Congenital tricuspid atresia

Tricuspid atresia: Where are we now?

Tricuspid atresia (TA) is a complex congenital heart disease that presents with cyanosis in the neonatal period. It is invariably fatal if left untreated and requires multiple stages of palliation. Early recognition and timely surgical intervention are therefore pivotal in the management of these infants. This literature review considers the pathophysiology, presentation, investigations, and classification of TA. Moreover, it discusses the evidence upon which the latest medical and surgical treatments are based, as well as numerous recent case reports. Further work is needed to elucidate the etiology of TA, clarify the role of pharmacotherapy, and optimize the surgical management that these patients receive.

Course of tricuspid atresia in the Fontan era

Tricuspid atresia is an uncommon form of congenital heart disease and long-term survival was rare before the Fontan era. It was thought that the long-term survival of patients with tricuspid atresia would be improved by the introduction of the Fontan procedure and its subsequent modifications. This study reviews the clinical course of 84 patients with tricuspid atresia identified in the first year of life in the Fontan era. Prior palliative operations, their results and their ultimate application for the Fontan procedure were considered. Eleven patients died before surgical intervention and 5 did not undergo catheterization or echocardiographic confirmation before death. Five children underwent the Fontan procedure without prior palliation and 1 child does not require palliation at the present time. Sixty-seven patients (80%) had surgical procedures before evaluation for the suitability of a Fontan operation. Thirty-four patients had a second surgical palliation and 9 patients had a third palliation. The surgical mortalities for the first, second and third palliative surgery were 17.9, 17.6 and 0%, respectively. Thirty-two patients (38%) underwent the Fontan procedure and 2 deaths occurred (6%). An estimate of the probability of surviving for 1 year was 64% (95% confidence limits 54 to 74%) and that of 8 years was 55% (95% confidence limits 44 to 66%).

Two-dimensional echocardiography in diagnosing tricuspid atresia. Differentiation from other hypoplastic right heart syndromes and common atrioventricular canal

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Left ventricular function in tricuspid atresia. Angiographic analysis in 28 patients

Thirty-one left ventricular (LV) biplane angiograms were performed in 28 patients with tricuspid atresia. Measurements of left ventricular end-diastolic volume (LVEDV) and left ventricular end-systolic volume were obtained by the modified Simpson's rule and systolic ejection fraction (EF) calculated. Left ventricular volumes and ejection fractions were also obtained in 19 control patients with no significant heart disease. The patients with tricuspid atresia were classified according to the appearance of the pulmonary vascularity on initial radiologic examination: Group A, decreased pulmonary vascularity; Group B, increased pulmonary vascularity. In the 13 group A infants who were unoperated, LVEDV was increased and EF mildly diminished. In the group B patients LVEDV was increased and EF normal. In the 12 group A patients with surgical shunts LVEDV was elevated. The five group A patients with long-standing systemic artery to pulmonary artery anastomoses (greater than 10 years) showed the largest LVEDV and the poorest EF. The angiographic data indicate that patients with tricuspid atresia experience significant LV dysfunction as a consequence of longstanding LV volume overload. The early detection of LV dysfunction may be an indication for a right ventricular bypass procedure in these patients.

Tricuspid atresia: clinical course in 101 patients

The clinical profile and course of 101 patients with tricuspid atresia seen at the Children's Hospital Medical Center, Boston, were reviewed; the electrocardiograms, hemodynamic data, associated anomalies, complications of the malformation and surgical results were outlined and a definition of anatomic types and radiologic groups formed in order to facilitate therapeutic decisions. Overall survival to 15 years of age was approximately 50 percent. Tricuspid atresia type 1 (normally related great arteries), group A (decreased pulmonary vascularity) was the most frequent category (54 percent); without surgery, these patients had only a 10 percent chance of survival beyond the 1st year of life. Surgical intervention improved chance of survival to 15 years of age to 50 percent. Overall surgical mortality was 23 percent. The Waterston shunt is the procedure of choice in symptomatic small infants with diminished pulmonary flow (group A). Type II patients with increased pulmonary blood flow (group B) would benefit from a pulmonary arterial band. In contrast, patients with group B, type I atresia would rarely need a pulmonary arterial band. Patients with spontaneously changing hemodynamics (group C) usually require a shunt later in life than those in group A, with more favorable operative results. Our experience indicates the continued need of early surgical palliation. New surgical approaches, such as the right atrial-pulmonary arterial anastomosis, may result in a more prolonged survival.

Tricuspid atresia with increased pulmonary blood flow. An analysis of 13 cases

The pathologic and clinical findings in 13 cases of tricuspid atresia and increased pulmonary blood flow encountered in UCLA Medical Center were reviewed. In seven, the great vessels were normally related (group I), and in six, the great vessels were transposed (group II). In all group II cases, aortic arch anomalies were encountered, a finding not duly emphasized in previous reports. Comparison of the two groups revealed significant clinical and laboratory differences. Group II patients typically presented with severe congestive heart failure and expired within the first 2 months of life. Group I patients usually presented with mild congestive heart failure which responded to therapy. Five of the latter demonstrated progressive change from increased to decreased pulmonary blood flow during their clinical course and eventually required palliative shunt procedures, four prior to the age of 2 years and one at 5 years of age.

While the electrocardiogram demonstrated right atrial enlargement and left ventricular hypertrophy in both groups, the mean frontal plane axis was between –15° and –100° in group I and –75° and +75° in group II. QRS vector loops tended to be superiorly oriented in group I and inferiorly oriented in group II.

Because the natural history and prognosis in these two groups differ significantly, diagnostic efforts should include determination of the relationship of the great vessels. When transposition of the great vessels is demonstrated, aortography should be performed because of the high incidence of aortic arch anomalies.

Observations on changing hemodynamics in tricuspid atresia without associated transposition of the great vessels

Three patients are discussed who, in early infancy, presented with mild cyanosis, cardiac decompensation, failure to thrive, and pulmonary congestion. These manifestations were associated with tricuspid atresia without transposition of the great vessels. The clinical course of these children, who in varying periods of time became progressively more cyanotic, with hearts becoming smaller, and with decreasing pulmonary blood flow, is unique. Cardiac catheterization and angiocardiographic studies were obtained at each end of the clinical spectrum in all of the children. Although a closing ventricular septal defect is thought to be the cause of the decreasing pulmonary flow, the studies were not conclusive. In all three patients, palliative systemic venous-to-pulmonary arterial anastomosis (Glenn procedure) relieved the symptoms of hypoxia.

Tricuspid atresia

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Tricuspid atresia

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