Defective lateralisation in children with congenitally malformed hearts

An integrative multiscale view of early cardiac looping

The heart is the first organ to form and function during the development of an embryo. Heart development consists of a series of events believed to be highly conserved in vertebrates. Development of heart begins with the formation of the cardiac fields followed by a linear heart tube formation. The straight heart tube then undergoes a ventral bending prior to further bending and helical torsion to form a looped heart. The looping phase is then followed by ballooning, septation, and valve formation giving rise to a four-chambered heart in avians and mammals. The looping phase plays a central role in heart development. Successful looping is essential for proper alignment of the future cardiac chambers and tracts. As aberrant looping results in various congenital heart diseases, the mechanisms of cardiac looping have been studied for several decades by various disciplines. Many groups have studied anatomy, biology, genetics, and mechanical processes during heart looping, and have proposed multiple mechanisms. Computational modeling approaches have been utilized to examine the proposed mechanisms of the looping process. Still, the exact underlying mechanism(s) controlling the looping phase remain poorly understood. Although further experimental measurements are obviously still required, the need for more integrative computational modeling approaches is also apparent in order to make sense of the vast amount of experimental data and the complexity of multiscale developmental systems. Indeed, there needs to be an iterative interaction between experimentation and modeling in order to properly find the gap in the existing data and to validate proposed hypotheses. This article is categorized under: Cardiovascular Diseases > Genetics/Genomics/Epigenetics Cardiovascular Diseases > Computational Models Cardiovascular Diseases > Molecular and Cellular Physiology.

Isolated left bronchial isomerism that was incidentally detected as a severe obstructive ventilatory disturbance in an asymptomatic adult patient: A case report

RATIONALE

Left bronchial isomerism is generally associated with abnormal arrangement of the atrium and abdominal viscera; therefore, its diagnosis is confirmed in early childhood.

PATIENT CONCERNS

Here we report a rare case involving a 36-year-old man with isolated left bronchial isomerism that presented as an asymptomatic severe obstructive ventilatory disturbance during pulmonary function tests performed as part of routine assessments for an orbital wall fracture. The patient was a current smoker and did not show any respiratory symptoms.

DIAGNOSIS

Chest computed tomography revealed left bronchial isomerism, and further tests showed that there was no involvement of other organs.

INTERVENTIONS

We recommended smoking cessation and the long-term use of an inhaled long-acting bronchodilator.

OUTCOMES

The findings from this case highlight the causative role of left bronchial isomerism in asymptomatic adults with chronic obstructive pulmonary disease.

LESSONS

Physicians should consider this condition as a cause of obstructive ventilatory disturbances in asymptomatic adult patients.

Surgical Management of Heterotaxy Syndrome: Current Challenges and Opportunities

Introduction:

Heterotaxy syndrome presents a unique challenge in surgical management, even in the current era. We hypothesized that certain anatomic subsets merit novel strategies.

Methods:

We analyzed morphologic details, surgeries, comorbidities, subsequent admissions, and survival using Kaplan-Meier methods and multivariable risk models from a single-institution experience of 103 consecutive patients with heterotaxy who underwent cardiac surgery between January 1, 1990, and May 31, 2016.

Results:

Of the 103 patients (50 males and 53 females), 31 had left atrial isomerism, 64 had right atrial isomerism (RAI), and 8 patients’ isomerism was indeterminate (IND), with first cardiac operation at a mean 1.0 year (standard deviation ±3.0 years) of age. Kaplan-Meier overall survival estimate was 83.1% at six months, 77.8% at one year, 65.9% at five years, and 52.1% at ten years. Survival was particularly low among RAI following repair of total anomalous pulmonary venous connection (TAPVC) at first operation, with one- and five-year survival of 57% and 46%, respectively. By multivariable analysis, the only risk factor for death during the early phase (hazard model) was repair of TAPVC at the first cardiac operation (hazard ratio [HR]: 4.4, P = .01), and risk factors during the longer term constant phase were atrioventricular valve (AVV) regurgitation (HR: 4.2, P < .01), male gender (HR: 3.7, P < .01), and two-ventricle repair (HR: 3.0, P = .02). Patients with heterotaxy undergoing the Fontan procedure had excellent subsequent survival (85% at ten years).

Conclusions:

This analysis of over 100 patients with heterotaxy identified TAPVC requiring initial repair as the major risk factor for early death and important AVV regurgitation as the major risk factor in the longer term. Survival with RAI and early repair of TAPVC were poor, with one-year mortality exceeding 40%. Patients with single ventricle completing the Fontan operation enjoyed outstanding ten-year survival (85%). Initial management of RAI requiring early repair of TAPVC remains challenging. For this high-risk subset, alternative strategies such as early referral for cardiac transplantation evaluation warrant consideration.

Spontaneous Left Cardiac Isomerism in Chick Embryos: Case Report, Review of the Literature, and Possible Significance for the Understanding of Ventricular Non-Compaction Cardiomyopathy in the Setting of Human Heterotaxy Syndromes

The outer shape of most vertebrates is normally characterized by bilateral symmetry. The inner organs, on the other hand, are normally arranged in bilaterally asymmetric patterns. Congenital deviations from the normal organ asymmetry can occur in the form of mirror imagery of the normal arrangement (situs inversus), or in the form of arrangements that have the tendency for the development of bilateral symmetry, either in a pattern of bilateral left-sidedness (left isomerism) or bilateral right-sidedness (right isomerism). The latter two forms of visceral situs anomalies are called “heterotaxy syndromes”. During the past 30 years, remarkable progress has been made in uncovering the genetic etiology of heterotaxy syndromes. However, the pathogenetic mechanisms causing the spectrum of cardiovascular defects found in these syndromes remain poorly understood. In the present report, a spontaneous case of left cardiac isomerism found in an HH-stage 23 chick embryo is described. The observations made in this case confirmed the existence of molecular isomerism in the ventricular chambers previously noted in mouse models. They, furthermore, suggest that hearts with left cardiac isomerism may have the tendency for the development of non-compaction cardiomyopathy caused by defective development of the proepicardium.

Utility of fetal magnetic resonance imaging in assessing the fetus with cardiac malposition

OBJECTIVE

Abnormal cardiac axis and/or malposition prompts evaluation of congenital heart disease; however, etiology may be difficult to clarify using obstetrical ultrasound or fetal echocardiography (echo) alone. We aimed to use fetal magnetic resonance imaging (MRI) as a complementary tool to identify causes of cardiac malposition.

METHODS

Review of fetuses diagnosed with cardiac malposition by fetal ultrasound and echo was performed. Etiology was classified as either because of heterotaxy syndrome or extracardiac masses. Reclassification was then performed with fetal MRI findings. Results were compared with postnatal diagnoses.

RESULTS

Forty-two fetuses were identified as having abnormal cardiac axis and/or malposition. Twenty three of 42 cases (55%) had extracardiac anomalies, while 19 (45%) were because of heterotaxy. Twelve of 42 (29%) cases were reassigned by fetal MRI (five in heterotaxy group and seven in the lung anomaly group). Four cases (33%) had both cardiac disease and extracardiac masses, not previously recognized. Fetal MRI clarified heterotaxy subtype or removed heterotaxy diagnosis in five (26%) patients. Fetal MRI findings were confirmed in 8 of these 12 cases postnatally.

CONCLUSION

Fetal MRI is a useful complementary tool to define etiology of cardiac malposition in complex cases for informative prenatal counseling and planning. © 2016 John Wiley & Sons, Ltd.

Outcome of Glenn Anastomosis for Heterotaxy Syndrome with Single Ventricle

A retrospective study was undertaken of 157 patients who underwent a Glenn anastomosis between January 1996 and May 2001. Of these, 33 had heterotaxy syndrome: 20 males and 13 females, with a mean age of 1.26 ± 2.8 years. Twenty-five had right atrial isomerism and 5 had left isomerism. A common atrioventricular valve was found in 24 patients, 18 had bilateral superior venae cavae, and 18 had anomalous pulmonary venous return. Repair was carried out in 8 patients with anomalous pulmonary venous return, and pulmonary artery augmentation was performed in 11. Compared to the 124 patients who had a Glenn operation for single ventricle without heterotaxy, there were significantly longer durations of mechanical ventilation, intensive care unit stay, and inotropic support, as well as higher mortality in the heterotaxy group. Heterotaxy syndrome with single ventricle still has a high rate of morbidity and mortality. Patients with severe atrioventricular valve regurgitation are at risk of early death. Complete Fontan circulation may not be possible in all patients, and Glenn anastomosis may be their final palliation.

Role of four-dimensional ultrasound (spatiotemporal image correlation and sonography-based automated volume count) in prenatal assessment of atrial morphology in cardiosplenic syndromes

OBJECTIVE

To assess the diagnostic role of four-dimensional ultrasound using spatiotemporal image correlation and Sonography-based Automated Volume Count (STIC-SonoAVC) in the identification of the morphology of the atrial appendages in cases with cardiosplenic syndrome.

METHODS

This was a retrospective investigation of 22 fetuses with cardiosplenic syndromes seen at our institution over a 5-year period from January 2004. As control groups, 10 normal fetuses, five cases with a non-isomeric atrioventricular septal defect and five cases with other congenital heart diseases were also analyzed. For all fetuses, one or more cardiac volume datasets were available for offline analysis. Two-dimensional and four-dimensional echocardiography was carried out in all cases at the time of diagnosis using high quality three-dimensional equipment. Dedicated software was used to assess chamber morphology using the SonoAVC technique, which allows the creation of casts of hollow structures. Two different operators used the software. The first performed all steps up to positioning of the region of interest box. The second operator, who was blinded to clinical information, then rendered the cardiac chambers using the SonoAVC technique. This operator then used the rendered image to subjectively assess atrial morphology.

RESULTS

Suitable rendered images of the cardiac chambers could be produced in 40/42 fetuses. In two cases of left atrial isomerism, advanced (34 weeks) and early (13 weeks) gestational age made it impossible to obtain adequate rendered images. In the remaining 40 cases (13 cases of left atrial isomerism, seven cases of right atrial isomerism, five cases of non-isomeric atrioventricular septal defect, five cases of other congenital heart diseases and 10 normal fetuses), atrial morphology was correctly identified by evaluation of the rendered images.

CONCLUSION

Four-dimensional ultrasound with SonoAVC rendering allows correct identification of the morphology of atrial appendages in all cases of cardiosplenic syndromes in which an adequate cardiac volume dataset can be obtained for analysis.

Magnetic resonance imaging of heterotaxis syndrome

Failure to establish normal left-right body axis (LRA) formation during embryogenesis results in heterotaxis, a multi-malformation syndrome. We report on a 20-year-old young woman who presented to the emergency room with upper abdominal pain. On chest X-ray, dextrocardia was noted. Ultrasound was inconclusive. Barium studies demonstrated non-rotation of the intestine. Magnetic resonance imaging (MRI) of the abdomen confirmed heterotaxis with abnormal arrangement of abdominal organs and vasculature. This is the first radiographic description of LRA in MRI. It provides a unique contribution to the wide morphological variety of lateralization defects in a single examination within 15 min and without the risks of ionizing radiation. In addition, a literature overview over the genetic aspects, broad morphological spectrum, and possible therapeutic consequences is given.

Controversies, genetics, diagnostic assessment, and outcomes relating to the heterotaxy syndrome

How best to analyse and describe the features of the situation commonly known as "visceral heterotaxy" remains controversial. Much of the disagreement devolves on how to deal with the concept of isomerism. In the opinion of some, the concept of bilateral right-sidedness and bilateral left-sidedness, while useful in helping to remember which abnormalities are likely to occur in asplenia or polysplenia, should not be granted the status of a specific "situs", since there are numerous examples of exceptions to these patterns. On the other hand, those who favour the concept of isomerism point out that, when describing only the heart, and taking the structure of the atrial appendages as the starting point for analysis, basing this on the extent of the pectinate muscles relative to the atrioventricular junctions, then the only possible arrangements for the appendages are the usual one, its mirror-image, and the two situations in which appendages of comparable morphology are found on both sides of the heart, these being the arrangements of right or left isomerism. It is certainly the case that the arrangement of the organs is not always in harmony with the arrangement of the atrial appendages, but those circumstances, in which there is disharmony, can readily be described by paying specific attention to each series of organs. On this basis, in this review, we describe the approach to heterotaxy, and isomerism of the atrial appendages, in terms of the genetic background, the diagnosis, and outcomes after cardiac surgery. Attention is given to the various diagnostic modalities, including fetal and postnatal echocardiography, recent tomographic and magnetic resonance imaging techniques, and the time-honoured approach using angiography.

Clinical investigations over 13 years to establish the nature of the cardiac defects in patients having abnormalities of lateralization

INTRODUCTION

The first step in diagnosing congenital cardiac malformations is to assess the arrangement of the atrial appendages. In patients with abnormal lateralization of the organs of the body, the arrangement of atrial appendages is neither normal, nor a mirror image of normal. There are 2 categories of abnormal arrangement based on the morphology of the atrial appendices, namely right isomerism and left isomerism, and in almost all instances these are found in the setting of so-called heterotaxy syndromes.

OBJECTIVE

To evaluate the various congenital cardiac malformations those are associated with abnormalities of lateralization, and to discuss the diagnostic tools, therapeutic options, and outcome for these patients.

PATIENTS AND METHODS

We studied 134 patients, who had been admitted to our department of paediatric cardiology with known abnormalities of lateralization and congenital cardiac defects between 1990 and 2003. The data relating to each patient was evaluated retrospectively. The arrangement of the atrial appendages was established echocardiographically, and/or angiographically, and/or on the basis of morphologic investigations during the operation. These studies showed that 43 (32.1%) of the patients had right isomerism, and 88 (65.7%) had left isomerism. In 2 (1.5%), there was mirror-imaged arrangement, while in the final patient (0.07%), we were unable to determine sidedness with certainty. The median age at diagnosis was 0.66 years, and the females outnumbered the males in a ratio of 3 to 1. Patients in the 2 isomeric groups were compared with regard to age, cardiac defects, diagnostic tools and outcomes.

RESULTS

The difference in mean ages of the two groups of patients was statistically significant, those with right isomerism being 1.0 minus or plus 1.5 years, as opposed to those with left isomerism being 3.3 minus or plus 4.7 years (P is less than 0.005). Of the patients with right isomerism, 32 (74.4%) had left-sided, and 11 (25.6%) right-sided hearts, whereas in those with left isomerism, the hearts were left-sided in 65 (73.9%), and right-sided in 21 (23.9%), with 2 (2.2%) positioned in the midline. Extracardiac totally anomalous pulmonary venous connection was more common in those with right isomerism, being found in 13 patients (30.2%) as opposed to 5 patients (5.7%) with left isomerism. In only 8 of those with right isomerism did we find two perforate atrioventricular valves (18.6%), this arrangement being found in 34 (38.6%) of those with left isomerism. Pulmonary atresia and stenosis were present in 40 (93.0%) of those with right isomerism, but also in 41 (46.6%) of the patients with left isomerism. Angiographic and echocardiographic investigations were concordant in about three-quarters of patients with both right and left isomerism. All patients with extracardiac totally anomalous pulmonary venous connection died. Overall, 22 of the patients with right isomerism died (51.2%), as opposed to 20 (22.7%) of those with left isomerism.

CONCLUSION

Our experience confirms that patients with right isomerism have more complex cardiac defects than those with left isomerism. Overall, the presence of isomerism carries a poor prognosis, the more so for right isomerism, with this related to the complex cardiac abnormalities. In our cohort, extracardiac totally anomalous pulmonary venous connection with pulmonary arterial obstruction was always a fatal combination. The mapping of cardiac and abdominal morphologies is still essential for proper diagnosis of these syndromes, especially in fetal life.

A case of right isomerism showing long survival without surgery

We report an autopsy case of right isomerism in a 42-year-old Japanese man. Although he had not undergone any surgical intervention, he was healthy and did not exhibit any symptoms of heart failure. The cardiac findings indicated right isomerism with complex and severe cardiac malformations, including a morphologically common atrium, common atrioventricular valve, double inlet right ventricle, total anomalous pulmonary venous drainage, pulmonary outflow obstruction, pulmonary atresia, and major aortopulmonary collaterals from the descending aorta. He had no spleen, and exhibited some gastrointestinal malformations. The absence of risk factors for mortality from right isomerism, such as pulmonary venous obstruction, AV valve regurgitation, sepsis or severe arrhythmia, might have contributed to the longevity of this patient. The presence of pulmonary outflow obstruction that is reported to confer a better prognosis might also have contributed to his longevity.

Heterotaxy syndrome with functional single ventricle: does prenatal diagnosis improve survival?

BACKGROUND

Despite improved outcome for many single ventricle lesions, staged reconstruction for heterotaxy syndrome with a functional single ventricle continues to have a high mortality. Prenatal identification of heterotaxy syndrome may improve long-term survival.

METHODS

Our database was reviewed from January 1996 to December 2004 for patients with heterotaxy syndrome. Assessment was made for prenatal diagnosis and echocardiographic characteristics of heterotaxy syndrome. We sought to assess the accuracy of fetal echocardiography in the diagnosis of heterotaxy syndrome and determine whether prenatal diagnosis and other risk factors have an impact on survival in patients with heterotaxy syndrome.

RESULTS

Of 81 patients that met criteria, 43 (53%) had prenatal diagnosis. Prenatal diagnosis had high specificity and positive predictive value for all findings but had low sensitivity for anomalous pulmonary veins. Among the 70 patients born alive, survival was 60% with median follow-up of 51.4 months (range, 6.5 to 109.7 months). Prenatal diagnosis did not improve survival (p = 0.09). None of the 11 patients with complete heart block (CHB) survived past 3 months of age. Two patients underwent heart transplantation as their first intervention and have survived. CHB and anomalous pulmonary venous connection were associated with shorter duration of survival.

CONCLUSIONS

Prenatal diagnosis of heterotaxy syndrome does not improve survival in patients who undergo single ventricle reconstruction. The most potent risk factors for poor outcome (CHB, anomalous pulmonary veins) are likely not impacted by identification in utero. In light of the poor outcome, cardiac transplantation as an initial therapy may be a viable option for some patients.

Cardiac anatomy revisited

In tomorrow's world of clinical medicine, students will increasingly be confronted by anatomic displays reconstructed from tomographically derived images. These images all display the structure of the various organs in anatomical orientation, this being determined in time-honoured fashion by describing the individual in the 'anatomical position', standing upright and facing the observer. It follows from this approach that all adjectives used to describe the organs should be related to the three orthogonal planes of the body. Unfortunately, at present this convention is not followed for the heart, even though most students are taught that the so-called 'right chambers' are, in reality, in front of their 'left' counterparts. Rigorous analysis of the tomographic images already available, along with comparison with dissected hearts displayed in attitudinally correct orientation, calls into question this continuing tendency to describe the heart in terms of its own orthogonal axes, but with the organ positioned on its apex, so that the chambers can artefactually be visualized with the right atrium and right ventricle in right-sided position. Although adequate for describing functional aspects, such as 'right-to-left' shunting across intracardiac communications, this convention falls short when used to describe the position of the artery that supplies the diaphragmatic surface of the heart. Currently known as the 'posterior descending artery', in reality it is positioned inferiorly, and its blockage produces inferior myocardial infarction. In this review, we extend the concept of describing cardiac structure in attitudinally correct orientation, showing also how access to tomographic images clarifies many aspects of cardiac structure previously considered mysterious and arcane. We use images prepared using new techniques such as magnetic resonance imaging and computerized tomography, and compare them with dissection of the heart made in time-honoured fashion, along with cartoons to illustrate contentious topics. We argue that there is much to gain by describing the components of the heart as seen in the anatomical position, along with all other organs and structures in the body. We recognize, nonetheless, that such changes will take many years to be put into practice, if at all.

On rotation, torsion, lateralization, and handedness of the embryonic heart loop: New insights from a simulation model for the heart loop of chick embryos

The internal organs of vertebrates show specific anatomical left-right asymmetries. The embryonic heart is the first organ to develop such asymmetries during a process called dextro-looping. Thereby the initially straight heart tube curves toward its original ventral side and the resulting bend becomes displaced toward the right side of the embryo. Abnormal displacement of the heart loop toward the left is rare and is called levo-looping. Descriptive studies have shown that the lateralization of the heart loop is driven by rotation around its dorsal mesocardium. However, nothing was known on the modes of this process. To gain insight into this subject, different modes of rotation were tested in a simulation model for the looping chick embryo heart. The morphological phenotypes obtained in this model were compared with normal and mirror-imaged embryonic hearts. The following observations were made. One, rotation of the heart loop around its dorsal mesocardium has two consequences: first, lateral displacement of its bending portion either toward the right (D-loop) or left (L-loop) side of the embryo, and second, torsion of the cardiac bend into a helical structure that is wound either clockwise (right-handed helix) or counterclockwise (left-handed helix). The normal loop presents as a D-loop with left-handed helical winding and its mirror image presents as an L-loop with right-handed helical winding. This conflicts with the use to define D-loops as right- and L-loops as left-handed structures. Two, dextro-looping might be driven almost exclusively by rightward rotation of the arterial pole of the loop. It becomes complemented by leftward rotation of the venous pole during the subsequent phase of looping. An inverse mode of rotation might drive levo-looping. Three, the two different helical configurations of heart loops both can occur as right-sided, median, or left-sided positional variants. When viewed from the front, all right-sided variants appear as D-loops and all left-sided variants appear as L-loops at the end of dextro- or levo-looping. Their true asymmetric phenotypes become fully apparent only after simulation of the subsequent phase of looping. The terms D- and L-loop obviously do not fully define the chirality of heart loops. The chirality of their helical configuration should be defined, too. The implications of these data with respect to molecular and experimental data are discussed.

[Genetics of congenital heart diseases]

New insights into the genetics of congenital heart diseases in human beings have been drawn these past years. The identification of genes for heart defects have led to a new clinical approach of these malformations in children and their families. These progresses have been made with the help of positional cloning as well as with the analysis of mouse models. These findings also yielded a new complexity in understanding the development of cardiac defects and led to revise the different classifications for congenital heart defects. Pediatric cardiologists have also improved their efficiency in defining cardiac phenotypes in affected individuals and in pedigrees with recurrent malformations. Genetic heterogeneity has made the molecular approach of a given defect difficult. In addition, intrafamilial variability still has scarce explanations. Finally, the contribution of epigenetic factors has to be kept in mind in specific conditions such as twin gestations. Clinical consequences of these findings remain at the present time limited for the patients themselves but in particular cases, genetic counseling has been dramatically improved.

Risk factors for heart disease associated with abnormal sidedness

BACKGROUND

The purpose of this study is to obtain information on potential familial and environmental risk factors for liveborn cases of heart disease associated with abnormal visceral and vascular sidedness, heterotaxy heart disease, so that hypotheses about this congenital cardiovascular malformation (CCVM) and its risk factors can be generated. We describe the characteristics of infants with heterotaxy heart malformations and case-control comparisons of interview data obtained on parental socio-demographic characteristics, occupational and household environmental exposures.

METHODS

Cases and controls are drawn from the Baltimore Washington Infant Study (BWIS) a population based case control study of CCVM diagnosed in the region from 1981-89.

RESULTS

Maternal diabetes (OR = 5.5, 95% CI = 1.6-19.1) and family history of malformations (OR = 5.1, 95% CI = 2.0-12.9) are strongly associated with cardiac disorders of sidedness. Cocaine use by mothers during the first trimester is associated with heterotaxy heart disease with odds of 3.7 (95% CI = 1.3-10.7). Cases of isolated dextrocardia shared risk factors with other heterotaxy malformations. The odds of a twin proband having heterotaxy heart disease is 4.8 (95% CI = 1.9-11.8) compared to singleton births. Twin probands are predominantly monozygotic twins in contrast to twin probands in other congenital cardiovascular malformations.

CONCLUSIONS

Our findings are consistent with a role for multiple genetic factors in the development of left-right axis formation and with variable cardiac phenotypes according to gene expression and possible gene-environment interactions. Association with monozygotic twinning and with parental cocaine use may point to additional mechanistic clues for future research.

Cardiac septation: a late contribution of the embryonic primary myocardium to heart morphogenesis

Heart morphogenesis comprises 2 major consecutive steps, viz. chamber formation followed by septation. Septation is the remodeling of the heart from a single-channel peristaltic pump to a dual-channel, synchronously contracting device with 1-way valves. In the human heart, septation occurs between 4 and 7 weeks of development. Cardiac looping and chamber formation bring the contributing structures into position to engage in septation. Cardiomyocytes that participate in chamber formation do not materially contribute to septation. The (re)discovery of the role of extracardiac mesenchymal tissue in atrioventricular septation, the appreciation that the formation of the right atrioventricular connection is more than a mere rightward expansion of the atrioventricular canal, the awareness that myocardium originating from the so-called anterior heart field regresses after its function as outflow-tract sphincter ceases, and the recent finding that the myocardialized proximal portion of the outflow-tract septum becomes the supraventricular crest have all significantly enhanced our understanding of the morphogenetic processes that contribute to septation. The bifurcation of the ventricular conduction system is the landmark that separates the contribution of the atrioventricular cushions and the outflow-tract ridges to septation and that divides the muscular ventricular septum in inlet, trabecular, and outlet portions.

Cardinal vein isomerism: an embryological hypothesis to explain a persistent left superior vena cava draining into the roof of the left atrium in the absence of coronary sinus and atrial septal defect

BACKGROUND

A persistent left superior vena cava (PLSVC) is a relatively frequent systemic venous anomaly associated with congenital heart defects. This anomaly has been explained with the persistence of the left superior cardinal vein. PLSVC usually drains into the right atrium, via coronary sinus, but it joins the left atrium in approximately 8% of the cases either directly in the setting of atrial isomerism, or via an unroofed coronary sinus, or through a coronary sinus type atrial septal defect.

CASE REPORT

We describe a case of an adult patient with atria in the situs solitus, PLSVC draining into the left atrium, atresia of coronary sinus without atrial septal defect, and with additional cardiac anomalies (ventricular septal defect and discrete subaortic stenosis).

CONCLUSION

A possible embryological explanation to this case rises from a right partial isomerism of the superior cardinal veins, which gives reason for both the coexistence of the PLSVC draining into the left atrium and the absence of coronary sinus, atrial septal defect, or coronary sinus ostium.

Isomeric arrangement of the left atrial appendages and visceral heterotaxy: two atypical cases

We present two cases in which there was isomeric arrangement of the left atrial appendages in association with multiple spleens and complete heart block. In both of these, the venous connections were normal. In one case the arrangement of the bronchial tree and the lungs was normal, the liver was left-sided, and the stomach was right-sided. In the other case, there was left isomeric broncho-pulmonary morphology, and both liver and stomach were right-sided. These unusual combinations show the need for full description of the morphology of other organs, and the venoatrial connections, in cases with isomeric arrangement of the atrial appendages. They also demonstrate that connection of the inferior caval vein cannot be taken as a reliable marker of an atrium having a morphologically right appendage.

Knowing left from right: the molecular basis of laterality defects

The apparent symmetry of the vertebrate body conceals profound asymmetries in the development and placement of internal organs. Asymmetric organ development is controlled in part by genes expressed asymmetrically in the early embryo, and alterations in the activities of these genes can result in severe defects during organogenesis. Recently, data from different vertebrates have allowed researchers to put forward a model of genetic interactions that explains how asymmetric patterns of gene expression in the early embryo are translated into spatial patterns of asymmetric organ development. This model helps us to understand the molecular basis of a number of congenital malformations in humans.

A unique case of ventricular isomerism?

Isomerism of the atria has often been described with various complex cardiac malformations. As far as is known, a case of 'ventricular isomerism' has never been recorded. Described is a specimen where, on the basis of morphological criterions, there are two right ventricles.

A unique case of ventricular isomerism?

Isomerism of the atriums has often been described with various complex cardiac malformations. As far as is known, a case of 'ventricular isomerism' has never been recorded. Described is a specimen where, on the basis of morphological criterions, there are two right ventricles.