angiographically.

Importance of right ventricular outflow tract angiography in distinguishing critical pulmonary stenosis from pulmonary atresia

OBJECTIVE

To investigate the spectrum of pulmonary atresia and critical pulmonary stenosis using right ventricular outflow tract angiography and explore its implications for catheter interventional treatment.

DESIGN

Prospective clinical study.

SETTING

Two paediatric cardiology centres.

SUBJECTS

11 neonates or infants (aged 1 day to 8 months; weighing 2.3 to 7.8 kg) with pulmonary atresia or where the differentiation of pulmonary atresia from critical pulmonary stenosis was unclear on either echocardiography or angiography.

METHODS

Right ventricular outflow tract angiography was performed on all patients to distinguish pulmonary atresia from critical pulmonary stenosis before opening the right ventricular outflow tract.

RESULTS

Right ventricular outflow tract angiography showed that three of seven patients diagnosed as pulmonary atresia by echocardiography had pin hole jets across the pulmonary valve; another had a probe patent valve that appeared imperforate on both echocardiography and right ventricular outflow tract angiography. Three of the four patients diagnosed by echocardiography as critical pulmonary stenosis were found on right ventricular outflow tract angiography to have pulmonary atresia. The remaining patient had such a tiny orifice that a second orifice had to be created with a radiofrequency catheter. The right ventricular outflow tract was opened successfully in 10 of the 11 patients, six of whom required application of radiofrequency energy. The right ventricular to aortic systolic pressure ratio fell from 1.4 (0.9 to 1.9) to 0.6 (0.2 to 1.1) (P < 0.05). All 11 patients were alive and well with transcutaneous oxygen saturations ranging from 84% to 95% at a median follow up duration of nine months.

CONCLUSIONS

Critical pulmonary stenosis and pulmonary atresia cannot always be accurately distinguished by echocardiography. Right ventricular outflow tract angiography helps to distinguish the two groups. In most cases the right ventricular outflow tract can be opened without mortality and with short to medium term survival.

Influence of right heart size on outcome in pulmonary atresia with intact ventricular septum

BACKGROUND

Neonates with pulmonary atresia and intact ventricular septum (PA-IVS) are frequently born with hypoplastic right heart structures that must grow after right ventricular decompression (RVD) procedures for a complete two-ventricle physiology to be achieved. Previous authors have asserted that neonatal right heart size or morphology will predict right heart growth potential. Since 1983, our bias has favored early RVD regardless of initial right heart size. In 1986, we recognized a subset of patients with coronary artery abnormalities associated with poor outcome after RVD and have defined these patients as having a right ventricular-dependent coronary circulation (RVDCC).

METHODS AND RESULTS

To assess the influence of right heart size on outcome independent of the presence of RVDCC, we measured echocardiographic right ventricular (RV) dimensions in 37 neonates with adequate studies presenting between 1983 and 1990. Coronary artery anatomy was adequately assessed by angiography in 36. RV volume and tricuspid valve (TV) diameter were significantly smaller in patients with RVDCC than in those without. However, there was no statistically significant association between RV volume or TV diameter and survival among patients with or without RVDCC: Among 29 patients without RVDCC, 23 of 24 (95.8%) who achieved RVD are alive compared with 1 of 5 (20%) who did not achieve RVD (P = .001). Twenty-one of the 23 survivors have a complete two-ventricle physiology with low right atrial pressure. Among 7 patients with RVDCC, 2 patients who underwent RVD died early of left ventricular failure, whereas 4 of 5 who did not undergo RVD have survived single ventricular palliation.

CONCLUSIONS

Small right heart size is associated with RVDCC but is not associated with survival in PA-IVS. Patients without RVDCC have improved survival after RVD regardless of neonatal right heart size.

Management evolution of pulmonary atresia and intact ventricular septum

To examine the impact on survival and clinical course of incorporating the morphologic classification of the right ventricle into the evolving management strategy for babies with pulmonary atresia and intact ventricular septum, the surgical results and follow-up status of the first 62 consecutive patients managed in this hospital between 1979 and 1990 were reviewed. Before 1984, all 23 babies from group I underwent primary right ventricular outflow reconstruction irrespective of right ventricular morphology and size. Since 1984, depending on the morphology and size of the right ventricle, 39 babies from group II had either closed transventricular pulmonary valvotomy (n = 31) or a shunt operation (n = 8). There were 10 hospital (43%) and 2 late deaths (total mortality 52%) in our group I patients. Three of the 11 long-term survivors had cyanosis at rest but none had any residual pressure gradient across the pulmonary outflow. Group II had 6 hospital (15%) and 4 late deaths (total mortality = 26%). Of the 29 long-term survivors, 9 had a second-stage right ventricular outflow reconstruction, 8 had balloon valvuloplasty and 2 had successful Fontan operation. At the latest follow-up, 5 children from this group have cyanosis at rest, 1 has a residual gradient (55 mm Hg) across the infundibulum, and 3 have right ventricular dysfunction. The hospital and total mortality for babies in group II was significantly lower than that in group I (p < 0.01). These data suggest that tailoring the treatment to the right ventricular anatomy results in a lower overall mortality although long term postoperative hemodynamic abnormalities are observed in both groups.

Noninvasive evaluation of newborns with congenital heart disease

Over the last decade, diagnosis and management of neonates with congenital heart disease have been greatly influenced by the constant expansion of noninvasive methods. We classify the most common congenital defects presenting in the first 2 weeks of life, based on clinical presentation and hemodynamic characteristics, followed by a discussion of echocardiographic findings in the most common congenital heart lesions and how ultrasound techniques can help solve problems frequently encountered during the early postoperative period.

Diagnosis and management of right ventricle-dependent coronary circulation in pulmonary atresia with intact ventricular septum

BACKGROUND

Coronary artery anomalies including 1) right ventricle (RV)-to-coronary artery fistulas, 2) coronary artery stenoses, and 3) coronary occlusions occur in patients with pulmonary atresia with intact ventricular septum (PA-IVS). In some, a large part of the coronary blood supply may depend on the RV. This RV-dependent coronary circulation may determine survival after right ventricular decompression (RVD): RVD may cause RV "steal" in the presence of fistulas alone and ischemia, coronary isolation, or myocardial infarction in the presence of coronary stenoses.

METHODS AND RESULTS

Eighty-two patients with PA-IVS who presented between January 1979 and January 1990 were reviewed; 26 (32%) had RV-to-coronary artery fistulas. Of these 26, 23 had adequate preoperative coronary angiograms for analysis. RVD was achieved in 16. Seven of 16 had fistulas only; each survived RVD. Six of 16 had stenosis of a single coronary artery [left anterior descending coronary artery (LAD), four; right coronary artery (RCA), two]; four of six survived RVD. Three of 16 had stenoses and/or occlusion of both the RCA and LAD; all three died shortly after RVD of acute left ventricular dysfunction.

CONCLUSIONS

1) Potential RV steal alone does not preclude successful RVD. 2) Fistulas with stenoses to a single coronary artery may not preclude successful RVD. 3) RVD appears to be contraindicated in the presence of stenoses and/or occlusion involving both the right and left coronary systems. Nonsurvival after RVD seems to depend on the amount of the left ventricular myocardium at risk, i.e., that which is distal to coronary artery stenoses, especially when involvement of both coronary arteries limits effective collateralization. Precise definition of coronary arterial anatomy is mandatory in neonates with PA-IVS.

Balloon valvuloplasty after pulmonary valvotomy for babies with pulmonary atresia and intact ventricular septum

During a 2 1/2-year period, staged procedures of transventricular closed pulmonary valvotomy followed by balloon valvuloplasty were attempted in 12 babies with pulmonary atresia and an intact ventricular septum. All babies immediately underwent valvotomy when echocardiography revealed a tripartite right ventricle with adequate inflow and outflow dimensions and without sinusoidal-coronary arterial fistulas. After valvotomy, the overall mortality rate was 25% (3/12), but the only surgical death (1/12, 8%) was due to failure to establish continuity between the right ventricular cavity and the pulmonary trunk. The other 2 babies died of neonatal complications after successful valvotomy. Angiocardiography performed 5 to 18 months after valvotomy documented substantial growth of the right ventricular inflow and outflow dimensions in the 9 survivors. Twelve balloon dilation procedures were then performed in 7 babies. All except 1 achieved a significant drop in the right ventricular to left ventricular peak systolic pressure ratio (0.96 +/- 0.40 to 0.56 +/- 0.28; p less than 0.01). Balloon valvuloplasty was not required in 1 baby and failed in the other, who then underwent successful right ventricular outflow tract reconstruction. After these staged procedures, follow-up at 1 month to 20 months (mean follow-up, 14.8 months) revealed resting cyanosis in 3 babies, which was related to severe residual infundibular stenosis (55 mm Hg) in 1 and a subnormal tricuspid valve annulus in 2. The remaining 5 babies (including 1 who required no valvuloplasty) were active and pink (saturation greater than 97%) and had a mean Doppler estimated gradient of 19 mm Hg (range, 8 to 36 mm Hg) across the pulmonary valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Cross-sectional echocardiographic measurements of right ventricular size and growth in patients with pulmonary atresia and intact ventricular septum

Fifteen patients with pulmonary atresia or critical pulmonary stenosis and intact ventricular septum were studied. All were operated on in the neonatal period, with valvotomy or a systemic to pulmonary arterial shunt, or both. In 12 patients, right ventricular to pulmonary arterial communication was established in the neonatal period. In three patients, only systemic to pulmonary arterial shunts were constructed. Six patients died. The median follow-up period for the surviving patients was 64 months (range, 12-87 months). Right and left atrial and ventricular dimensions and areas, the tricuspid annular diameter, and the cross-sectional area of the aortic root were measured in cross-sectional echocardiograms from the neonatal period, at the age of 1 year, and at the latest clinical follow-up. A classification of right ventricular morphology was made, based on identification of the inlet, the trabecular, and the outlet parts. Most of the patients had hypoplastic right ventricles at birth but at the latest follow-up, seven of nine surviving patients had right ventricles in the normal range. Right ventricular growth was better in patients who were given a right ventricular to pulmonary arterial communication in the neonatal period and those with complete right ventricular anatomy. The patients who died had severely hypoplastic right ventricles and small tricuspid valves.

The management of symptomatic neonates with suspected congenital heart disease using combined cross-sectional echocardiography and pulsed Doppler flow study as the definitive investigations

We studied prospectively 140 consecutive symptomatic neonates with suspected congenital heart disease by combined cross-sectional and pulsed Doppler echocardiography. Using the sequential segmental approach, the anatomy at all cardiovascular junctions was clearly defined in 89 (64%) babies. Based on the non-invasive investigations, 47 went to surgery while 42 babies were treated medically. The other 51 babies underwent further cardiac catheterisation. Of these, only 23 (16%) required diagnostic catheterisation prior to their management decision. The remaining 28 babies were catheterised for (1) angiographic measurement of anatomical structures (n = 12), (2) haemodynamic measurement (n = 1), and (3) balloon atrial septostomy (n = 15). One hundred and two babies had ultimate verification of their echocardiographic diagnoses. A total of 612 cardiovascular segments were identified. There were 33 (5%) echocardiographic errors, 23 of missed or uncertain diagnosis and 10 wrong interpretations. The diagnostic sensitivity and specificity for the combined non-invasive technique were thus 96 and 98%, respectively. Only one death was attributed directly to an echocardiographic error. Hence when the clinical outcome was taken into consideration, 88 of the 89 neonates without an initial catheterisation were judged to be appropriately managed for their presentation.