Alternate pathways to pulmonary venous flow in left-sided obstructive anomalies

Levoatrial Cardinal Vein: Occluder Embolization and Complication Management

In rare cases, levoatrial cardinal vein may occur as an isolated condition without additional congenital anomalies. Depending on the direction and flow of the shunt, this pathology may produce symptoms; alternatively, it may be asymptomatic, as in the case presented in this study. In asymptomatic cases, complications, such as paradoxical embolism and brain abscess, can arise later. In the 11-year-old patient whose case is presented here, the levoatrial cardinal vein was asymptomatic and incidentally detected. The percutaneous closure method was applied first. However, by 16 hours after the procedure, the occluder device had embolized to the iliac artery. Emergency surgery was performed; first, the occluder device was removed, and levoatrial cardinal vein ligation was then performed via a mini-thoracotomy. The symptoms, diagnosis, and treatment modalities of isolated levoatrial cardinal vein are discussed in the context of this case described herein.

The myocardial and coronary histopathology and pathogenesis of hypoplastic left heart syndrome

Hypoplastic left heart syndrome has the greatest mortality rate among all CHDs and without palliation is uniformly fatal. Despite noble efforts, the aetiology of this syndrome is unknown and a cure remains elusive. The genetic and anatomic heterogeneity of hypoplastic left heart syndrome supports a rethinking of old hypotheses and warrants further investigation into the histological and vascular variations recognised with this syndrome. In an effort to elucidate the pathogenesis of hypoplastic left heart syndrome, this review will focus on its unique myocardial and coronary pathology as well as evaluate the association of hypoplastic left heart syndrome with the endocardial fibroelastosis reaction.

Ventriculocoronary artery connections with the hypoplastic left heart: a 4-year prospective study: incidence, echocardiographic and clinical features

Ventriculocoronary connections (VCCs), also called sinusoids, occur with hypoplastic left heart (HLH). Previous reports are limited to case reports, pathologic series, and surgical series with limited detail, which may underestimate the incidence and overestimate the severity of VCCs in HLH. A study was conducted to determine the incidence VCCs in HLH, their effect on survival, and their echocardiographic and clinical features. The echocardiograms and medical records of 100 consecutive neonatal HLH cases were analyzed. All had an aortic and a mitral valve diameter and a left ventricular (LV) volume less than Z-3. For palliation, Norwood, Sano, or hybrid procedures were used, and if the patient was alive, subsequent bidirectional Glenn and extracardiac Fontan procedures were applied. Cases were classified as manifesting mitral and aortic atresia (MAAA), mitral and aortic stenosis (MSAS), or mitral stenosis and aortic atresia (MSAA). All other diagnoses or any case with additional cardiac anomalies were excluded from the study. Overall, VCCs were found in 15% of the cases. They occurred in 56% of the MSAA subtype cases and were not statistically associated with a high mortality rate. However, in one case, large and multiple VCCs definitely caused or contributed to early death. All VCCs had a transmyocardial course, a turbulent color-Doppler flow, and a dominant usually retrograde systolic coronary artery flow pattern. The VCCs were associated (p < 0.05) with MSAA, endocardial fibroelastosis, and ascending aortic size less than 2 mm. As shown by the findings, 15% of the HLH patients had MSAA with VCCs. Unless the VCCs were large or extensive, they did not contribute to mortality. Detailed echocardiographic analysis of VCCs in HLH was feasible. Recent reports emphasize more severe cases.

Levoatrial cardinal vein in mitral atresia and closed foramen ovale: prenatal diagnosis and perinatal management

A levoatrial cardinal vein is a rare cardiovascular anomaly that may be present in malformed hearts with severe left heart obstruction and restrictive interatrial communication. We report the prenatal diagnosis at 23 weeks of a fetus with mitral atresia, double-outlet right ventricle, premature closure of the foramen ovale and a levoatrial cardinal vein draining into the innominate vein. In a prior examination performed elsewhere the levoatrial cardinal vein had been interpreted as an aortic arch perfused retrogradely, and hypoplastic left heart syndrome with aortic atresia had been diagnosed. Prenatal management, induction at 38 weeks and postnatal examinations and treatment are reported. To the best of our knowledge, this is the first reported prenatal diagnosis of this embryological vessel, presenting a potential pitfall for prenatal echocardiography.

Anomalies of left coronary artery origin affecting surgical repair of hypoplastic left heart syndrome and Shone complex

There has traditionally been less concern regarding coronary anomalies with left-sided congenital heart lesions such as hypoplastic left heart syndrome (HLHS)or Shone complex than with other lesions. However, coronary anomalies in this setting can profoundly affect surgical intervention, particularly when surgical repair involves the ascending aorta. We describe four patients with congenital left-sided heart lesions in which left coronary artery (LCA) anomalies substantially affected intervention and outcome. In the first two cases, the coronary anomalies were not identified prospectively and resulted in surgical injury directly to the coronary or to its surrounding region. In the latter two cases, successful identification of the coronary anomaly preoperatively allowed for modification of surgical technique and/or intervention. We conclude that detailed coronary artery assessment should be part of the routine echocardiographic evaluation of congenital left-sided heart lesions that require surgery.

Partially anomalous pulmonary venous connection treated by interventional catheterization

A young man had anomalous connection of the veins draining the upper lobe of the left lung to both a left-sided vertical vein and the left atrium. The ratio of pulmonary to systemic flows was 1.7 : 1, and he was symptomatic with evidence of volume overload of the right heart. He was successfully treated by percutaneous placement of an Amplatzer ductal occlusion device into the vertical vein.

Prenatal diagnosis of ventriculocoronary arterial fistula in a fetus with hypoplastic left heart syndrome and aortic atresia

In a fetus with a hypoplastic left heart syndrome detected at 26 weeks' gestation, a communication between the left ventricular cavity and the left coronary artery was detected using color Doppler. Bidirectional flow was demonstrated and the ventricle was shown to be filled via the fistula during diastole. After premature birth at 31 weeks and neonatal death, autopsy confirmed the findings. Because the association of a heart defect with ventriculocoronary communications worsens the neonatal prognosis, it should be ruled out in fetuses with hypoplastic left heart syndrome before parents are counseled.

Isolated left ventricular ischemia after the Norwood procedure

Aortic atresia is the most severe variant of hypoplastic left heart syndrome (HLHS), and has been associated with significant mortality after stage I palliation. Coronary artery abnormalities are more prominent in this group of patients, especially in the presence of a patent mitral valve. Herein, we describe a case of isolated left ventricular ischemia after the Norwood procedure in a neonate with hypoplastic left heart syndrome, left ventricular hypertrophy, mitral stenosis, aortic atresia, and anomalous left coronary artery.

Premature closure of the foramen ovale associated with aortic stenosis, left ventricular dilation with thrombus, and early mortality

Premature foramen ovale (FO) closure has been postulated as a cause of hypoplastic left heart syndrome. We suggest that premature FO closure is also associated with left ventricular (LV) dilation and LV thrombus formation, and that FO closure in patients with aortic stenosis and LV dilation is a secondary event that occurs later in gestation than that seen with the hypoplastic left heart.

The levoatriocardinal vein: morphology and echocardiographic identification of the pulmonary-systemic connection

OBJECTIVES

This study considers the array of pulmonary-systemic connections made by the levoatriocardinal vein. The primary and associated lesions that play a role in forming this vein are examined, and echocardiography is discussed as a method for its rapid identification.

BACKGROUND

The levoatriocardinal vein is a pulmonary-systemic connection that provides an alternative egress for pulmonary venous blood in left-sided obstructive lesions. It is thought to result from the persistence of anastomotic channels that connect the capillary plexus of the embryonic foregut to the cardinal veins. Only 12 cases of levoatriocardinal vein have been reported since its first description in 1926. A comprehensive description of the morphology and echocardiographic identification of this lesion has been unavailable because of its rarity.

METHODS

A retrospective study was performed in 13 patients with a levoatriocardinal vein from the University of California, San Francisco. Echocardiographic findings were compared with those obtained by angiography or at necropsy. In addition, the details of 12 previously published case reports were reviewed. Age at presentation, primary obstruction to pulmonary venous return, integrity of the atrial septum and origin and drainage of the levoatriocardinal vein were compared.

RESULTS

Patient age at presentation was < 2 years, with most patients presenting before age 6 months. Variations of the hypoplastic left heart syndrome accounted for the majority of primary defects encountered, although multiple but less severe left-sided lesions were seen. The atrial septum was functionally intact in most patients. The levoatriocardinal vein, defined echocardiographically, originated predominantly from the smooth-walled left atrium and drained to the superior vena cava or innominate vein; however, variations of this pattern existed.

CONCLUSIONS

As a physiologic entity, the levoatriocardinal vein provides a mechanism for decompression of pulmonary venous return primarily in patients with left ventricular inflow obstruction. A levoatriocardinal vein is thought to form when the atrial septum fails to provide an alternate egress for left atrial blood. However, when a septal defect or alternative shunt occurs in conjunction with a levoatriocardinal vein, the clinical presentation may be postponed. Echocardiography provides a rapid, noninvasive modality for identifying the pulmonary-systemic connection, which may masquerade as the vertical vein in anomalous pulmonary venous connection or act as an occult source of left to right shunting in patients undergoing surgery for hypoplastic left heart syndrome.

Organized thrombus in left main coronary artery in hypoplastic left heart syndrome

A neonate is reported in whom, during Norwood stage I correction for hypoplastic left heart syndrome with mitral stenosis, an organized thrombus was found to protrude from the left coronary ostium into the aortic root. With ventricular assist device support the patient survived despite severe left ventricular ischemia. The presumed origin of the thrombus is from left ventriculocoronary arterial connections that serve to decompress the blind left ventricular cavity.

Morphological features of the levoatriocardinal (or pulmonary-to-systemic collateral) vein

Three cases with an anomalous pulmonary-to-systemic collateral vein (levoatriocardinal vein) connecting the left atrium or one of the pulmonary veins to a systemic vein are described. In two of these cases the atrial septum is intact, the left atrioventricular connection is absent (mitral atresia), and the anomalous vein is the escape channel for pulmonary venous return. In the remaining case, a muscular membrane divides the left atrium, separating the pulmonary venous component from the distal component. The collateral vein may be mistaken for the vertical vein that is associated with totally anomalous pulmonary venous connections, but in all our cases the pulmonary veins inserted normally into the left atrium. Cross-sectional echocardiography, including conventional and color flow Doppler mapping, should overcome potential difficulties in diagnosis.

Echocardiographic demonstration of an unusual pulmonary venous pathway in a patient with left ventricular inflow obstruction

A newborn infant with mitral atresia and a restrictive patent foramen ovale had normal pulmonary venous connection to the left atrium demonstrated by echocardiography. However, pulmonary venous blood then coursed through an unusual pathway in the roof of the left atrium into the right atrium. This case illustrates the need for the echocardiographer to be reminded of and then search for unusual drainage pathways in cases of left ventricular inflow obstruction, even when the pulmonary veins connect normally.

Hypoplastic left heart syndrome with premature closure of foramen ovale: report of an unusual type of totally anomalous pulmonary venous return

We report on a case of hypoplastic left heart syndrome (HLHS), associated with premature closure of the foramen ovale and an unusual type of totally anomalous pulmonary venous return. The existence of an anomalous connection of the right upper pulmonary vein to the superior vena cava-right atrial (SVC-RA) junction and the existence of the anomalous intrapulmonary venous channel between right upper and lower pulmonary vein allowed all the pulmonary blood to drain into the SVC-RA junction, whereas she had only partially anomalous pulmonary venous connection. The several intrapulmonary venous channels helped to delay the progression of pulmonary venous obstruction. Chromosomal analysis revealed that the patient had XO Turner syndrome. We conclude that all infants with HLHS should be carefully evaluated for the existence of anomalous pulmonary venous return. Two-dimensional Doppler echocardiography is one of the most useful techniques for evaluating such anomalies.

Prenatal diagnosis of aortic atresia by colour Doppler flow mapping

A case of aortic atresia with insufficiency of mitral valve diagnosed prenatally at 33 weeks of gestation is presented. An accurate diagnosis of this fetal cardiovascular malformation was possible by application of Doppler colour flow mapping, which demonstrated (a) the absence of forward flow in the hypoplastic ascending aorta, (b) reverse flow of blood from the ductus arteriosus into the severely hypoplastic ascending aorta in the late systole, (c) pansystolic mitral valve regurgitation, and (d) absent flow across the foramen ovale as a result of premature closure of the foramen ovale.

Cross-sectional and contrast echocardiography in the diagnosis of interatrial communications through the coronary sinus

An interatrial communication through the mouth of the coronary sinus is a rare cardiac anomaly. It is usually associated with a left superior caval vein draining into the coronary sinus and is frequently part of a complex congenital malformation of the heart. Failure to recognize this defect before surgical repair of the primary cardiac lesion may lead to persistent interatrial shunting, which may in turn cause postoperative cyanosis. This report describes two cases of interatrial communication through the coronary sinus diagnosed prospectively by echocardiography. It demonstrates the important role of contrast echocardiography in the evaluation of patients suspected of having this malformation.

Maternal phenylketonuria-chronology of the detrimental effects on embryogenesis and fetal development: pathological report, survey, clinical application

Maternal phenylketonuria (PKU) is likely to have detrimental effects on embryogenesis and fetal development. Manifestations in the offspring include spontaneous abortion, various congenital malformations, intrauterine growth retardation, and microcephaly. The time at which the metabolic abnormalities induce pathologic embryogenesis can be documented by knowing the time of the development of specifically damaged organ systems. This review reveals that, while the most recognized congenital malformations occur in the heart, the most common abnormality is growth inhibition occurring throughout pregnancy. The organ system most commonly affected by this growth inhibition is the brain, resulting in a high incidence of micrencephaly. It appears that maternal phenylketonuria interferes with appropriate fetal growth and that this effect occurs during the entire course of pregnancy and has no tissue specificity. This information can be both informative to pathologists and useful to clinicians.

Left atrial to coronary sinus fenestration (partially unroofed coronary sinus). Morphological and angiocardiographic observations

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[Agenesis of the ductus arteriosus Botalli and premature closure of the foramen ovale, in combination with mitral valve atresia, hypoplastic left ventricle, transposition of the great arteries, and pulmonary valve atresia (author's transl)]

Agenesis of the Ductus arteriosus Botalli is a rare anomaly, which is known to occur in combination with truncus arteriosus, tetralogy of Fallot with pulmonary valve agenesis and also in simple tetralogy. The authors report on a case, where neither a ductus nor any remnant of it could be found in a complex heart malformation consisting of premature closure of the Foramen ovale, mitral atresia, hypoplastic left ventricle, transposition of the great arteries, pulmonary valve atresia and hypoplastic pulmonary artery. Speculations as to the pathogenesis of this anomaly presume slowing and eventual arrest of the ductal blood flow as a consequence of closure of the Foramen ovale in early fetal life. Thus total involution and disappearance of the distal part of the sixth aortic arch also on the left side seem conceivable.

Congenital obstructive lesions involving the major pulmonary veins, left atrium, or mitral valve: a clinical, laboratory, and morphologic survey

The clinical, laboratory, and morphologic features of congenitally obstructive lesions causing pulmonary venous hypertension are reviewed. These lesions are responsible for considerable infant mortality and morbidity, especially in the first weeks of life, are not infrequently encountered in older children, and are occasionally seen in adults. The presence of a malformation causing pulmonary venous hypertension often can be detected clinically, but precise anatomical and physiological diagnoses, usually necessary for optimal patient management, often can be made only by detailed laboratory study. Cardiac catheterization and angiocardiography remain the prime modes of accurate diagnosis in such patients, many of whom have other significant cardiovascular malformations, and echocardiography is an extremely useful adjunct, especially in patients with mitral valvular stenosis, hypoplasia, or atresia. The only definitive treatment in any of these patients is operative relief of the obstruction, and the chances of success depend not only on the skill of the surgeon, but also on the nature of the obstructing lesion, the types of associated malformations, and the precision with which these are defined preoperatively.