Low pressure giant pulmonary artery aneurysms in the adult: natural history and management strategies

OBJECTIVE

To describe aspects of the natural history and pathophysiology of giant low pressure pulmonary artery aneurysms and to propose potential surgical strategies.

DESIGN

Cross sectional retrospective review.

SETTING

Supraregional tertiary referral centre.

PATIENTS

All adult patients referred for assessment of giant pulmonary artery aneurysm retrospectively identified from the Mayo Adult Congenital Heart Disease Clinic database.

METHODS

Patient data were reviewed from hospital records, including echocardiograms, magnetic resonance images, radiographs, and histology slides.

RESULTS

Four patients were identified with a median age of 52 years (range 37-64 years). Presenting symptoms were effort related dyspnoea, chest discomfort, and hoarseness in one patient. All patients had pulmonary regurgitation and clinical evidence of right ventricular enlargement in association with a pulsatile mass at the upper left sternal edge. Transthoracic echocardiography showed the giant pulmonary artery aneurysm involving the main pulmonary artery and proximal branches, and confirmed severe pulmonary regurgitation in all patients. None of the patients had intimal tearing, medial dissection, or pulmonary arterial rupture. The pulmonary valve was replaced to relieve symptoms and preserve right ventricular function. Pulmonary arterial histology showed medial degeneration of elastic fibres with accumulation of basophilic ground substance.

CONCLUSIONS

Rupture or dissection of these low pressure aneurysms is rare. The timing of surgical intervention should be determined by changes in right ventricular size and function resulting from pulmonary regurgitation or pulmonary stenosis, and not the size of the aneurysm.

Coarctation of the aorta: outcome of pregnancy

OBJECTIVES

The study sought to determine the outcome of pregnancy in women with coarctation of the thoracic aorta.

BACKGROUND

Patients with coarctation of the thoracic aorta are expected to reach childbearing age, but data on the outcome of pregnancy in this population are limited.

METHODS

The Mayo Clinic database was reviewed for women of childbearing age (> or =16 years old) with a diagnosis of aortic coarctation evaluated from 1980 to 2000. Spectrum of cardiovascular disease, surgical history, and obstetrical and neonatal outcomes were determined.

RESULTS

Fifty women with coarctation had pregnancies: 30 had coarctation repair before pregnancy, 10 had repair after pregnancy, 4 had repair both before and after pregnancy, and 6 had no history of repair. The 50 women had 118 pregnancies resulting in 106 births. There were 11 miscarriages (9%), 4 premature deliveries (3%), and 1 early neonatal death; 38 deliveries (36%) were by cesarean section. Of the 109 offspring, 4 (4%) had congenital heart disease. A patient with Turner syndrome died of a Stanford type A dissection at 36 weeks of pregnancy. Nineteen women (38%) were known to have hemodynamically significant coarctation during pregnancy (gradient > or =20 mm Hg). Fifteen women (30%) had hypertension during their pregnancy, 11 of whom (73%) had hemodynamically significant coarctation during that time (8 with native and 3 with residual/recurrent coarctation).

CONCLUSIONS

Major cardiovascular complications were infrequent but continue to be a source of concern for patients with coarctation who become pregnant. Systemic hypertension during pregnancy was common and related to the presence of a significant coarctation gradient.

Ventricular septal defects in adults

Because congenital ventricular septal defects are of different sizes and locations, their clinical presentation, natural history, and treatment vary greatly. This review discusses the different types of ventricular septal defects commonly seen in adults in the authors' experience and in published literature. Ventricular septal defects are either isolated small defects or larger defects associated with pulmonary stenosis, pulmonary hypertension, or aortic regurgitation. These associations play an important role in the pathophysiologic consequences of the defect, its long-term complications, and treatment options. Knowledge of the different clinical presentations in adulthood and the specific features pertinent to these defects will help in the assessment and the care of adult patients with one of the most common congenital cardiac malformations.

Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta

BACKGROUND

Coarctation of the aorta is commonly associated with recoarctation or additional cardiovascular disorders that require intervention. The best surgical approach in such patients is uncertain. Ascending-to-descending aortic bypass graft via the posterior pericardium (CoA bypass) allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.

METHODS AND RESULTS

Between 1985 and 2000, 18 patients (13 males and 5 females, mean age 43+/-13 years) with coarctation of the aorta underwent CoA bypass through median sternotomy. Before operation, average New York Heart Association class was II (range I to IV), and 15 patients (83%) had systemic hypertension. One or more previous cardiovascular operations had been performed in 12 patients (67%); 10 patients had >/=1 prior coarctation repair. Two patients had prior noncoarctation cardiovascular surgery. Concomitant procedures performed in 14 patients (78%) included the following: aortic valve replacement in 9; coronary artery bypass surgery in 3; mitral valve repair in 2; and septal myectomy, mitral valve replacement, aortoplasty, subaortic stenosis resection, ventricular septal defect closure, and ascending aorta replacement in 1 patient each. All patients survived the operation and were alive with patent CoA bypass at a mean follow-up of 45 months. No graft-related complications occurred, and there were no instances of stroke or paraplegia. Systolic blood pressure fell from 159 mm Hg before surgery to 125 mm Hg after surgery.

CONCLUSIONS

CoA bypass via median sternotomy can be performed with low morbidity and mortality. Although management must be individualized, extra-anatomic CoA bypass via the posterior pericardium is an excellent single-stage approach for patients with complex coarctation or recoarctation and concomitant cardiovascular disorders.

Late pulmonary valve replacement after repair of tetralogy of Fallot

BACKGROUND

Pulmonary regurgitation appears to be well tolerated early after repair of tetralogy of Fallot; however, it may result in progressive right ventricular dilatation and dysfunction necessitating eventual valve replacement. Our objective was to review our experience with late pulmonary valve replacement after complete repair of tetralogy of Fallot.

METHODS AND RESULTS

A total of 42 patients (16 female and 26 male) were operated on between July 1, 1974, and January 1, 1998. Mean age was 22 years (range 2-65 years). The mean interval between tetralogy repair and pulmonary valve replacement was 10.8 years (range 1.6 months-33 years). Mean follow-up was 7.8 +/- 6.0 years (maximum 23 years). Indications for pulmonary valve replacement included decreased exercise tolerance in 58%, right heart failure in 21%, arrhythmia in 14%, syncope in 10%, and progressive isolated right ventricular dilatation in 7%. Heterograft prostheses were used in 33 patients and homografts in 9. Five patients underwent isolated pulmonary valve replacement; concomitant procedures performed in 37 patients included tricuspid valve repair/replacement (n = 18), residual ventricular septal defect repair (n = 12), atrial septal defect closure (n = 4), pulmonary artery patch angioplasty (n = 17), and right ventricular outflow tract enlargement (n = 13). One patient died early (2%) of multiorgan failure. There were 6 late deaths, 3 of which were cardiac related. Survival was 95.1% +/- 3.4% and 76.4% +/- 8.9% at 5 and 10 years, respectively. Functional class of patients was improved significantly; preoperatively, 76% of patients were in New York Heart Association class III-IV, and after pulmonary valve replacement, 97% of surviving patients were in class I-II (P =.0001). Moderate to severe reduction in right ventricular function was noted on preoperative echocardiography in 59% and on late echocardiography in 18% (P =.03). Of the 5 patients who had supraventricular arrhythmias before pulmonary valve replacement, 1 had postoperative recurrence and the arrhythmia is controlled with antiarrhythmic therapy; the other 4 are in normal sinus rhythm at late follow-up. Eight patients subsequently underwent pulmonary valve re-replacement without early mortality at a mean interval of 9.0 +/- 4.2 years (range 3.8-16.8 years). Freedom from pulmonary valve re-replacement was 93.1% +/- 4.7% and 69.8% +/- 10.7% at 5 and 10 years, respectively. The only significant risk factor for re-replacement was young age at the time of the initial pulmonary valve replacement (P =.023).

CONCLUSION

Late pulmonary valve replacement after tetralogy repair significantly improves right ventricular function, functional class, and atrial arrhythmias, and it can be performed with low mortality. Subsequent re-replacement may be necessary to maintain functional improvement.

Accessory mitral valve leaflet

The presence of accessory mitral valve tissue in the left ventricular outflow tract (LVOT) is a rare cause of obstruction. Previous cases reported in the literature are associated either with other complex congenital abnormalities, or with other forms of LVOT obstruction. This report presents the first case of a duplication of the anterior leaflet of the mitral valve occurring as an isolated congenital anomaly. It produced mild subaortic obstruction. The report emphasizes the importance of transthoracic two-dimensional echocardiography and Doppler assessment in the recognition of congenital abnormalities of the mitral valve and subvalvular apparatus as a differential diagnosis of subaortic stenosis.

Idiopathic annular dilation: a rare cause of isolated severe tricuspid regurgitation

The management of patients with severe tricuspid regurgitation (TR) requires the clinician to clarify the mechanism of regurgitation. Primary disorders of the tricuspid valve, either congenital or acquired, may be readily identified by echocardiography. Severe TR most often results from left-sided heart disease and secondary pulmonary hypertension. Cardiomyopathic processes may also cause right ventricular failure and functional TR. We report three patients with severe TR due to idiopathic annular dilation. The tricuspid valves were otherwise normal on surgical inspection, and the pulmonary pressures were not significantly elevated. Each patient was aged over 65 years and had chronic atrial fibrillation with preserved left ventricular systolic function. Surgical treatment was associated with marked clinical improvement. Clinicians should recognize this unusual but treatable cause of right-sided congestive heart failure.

Permanent pacing in patients with univentricular heart

Patients with one of several varieties of malformation designated as "univentricular hearts" may be especially challenging when permanent pacing is required. Our objective was to review our experience in this subset of patients that had undergone permanent pacing and thus determine the optimal approach. A retrospective chart review was done of 32 patients with some variety of "univentricular" malformation who had required permanent pacing at our institution. Although technically challenging, permanent pacing in this group of patients can be successful through several approaches. The various approaches, as well as consideration of the differences that exist between patients undergoing septation and those undergoing a Fontan procedure are discussed. Although long-term permanent pacing is possible in this group of patients, before pacing begins, a thorough understanding of the anatomy and prior surgical procedures is necessary. Use of a combined atrial transvenous and ventricular epicardial pacing system may work well for some patients. With the development of newer and more reliable coronary sinus leads, dual chamber transvenous pacing with ventricular stimulation via the coronary sinus could become the approach of choice in some patients with "univentricular hearts."

Pregnancy among women with congenitally corrected transposition of great arteries

OBJECTIVES

The outcome of pregnancy in congenitally corrected transposition of the great vessels was studied in 22 women.

BACKGROUND

Women with congenitally corrected transposition of the great vessels often reach childbearing age. Although reports on the outcome of pregnancy in these women are available, the number of patients is small.

METHODS

The medical and surgical databases at the Mayo Clinic were reviewed, and 36 women >16 years old with congenitally corrected transposition of the great vessels were identified. All of them were contacted, and 22 who had pregnancies were identified and the outcome of pregnancy was evaluated.

RESULTS

Twenty-two women had 60 pregnancies resulting in 50 live births (83%). Forty-four deliveries (88%) were vaginal and 6 (12%) were by cesarean section. One delivery was premature at 29 weeks. There was one successful twin pregnancy. There were 11 unsuccessful pregnancies. One patient developed congestive heart failure late in pregnancy because of systemic atrioventricular valve regurgitation and required valve replacement in the early postpartum period. One patient had a total of 12 pregnancies, including 1 twin pregnancy and 2 unsuccessful pregnancies. She had multiple pregnancy-related complications, including toxemia, congestive heart failure, endocarditis and myocardial infarction (single coronary artery). No other serious pregnancy-related maternal complications and no pregnancy-related deaths occurred. The mean birth weight of the infants (n = 32) was 3.2 +/- 0.4 kg. None of the 50 live offspring have been diagnosed with congenital heart disease.

CONCLUSIONS

Successful pregnancy can be achieved in most women with congenitally corrected transposition of the great arteries. The rate of fetal loss and maternal cardiovascular morbidity is increased. Because of the small number of births, the risk of congenital heart disease in offspring of women with congenitally corrected transposition of the great arteries is uncertain.

Piercing and tattooing in patients with congenital heart disease: patient and physician perspectives

PURPOSE

The frequency and safety of ear piercing and tattooing were assessed in a group of children, adolescents, and adults with congenital heart disease (CHD). Also, a group of physicians who care for adolescents and adults with CHD were surveyed for opinions and experiences regarding piercing and tattooing.

METHODS

An eight-question survey was mailed to 445 patients (181 adults and 264 children) from one center. A different five-question survey was mailed to 176 physician members of the International Society of Adult Congenital Cardiac Disease.

RESULTS

The patient survey was completed by 152 of 445 (34%) patients (mean age +/- standard deviation 19.8 +/- 16.2 years; range 0.25-67 years). Eighty-eight of 152 (58%) patients were female. Ear piercing occurred in 65 of 152 (43%) patients (mean age 12.4 +/- 8.7 years; range 0.25-45 years). Prior to piercing, only 4 of 65 (6%) patients took antibiotics, but 15 of 65 (23%) had piercing-related infections. No patient had endocarditis. Infections occurred 1 week to 3 years after piercing. All were local skin infections. Tattoos were placed in 8 of 152 (5%) patients (median age 17.5 years; range 13-56 years). No antibiotic use or infections were reported in patients with tattoos. The physician survey was completed by 118 of 176 (67%) physicians. The majority of physicians did not approve of patients having piercing or tattooing performed. However, 60% of physicians believed that antibiotic prophylaxis is indicated for these procedures.

CONCLUSIONS

Despite the opinion of many physicians, most patients do not take antibiotic prophylaxis for piercing and tattooing. Patients apparently do not suffer serious sequelae. The efficacy of standard antibiotic regimes as applied to ear piercing and tattooing requires further study, since these procedures are increasingly popular in modern society.

Noncardiac surgery in Eisenmenger syndrome

OBJECTIVES

The purpose of this study was to evaluate the morbidity and mortality associated with noncardiac surgery (NCS) in patients (pts) with Eisenmenger syndrome.

BACKGROUND

Noncardiac surgery in pts with Eisenmenger syndrome is associated with increased cardiovascular complications.

METHODS

Fifty-eight pts with Eisenmenger syndrome (17M, 41F aged 18 to 69 years (mean 41 years) who had been followed for up to 41.5 years (mean 9.3 years) were retrospectively evaluated for any NCS done at > or = 17 years of age.

RESULTS

Twenty-four pts had a total of 28 NCSs at an age of 17 to 55 years (mean 29 years) including 9 tubal ligations, 3 neurosurgeries, 3 cholecystectomies, 3 hysterectomies, 3 vasectomies, and 1 each spinal fusion, appendectomy, eye enucleation, hernia repair, hand surgery, tonsillectomy and therapeutic abortion. There were two deaths (7%), one following spinal fusion and the other following appendectomy at another institution. Fourteen of these NCSs were performed at our institution, including 11 under general anesthesia. The duration of anesthesia varied from 75 to 525 min (mean 165 min). All pts remained in sinus rhythm. The lowest systolic blood pressure (BP) ranged from 78 to 125 mm Hg. Of those 11 pts, 9 were extubated immediately after surgery and 2 needed dopamine. Ten patients were discharged without any complications, including 3 within 1 day of surgery. One death occurred 10 days following spinal fusion. This pt had the longest anesthesia (525 min) and an intraoperative systolic BP as low as 78 mm Hg. She also needed the largest fluid administration (6,475 cc) in addition to postoperative mechanical ventilation and dopamine.

CONCLUSIONS

Adult pts with Eisenmenger syndrome are at increased risk with NCS, but with current/modern techniques, the risk of death is less than previously thought. In the vast majority of cases, NCS can be undertaken without substantial morbidity, and early extubation is achievable. However, even with relatively minor surgery, significant complications, including death, can occur. Referral to major centers with expertise in the care of pts with Eisenmenger syndrome is advisable.

Late results of bioprosthetic tricuspid valve replacement in Ebstein's anomaly

BACKGROUND

Historically, porcine bioprosthetic valves have poor durability in pediatric patients; nearly half will require replacement within 5 years. However, our early experience with patients having Ebstein's anomaly suggests that tricuspid bioprostheses in this anomaly might have better durability.

METHODS

One hundred fifty-eight patients who received a primary tricuspid bioprosthesis because of tricuspid valve anatomy unsuitable for repair between April 1972 and January 1997 were reviewed. Results were analyzed and Kaplan-Meier curves were constructed to estimate patient survival and probability of remaining free of reoperation.

RESULTS

Follow-up of 149 patients (94.3%) who survived 30 days ranged up to 17.8 years (mean, 4.5 years). Ten-year survival was 92.5%+/-2.5% (SE), 129 late survivors (92.1%) were in New York Heart Association class I or II, and 93.6% were free of anticoagulation. Freedom from bioprosthesis replacement was 97.5%+/-1.9% at 5 years and 80.6%+/-7.6% at 10 and 15 years.

CONCLUSIONS

Bioprosthesis durability in the tricuspid position in patients with Ebstein's anomaly compares very favorably with bioprosthesis durability in other cardiac valve positions, especially for pediatric patients, and also compares favorably with tricuspid bioprosthesis durability in patients with other diagnoses.

Right-sided maze procedure for right atrial arrhythmias in congenital heart disease

BACKGROUND

Atrial fibrillation and flutter, commonly associated with congenital heart anomalies that cause right atrial dilatation, may cause significant morbidity and reduction of quality of life, even after surgical repair of the anomalies.

METHODS

In an effort to reduce the incidence of atrial tachyarrhythmias after repair of right-sided congenital heart disease, we performed a concomitant right-sided maze procedure.

RESULTS

Eighteen patients with paroxysmal atrial fibrillation or flutter (n = 12) or chronic atrial fibrillation or flutter (n = 6) aged 10.9 to 68.4 years (mean 34.9 years) underwent a right-sided maze in association with repair of Ebstein's anomaly (n = 15), congenital tricuspid insufficiency (n = 2), and isolated atrial septal defect (n = 1). There were no early deaths, reoperations, or complete heart block. Discharge rhythm was sinus (n = 16) or junctional (n = 2). Follow-up was complete in all 18 patients and ranged from 3.1 to 17.2 months (mean 8.1 months); all are in New York Heart Association class I. Early postoperative arrhythmias developed in 3 patients (all were converted to sinus rhythm by antiarrhythmic drugs). There were no late deaths or reoperations.

CONCLUSIONS

The inclusion of a right-sided maze procedure with cardiac repair in patients having congenital heart anomalies that cause right atrial dilatation and associated atrial tachyarrhythmias is effective in eliminating or reducing the incidence of those arrhythmias.

Coarctation of the aorta: collateral flow assessment with phase-contrast MR angiography

OBJECTIVE

The purpose of this report is to describe a new use of MR imaging in coarctation of the aorta. The specific question addressed was how well collateral blood flow in intercostal arteries, as determined by phase-contrast MR angiography, correlated with findings during surgery or catheterization in patients with coarctation of the aorta.

CONCLUSION

Phase-contrast MR angiography is an excellent technique for detecting the presence or absence of collateral blood flow in the intercostal arteries of patients with coarctation of the aorta. Knowing whether collateral blood flow is present in patients with narrowing of the juxtaductal aorta should help assess the clinical hemodynamic significance of the coarctation.

Mimics of Ebstein's anomaly

The purpose of this study was to determine the most discriminating clinical and echocardiographic features that are most helpful in correctly identifying Ebstein's anomaly of the tricuspid valve from other causes of tricuspid regurgitation. Ebstein's anomaly is an uncommon malformation of the tricuspid valve with diagnostic echocardiographic features. Other cardiac disorders associated with tricuspid valve regurgitation and predominate right-sided heart chamber enlargement can be misdiagnosed as Ebstein's anomaly. All patients who were referred to our institution between 1982 and 1995 with the diagnosis of Ebstein's anomaly but were found to have other abnormalities of the tricuspid value or right ventricle were identified. Their clinical, echocardiographic, and surgical records were reviewed retrospectively. Twenty-two patients (12 males and 10 females), aged 7 to 68 years (mean 33 years), were referred to our institution with the diagnosis of Ebstein's anomaly but were found to have another abnormality that mimicked clinical and diagnostic features of Ebstein's anomaly. The most common initial symptom was exercise intolerance (13 [59%] patients) followed by atrial arrhythmia (seven [32%] patients). Two patients had cyanosis. Three patients had paroxysmal and six had chronic atrial fibrillation/flutter. Cardiomegaly on chest x-ray film was noted in 18 (82%) patients. Referral diagnosis of Ebstein's anomaly had been made by echocardiography (12 patients), cardiac catheterization (four patients), both techniques (five patients), and echocardiography and magnetic resonance imaging (one patient). All 22 patients had predominate right atrial and right ventricular enlargement, and 18 (82%) of 22 patients also had right ventricular dysfunction. However, Ebstein's anomaly was confidently ruled out with repeat comprehensive echocardiography at our institution by establishing (1) absence of significant apical displacement of the septal tricuspid valve leaflet (> or = 8 mm/m2) and (2) lack of a redundant, elongated, anterior tricuspid valve leaflet in all 22 patients (100%). All had significant tricuspid regurgitation caused by tricuspid valve dysplasia (nine patients), tricuspid valve prolapse (four patients), trauma (four patients), right ventricular dysplasia (three patients), endocarditis (one patient), and annular dilation caused by free pulmonary regurgitation (one patient). In all 15 patients who subsequently underwent surgery (tricuspid valve repair [seven patients] or replacement [eight patients]), the absence of Ebstein's anomaly was confirmed. Echocardiographic absence of the characteristic degree of displacement of the septal leaflet of the tricuspid valve (> or = 8 mm/m2) and the presence of a nonelongated, nonredundant anterior tricuspid valve leaflet consistently excluded the diagnosis of Ebstein's anomaly. Under such circumstances, other anomalies of the tricuspid valve or right ventricle were consistently identified. Recognition of the mimics of Ebstein's anomaly had important surgical implications.

Permanent pacing in Ebstein's anomaly

Patients with Ebstein's anomaly present unique challenges to permanent pacing due to anatomical variations and tricuspid valve replacement. We retrospectively reviewed our experience with permanent pacing in patients with Ebstein's anomaly between 1976 and 1993. We identified 401 patients with Ebstein's anomaly, of whom 15 (3.7%) required permanent pacing (1 of the 15 was implanted elsewhere). Of the 15, there were 8 females and 7 males (mean age 32 years [range 7-74]); the indications for pacing were AV block in 11 and sinus node dysfunction in 4. Eight patients were programmed with VVI and seven with DDD. All VVI patients were paced epicardially. Two patients with DDD pacemakers had transvenous atrial and ventricular leads, 4 DDD patients had transvenous atrial leads and epicardial ventricular leads, and 1 patient had both epicardial and transvenous systems. Associated surgical procedures included tricuspid valve replacement in 14 of 15, atrial septal defect repair in 10 of 15, atrioplasty in 7 of 15, prior tricuspid annuloplasty in 4 of 15, pulmonary vein dilation in 1 of 15, and conduction system ablation in 2 of 15. Patients had a mean follow-up of 35 months (range 1-168 months). Complications requiring operative intervention occurred in four patients. One patient had displacement of a transvenous ventricular lead. A second patient had an epicardial lead failure. A third patient had a nonfunctioning atrial lead that displaced across the tricuspid valve, causing severe tricuspid regurgitation. The fourth patient had multiple epicardial and endocardial leads exit block with secondary diaphragmatic stimulation. Permanent pacemakers were required in 3.7% of patients with Ebstein's anomaly, with the indication being intrinsic conduction disease in the majority of patients. Ninety-three percent of patients required tricuspid valve replacement, suggesting more severe manifestation of Ebstein's anomaly. Twenty-seven percent had complications requiring surgical intervention. Thus, permanent pacing in patients with Ebstein's anomaly can be challenging and should be approached by an experienced physician.

Partial anomalous pulmonary venous connection: diagnosis by transesophageal echocardiography

OBJECTIVE

This study sought to demonstrate that with proper technique, identification of the normal and abnormal pulmonary venous connection can be made with confidence using transesophageal echocardiography (TEE).

BACKGROUND

Partial anomalous pulmonary venous connection (PAPVC) is an uncommon congenital anomaly whose diagnosis has classically been made using angiography.

METHODS

We performed a retrospective review of all patients of all ages with PAPVC diagnosed at the Mayo Clinic who had undergone TEE because of either right ventricular volume overload or suspected intracardiac shunting by transthoracic echocardiography or intraoperatively.

RESULTS

A total of 66 PAPVCs were detected in 43 patients (1.5/patient); in 2 additional patients, TEE suggested, but did not diagnose, PAPVCs. Shortness of breath was the most common presenting symptom (42.2%), followed by heart murmur and supraventricular tachycardia. Right-sided anomalous veins were identified in 35 patients (81.4%), left-sided in 7 (16.3%) and bilateral in 1 (2.3%). There was a single anomalous connecting vein in 23 patients (53.5%), two in 18 (41.9%), three in 1 (2.3%) and four in 1 (2.3%). The connecting site was the superior vena cava (SVC) in 39 veins (59.1%), right atrial-SVC junction in 6 (9.1%), right atrium in 8 (12.1%), inferior vena cava in 1 (1.5%) and the coronary sinus in 2 (3.0%). Ten anomalous left pulmonary veins were connected by a vertical vein to the innominate vein (15.1%). Sinus venosus atrial septal defect (ASD) was the most common associated anomaly in 22 patients (49%), followed by ostium secundum ASD in 6 and patent foramen ovale in 4. Fifteen patients had an intact atrial septum. Thirty-one patients (68.8%) underwent surgical repair. PAPVC was confirmed in all patients, including the two whose TEE results were suggestive of PAPVC. All 49 PAPVCs detected by TEE preoperatively were confirmed at the time of operation.

CONCLUSIONS

TEE is highly diagnostic for PAPVC and can obviate angiography. Accurate anatomic diagnosis may influence the need for medical and surgical management. TEE should be performed in patients with right ventricular volume overload when the precordial examination is inconclusive.

Aortic valve replacement after repair of pulmonary atresia and ventricular septal defect or tetralogy of Fallot

OBJECTIVE

Little attention has been paid to the occurrence of aortic regurgitation after complete repair in patients with pulmonary atresia and ventricular septal defect or tetralogy of Fallot. To highlight the development of aortic regurgitation or aortic root dilation severe enough to necessitate aortic valve replacement with or without aortic aneurysmorrhaphy or aortic root replacement, we retrospectively reviewed the records of patients who underwent aortic valve operation at our institution subsequent to repair of pulmonary atresia and ventricular septal defect or tetralogy of Fallot.

METHODS

We searched the Mayo Clinic database for patients with pulmonary atresia and ventricular septal defect or tetralogy of Fallot who subsequently had aortic valve or aortic root operations. The degree of aortic regurgitation before operation was noted. Aortic sinus and root dimensions were measured.

RESULTS

Sixteen patients underwent complete repair at a median age of 17 years, followed by an aortic operation a median of 13.5 years later. All 16 patients had dilated aortic sinuses at the time of the aortic valve operation. These 16 patients had aortic valve replacement: 11 with mechanical prostheses and 5 with bioprostheses. Five of the 16 also had reduction of aortic dilation by lateral aneurysmorrhaphy, and 1 had graft replacement of the ascending aorta. Five patients had associated conditions (evidence of valvular damage, recurrent ventricular septal defect, or history of endocarditis) discovered at the aortic valve operation that have been reported to be related to the development of aortic regurgitation. The remaining 11 patients had progressive aortic regurgitation despite complete, uncomplicated repair.

CONCLUSIONS

Progressive aortic regurgitation and aortic root dilation can occur despite complete repair of pulmonary atresia and ventricular septal defect or tetralogy of Fallot.

Outcome of pregnancy in patients with complex pulmonic valve atresia

Fifteen women with complex pulmonary atresia who had pregnancies were retrospectively reviewed. Although no pregnancy-related deaths occurred, complications were noted in 3 patients and risk of fetal loss and premature birth were increased, none of the 10 offspring had congenital heart disease.

Diagnosis of sinus venosus atrial septal defect with transesophageal echocardiography

BACKGROUND

Sinus venosus atrial septal defect (SVD) is underdiagnosed with transthoracic echocardiography because of its posterior (far field) location. Transesophageal echocardiography (TEE) should be ideally suited to diagnose SVD, given the proximity of the transducer to the defect.

METHODS AND RESULTS

A retrospective study was undertaken that used the medical history, echocardiographic findings, and surgical data of patients identified from computer records as having the diagnosis of SVD during the period in which TEE has been in use (1987 to 1995). Twenty-five patients (14 females and 11 males; median age, 45 years; range, 10 to 75 years) with SVD had TEE between 1987 and 1995. Prior transthoracic echocardiography clearly defined the SVD in 3 of these patients, and it was suspected in another 11 on the basis of color-flow imaging. Ten patients had unexplained dilatation of the right side of the heart, which prompted TEE examination. SVD was visualized with TEE in all 25 patients and ranged in size from 1 to 3 cm. Thirty-seven right-sided anomalous pulmonary venous connections were identified in 23 patients. No left-sided anomalous pulmonary venous connections were detected. Anatomic confirmation was obtained in all 23 surgical patients. No patient required preoperative cardiac catheterization for diagnosis.

CONCLUSIONS

TEE is accurate for the diagnosis of SVD and should be undertaken in any patient with unexplained dilatation of the right side of the heart. The associated pulmonary venous abnormalities can be identified with TEE. Cardiac catheterization for diagnostic purposes should not be required before surgical correction.

Cerebrovascular events in adult patients with cyanotic congenital heart disease

OBJECTIVES

We sought to determine the frequency of spontaneous cerebrovascular events in adult patients with cyanotic congenital heart disease and to evaluate any contributing factors.

BACKGROUND

Cerebrovascular events are a serious complication of cyanotic congenital heart disease in infants and children but are said to be uncommon in adults.

METHODS

Between 1988 and 1995, 162 patients with cyanotic congenital heart disease (mean age 37 years, range 19 to 70) were retrospectively evaluated for any well documented cerebrovascular events that occurred at > or = 18 years of age. Events related to procedures, endocarditis or brain abscess were excluded.

RESULTS

Twenty-two patients (13.6%) had 29 cerebrovascular events (1/100 patient-years). There was no significant difference between those with and without a cerebrovascular event in terms of age, smoking history, degree of erythrocytosis, ejection fraction or use of aspirin or warfarin (Coumadin). Patients who had a cerebrovascular event had a significantly increased tendency to develop hypertension, atrial fibrillation, microcytosis (mean corpuscular volume < 82) and history of phlebotomy (p < 0.05). Even when patients with hypertension or atrial fibrillation were excluded, there was an increased risk of cerebrovascular events associated with microcytosis (p < 0.01).

CONCLUSIONS

Adults with cyanotic congenital heart disease are at risk of having cerebrovascular events. This risk is increased in the presence of hypertension, atrial fibrillation, history of phlebotomy and microcytosis, the latter condition having the strongest significance (p < 0.005). This finding leads us to endorse a more conservative approach toward phlebotomy and a more aggressive approach toward treating microcytosis in adults with cyanotic congenital heart disease.

Improved early morbidity and mortality after Fontan operation: the Mayo Clinic experience, 1987 to 1992

OBJECTIVES

This study sought to evaluate changes in early morbidity and mortality as well as predictors of outcome in our most recent 339 patients undergoing modified Fontan operations.

BACKGROUND

The Fontan operation is the preferred definitive palliation for patients with functional single ventricles. Previously reported early mortality rates after Fontan operation have been substantial.

METHODS

Records of 339 consecutive patients who had a Fontan operation at the Mayo Clinic between 1987 and 1992 (recent cohort) were reviewed. This cohort was compared with the previous 500 patients who had Fontan operations performed between 1973 and 1986 (early cohort).

RESULTS

Recently, overall early mortality after Fontan has decreased significantly compared with that for the early cohort (from 16% to 9%, p = 0.002). This decline occurred despite increased anatomic complexity of patients. Short-term posthospital survival has also improved significantly in recent patients. One-year survival improved to 88% from 79%, and 5-year survival to 81% from 73% (p = 0.006). Patients with common atrioventricular valves and those who took daily preoperative diuretic medication or had either postoperative renal failure or elevated postbypass right atrial pressure were at increased risk for early mortality. Young age was not found to be a risk factor for early mortality. Early mortality for patients with heterotaxia decreased dramatically: recent 30-day mortality was 15% compared with 41% in the early heterotaxy cohort.

CONCLUSIONS

Many factors may have contributed to decreased early mortality after Fontan. Improved patient selection, younger age at time of operation, refinements in surgical techniques and postoperative management may all have had important roles. Proposed technical modifications of the Fontan operation must be evaluated in light of these improved results.

Protein-losing enteropathy after the Fontan operation: successful treatment by percutaneous fenestration of the atrial septum

Protein-losing enteropathy (PLE) after the Fontan operation is a life-threatening complication that may be refractory to medical therapy. Herein we describe a percutaneous atrial fenestration that was performed in a 42-year-old man with a double-inlet left ventricle who had undergone a Fontan operation 9 years earlier. Severe PLE developed, and despite frequent infusions of protein, his albumin level was 1.8 g/dL. The diagnosis of PLE was confirmed by an alpha(1)-antitrypsin clearance of 425 mL in 24 hours (normal 27 or less). Percutaneous atrial fenestration resulted in dramatic clinical improvement and resolution of the PLE. At 5-month follow-up, the patient's albumin level was 4.2 g/dL, his alpha(1)-antitrypsin clearance was normal, and he was free of ascites and edema.

Survival into adulthood of patients with unoperated single ventricle

Adult patients with double-inlet left ventricle and perfectly balanced circulation may survive into the sixth decade with good functional capacity and preserved ventricular function. This should be considered before such patients are referred for a Fontan repair.

Cor triatriatum dexter in an adult diagnosed by transesophageal echocardiography: a case report

Cor triatriatum dexter is a rare congenital heart malformation in which a persistent right sinus venosus valve divides the right atrium into two chambers. Before echocardiography, this anomaly has been rarely diagnosed before surgery or death. This is a case of cor triatriatum dexter in an adult with lifelong exertional cyanosis and dyspnea. A definitive diagnosis of cor triatriatum dexter with associated heart defects was best made by transesophageal echocardiography at 47 years of age. Subsequent surgical intervention confirmed all of the echocardiographic findings and successful correction of the defects was performed.

Results of an autologous tissue reconstruction for replacement of obstructed extracardiac conduits

Between May 1983 and March 1, 1995, 50 patients had replacement of an obstructed pulmonary ventricle-pulmonary artery conduit with an autologous tissue reconstruction in which a prosthetic roof was placed over the fibrous tissue bed of the explanted conduit. The roof was constructed with xenograft pericardium (most recently) (n = 42), homograft dura mater (n = 5), or Dacron fabric (n = 3). Patient ages ranged from 5 to 34 years (median 16 years). The explanted conduits were Hancock conduits (n = 33), Tascon conduits (n = 6), homograft (n = 4), Dacron tube (n = 3), and others (n = 4). Preoperative maximum systolic gradients ranged from 44 to 144 mm Hg (median 78 mm Hg). Thirty-seven concomitant cardiac procedures were done in 29 patients. When a valve was necessary (n = 15), it was possible to place a large-sized valve in the autologous tissue reconstructions (range 22 to 29 mm, median 26 mm). Cardiopulmonary bypass times ranged from 34 to 223 minutes (median 84 minutes), and aortic crossclamp times ranged from 0 (in 32 patients) to 109 minutes (median 0 minutes). Intraoperative postrepair peak systolic gradients from pulmonary ventricle to pulmonary artery ranged from 0 to 33 mm Hg (median 13 mm Hg). There was one early death (2%) in a patient who had additional cardiac procedures. Follow-up was complete in all patients and ranged from 1 month to 11.8 years (median 7.5 years). There were two sudden late deaths: conduits in both were known to be free from obstruction. Forty-four of the 47 surviving patients had evaluation of the gradient by echocardiography or cardiac catheterization 1 month to 11 years (median 7 years) after operation. The gradients ranged from 5 to 45 mm Hg (median 20 mm Hg). None of the conduits developed an obstructive peel, valve obstruction, or valve incompetence. At 10 years, the freedom from reoperation for conduit obstruction was 100%, and freedom from reoperation for any cause was 81%. This technique simplifies conduit replacement, allows for a generous-sized outflow tract, has a low risk, and yields late results that appear superior to those of cryopreserved homografts or other types of extracardiac conduits.

Partial atrioventricular canal defect: long-term follow-up after initial repair in patients > or = 40 years old

OBJECTIVES

This study was undertaken to determine the results of repair of partial atrioventricular (AV) canal in patients > or = 40 years old.

BACKGROUND

Although postoperative outcomes in younger patients have been well documented, the fate of older patients with repaired partial AV canal is less clear.

METHODS

From 1958 to 1990, 31 patients 40 to 71 years old (mean age 51) had repair of partial AV canal. Twenty-three patients had repair of the cleft mitral valve; two had mitral valve replacements; and six needed no mitral valve operation.

RESULTS

Early mortality was 6%. One patient was lost to follow-up. Nine of the early survivors are known to have died. There is a small but significant development over the long term of atrial arrhythmias, complete heart block, subaortic stenosis, recurrent mitral regurgitation and, rarely, mitral stenosis. Three of the 28 patients available for follow-up had mitral valve reoperation and subaortic stenosis developed in 2. Nineteen patients were alive in 1991 (mean follow-up 14 years). Seven patients were in New York Heart Association functional class I, eight were in class II, and four were in class III. Fifteen of the 19 patients reported sustained postoperative improvement.

CONCLUSIONS

Patients > or = 40 years old can have partial AV canal repair with low risk. Long-term survival is good, with subjective improvement in symptoms. Late complications occur but are uncommon, suggesting that long-term follow-up is warranted.

Late results of systemic atrioventricular valve replacement in corrected transposition

From December 1964 to October 1993, 40 patients (aged 5 months to 70 years, mean 21.8 years, median 13.6 years) with corrected transposition and systemic atrioventricular valve insufficiency underwent replacement (n = 39) or repair (n = 1) of the systemic atrioventricular valve. Thirty-nine patients had situs solitus and 1 had situs inversus. Associated anomalies included Ebstein's malformation of the systemic atrioventricular valve (n = 22), ventricular septal defect (n = 19), and pulmonary stenosis (n = 14). Preoperatively, 16 patients (40.0%) had complete heart block and 27 patients (67.5%) were in New York Heart Association functional classes III and IV. The early mortality was 10.0% (n = 4) and 8 patients died subsequently. The principal cause of death in all 12 patients was systemic ventricular failure. Overall survival including early mortality was 78.0% at 5 years and 60.7% at 10 years; survival excluding early mortality was 86.7% at 5 years and 67.5% at 10 years. Survivorship correlated with preoperative systemic ventricular ejection fraction of 44% or more (p < 0.001) and later interval of operation (9 deaths in 15 patients before 1981 versus 3 deaths in 25 patients subsequently) (p = 0.06). There were no cases of surgically induced complete heart block. Two patients underwent late reoperations related to the systemic atrioventricular valve prosthesis. Follow-up extended to 26.0 years (median 4.7 years). At last follow-up, 18 of the 28 survivors were in New York Heart Association functional class I, 9 were in class II, and 1 was in class III. We conclude that the results of systemic atrioventricular valve replacement in corrected transposition have improved significantly during the past decade. To preserve systemic ventricular function, we suggest operation be considered at the earliest sign of progressive ventricular dysfunction as assessed by serial clinical evaluation and echocardiography.

Adults with congenital heart disease: patient knowledge of endocarditis prophylaxis

OBJECTIVE

To determine whether adults with congenital heart disease have adequate knowledge of infective endocarditis and endocarditis prophylaxis and to ascertain whether an educational program effectively improves patient knowledge and compliance.

MATERIAL AND METHODS

We asked 102 consecutive patients to complete a 12-question survey to assess their knowledge of heart disease, infective endocarditis, and endocarditis prophylaxis.

RESULTS

Of 102 patients, 100 (98%) completed the questionnaire. Sixty-eight patients knew the name of their heart disease. Fifty patients correctly defined endocarditis, but only 43 knew hygiene measures that could prevent endocarditis. Ninety-six patients knew that they needed to take "a medicine" before dental procedures, and 76 of those patients (79%) knew that an antibiotic was necessary. Patient use of cardiac medications and a history of endocarditis correlated significantly with knowledge of endocarditis. Patients who had been to the Adult Congenital Heart Disease Clinic at least once knew endocarditis prevention measures and the importance of regular dental and cardiology follow-up significantly more frequently than did first-time attendees. Despite educational counseling, however, patient recall of endocarditis and its prevention is disappointing.

CONCLUSION

Many adults with congenital heart disease have inadequate knowledge of their cardiac lesion, endocarditis, and endocarditis prophylaxis. Educational efforts for adults with congenital heart disease need to be updated and reinforced regularly.

Ebstein's anomaly: outcome of pregnancy

OBJECTIVES

The outcome of pregnancy in Ebstein's anomaly was studied in 72 such patients (44 women, 28 men) who had had pregnancies or fathered children.

BACKGROUND

Patients with Ebstein's anomaly often reach childbearing age. Reports of the outcome of pregnancy in Ebstein's anomaly are available; however, the number of patients is small.

METHODS

The medical and surgical data bases at the Mayo Clinic were reviewed, and 145 patients (62 men, 83 women) of childbearing age with Ebstein's anomaly were located. All patients were contacted, and 72 patients (44 women, 28 men) with offspring were identified and reviewed in detail to assess the outcome of pregnancy.

RESULTS

Forty-four women had 111 pregnancies resulting in 85 live births (76%). Seventy-six deliveries (89%) were vaginal, and nine (11%) were by cesarean section. Twenty-three deliveries were premature. There were 19 spontaneously unsuccessful pregnancies, 7 therapeutic abortions and 2 early neonatal deaths. The mean birth weight of the infants born to cyanotic women was 2.53 kg, which was significantly lower than the mean birth weight of infants born to acyanotic women (3.14 kg [p < 0.001]). The overall incidence of congenital heart disease in the 158 offspring of parents with Ebstein's anomaly was 4% (6 of 158). The incidence of congenital heart disease was 6% (5 of 83) in the offspring of women with Ebstein's anomaly and 1% (1 of 75) in that of men. There was a 0.6% (1 of 158) incidence of familial Ebstein's anomaly. There were no serious pregnancy-related maternal complications, which included maternal death, stroke, congestive heart failure, arrhythmias or endocarditis.

CONCLUSIONS

Pregnancy in women with Ebstein's anomaly is well tolerated. It is associated with an increased risk of prematurity, fetal loss and congenital heart disease in the offspring. In addition, a significantly lower birth weight is found in the offspring of cyanotic versus acyanotic women with Ebstein's anomaly. Paternal Ebstein's anomaly also seems to result in an increased risk of congenital heart disease in the offspring compared with the incidence in the general population.

Tetralogy of Fallot and pulmonary atresia/ventricular septal defect

Surgical repair of tetralogy of Fallot is associated with excellent results. Long-term complications include arrhythmias, sudden death, and right ventricular aneurysm formation. Reoperation is necessary in approximately 5% of patients for residual ventricular septal defect, pulmonary regurgitation, or pulmonary stenosis. Pulmonary atresia/ventricular septal defect is a more complex situation, and the anatomy needs careful delineation by cardiac catheterization prior to any surgical intervention. Palliation with a shunt or first-stage repair may be effective, or radical repair may be considered in those with adequate pulmonary distribution.

Tricuspid atresia and univentricular heart after the Fontan procedure

Patients undergoing the Fontan operation must be selected carefully. The best results are obtained in those who fulfill the criteria of Choussat et al. Other treatment options are now available. Patients known to be at high risk for the Fontan procedure should be considered for cavopulmonary anastomoses or cardiac transplantation. It is unknown whether performing the Fontan operation at an earlier age will help prevent the long-term problems with ventricular dysfunction. Long-term follow-up of all patients following the Fontan procedure is mandatory with noninvasive assessment of ventricular function and the anastomotic site. Arrhythmias should be managed aggressively with prompt restoration of sinus rhythm, when possible, ideally with antiarrhythmic agents with little or no negative inotropic action. Periodic assessment of serum proteins should be performed. Although the operative risk of the Fontan operation has continued to improve over the last few years, and in one series has been as low as 8%, long-term complications continue and reinforce the concept of the Fontan operation being a palliative rather than a curative procedure.

Operative treatment of Ebstein's anomaly

From April 1972 to February 12, 1991, 189 patients with Ebstein's anomaly underwent repair. Ages ranged from 11 months to 64 years (median 16 years, mean 19.1 years). In 58.2%, tricuspid valve reconstruction was possible, and in 36.5%, a prosthetic valve, usually a bioprosthesis, was inserted. In 5.3%, a modified Fontan or other procedure was performed. There were 12 hospital deaths (6.3%). All 28 patients who had accessory conduction pathways (Wolff-Parkinson-White syndrome) underwent successful ablation of the pathways as part of the operative treatment. Follow-up was obtained in 151 (85.3%) patients. Of those patients followed up more than 1 year after operation, 92.9% were in New York Heart Association class I or II. There were 10 late deaths: seven cardiac (four sudden), two noncardiac, and one of an unknown cause. Postoperative Doppler echocardiographic assessment showed the atrial septum was intact in all patients and tricuspid valve function was good to excellent in most patients. Four of the 110 patients (3.6%) who underwent valve reconstruction required reoperation 1.4 to 14.1 years later. Postoperative reduction in heart size was usual, atrial arrhythmias were reduced, and late postoperative exercise testing showed a significant improvement in performance: Maximal oxygen consumption increased from a mean of 47% of predicted value before the operation to a mean of 72% after the operation. Nine patients had a total of 12 successful pregnancies with deliveries of normal children.

The potential contribution of cardiac replacement to the control of cardiovascular diseases. A population-based estimate

The potential number of individuals who might benefit from a cardiac replacement procedure (either cardiac transplantation or insertion of a total artificial heart) was retrospectively estimated from medical records for residents of Olmsted County, Minnesota, who had died during a 5-year period. Residents were divided into two age groups: those younger than 15 years (pediatric) and those 15 to 69 years (adult). During the 5-year period of observation, cardiac disease led to death in 17 of the 8342 live births in Olmsted County. Cardiac disease also caused the deaths of 248 adults meeting the age criteria. Five children and 35 adults met all criteria for cardiac replacement. Extrapolation to the total population of the United States suggests that 2167 children (a 95% confidence interval of 361 to 3972) and 16,500 adults (a 95% confidence interval of 11,456 to 22,959) per year could potentially benefit from cardiac replacement.

Intravascular ultrasound imaging: in vitro validation and pathologic correlation

Intravascular ultrasound imaging is a new method in which high resolution images of the arterial wall are obtained with use of a catheter placed within an artery. An in vitro Plexiglas well model was used to validate measurements of the luminal area, and an excellent correlation was obtained. One hundred thirty segments of fresh peripheral arteries underwent ultrasound imaging and the findings were compared with the corresponding histopathologic sections. Luminal areas determined with ultrasound imaging correlated well with those calculated from microscopic slides (r = 0.98). Three patterns were identified on the ultrasound images: 1) distinct interface between media and adventitia, 2) indistinct interface between media and adventitia but different echo density layers, and 3) diffuse homogeneous appearance. The types of patterns depended on the relative composition of the media and adventitia. Calcification of intimal plaque obscured underlying structures. Atherosclerotic plaque was readily visualized but could not always be differentiated from the underlying media.

Sudden coronary death

Many reports have described the amounts of atherosclerotic plaque in victims of sudden coronary death, defining the number of coronary arteries narrowed at some point greater than 75% in cross-sectional area (XSA). In order to quantitate more precisely the amount and distribution of plaque, 70 victims of sudden coronary death aged 22-81 years (mean 50) were studied. The four major epicardial coronary arteries (left main, left anterior descending, left circumflex, and right) from each of 70 victims were cut into 5-mm segments (average 50 per patient) and a histologic section prepared from each segment. The amount of luminal narrowing by plaque was categorized into five groups (0-25%, 26-50%, 51-75%, 76-95%, 96-100%). Of 3,484 five-mm segments, 950 (27%) were narrowed 76-100% in XSA. Comparison of 31 previously symptomatic victims (angina pectoris and/or myocardial infarction) to 39 victims who had been asymptomatic disclosed a higher mean percent of severely narrowed segments (30% vs. 25%, p = less than 0.005) and a lower mean percent of minimally narrowed segments in the symptomatic group. Comparison of the 31 patients with a healed myocardial infarction at necropsy with 39 patients with no left ventricular scar disclosed a higher mean percent of segments severely narrowed (33% vs. 24%, p = less than 0.001) and a lower mean percent of segments narrowed minimally in those with a left ventricular scar (13% vs. 26%, p = less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral flow velocity curves as a function of different loading conditions: evaluation by intraoperative transesophageal Doppler echocardiography

Transesophageal pulsed wave Doppler echocardiography was performed intraoperatively on 10 patients undergoing coronary artery bypass operation. Mitral flow velocity curves and hemodynamic values were recorded during control conditions and intravenous infusion of (1) nitroglycerin, (2) phenylephrine, and (3) fluids. During nitroglycerin infusion blood pressure and wedge pressure decreased, peak filling velocity decreased, and deceleration time increased compared with control values. During infusion of phenylephrine blood pressure increased, there was a trend toward a decrease in peak filling velocity, and deceleration time increased. During infusion of fluids wedge pressure increased, deceleration time decreased, and peak filling velocity increased. Mitral flow velocity curves are therefore altered by changes in hemodynamic loading conditions.

Transposition of the great arteries: late results in adolescents and adults after the Mustard procedure

A selected group of 18 patients aged 15-27 years with transposition of the great arteries and a previous Mustard procedure were evaluated to determine their functional ability and clinical state. Arrhythmias were common, occurring at some time in 16/18 (89%). Arrhythmia was serious in four; two of them required pacing and two had cardiac arrests, one resulting in death. Seven (41%) had right ventricular dysfunction; this was progressive in three. Tricuspid regurgitation was present in seven (41%); it occurred in patients with normal and reduced right ventricular ejection fractions. Regurgitation became progressively worse as the right ventricle dilated. Left ventricular function was well preserved in most patients. Fourteen (82%) of this pioneer group were leading normal lives (ability index 1 or 2). Although these results are acceptable concern remains about the probability of deteriorating right ventricular function.

Tricuspid atresia with transposition of the great arteries in adolescents and adults: current state and late complications

The outcome was reviewed in 17 patients aged 15-40 years with tricuspid atresia and transposed great arteries selected by survival beyond age 14 years. Only five lead normal lives (ability index 1 or 2); the rest are dead or disabled. Arrhythmias occurred in seven. Maintenance of sinus rhythm is important because incessant atrial arrhythmias cause serious symptomatic deterioration. Pulmonary vascular disease and subaortic stenosis were important determinants of late mortality and morbidity. Because the mortality associated with the Fontan operation was high in these patients it should be performed with impeccable surgical technique and only in those who fulfil all the selection criteria for the operation. A shunt is the preferred option when any of the criteria are not met.