PULMONARY ATRESIA WITH INTACT VENTRICULAR SEPTUM

Multiple coronary artery fistulae with biventricular hypertrophy

Here, we report a case of multiple coronary artery fistulae with biventricular hypertrophy. The initial diagnosis of multiple coronary artery fistulae, draining into the left as well as the right ventricle, was made by standard transthoracic 2-dimensional and Doppler echocardiography. Later, multiple coronary fistulae communicating with the left ventricle through persistent sinusoids were diagnosed by coronary angiography.

Isolated noncompaction cardiomyopathy presenting with paroxysmal supraventricular tachycardia--case report and literature review

Isolated noncompaction cardiomyopathy is an exceedingly rare congenital cardiomyopathy. A case of isolated noncompaction cardiomyopathy is reported and the literature on the subject collected through a comprehensive literature search is reviewed. Fewer than 100 cases of this condition have been reported. Isolated noncompaction cardiomyopathy is caused by a defect in cardiac morphogenesis resulting in an arrest of compaction of loose interwoven meshwork of myocardial fibers during intrauterine life, which results in severe systolic dysfunction as well as undue hypertrophy of the involved walls of the ventricles. Although the most frequent sites involved are left ventricular apex and inferior wall, involvement of other left ventricular walls and right ventricle has also been reported. Etiology of the isolated noncompaction of myocardium is not clear. Familial cases have been reported and the mode of inheritance is heterogeneous. In X-linked form of the disease, a locus has been found on Xq28, and mutations have been reported in G4.5 gene. The age of onset of symptoms ranges from infancy to the geriatric age. Patients with isolated noncompaction cardiomyopathy have a high incidence of heart failure, arrhythmias, and thromboembolism. The most common presentation is congestive heart failure. Arrhythmias include atrial arrhythmias, ventricular tachycardia, and sudden cardiac death. The patient reported in this article presented with paroxysmal supraventricular tachycardia. Echocardiography is the procedure of choice to establish diagnosis. Due to the lack of associated cardiac anomalies, antenatal detection is difficult. The treatment is that for congestive heart failure, arrhythmias, and thromboembolism. The end-stage congestive heart failure is managed with heart transplantation and potential life-threatening ventricular tachyarrhythmias with an implantable cardioverter defibrillator. Prognosis is poor and the common causes of death are intractable heart failure and sudden cardiac death.

Echocardiographic and pathoanatomical characteristics of isolated left ventricular non-compaction: a step towards classification as a distinct cardiomyopathy

AIM

To determine clear cut echocardiographic criteria for isolated ventricular non-compaction (IVNC), a cardiomyopathy as yet "unclassified" by the World Health Organization. The disease is not widely known and its diagnosis mostly missed.

METHODS AND RESULTS

In seven out of a series of 34 patients with IVNC the in vivo echocardiographic characteristics were validated against the anatomical examination of the heart removed after death in four and due to heart transplantation in three patients. Four morphological criteria diagnostic for IVNC were found. (1) Coexisting cardiac abnormalities were absent (by definition). (2) A two layer structure was seen, with a compacted thin epicardial band and a much thicker non-compacted endocardial layer of trabecular meshwork with deep endomyocardial spaces. A maximal end systolic ratio of non-compacted to compacted layers of > 2 is diagnostic. (3) The predominant localisation of the pathology was to mid-lateral (seven of seven patients), apical (six), and mid-inferior (seven) areas. The pathological preparations confirmed the echocardiographic findings. Concomitant regional hypokinesia was not confined to the non-compacted segments. (4) There was colour Doppler evidence of deep perfused intertrabecular recesses.

CONCLUSIONS

Four clear cut echocardiographic diagnostic criteria were established. It is suggested that the WHO classification of cardiomyopathies be reconsidered to include IVNC as a distinct cardiomyopathy.

Nonneoplastic diseases of aorta and pulmonary trunk--Part V

This five-part review focuses on selected nonneoplastic diseases of the aorta and pulmonary trunk. Because many more diseases affect the aorta compared with the pulmonary trunk and the right and left main pulmonary arteries, most of this review will be devoted to disorders of the aorta. Part V of this five-part series on diseases of the aorta and the pulmonary trunk focuses on nonneoplastic diseases of the pulmonary trunk and the right and left main pulmonary arteries.

Isolated noncompaction of the myocardium in adults

OBJECTIVE

To describe the entity of isolated ventricular noncompaction (IVNC) and present a series of cases of this rare disorder in an adult population.

MATERIAL AND METHODS

We review a 10-year experience with the diagnosis of IVNC and discuss the clinical, echocardiographic, and pathologic features of this condition. Echocardiographic diagnostic criteria included the absence of coexisting cardiac abnormalities, the presence of prominent and excessive trabeculations of one or more ventricular wall segments, and intertrabecular spaces perfused from the ventricular cavity. Pathologic examination focused on regions with exaggerated trabeculations and deep intertrabecular spaces.

RESULTS

IVNC is an unexplained arrest of myocardial morphogenesis previously encountered mainly in pediatric patients. Among 37,555 transthoracic echocardiographic studies performed at our hospital between January 1984 and October 1993, 17 cases of IVNC were identified in adult subjects (14 men and 3 women, 18 to 71 years of age). The mean time from onset of symptoms to correct diagnosis was 3.5 +/- 5.7 years, and the mean duration of follow-up was 30 +/- 28 months. Common clinical symptoms were heart failure, ventricular arrhythmias, and a history of embolic events. Two-dimensional echocardiography revealed 10 patients with left ventricular and 7 (41%) with biventricular IVNC. During a 6-year follow-up period, eight patients died and two underwent heart transplantation.

CONCLUSION

Although the diagnosis of IVNC in an adult population is often delayed because of similarities with more frequently diagnosed conditions, two-dimensional echocardiography will facilitate the diagnosis of IVNC in this subset of patients. Because of the high incidence of heart failure, ventricular arrhythmias, and embolization in adults with IVNC, early diagnosis is important.

Abnormalities of the coronary circulation in pulmonary atresia and intact ventricular septum

To identify developmental aspects and establish morphologic criteria useful for clinical recognition of sinusoids and coronary artery abnormalities in pulmonary atresia and intact ventricular septum, we studied 17 autopsy hearts with this lesion. Hearts from age- and weight-matched infants served as controls. There were two stillborn fetuses, 12 full-term neonates, and 3 infants. None of the eight hearts with normal or large-sized right ventricular chambers had sinusoids or coronary artery abnormalities. Five of nine hearts with small right ventricular chambers had sinusoids; all five lacked trabecular and outlet portions of the ventricle. Four of these five contained major coronary artery abnormalities: atrophy of one or both coronaries proximal to a communication between a sinusoid and the coronary artery. We conclude (1) there is a strong association between the presence of sinusoids and coronary anomalies, supporting the developmental concept of abnormal persistence of embryonic right ventricular sinusoid--coronary artery communications in pulmonary atresia and intact ventricular septum; (2) the absence of trabecular and outlet portions of the small right ventricle indicates a strong possibility of coronary artery abnormalities; and (3) this initial report of a fully-developed lesion in a mid-gestation fetus documents that the coronary artery problem may arise early in fetal life.

Coronary arterial abnormalities in pulmonary atresia with intact ventricular septum

The incidence and severity of abnormalities of the coronary arteries were evaluated in 35 necropsy patients with pulmonary atresia and an intact ventricular septum. Right ventricular to coronary artery fistulous connections were found in more than 60% of the cases. All patients with fistulous connections had histologic abnormalities of the coronary arteries. In 50% the lesions were mild, with medial and intimal thickening producing up to moderate luminal stenosis. In 50% there was loss of normal arterial wall structure and severe narrowing or obliteration of the arterial lumen. The coronary arterial fistulas and histologic abnormalities were prevalent in those with underdevelopment of the tricuspid valve and right ventricular cavity but were not found in patients with a normal or dilated tricuspid valve anulus. The coronary arterial abnormalities were found in more than 80% of patients with a tricuspid valve/mitral valve ratio less than 1. A single coronary artery occurred in 6 patients (17%) of this series. In 80% of those with 1 coronary artery arising from the other, the aberrantly arising coronary artery crossed anteriorly to the pulmonary artery and could be at risk in surgical attempts to reconstruct the right ventricular outflow. Aortography is recommended if the coronary arteries are not clearly delineated on ventricular cineangiocardiography.

Persisting myocardial sinusoids of both ventricles as an isolated anomaly: echocardiographic, angiographic, and pathologic anatomical findings

The persistence of myocardial sinusoids in both ventricles as an isolated anomaly is described. A 21-year-old patient had progressive heart failure considered as cardiomyopathy of obscure etiology. Two-dimensional echocardiography demonstrated channel-like structures in the thickened myocardium of both hypokinetic ventricles. Angiography showed a honeycomblike inner contour in both ventricles. Autopsy proved the diagnosis of persistent sinusoids in a thickened myocardium.

Two-dimensional echocardiographic evaluation of right ventricular size and function in newborns with severe right ventricular outflow tract obstruction

Critical pulmonary stenosis or atresia with intact ventricular septum represents a congenital cardiac lesion for which the long-term prognosis appears to depend partly on the size of the right ventricle. Thus, the capability of noninvasive assessment of right ventricular size to predict operative outcome was examined in 15 infants (aged 1 to 30 days, mean 5.6) with severe right ventricular outflow tract obstruction (either critical pulmonary stenosis [7 patients] or pulmonary atresia with intact ventricular septum [8 patients]). Using echocardiography in two orthogonal subxiphoid views, right ventricular volume, wall thickness, area change fraction, ejection fraction and tricuspid anulus dimension were measured. All patients with a normalized right ventricular enddiastolic volume of less than 5 ml/m2 and a normalized tricuspid anulus dimension of less than 1.0 cm/m2/3 required a shunt operation. Only one patient with a volume of more than 6 ml/m2 and a normalized tricuspid anulus dimension of more than 1.4 cm/m2/3 required more than relief of right ventricular outflow tract obstruction. In this patient, residual severe pulmonary stenosis necessitated the shunt procedure. One patient with a volume of more than 6 ml/m2 had an anulus diameter of less than 1.4 cm/m2/3 and one patient with an anulus diameter of more than 1.4 cm/m2/3 had a volume of less than 6 ml/m2; both required shunt procedures. It therefore appears that if either the ventricular volume or tricuspid anulus size is excessively small, a shunt procedure is necessary. Wall thickness, area change fraction and ejection fraction measurements were not significantly correlated with right ventricular volume or postoperative outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical closure of the tricuspid valve for pulmonary atresia, intact ventricular septum, and right ventricle to coronary artery communications

A surgical approach is reported for a patient with pulmonary atresia, intact ventricular septum, and right ventricle to coronary artery communications through sinusoids. A shunt procedure was performed at two days of age; the right ventricular outflow tract was not opened. At subsequent catheterization, the tricuspid valve was temporarily closed with a balloon catheter and no change was seen in the ECG. At five months of age, the right ventricle was plicated and a patch was sewn over the tricuspid valve. One year after surgery, neither the right ventricular cavity nor the sinusoids could be demonstrated at angiocardiography; ECG changes of left ventricular ischemia have resolved, and the child is growing normally.

Right ventricular infarction with cardiac rupture in an infant with pulmonary valve atresia with intact ventricular septum

This report describes an 8 day old infant with pulmonary valve atresia, hypoplastic and hypertensive right ventricle and myocardial sinusoid-left anterior descending coronary artery connections. A large right ventricular sinusoid complex developed that was associated with transmural right ventricular necrosis and cardiac rupture. This is the first report to document transmural myocardial infarction and rupture in pulmonary valve atresia with intact septum, and this condition should be added to the causes of myocardial infarction in infancy. A reduced number of caliber of sinusoid-coronary artery channels may be responsible for right ventricular damage in this condition.

Pulmonary atresia with and without ventricular septal defect: a different etiology and pathogenesis for the atresia in the 2 types?

In 15 of 20 hearts of neonates with pulmonary atresia and intact septum (PA-IVS) and in 4 with critical pulmonary stenosis, the pulmonary valve consisted of 3 fused cusps. One of the 11 patients with a ventricular septal defect (PA-VSD) had a well-developed pulmonary root; in 8 the pulmonary trunk arose from a dimple. Two had a bicuspid valve. In 10 of the 20 patients with PA-IVS and in those with critical stenosis, the diameter of the pulmonary trunk was normal or larger than normal. The authors believe that this is related to flow through an initially patent pulmonary valve and, perhaps more importantly, to poststenotic dilatation. In all hearts with PA-VSD, the pulmonary trunk was very small. In the patients with PA-IVS and a normal-sized pulmonary trunk and in 3 with critical pulmonary stenosis, the morphology of the ductus arteriosus was normal, suggesting that even in the former the valve was patent before birth, allowing forward flow. In all patients with small pulmonary trunk, the ductus was long, tortuous, and originated from the aortic arch in a proximal position, suggesting that reversal of flow had occurred early in development. The authors postulate that in patients with ventricular septal defect (VSD), the pulmonary ostium becomes atretic early in development, at or shortly after partitioning of the truncoconal part of the heart has taken place but before closure of the ventricular septum. In patients with intact ventricular septum, on the other hand, atresia very likely occurs sometime after cardiac septation has been completed. In these cases the pulmonary atresia may be due to a prenatal inflammatory process, rather than representing a true congenital malformation.

Congenital hypoplasia of the pulmonary trunk without a ventricular septal defect in a goat lamb

Congenital hypoplasia of the pulmonary trunk without a ventricular septal defect was diagnosed in a goat lamb. Clinical weakness, dyspnoea, blue mucous membranes, tachycardia, and abnormal heart sounds were related to post mortem findings. The malformation of the heart resulted in an amphibian like - one chamber heart - circulation.

Pulmonary atresia with intact ventricular septum and ventriculocoronary communications: surgical significance

The first stage of a repair of pulmonary atresia with intact ventricular septum (type I) was attempted in a 2-day-old infant. At surgery, decompression of the hypertensive small right ventricle was followed by a sudden loss of myocardial contractility and death. Postmortem examination revealed a fistula with a large orifice in the right ventricular infundibulum that communicated directly with the left main coronary artery. Severe hypertensive changes indicative of abnormally high perfusion pressure were noted in the distal left coronary artery branches. The clinical course suggests that the effect of relieving right ventricular outflow obstruction was a reduction of left main coronary artery blood flow, resulting in fatal intraoperative myocardial ischemia. This unusual case draws attention to the anomalous ventriculocoronary communications often present in pulmonary atresia and their potential for limiting a successful surgical repair.

Absent proximal left main coronary artery in association with pulmonary atresia

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

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

Congenital pulmonary atresia with tricuspid insufficiency: morphologic study

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

Ultrasound in the diagnosis of congenital heart disease

In addition to recording the motion of the mitral, tricuspid, aortic, and pulmonic valves, echocardiography can identify right and left ventricular cavities and the interventricular septum. Disorders such as atrial-septal defect, valvular and subvalvular aortic stenosis, pulmonic stenosis, Ebstein's anomaly of the tricuspid valve, and the hypoplastic left-heart syndrome can readily be evaluated by echocardiography. In tetralogy of Fallot and truncus arteriosus, discontinuity between the anterior aortic wall and septum with overriding aorta has been demonstrated. Doubleoutlet right ventricle is associated with posterior aortic wall and mitral valve discontinuity. In disorders such as single ventricle, tricuspid atresia, and endocardial cushion defect with common A-V canal, echocardiographic demonstration of the absence of the interventricular septum has provided the clinician with valuable information. Newer techniques such as compound-B ultrasonography, which produces a two-dimensional cross-sectional image of intracardiac structures, and multiscan echocardiography will enhance the use of conventional echocardiography by providing a more accurate anatomic display of cardiac chambers and outflow vessels.

PULMONARY VALVE ATRESIA WITH INTACT VENTRICULAR SEPTUM

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Contributions of intramyocardial sinusoids in pulmonary atresia and intact ventricular septum to a right-sided circular shunt

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Severe congenital tricuspid incompetence in the neonate

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

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

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

Pulmonary valve atresia with intact ventricular septum. Report of a case with long survival and pulmonary blood supply from an anomalous coronary artery

A case of pulmonary valve atresia with intact ventricular septum' with long survival in the absence of a patent ductus arteriosus, is presented. The patient, alive at 21 years of age, has the anterior descending branch of the left coronary artery originating from the pulmonary artery. Thus, the pulmonary blood supply is obtained from the right coronary artery via intercoronary anastomoses. No similar case has been reported previously.