Pulsed Doppler echocardiographic assessment of the pulmonary venous pathway after the Mustard or Senning procedure for transposition of the great arteries

Arrhythmias in adult congenital heart disease

Recent advances in pediatric cardiology and cardiac surgery have allowed a rapidly expanding population of patients with congenital heart disease to thrive well into their adult years. Often after prolonged uneventful clinical courses as children and adolescents, arrhythmias may surface later in life. These arrhythmias are a major source of morbidity. In addition, sudden death is the leading cause of mortality in adult patients with congenital heart disease. This review highlights the various types of brady- and tachyarrhythmias encountered in the more common forms of adult congenital heart disease and explores prognostic implications and therapeutic options.

Long-term outcomes after the atrial switch for surgical correction of transposition: a meta-analysis comparing the Mustard and Senning procedures

Most adults with regular transposition (the combinations of concordant atrioventricular and discordant ventriculo-arterial connections) have undergone either the Mustard or Senning procedure in childhood. It is unclear whether adverse events differ according to the surgery performed. With this in mind, we conducted a systematic review and meta-analysis to compare long-term outcomes. We searched systematically entries to MEDLINE and EMBASE databases from January 1966 through August 2003, supplementing the search by secondary sources. Comparative studies were required to include at least 10 patients in each cohort of Mustard or Senning procedure, and to report overall survival. Data were extracted by two independent reviewers. We used a component approach to assess quality. On the basis of assessment of heterogeneity, we then used a random-effects model for pooled analyses. In all, we included seven studies, incorporating 885 patients. We found a trend towards lower mortality for the 369 patients undergoing a Mustard procedure when compared to 474 submitted to the Senning operation, with a hazard ratio of 0.63 and 95% confidence intervals between 0.35 and 1.14 (p = 0.13). This trend increased with the size of the sample (p = 0.004). Obstruction in the systemic venous pathway was more common in those having the Mustard procedure, with a risk ratio of 3.5 and 95% confidence intervals from 1.8 to 7.0 (p < 0.001), with a trend towards greater obstruction of the pulmonary venous pathway in those undergoing the Senning procedure, 7.6% vs. 3.8% (p = 0.27). A trend towards fewer residual shunts was observed for those with Mustard baffles, 7.0% vs. 14.1% (p = 0.10). Sinus nodal dysfunction, however, was more common after the Mustard procedure. Data regarding atrial tachydysrhythmias was inconclusive. Systemic cardiac failure and functional capacity, was similar. We conclude that outcomes are not uniform among patients submitted to the Mustard and Senning procedures. Knowledge of such differences may facilitate stratification of risk and follow-up.

Intermediate outcome after Mustard and Senning procedures: A study by the Congenital Heart Surgeons Society

Although atrial switch is rarely performed today except as part of a "double switch" operation, there continues to be interest in the long-term outcome of the procedure because of the many Mustard and Senning survivors who are in follow-up. In contrast to most other reported series on atrial switch, this study by the Congenital Heart Surgeons Society (CHSS) is a prospective multiinstitutional study of patients encountered in a relatively short time frame during the late 1980s. Between 1985 to 1989, 20 centers with surgeons belonging to the CHSS prospectively registered patients <15 days of age presenting with simple or complex transposition of the great arteries (TGA). The patients were assigned to protocol groups based on intent to treat (arterial switch, Mustard, or Senning). Data were abstracted in the Data and Analysis Center, which in most cases, conducted the annual follow-up. Among the 281 patients who had an atrial switch, there were 108 Mustard and 173 Senning procedures. For the combined atrial switch population, the survival at 1 month, 5 years and 10 years was 90%, 85%, and 84%, respectively. Results for the Mustard were better than for the Senning with survival at 1 month, 5 years, and 10 years being 96% versus 86%, 95% versus 80%, 93% versus 78%; (P <.001) for Mustard versus Senning. While the major mortality risk occurred in the first postoperative month for both groups, thereafter, the late rate of death from 1 to 10 years after operation was 0.78%/year Senning versus 0.23%/year Mustard (P <.05). TGA/ventricular septal defect (VSD), lower weight, younger age, cardiac positional anomalies, and procedures on the left ventricle (LV) outflow all correlated significantly with poor outcome. There were 19 reoperations including 2 for right ventricle (RV) failure, 12 for pathway obstruction, and 5 for baffle leak with a 36% overall mortality. Freedom from any pathway obstruction at 10 years was 95%. A permanent pacemaker was required in 21 patients with the significant risk factors including TGA/VSD and a Senning, and previous atrial septectomy. Freedom from a pacemaker insertion at 10 years was 91%. For both Mustard and Senning, 60% of patients were in New York Heart Association (NYHA) functional Class I with the remaining in Class II. This study of atrial switch outcomes by the CHSS suggests that the subgroup undergoing a Mustard procedure had better early and late survival than those undergoing a Senning operation. The overall incidence of baffle pathway obstruction was low though reoperation for this complication carried high risk. Serious arrhythmia requiring medication and the need for a permanent pacemaker were both relatively uncommon. The incidence of severe right heart failure was very low, although only 60% of patients are unrestricted in their activity. Copyright 2000 by W.B. Saunders Company

[Double-balloon angioplasty of pulmonary venous drainage obstruction after the Senning procedure in transposition of the great vessels]

A six and half-year old boy with Senning operation for transposition of the great arteries, showed recurrent atrial flutter and obstruction of the pulmonary venous atrium from the early postoperative period. By Doppler examination a peak gradient of 13 mmHg at the isthmus level was recorded in the pulmonary venous atrium. A successful double-balloon dilatation of stenotic area was performed via a retrograde, transaortic, approach through angioplasty. Six months after the procedure the enlargement of the stenosis persists, and the patient is clinically asymptomatic and arrhythmia-free without medication.

Pulmonary vein Doppler echocardiography after left atrial operation

BACKGROUND

Intraoperative transesophageal echocardiography provides the surgical team with important guidance during operations for congenital heart disease. Doppler echocardiography adds hemodynamic information to that provided by two-dimensional imaging. Here we describe intraoperative pulmonary vein Doppler echocardiography after operation involving the left atrium.

METHODS

Intraoperative two-dimensional and pulsed-wave Doppler echocardiography of pulmonary veins were performed after surgical repair of anomalous pulmonary venous return in 4 patients.

RESULTS

In 3 patients, intraoperative pulmonary vein Doppler findings were suggestive of obstruction. The surgical repair was thought to be excellent, and there was no obstruction apparent anatomically or clinically. No further intervention was performed, and all patients recovered uneventfully. No pulmonary venous obstruction was noted on follow-up two-dimensional echocardiography, and follow-up pulmonary vein Doppler echocardiography showed the expected pattern.

CONCLUSIONS

An obstructive pattern in the pulmonary vein Doppler was seen in 3 of 4 patients studied immediately after repair of anomalous pulmonary venous return. No obstruction, however, was manifest then or subsequently. The abnormal Doppler pattern, thus, is not indicative of pulmonary venous obstruction. We propose that acute postoperative changes in left atrial volume and compliance and acute postoperative tissue changes in the left atrium explain the abnormal pulmonary vein Doppler patterns observed.

Balloon dilatation of complete obstruction of the superior vena cava after Mustard operation for transposition of great arteries

Balloon dilatation was successfully performed in two patients with complete obstruction of the superior vena cava baffle junction after a Mustard operation for transposition of the great arteries. Evidence for complete relief of obstruction in the first patient, aged 4 years, was obtained by angiography, which showed improved calibre at the site of obstruction and improved haemodynamic pressure measurement after the balloon dilatation. In the second patient, aged 14 years, the relief was incomplete; in this patient a 3 cm long 3 mm diameter Palmaz stent was successfully implanted.

Medium-term clinical results after the Senning procedure with haemodynamic and angiographic evaluation of the venous pathways

OBJECTIVE

To assess the clinical condition of patients and the adequacy of their newly constructed venous pathways after the Senning operation for simple transposition of the great arteries.

PATIENTS AND DESIGN

All 34 patients who had the Senning operation between March 1983 and December 1986 were reviewed. Survivors had detailed cardiac catheterisation studies one to two years later and clinical evaluation two to six years after surgery.

RESULTS

There were two operative deaths (6%), one sudden late death (after two years), and 31 survivors (91%). No clinical evidence of obstructed venous pathways was found and there was no need for reoperation for any reason. The average mean (SD) pressure gradient at the junction of the superior vena cava and systemic venous atrium was 2.0 (1.7) mm Hg, although two patients had gradients of 7 mm Hg. The average gradient was 0.7 (1) mm Hg in the inferior vena caval pathway, and 1.4 (1.1) mm Hg between the mean pulmonary arterial wedge and pulmonary venous atrial pressures. Only the two patients with gradients of 7 mm Hg at the junction of the superior vena cava and the systemic venous atrium had considerable narrowing of the pathway and retrograde flow in the azygos vein to below the diaphragm.

CONCLUSION

A small series of patients were comprehensively studied after the Senning operation for simple transposition of the great arteries. Scrupulous technique in the construction of the venous pathways has had excellent results with no need for reoperation for obstruction in either the systemic or pulmonary pathways. Clinical observation alone may fail to identify patients with venous pathway obstruction, therefore careful assessment is required, even in patients who are physically normal.

Imaging of pulmonary venous pathway obstruction in patients after the modified Fontan procedure

To evaluate the efficacy of chest roentgenograms and echocardiograms in identifying pulmonary venous pathway obstruction in patients after the modified Fontan procedure, the records of 297 patients who underwent 307 Fontan procedures between 1984 and 1990 were reviewed. Twelve cases of pulmonary venous pathway obstruction documented by autopsy (3 cases) or cardiac catheterization (9 cases with an A wave gradient greater than or equal to 4 mm Hg) were found in 10 patients (mean age 43 +/- 28 months). The mechanisms of obstruction included narrow pulmonary vein ostia in six cases, narrow left atrial outlet in four and atrial baffle obstruction in three. Two causes of obstruction were present in one case. No patient had pulmonary venous congestion on chest roentgenograms. Pathway diameters indexed to 3 square root of body surface area with two-dimensional echocardiography were found to be 6.8 +/- 1.2 mm/3 square root of m2 in the subcostal frontal view, 7.9 +/- 0.6 mm/3 square root of m2 in the subcostal sagittal view and 6.5 +/- 1.7 mm/3 square root of m2 in the apical "four-chamber" view. These values differed significantly from those in 11 age-matched patients undergoing the Fontan procedure without pulmonary venous pathway obstruction documented by catheterization (p = 0.001). With pulsed Doppler ultrasound, there was a relatively narrow range of velocities distal to the obstruction (1.3 to 2.5 m/s). In five of the seven cases with pulsed Doppler measurements, flow was continuous and the Doppler spectral recordings were not phasic. Thus, in patients who have undergone the Fontan procedure and have pulmonary venous pathway obstruction 1) chest roentgenography cannot be used as a screening tool; 2) distal velocities as low as 1.3 m/s occur, usually with nonphasic, continuous forward flow; and 3) pathway diameters indexed to 3 square root of body surface area may be used as an output-independent parameter to cross-check Doppler data.

Systemic venous flow during cardiac surgery examined by intraoperative transesophageal echocardiography

Patterns of systemic venous return change after cardiac surgery. However, the exact timing and underlying mechanisms are not well understood. To analyze these changes transesophageal echocardiography was used to evaluate 21 patients (mean age 56 +/- 17 years) during cardiac surgery. Eleven patients underwent coronary bypass grafting, 2 had ablation of accessory bundles, 4 had mitral and 4 had aortic valve replacements. All were in sinus rhythm and were undergoing their first cardiac operation. Hepatic and pulmonary venous flow, tricuspid annular motion, and signs of tricuspid regurgitation were recorded sequentially 5 times: (A) with chest closed, (B) with chest open and pericardium closed, (C) with both chest and pericardium open, (D) after cardiopulmonary bypass with chest open, and (E) after cardiopulmonary bypass with chest closed. The hepatic venous Doppler flow velocity integrals (cm) changed, from stage A to stage E: systolic flow decreased from 5.9 +/- 5.2 to 2.2 +/- 1.4 (p less than 0.01); diastolic flow increased from 3.1 +/- 1.5 to 4.8 +/- 3.3 (p less than 0.001); and systolic to diastolic ratio decreased from 2.0 +/- 1.2 to 0.7 +/- 0.6 (p less than 0.001). Reversed flow at the end of ventricular systole was present in 9 patients (43%) at stage A and in all patients at stage E. Decreased tricuspid annular motion was noted in all but 1 patient after cardiopulmonary bypass. No patient presented significant tricuspid regurgitation at any stage. In conclusion, the significant change in the pattern of systemic venous return after open heart surgery is not due to opening of the chest wall or parietal pericardium, or to tricuspid regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon dilation of pulmonary venous pathway obstruction in an infant after the mustard procedure

Pulmonary venous pathway obstruction developed after a Mustard procedure in an infant with transposition of the great arteries. The stenosis was successfully dilated by the percutaneous balloon technique with immediate clinical, echocardiographic, and hemodynamic improvement, which has persisted for 8 months after dilation. This technique is a feasible alternative to reoperation in such an obstruction, even in infants.

Doppler assessment of pulmonary venous flow in healthy subjects and in patients with heart disease

Pulmonary venous flow as assessed by Doppler echocardiography is a current topic of investigation. Pulmonary venous flow has been used recently as part of a comprehensive assessment of left ventricular diastolic filling dynamics in restrictive myocardial diseases and constrictive pericarditis. Abnormalities of flow have been described in dilated cardiomyopathy, congenital heart disease, and arrhythmias. With the advent of transesophageal echocardiography, pulmonary venous flow can be readily obtained in all patients by pulsed-wave Doppler echocardiography. Recently, it has been used to assess the severity of mitral regurgitation and to estimate mean left atrial pressure. This article emphasizes the utility, physiology, and technique of measuring pulmonary venous flow with Doppler echocardiography in health and in disease.

Pulmonary venous flow velocity pattern as assessed with transthoracic pulsed Doppler echocardiography in subjects without cardiac disease

Pulmonary venous flow velocity pattern (PVFVP) was analyzed in 53 subjects (aged 25 to 77 years, mean 47) without cardiovascular disease who underwent transthoracic pulsed Doppler echocardiography. The forward flow velocity pattern was biphasic in 37 of the 53 subjects, with each of the 2 peaks in systole and diastole; flow was triphasic with 2 peaks in systole and the other peak in diastole in the remaining 16 subjects. Peak systolic and diastolic flow velocity ranged from 28 to 84 cm/s and from 27 to 71 cm/s, respectively. Mean systolic flow velocity was significantly greater than mean diastolic flow velocity (53 +/- 12 vs 47 +/- 11 cm/s, p less than 0.01). Systolic flow velocity and the ratio of systolic to diastolic flow velocity increased and diastolic flow velocity decreased with aging (r = 0.52, p less than 0.001, r = 0.70, p less than 0.001 and r = -0.49, p less than 0.001, respectively). Reverse flow occurred during the atrial contraction phase and its velocity (mean 20 cm/s) increased with aging (r = 0.56, p less than 0.001). The parameters of PVFVP were compared with the ratio of peak early diastolic filling velocity to peak filling velocity at atrial contraction (E/A ratio) measured in the transmitral flow velocity pattern. As E/A ratio increased, systolic flow velocity and systolic/diastolic flow ratio and peak reverse flow velocity decreased (r = -0.40, p less than 0.01, r = -0.67, p less than 0.001 and r = -0.68, p less than 0.001, respectively) and diastolic flow velocity increased (r = 0.58, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative values of the precordial and transesophageal approaches in the echocardiographic evaluation of atrial baffle function after an atrial correction procedure

Previous methods used to assess atrial baffle function after correction of transposition of the great arteries have included precordial echocardiography and cardiac catheterization. To evaluate whether single plane transesophageal echocardiography might provide additional information, its findings were correlated with information derived from both precordial echocardiography and cardiac catheterization in 15 patients (14 Mustard procedures, 1 Senning procedure) aged 4.2 to 33 years (mean 16.3). Precordial ultrasound with combined imaging, color flow mapping and pulsed Doppler ultrasound visualized the supramitral portion of the common systemic venous atrium in every case but could identify only superior limb obstruction in three of six patients, mid-baffle obstruction in zero of two and inferior limb obstruction in zero of two patients. Transesophageal studies with use of the same range of ultrasound methods demonstrated superior limb obstruction (severe in four, mild in two) in six of six patients, mid-baffle obstruction in two of two and inferior limb obstruction in two of two patients. The entire pulmonary venous atrium was equally well interrogated by either ultrasound approach, with both identifying three cases (two mild, one moderate) of mid-pulmonary venous atrium obstruction. However, individual pulmonary vein velocity profiles could only be recorded by transesophageal pulsed Doppler ultrasound. Precordial studies identified baffle leaks (1 large, 2 small) in only three patients, whereas transesophageal studies identified 11 such baffle leaks (1 large, 10 small), which were multiple in two patients. It is concluded that transesophageal echocardiography provides a more detailed and accurate assessment of atrial baffle morphology and function than is provided by either precordial ultrasound or cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

The potential value of transoesophageal evaluation of individual pulmonary venous flow after an atrial baffle procedure

Following a Mustard's procedure, transoesophageal echocardiography allowed the visualization of all 4 pulmonary veins in 7/12 patients (mean age 14.8 years) and of three veins in a further 2 patients. Both upper pulmonary veins could be visualized consistently. No patient had an isolated pulmonary venous stenosis. In 9 patients in sinus rhythm, computer analysis of Doppler tracings from the left upper pulmonary vein showed significantly lower systolic peak velocities (mean 0.39 +/- 0.10 m/s) and time velocity integrals (mean 6.9 +/- 1.66 cm) than in normal subjects (mean 0.6 +/- 0.09 m/s and 14.4 +/- 2.97 cm respectively; P less than 0.001). We postulate that this is due to compromised atrial relaxation and compliance. In contrast, patients in junctional rhythm (mean 10.7 vs. 7.7 cm in normal subjects). Flow reversal during early ventricular systole (due to tricuspid regurgitation or atrial contraction after retrograde conduction during junctional rhythm) was detected in 6/12 patients. These results confirm that the transoesophageal approach should allow the identification of isolated pulmonary venous obstruction after a Mustard procedure. In addition. detailed analysis of tracings of flow in the pulmonary veins can document the presence of compromised atrial relaxation and help to evaluate the severity of tricuspid regurgitation. It may provide a new index with which to assess impaired systemic ventricular function.

Do asymptomatic school children have normal haemodynamics 6-13 years after Mustard's operation?

Twenty asymptomatic school children who had undergone Mustard's operation for simple complete transposition (concordant atrioventricular and discordant ventriculo-arterial connexions) were catheterised electively 6-13 years later. The studies were carried out under general anaesthesia in air and in 100% O2. Oxygen consumption was measured and end-tidal gases were monitored using respiratory mass spectrometry. There was significant left ventricular outflow tract obstruction in 2 patients. Cardiac output in air was normal in 15 and decreased in 5 patients. The pulmonary vascular resistance was normal in 18 of 19 cases, but grossly elevated in one patient. Baffle dysfunction was present in 11 patients: 10 with important gradients between the venous pathways and the systemic venous atrium, and 5 with a leak identified either by a left-to-right shunt or by the course of the catheter. Balloon dilatation was attempted in the inferior caval venous channel in 6 and in the superior caval venous channel in 2. Mean gradient before the dilatation fell after the procedure. No pulmonary venous obstruction was identified. Even in this group of children selected as asymptomatic, approximately half had a detectable haemodynamic abnormality.

Balloon dilation of pulmonary venous pathway obstruction after Mustard repair for transposition of the great arteries

Percutaneous balloon dilation was attempted in three patients with mid baffle pulmonary venous pathway obstruction after the Mustard operation for transposition of the great arteries. The procedure was unsuccessful in a 3 year old boy. Evidence for relief of obstruction in the other two patients (7 and 14 years old, respectively) consisted of angiographic demonstration of improved caliber at the site of the pulmonary venous pathway narrowing, improvement in the Doppler spectral signal at this site from an "obstructed" to a "normal" pattern as well as symptomatic improvement. Balloon dilation was performed twice in one of these patients. The Doppler and symptomatic improvement were sustained in both patients at short-term follow-up (5 and 6 months, respectively). This technique may offer effective relief of pulmonary venous pathway obstruction in some patients with this complication of the Mustard operation.

Pulmonary venous and systemic ventricular inflow obstruction in patients with congenital heart disease: detection by combined two-dimensional and Doppler echocardiography

Obstruction to pulmonary venous return may be associated with a number of congenital cardiovascular abnormalities occurring both before and after surgery. Hemodynamic assessment by cardiac catheterization is often difficult. A noninvasive method for detection and quantitation of obstruction to systemic ventricular inflow would be clinically useful. Two-dimensionally directed pulsed and continuous wave Doppler echocardiography was performed before cardiac catheterization in 31 patients thought clinically to have possible obstruction to left ventricular inflow or pulmonary venous return. Primary diagnoses included transposition of the great arteries after the Mustard or Senning procedure in nine patients, total anomalous pulmonary venous connection in nine (in two after surgical repair), cor triatriatum in eight (in four after surgical repair), congenital mitral stenosis in four (in one after surgical repair) and mitral atresia in one. Severe obstruction was defined as a mean pressure gradient at catheterization of greater than or equal to 16 mm Hg at any level of the pulmonary venous return or of the systemic ventricular inflow. Severe obstruction was predicted if Doppler examination measured a flow velocity of greater than or equal to 2 m/s across any area of inflow obstruction. At catheterization, 12 patients (39%) had severe obstruction to left ventricular inflow or pulmonary venous return and all obstructions were correctly detected by Doppler echocardiography. The site of pulmonary venous obstruction was localized by two-dimensionally directed pulsed Doppler study. Patients with a lesser degree of obstruction had a lower Doppler velocity, but none had a maximal Doppler velocity of greater than or equal to 2 ms/s.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulsed Doppler echocardiographic assessment of extraparenchymal pulmonary vein flow

Extraparenchymal pulmonary vein flow profiles were assessed by pulsed Doppler echocardiography in three groups of patients. Group I comprised 41 normal patients. Group II comprised 16 patients, 10 of whom had nonpulsatile pulmonary artery flow (5 with a right atrium to pulmonary artery Fontan procedure and 5 with a Glenn shunt). Six patients with pulsatile pulmonary artery flow had simultaneous Doppler and left atrial pressure measurements during cardiac catheterization. Group III comprised one patient with pulmonary vein obstruction, six with a large left to right shunt at ventricular level and two with pulmonary vascular disease. In Group I, biphasic forward pulmonary vein flow occurring during ventricular systole and diastole was observed in 26 subjects, 15 others had triphasic flow. In those with triphasic flow, the ventricular systolic component was divided into early and late. Reversed flow in the pulmonary veins during atrial systole was seen in 36 of the 41 subjects. The flow pattern in Group II was identical irrespective of the presence of pulsatile or nonpulsatile flow. The two periods of ventricular systolic flow occurred during the a to c and c to x descent, with the ventricular diastolic flow occurring during the y descent. Variations in waveform were mirrored in the left atrial pressure. Neither increased nor decreased pulmonary artery flow substantially altered the pattern. Pulmonary vein obstruction produced a distinctive pattern of high velocity turbulent flow. This technique demonstrates that extraparenchymal pulmonary vein flow is dependent on left atrial pressure events. It has major potential applications in patients who are prone to develop pulmonary vein obstruction.

Pulsed Doppler echocardiography in the preoperative evaluation of total anomalous pulmonary venous connection

Pulmonary venous flow was evaluated by pulsed Doppler echocardiography in 38 patients with total anomalous pulmonary venous connection. Twenty-nine of these 38 had no associated intracardiac anomaly (Group I), and 9 had complex intracardiac anatomy associated with low pulmonary blood flow (Group II). In Group I the drainage was infracardiac in nine, supracardiac in seven, intracardiac in eight and mixed in five. In both groups, in those with venous obstruction the flow in the individual pulmonary veins and ascending or descending vein was nonphasic, varying only with respiration. Flow in the absence of obstruction was phasic, varying with the cardiac cycle. Distal to a site of obstruction the flow was nonlaminar and of high velocity irrespective of the amount of pulmonary blood flow. The pulsed Doppler technique provides important physiologic information in the patient with total anomalous pulmonary venous connection before surgical intervention.

Use of Doppler techniques (continuous-wave, pulsed-wave, and color flow imaging) in the noninvasive hemodynamic assessment of congenital heart disease

Doppler echocardiography is a relatively new technique that has become an integral part of the cardiovascular ultrasound examination. The hemodynamic information provided by the Doppler technique is complementary to the tomographic anatomy depicted by the two-dimensional examination and, in some patients, may obviate the need for cardiac catheterization. In this article, we focus on the role of Doppler echocardiography in the noninvasive diagnosis of congenital cardiac abnormalities.