Juxtaposition of the atrial appendages: a clinical series of 22 patients

Because the outcome of a large clinical series of patients with juxtaposition of the atrial appendages (JAA) has not previously been reported, a retrospective study was performed on patients diagnosed with JAA at a tertiary medical center. Patients with JAA were identified through a computerized database search, and echocardiograms and medical records of patients with JAA were reviewed. Twenty-two patients with JAA were identified, with an overall incidence of 0.28%. All but 2 patients were diagnosed prospectively with JAA by echocardiography. The lesion-specific incidences and associated lesions were similar to those of large autopsy and surgical series. Abnormal conotruncal anatomy was more frequently seen with juxtaposition of the right atrial appendage (JRAA) vs juxtaposition of the left atrial appendage (JLAA) (14/15 vs 4/7), as was atrial outlet obstruction (6/15 vs 2/7). JLAA was more frequently associated with complex atrioventricular anatomy (3/7 vs 1/15). Patients with JAA underwent single ventricle palliation in 11/22 cases with 6 deaths; biventricular repair was performed in 8/22 cases with no deaths. Surgical outcomes for patients with JRAA and JLAA were similar, and survival was predominantly influenced by suitability for biventricular repair.

Ticlopidine plus aspirin for coronary thrombosis in Kawasaki disease

Selective inhibitors of the adenosine 5'-diphosphate pathway of platelet activation have been used rarely in children in the United States. We report the successful use of ticlopidine, together with aspirin, in a 7-month-old infant with Kawasaki disease complicated by a thrombus in a giant coronary aneurysm that failed to resolve with thrombolytic therapy. Kawasaki disease, coronary aneurysms, antithrombotic therapy, ticlopidine, children.

Abnormal myocardial mechanics in Kawasaki disease: rapid response to gamma-globulin

BACKGROUND

The time course and rate of recovery of myocardial dysfunction in association with Kawasaki disease in response to intravenous gamma-globulin is unknown and may provide mechanistic clues.

METHODS AND RESULTS

The acute changes in myocardial contractility in 25 patients with Kawasaki disease were evaluated by noninvasive stress-shortening and stress-velocity analysis. Echocardiograms were performed before and then daily for 4 days during which the patients received gamma-globulin 1.6 to 2 g/kg. Before treatment, contractility was abnormally low (<2 SD) in 14 patients (56%). Contractility increased significantly (2 SD increase) in 17 (68%), including 13 of 14 with depressed contractility and 4 whose initial contractility fell within normal limits. Of the 14 patients with depressed contractility, 8 (57%) normalized within 24 hours and a further 5 (35.7%) normalized within 6 months. A clinical response to treatment (fall in C-reactive protein by 50% and/or resolution of fever within 4 days) was seen in 22 patients (88%). Contractility increased in 17 of the 22 clinical responders and was normal before therapy in the other 5. The 3 patients who did not respond clinically also had no change in contractility with gamma-globulin therapy. Long-term (more than 12 months) follow-up was available in 19 patients. All patients had normal contractility at late follow-up.

CONCLUSIONS

More than half the patients with Kawasaki disease have abnormal contractility at presentation. Myocardial response to gamma-globulin therapy is associated with rapid improvement in myocardial mechanics, with a high concordance between the clinical and myocardial response to therapy. The speed of recovery suggests that depressed contractility in patients with Kawasaki disease is caused by a rapidly reversible process such as circulating toxins or activated cytokines. Long-term outcome is good even in those patients with slow recovery of myocardial function.

Survival in neonatal biventricular repair of left-sided cardiac obstructive lesions associated with hypoplastic left ventricle

Patients with left ventricular hypoplasia and left-sided heart obstructive lesions other than critical aortic stenosis may be inappropriately subjected to single ventricular repair because their assessment is based on faulty qualitative evaluations or on quantitative methods developed for critical aortic stenosis. Patients with left ventricular hypoplasia and left-sided heart obstructions other than critical aortic stenosis successfully underwent biventricular repair despite "failing" to pass established criteria for critical aortic stenosis.

Usefulness of tacrolimus versus cyclosporine after pediatric heart transplantation

This study compared the early clinical course of 9 pediatric heart transplantation recipients treated with cyclosporine A-based immunosuppression with 10 similarly aged recipients treated with tacrolimus-based therapy. One-year follow-up after transplantation revealed that tacrolimus-treated children had similar left ventricular function, experienced fewer episodes of severe rejection, were more rapidly weaned from corticosteroids, and had relatively few side effects from immunosuppression compared with cyclosporine A-treated children.

Clinical implications and possible association of malposition of the branch pulmonary arteries with DiGeorge syndrome and microdeletion of chromosomal region 22q11

We describe a series of 10 patients with malposition of the branch pulmonary arteries (4 patients with crossing [crossed pulmonary arteries] and 6 patients without crossing), 2 of whom had a short main pulmonary artery segment that resulted in iatrogenic right pulmonary artery stenosis after pulmonary artery band placement. DiGeorge syndrome was seen in 5 patients and 4 had microscopic deletion of chromosomal region 22q11.

Left heart obstructive lesions and left ventricular growth in the midtrimester fetus. A longitudinal study

BACKGROUND

Isolated case reports that suggest the potential for development of left heart hypoplasia late in gestation provide the only information about the in utero natural history of left heart obstructive lesions.

METHODS AND RESULTS

We reviewed the prenatal and postnatal echocardiograms of 21 fetuses with left heart obstructive lesions, including 15 with serial antenatal study, to elucidate the antenatal natural history of this spectrum of disease and to identify features indicative of postnatal disease severity. Ventricular, atrioventricular valve, and great artery dimensions were measured and growth curves were developed with comparisons to data from 47 normal fetuses. Fetuses were divided into groups according to whether postnatally the left heart was capable (group 1, n = 10) or incapable (group 2, n = 7) of supporting the systemic circulation in the presence of a patent aortic valve. Group 3 (n = 4) included fetuses with aortic atresia. At the initial examination (21.7 +/- 3.4 weeks' gestation), left heart dimensions were normal or reduced, with the most diminutive measurements in group 3. Three fetuses in group 2 and most in group 1 had normal initial left heart dimensions. Subsequent growth of left heart structures either paralleled normal growth or was reduced, the latter resulting in the development or progression of left heart hypoplasia. All left heart dimensions grew more slowly in group 2 and group 3 than in group 1 (P < .05). Other prenatal features observed only in groups 2 and 3 included reversed (n = 10) or bidirectional (n = 1) foramen ovale flow and retrograde distal arch flow (n = 9). Initial midtrimester mitral valve and ascending aorta z scores and the growth rates of all left heart structures correlated strongly with postnatal left ventricular end-diastolic dimension (P = .0007 to .03, r = .57 to .82) and could be additional indicators of postnatal disease severity. One group 1 fetus developed severe aortic stenosis late in gestation.

CONCLUSIONS

The potential for the in utero development or progression in severity of left heart obstruction and hypoplasia in left heart obstructive lesions necessitates serial prenatal study in affected fetuses carried to term.

Echocardiographic predictors of candidacy for successful transcatheter atrial septal defect closure

We reviewed pre-closure echocardiograms on all patients undergoing transcatheter atrial septal defect (ASD) closure with the Bard double-umbrella occluder device aided by simultaneous transesophageal echocardiography to determine precatheterization predictors of outcome. Transesophageal echocardiograms were performed on 28 of 132 patients (22%) undergoing device closure (age = 3-72 years, mean = 14 years; weight = 15-68 kg, mean = 35 kg). Three devices were removed because of unstable position. Of the remaining 25 patients, 21 had effective closure (residual flow diameter < or = 3 mm) and 18 had favorable arm position (device arm on proper side of the septum and not in contact with an atrioventricular valve leaflet). Only ASD size predicted effective closure. All patients with a maximum defect size of < 13 mm had effective closure. Among the 17 patients with defects > or = 13 mm, 10 had effective closure, 4 had significant residual flow, and 3 had devices removed for unstable position. Atrial dimensions and rim size did not predict effective closure. There were no pre-closure predictors of favorable arm position which was associated only with the size of the device implanted.

Infantile dilated cardiomyopathy. Relation of outcome to left ventricular mechanics, hemodynamics, and histology at the time of presentation

BACKGROUND

For patients with acute dilated cardiomyopathy, definition of prognosis and of clinical features predictive of outcome is particularly important due to the availability of cardiac transplantation and other innovative treatment strategies.

METHODS AND RESULTS

We reviewed our experience with 24 children under 2 years of age with dilated congestive cardiomyopathy to determine outcome and potential predictive variables. Clinical, serological, ECG, echocardiographic, hemodynamic, and histological findings were analyzed. Idiopathic cardiomyopathy or myocarditis constituted 29% of the patients presenting with congestive heart failure without structural heart disease. Among these patients, 45% recovered completely, 25% survived with persistent left ventricular dysfunction, and 30% died. All except one of the deaths occurred during the first 2 months after presentation. Poorer outcome and higher mortality were associated with a more severely depressed left ventricular ejection fraction and/or a more spherical left ventricular shape at presentation. Histological evidence of myocardial inflammation was a favorable prognostic indicator, whereas histological evidence of endocardial fibroelastosis was associated with a poor outcome. During the recovery phase, diastolic volume fell rapidly. Ventricular mass was elevated from the earliest observations and fell more slowly, with persistent elevation of the mass-to-volume ratio up to 2 years. Function and contractility improved over the first several months in most patients who recovered, although in occasional patients continued improvement was seen for as long as 2 years after presentation.

CONCLUSIONS

Histological and echocardiographic features can be used to identify patients at particularly high risk for death. To have any impact on outcome, decisions about cardiac transplantation must be reached rapidly, since almost all deaths occurred within the first 2 months after presentation. Recovery of function is often rapid, but continued improvement may be seen for as long as 2 years.

Coronary echocardiography in 406 patients with d-loop transposition of the great arteries

OBJECTIVES

The reliability of two-dimensional echocardiography for determining the proximal coronary artery anatomy in d-loop transposition of the great arteries was investigated in 406 infants who underwent surgical repair at one institution.

BACKGROUND

The origin and proximal course of the main coronary arteries can affect the surgical results of the arterial switch operation. Preoperative determination of the coronary artery anatomy appears to be advantageous for the surgeon.

METHODS

All infants with d-loop transposition who underwent a two-dimensional echocardiogram and primary surgical repair at our institution between 1987 and 1992 were identified, and the echocardiographic, operative and, when available, autopsy reports were reviewed for coronary artery anatomy, presence of a ventricular septal defect and the spatial relation between the arterial roots. The two-dimensional echocardiographic findings were compared with surgical or autopsy findings. The relation between proximal coronary artery anatomy and 1) a ventricular septal defect, and 2) the spatial orientation of the arterial roots was investigated. Twenty-seven infants diagnosed with an intramural coronary artery were not included because they are the subjects of another report.

RESULTS

Excluding intramural coronary artery patterns, 10 different types of coronary artery anatomy were seen in these 406 patients. The coronary arteries were imaged adequately in 387 (95%) of the 406 patients. The coronary artery anatomy was determined correctly by two-dimensional echocardiography in 369 (95.4%) of the 387 patients, with 18 errors in diagnosis. During the most recent 2.5 years, 193 (98.5%) of 196 patients were diagnosed correctly, with three diagnostic errors. Patients with a ventricular septal defect or side-by-side great arteries are more likely to have an unusual coronary pattern.

CONCLUSIONS

Echocardiography appears to be highly reliable for determining proximal coronary artery anatomy in d-loop transposition of the great arteries. An unusual coronary artery pattern is more likely in patients with side-by-side great arteries or posterior aorta or a ventricular septal defect, or both.

Diagnosis of intramural coronary artery in transposition of the great arteries using two-dimensional echocardiography

BACKGROUND

An intramural coronary is an uncommon but potentially significant risk factor for transfer of the coronary arteries as part of the arterial switch operation for transposition of the great arteries. Preoperative diagnosis is advantageous because it helps prevent accidental injury to the intramural coronary artery during transection of the aortic root and excision of the coronary artery ostium from the aorta. Therefore, we investigated the reliability of two-dimensional echocardiography for detecting an intramural coronary artery in infants with d-transposition of the great arteries.

METHODS AND RESULTS

All infants with d-transposition of the great arteries who underwent echocardiography and primary surgical repair at this institution between January 1987 and June 1992 were identified by search of the cardiology data base. From this group, all patients diagnosed with an intramural coronary artery were identified by review of the echocardiographic, surgical, and autopsy reports. Among 435 infants with transposition, 29 infants were diagnosed as having an intramural coronary artery. In 27 cases, the diagnosis was confirmed at surgery or autopsy, and there were two false-positive echocardiographic diagnoses (specificity, 99.5%). Twenty of the 27 patients with an intramural coronary artery were correctly diagnosed prospectively by echocardiography (sensitivity, 75%), including 17 of 23 patients with an intramural left coronary artery or left anterior descending coronary artery and 3 of 4 patients with an intramural right coronary artery. Two primary diagnostic criteria were identified: a major coronary artery arising from the contralateral septal sinus, near the usually intercoronary commissure, and a course for this vessel within the posterior aortic wall between the great arteries, creating a "double-border" appearance. Retrospective review using these criteria identified 26 of the 27 intramural arteries with no false-positive diagnoses.

CONCLUSIONS

We conclude that coronary echocardiography is a very promising technique for detecting an intramural coronary artery in transposition of the great arteries. Careful prospective application of the identified diagnostic criteria should greatly improve the diagnostic accuracy.

Conal anatomy in 119 patients with d-loop transposition of the great arteries and ventricular septal defect: an echocardiographic and pathologic study

OBJECTIVES

We sought to study the range of conal morphology in transposition of the great arteries with ventricular septal defect and their embryologic and surgical implications.

BACKGROUND

Conal anatomy in transposition of the great arteries and ventricular septal defect is variable and might affect surgical repair.

METHODS

Conal anatomy was explored using two-dimensional echocardiography in 119 patients with transposition of the great arteries and a large ventricular septal defect who presented between 1984 and 1991. The influence of conal anatomy on surgical technique was determined by review of the operative reports. Specimens of transposition of the great arteries with unusual conal anatomy were selected from the Cardiac Registry for comparison with the echocardiograms.

RESULTS

One hundred five patients (88.2%) had subaortic conus only with no subpulmonary conus (Group 1). Subarterial conus was present bilaterally in eight patients (6.7%) (Group 2). Four patients (3.4%) had only subpulmonary conus with no (or minimal) subaortic conus (Group 3). Among these four patients, the aorta was posterior to the pulmonary artery in one patient, side by side relative to the pulmonary artery in two patients and slightly anterior in the fourth patient. Subarterial conus was absent bilaterally in two patients (1.7%) (Group 4); the aorta was slightly posterior in one and side by side with the pulmonary artery in the other.

CONCLUSIONS

This variability of conal anatomy in transposition of the great arteries with ventricular septal defect implies four mechanisms by which transposition can occur. The conal anatomy appeared to affect surgical repair in Groups 1 and 2 insofar as it influenced ventricular outflow tract obstruction. In Groups 3 and 4, an arterial switch operation was performed in four of the six patients. The posterior location of the aorta obviated the need for the Lecompte maneuver in two of these four patients. In the remaining two cases in Groups 3 and 4, the condition was repaired by directing the left ventricular outflow across the ventricular septal defect to the aorta using a patch, with or without placement of a conduit from the right ventricle to the pulmonary artery.

Sonography of the fetal heart: normal variants and pitfalls

Sonographic evaluation of the fetal heart is an important part of obstetric sonography. The sonographer and sonologist should be familiar with the sonographic appearance of the normal fetal heart and with common structural abnormalities. Occasionally, normal structures in or adjacent to the fetal heart may simulate an abnormality. Although one should seek consultative sonography in instances of uncertain or questionable findings, unnecessary referral and concern may be avoided in some cases if the sonologist is familiar with normal variants and pitfalls. In this pictorial essay, we present several such pitfalls that we and others have observed in the four-chamber view (Fig. 1) and in views of the ventricular outflow tracts (Figs. 2 and 3).

Two-dimensional echocardiographic anatomy of atrioventricular alignment discordance with situs concordance

Relationships between the atria and the ventricles are commonly described in terms of either atrioventricular (AV) alignments (or connections) or AV situs (i.e., the type of atrial situs and the type of ventricular situs or ventricular loop). With either method of analysis, only one type of AV relationship (situs or alignment) is diagnosed specifically and is considered to be predictive of the other type of AV relationship. The two-dimensional echocardiographic characteristics of two patients with incongruent AV situs and alignments are described for the first time. Patient 1 had situs solitus of the viscera and atria (S), ventricular D-loop (D), and solitus normally related great arteries (S), or (S,D,S) segmental combination with concordant AV situs. However, the right-sided right atrium drained into the inferior and right-sided left ventricle, and the left-sided left atrium drained into the superior and left-sided right ventricle. Hence AV alignment discordance was present. Patient 2 had visceroatrial situs solitus (S), ventricular D-loop (D), and double-outlet right ventricle with a rightward aortic valve (D), or (S,D,D) segmental set (AV situs concordance). Similar to patient 1, AV alignment discordance was demonstrated. In both patients the diagnosis was established by two-dimensional echocardiography and subsequently confirmed by cardiac catheterization. The key to accurate echocardiographic diagnosis of this congenital heart disease was independent analysis of the AV alignments and the segmental situs of the three main cardiac segments. This diagnosis was determined by scanning from the parasternal, subxiphoid, and apical windows.(ABSTRACT TRUNCATED AT 250 WORDS)

Natural history and patterns of recovery of contractile function in single left ventricle after Fontan operation

BACKGROUND

Before the era of the Fontan procedure, the typical course of patients with single left ventricle (LV) consisted of heart failure and death during the second or third decade of life. Despite the advent of effective palliative therapy, ventricular dysfunction remains a significant clinical problem for these patients.

METHODS AND RESULTS

To investigate the causes of ventricular dysfunction in these patients and to determine whether Fontan-type repair reverses deterioration of LV function, the ventricular dimensions, volume, shape, wall stress, and systolic function were determined by echocardiography in 84 patients 0.2-35 years old with double-inlet single LV or tricuspid atresia. Measurements were obtained in 67 patients after palliation (arterial shunt or pulmonary artery band) and in 47 patients a median of 4.4 years after a Glenn (n = 9) or a Fontan operation (n = 38). Before a Fontan procedure, ventricular volumes were 2 to 3 times normal. Ventricular afterload, assessed as circumferential and meridional end-systolic wall stress, became abnormal after 2 years of age. With age, LV shape changed progressively from ellipsoidal to spherical, as indicated by the decrease in long axis:short axis ratio from normal (1.9) toward unity. Concomitantly, the ratio of circumferential to meridional end-systolic wall stress fell from 1.3 to unity, the ratio of a sphere at equilibrium. This age-related change in shape and load occurred in concert with progressive deterioration of LV systolic function and contractility. Aortic oxygen saturation, an indicator of pulmonary blood flow and therefore volume work in single-ventricle physiology, was inversely and independently correlated with contractility. In the group of patients in whom a Glenn or a Fontan operation was performed at < 10 years of age, ventricular dimensions, volumes, and wall stress diminished and LV function and contractility improved after surgery (p < 0.001). In patients undergoing surgery after 10 years of age, few had improvement of LV function after surgery. Postoperative ventricular function and contractility were inversely related to age at surgery and to aortic oxygen saturation measured before surgery.

CONCLUSIONS

Although Fontan-type repair of single ventricle early in life is associated with reversal of the abnormal contractile mechanics associated with age and volume load, this capacity for recovery diminishes with age at surgery.

Surgical management of late right ventricular failure after Mustard or Senning repair

BACKGROUND

Information on surgical management and outcome in patients who develop symptomatic right ventricular failure after prior Mustard or Senning operations is limited.

METHODS AND RESULTS

From March 1987 to March 1991, 10 patients 3.6-23.5 years old (median, 7.0 years) with transposition of the great arteries and prior Mustard (six patients) or Senning (four patients) repairs (performed at ages 2 months to 5 years; median, 6 months) underwent surgical intervention for symptomatic right ventricular failure. In five of 10 patients, anatomic correction with either an arterial switch operation (three patients) or a pulmonary artery-to-aorta anastomosis and right ventricle-to-pulmonary artery conduit (two patients) was performed. Before anatomic correction in these five patients, four of five patients had a pulmonary artery band to prepare the left ventricle. The interval between preparation and correction ranged from 8 days to 12 months (median, 2 months). One patient died after an arterial switch operation. In the remaining five patients, coexisting left ventricular dysfunction precluded anatomic correction; all five patients survived cardiac transplantation. Survival for the entire group of 10 patients is 90%, and the median postoperative hospital stay was 17 days. During follow-up (12-62 months; median, 27 months), there were no deaths. Neoaortic insufficiency after anatomic correction was common (mild in one patient, moderate in two patients, and severe in one patient who required aortic valve replacement 4 months after surgery). In the transplantation group, one patient developed lymphoma 3 months after transplantation but is currently in remission after reduction of immunosuppression.

CONCLUSIONS

In patients who develop late right ventricular failure after Mustard or Senning repair, surgical intervention with either anatomic correction or cardiac transplantation can be done with acceptable morbidity and low mortality. Neoaortic valve insufficiency demands close follow-up after anatomic correction.

Diagnosis of anomalous left coronary artery by Doppler color flow mapping: distinction from other causes of dilated cardiomyopathy

BACKGROUND

Anomalous origin of the left coronary artery from the pulmonary trunk is difficult to diagnose reliably by two-dimensional echocardiography. Therefore, Doppler color flow mapping was tested in 29 patients with dilated cardiomyopathy or anomalous left coronary artery, or both.

METHODS AND RESULTS

All patients with anomalous left coronary artery (10 patients) or dilated cardiomyopathy (27 patients) (excluding those with other known causes for cardiomyopathy) examined between January 1988 and May 1991 were identified. The direction of flow in the three main segments of the left coronary system was determined by Doppler color flow mapping. In all 10 patients with anomalous left coronary artery, flow mapping demonstrated an abnormal jet from the left coronary artery into the pulmonary trunk and retrograde flow in at least two segments of the left coronary system. The diagnosis was confirmed in all 10 patients at operation. Doppler color flow mapping, performed in 19 of the 27 patients with dilated cardiomyopathy, demonstrated anterograde flow in at least one segment of the left coronary system in 16 of the 19 patients; flow direction was not determined in the other 3 patients. Coronary artery anatomy was confirmed by aortic root or left ventricular angiography in 14 patients and at autopsy in 1 patient and was not directly confirmed in 4 patients. Left ventricular function spontaneously improved to normal in three of the latter four patients, a clinical course not consistent with anomalous left coronary artery. The left coronary artery appeared to arise from the aortic root by two-dimensional echocardiographic imaging alone in all patients with dilated cardiomyopathy and in 5 of 10 patients with anomalous left coronary artery (50% false negative diagnoses).

CONCLUSIONS

Detection of an abnormal jet into the pulmonary trunk and retrograde flow in the left coronary system by Doppler color flow mapping is reliable for diagnosing anomalous left coronary artery whereas two-dimensional echocardiographic imaging alone is often inconclusive or misleading. Determining flow direction in the left coronary system in patients with dilated cardiomyopathy is useful for excluding anomalous left coronary artery but is technically more difficult to document in this condition than in anomalous left coronary artery.

Developmental modulation of myocardial mechanics: age- and growth-related alterations in afterload and contractility

Somatic growth is associated with alterations in myocardial mechanics in children with heart disease and in most animal models of congenital heart disease. However, the effect of age and body size on myocardial contractility and loading conditions in normal infants and children is not known. Therefore, 256 normal children aged 7 days to 19 years (34% less than 3 years old) were evaluated with noninvasive indexes of left ventricular contractility and loading conditions. Two-dimensional and M-mode echocardiographic recordings of the left ventricle were obtained with a phonocardiogram, indirect pulse tracing and blood pressure recordings. Left ventricular dimensions, wall thickness and pressure measurements obtained from these data were used to calculate peak and end-systolic circumferential and meridional wall stress and mean and integrated meridional wall stress. Velocity of shortening adjusted for heart rate was compared with end-systolic stress to assess contractility independently of loading status. The subjects were stratified for gender and each of the derived variables was related to age and body surface area. Ventricular shape, assessed as the major/minor axis ratio, and the circumferential/meridional stress ratio were found to be invariant with growth. The ratio of posterior wall thickness to minor axis dimension did not change with age, despite the normal age-related increase in blood pressure. The increase in pressure despite unvarying ventricular shape and wall thickness/dimension ratio resulted in a substantial increase in wall stress that was most dramatic during the first few years of life. In association with the increase in afterload, systolic function decreased with age. However, the age-related decrease in the velocity of shortening was greater than that expected from the increase in afterload alone, indicating a higher level of contractility in infants and children during the first years of life than in older subjects. The process of normal growth and development, similar to that in children with heart disease, is associated with a rapid decrease in the trophic response to hemodynamic loads, resulting in an age-associated increase in wall stress. There is a similar but somewhat more rapid decrease in contractility, with the highest values seen in the youngest patients.

Bulboventricular foramen size in infants with double-inlet left ventricle or tricuspid atresia with transposed great arteries: Influence on initial palliative operation and rate of growth

Bulboventricular foramen obstruction may complicate the management of patients with single left ventricle. Bulboventricular foramen size was measured in 28 neonates and infants greater than 5 months old and followed up for 2 to 5 years in those patients whose only systemic outflow was through the foramen. The bulboventricular foramen was measured in two planes by two-dimensional echocardiography, its area calculated and indexed to body surface area. One patient died before surgical treatment. The mean initial bulboventricular foramen area index was 0.94 cm2/m2 in 12 patients (Group A) in whom the foramen was bypassed as the first procedure in early infancy. The remaining 15 patients underwent other palliative operations but the bulboventricular foramen continued to serve as the systemic outflow tract. There was one surgical death. Six (Group B) of the 14 survivors developed bulboventricular foramen obstruction during follow-up (mean initial bulboventricular foramen area index 1.75 cm2/m2). The remaining eight patients (Group C) did not develop obstruction during follow-up and had an initial bulboventricular foramen larger than that in the other two groups (mean initial bulboventricular foramen area index 3.95 cm2/m2). All patients with an initial bulboventricular foramen area index less than 2 cm2/m2 who did not undergo early bulboventricular foramen bypass developed late obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary valve-moderator band distance and association with development of double-chambered right ventricle

Double-chambered right ventricle (DCRV), a form of right ventricular outflow obstruction that sometimes accompanies a ventricular septal defect (VSD), is associated with superior and rightward displacement of the septal insertion of the moderator band. It was hypothesized that this superior displacement is present and identifiable by echocardiography in patients with a VSD even before right ventricular outflow tract obstruction develops. Eight patients who had a previous echocardiographic study showing a VSD alone were echocardiographically diagnosed as having DCRV. Their initial echocardiographic studies were reviewed, and superior displacement of the moderator band was quantified by measuring the distance between the pulmonary valve and moderator band, normalized to tricuspid anulus diameter. These measurements were compared with those from the initial studies of the following 3 other groups: (1) an age-matched group of 10 patients with no structural heart disease; (2) an age-matched group of 10 patients with a VSD who did not develop DCRV; and (3) a group (not age-matched) of 10 patients with VSD and DCRV in whom subpulmonary obstruction was present on the initial study. The 8 patients who eventually developed subpulmonary obstruction had significant superior displacement of the moderator band at the time of their initial echocardiogram compared with that of the 2 age-matched control groups (p less than 0.01). In contrast, there was no significant difference in moderator band displacement between these patients and the 10 with DCRV who already had right ventricular outflow obstruction at their initial study (p = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional echocardiography in the pre- and postoperative management of totally anomalous pulmonary venous connection

The records of 23 infants who underwent surgical repair of isolated totally anomalous pulmonary venous connection were reviewed to assess the accuracy of pre- and postoperative echocardiographic diagnoses. Preoperative echocardiographic diagnoses were accurate in 22 of 23 patients, including the sites of connection of the individual pulmonary veins. Cardiac catheterization in 13 patients confirmed the echocardiographic findings. Analysis of multiple pre- and postoperative variables revealed no statistically significant difference between the infants with and without catheterization, although there was a tendency toward a higher mortality rate in the catheterized group. Postoperative echocardiographic examination revealed obstruction to pulmonary venous return in 7 of 19 patients. Catheterization confirmed the echocardiographic findings, localizing the obstruction in one patient. The size of the venoatrial anastomosis was measured on postoperative echocardiograms performed on 14 patients. The cross-sectional area of the anastomosis was less than 0.3 cm2/m2 of body surface area in the four patients with obstruction of the anastomosis, and greater than 0.95 cm2/m2 in all long-term survivors examined. Two-dimensional echocardiography with pulsed Doppler examination and Doppler color flow mapping is an excellent means of diagnosing totally anomalous pulmonary venous connection. The connections of the individual pulmonary veins can be identified in nearly all cases. Surgical repair can usually be undertaken on the basis of echocardiographic diagnosis alone. Echocardiography also provides an extremely accurate method of evaluating surgical repair and of identifying and localizing postoperative obstruction to pulmonary venous return.

The "laid-back" aortogram: an improved angiographic view for demonstration of coronary arteries in transposition of the great arteries

Preoperative demonstration of coronary arterial anatomy may be important for babies undergoing the arterial switch operation. Echocardiography is clearly useful, but may not unequivocally show all coronary branches. Standard angiographic views can be confusing. An improved angiographic projection in which the frontal x-ray tube is caudally angled, resulting in a "laid-back" position of the image intensifier and cine camera, provides superior visualization of the coronary arteries and their relation to the aorta and the pulmonary artery. The balloon occlusion technique is used for opacification of the aortic root from the transvenous approach. Injection of 1 ml/kg of contrast delivered in 1/2 to 1 second provides the best images. The caudal aortogram is easier to interpret than standard views and facilitates description and recognition of various coronary patterns. The relation between the pulmonary artery and the aorta, the origins of the coronary arteries from the facing sinuses and their proximity to the intercoronary commissures, and the myocardial distribution of each coronary vessel are shown clearly. The caudal view therefore offers significant advantages over conventional projections for demonstration of coronary arterial anatomy in infants with transposition of the great arteries or double-outlet right ventricle.

Orthotopic heart transplantation for complex congenital heart disease

Orthotopic heart transplantation has become standard therapy for end-stage cardiomyopathy in children and adults, but there has been much less experience with transplantation for complex congenital heart disease. In this report experience with orthotopic transplantation in seven children with various forms of complex congenital heart disease is reviewed. Diagnoses included hypoplastic left heart syndrome in two (after stage I palliation), left ventricular diverticulum in one, single ventricle in two (dextrocardia, atrial situs inversus, and total anomalous pulmonary venous return in one patient and post-Fontan repair in the second), D-transposition of the great arteries and ventricular septal defect (post-Senning repair and ventricular septal defect closure) in one, and Ebstein's anomaly with biventricular dysplasia in one. Six of the seven were hospital survivors and there has been one late death at 2 1/3 years. Modifications of the standard operative technique to fit the anatomic variations in these defects are reviewed.

Left ventricular contractility and function in Kawasaki syndrome. Effect of intravenous gamma-globulin

To investigate the effect of Kawasaki syndrome on myocardial function, as well as the influence of high-dose intravenous gamma-globulin therapy on resolution of functional abnormalities, we studied 98 patients with Kawasaki syndrome during five time intervals from onset of illness: 1) 10 days or less, 2) 11-31 days, 3) 1-3 months, 4) 3-12 months, and 5) 1-3 years. Normal controls included 48 children under age 8 years, without known cardiovascular disease. Using two-dimensional directed M-mode echocardiograms, we obtained chamber dimensions, fractional shortening, rate-corrected velocity of shortening (Vcfc) adjusted for end-systolic wall stress, and early diastolic function parameters that included adjusted peak rates of left ventricular dimension change, wall thinning, and their respective timing. Left ventricular systolic and diastolic dimensions were larger (both p less than 0.01) in patients than in normal subjects in period 1. Stress-adjusted Vcfc was much lower in patients in the 3 months after disease onset; by period 5, contractility was comparable in patients and normal subjects. Adjusted indexes of early diastolic function did not differ significantly between patients and normal subjects. To investigate the effect of gamma-globulin, we analyzed data on 47 patients prospectively randomized to therapy with aspirin alone (n = 19, 40%) or to aspirin plus gamma-globulin, 400 mg/kg/day for 4 consecutive days (n = 28, 60%). In period 1, before treatment, the two groups had mean fractional shortening and stress-adjusted Vcfc comparable to each other but much lower than those of normal subjects (p less than or equal to 0.001). Patients treated with aspirin alone continued to have diminished fractional shortening and Vcfc compared with normal subjects in periods 2, 3, and 4 (all p less than or equal to 0.05). In contrast, fractional shortening and Vcfc in gamma-globulin-treated patients in these periods were comparable to those of normal subjects. By period 5, no difference was detected in systolic function or contractility between either treatment group and normal subjects. We conclude that early abnormalities of left ventricular contractility and myocardial function, as assessed by echocardiography, generally resolve by 1-3 years after disease onset and that recovery is accelerated by administration of IVGG in the acute phase.

Recognition of abnormal connections of coronary arteries with the use of Doppler color flow mapping

Anomalous connection of a coronary artery to a ventricle or pulmonary artery causes shunting of blood from the coronary circuit and may produce myocardial ischemia. Such a coronary anomaly may occur in isolation or with other defects. Doppler color flow mapping and two-dimensional echocardiography were used to diagnose anomalous coronary connections in 13 patients, 1 day to 7 years of age, over a 1 year period. The diagnoses were anomalous origin of the left coronary artery from the pulmonary trunk in five patients, a coronary artery to left ventricle fistula or coronary artery to pulmonary artery fistula in four patients with other complex defects, right ventricular sinusoids in two patients with pulmonary atresia and intact ventricular septum and an isolated coronary artery fistula in two patients. In all cases, the abnormal coronary connection was recognized on the basis of an abnormal, continuous or to and fro flow pattern in the fistula and its connections as demonstrated by scanning in multiple views with Doppler color flow mapping. The low spatial resolution of Doppler color flow mapping limits the anatomic detail available; nonetheless, it is a significant advance in the noninvasive diagnosis of abnormal coronary connections.

Echocardiographic diagnosis of fetal heart defects in mid trimester

One hundred and thirty five consecutive fetuses of between 16 and 23 weeks' gestation that were considered to be at high risk of having structural heart defects were examined prospectively to determine the reliability of echocardiography for diagnosing such defects in mid trimester. Each echocardiogram was done in a standard manner and cardiac anatomy was analysed segmentally. Twelve fetuses were excluded from analysis because of lack of follow up. Of the remaining 123 fetuses, 109 had no evidence of heart disease when followed up. In this group the prenatal echocardiogram was normal in 105 and technically inadequate in four; thus there were no false positive diagnoses of heart disease in fetuses subsequently shown to have normal hearts. Fourteen had heart defects at follow up. The serious defect was correctly diagnosed prenatally in 10 of 14 cases, whereas in the other four the prenatal echocardiogram was considered normal. Some errors were made in diagnosing associated segmental defects particularly if the heart disease was complicated. Therapeutic abortion was carried out in seven cases; in five of the fetuses the prenatally diagnosed heart defect was the sole or an important contributing reason for the abortion. We conclude that echocardiography is a reliable method for diagnosing many heart defects in the mid trimester.

Midterm results after the arterial switch operation for transposition of the great arteries with intact ventricular septum: clinical, hemodynamic, echocardiographic, and electrophysiologic data

Although the short-term results of atrial level repair of transposition of the great arteries (TGA) are satisfactory, longer follow-up has disclosed a significant incidence of systemic right ventricular dysfunction and rhythm disturbances. The arterial switch operation (ASO) may represent a major improvement by restoring the left ventricle as the systemic ventricle and avoiding extensive atrial surgery. We have prospectively evaluated 49 consecutive survivors of ASO for TGA with intact ventricular septum (IVS) by clinical examination, echocardiography, cardiac catheterization, ambulatory electrocardiographic monitoring, and invasive electrophysiologic studies. The mean length of follow-up has been 29 +/- 14 (SD) months after surgery. All children are currently asymptomatic and on no medications. Severe supravalvular pulmonary stenosis (greater than 60 mm Hg) was present in five children, all of whom have undergone reoperation. No patient has severe supravalvular aortic obstruction. Mild degrees of supravalvular pulmonary or aortic obstruction have not progressed. Seven children (14%) have trivial or mild aortic regurgitation. Two children have proximal occlusion of the left anterior descending coronary artery with adequate retrograde collateral perfusion. One child had an electrocardiographic pattern of inferior myocardial infarction without evidence of ventricular dysfunction. Systemic (left) ventricular function is normal as measured by end-diastolic pressure (mean 7 +/- 6 mm Hg), ejection fraction (mean 68 +/- 6%), end-diastolic volume (mean 101 +/- 22% of predicted normal), and cardiac index (mean 4.7 +/- 1.3 liters/min/m2). Only one patient has sinus node dysfunction. There have been no late deaths. These early results are encouraging. We conclude that the arterial switch operation is currently the procedure of choice for neonates with TGA and IVS.

Left ventricular mechanics in the normal newborn

The transition from fetal to neonatal circulatory status is accompanied by marked alteration in relative right and left ventricular systolic and diastolic pressure. These alterations would be expected to influence both global and regional performance of the left ventricle. To address this issue, sequential two-dimensional echocardiographic studies were performed in normal newborns during the first days of life. Global and regional left ventricular wall motion were quantified by computer digitization with the use of an automated edge detection algorithm and a floating-center-of-mass model. Comparison was made with a control group of normal infants and young children and the sequential change over the first 5 days of life was assessed. Newborns were found to have a circular left ventricular configuration at end-diastole beginning on day 1. At end-systole, however, there was significant left ventricular distortion due to septal flattening, which persisted until day 3 and resolved entirely by day 5 of life. Regional wall motion analysis demonstrated a corresponding augmentation of septal and contralateral left ventricular free wall systolic movement during the first days of life, with a normal pattern attained by day 4. Due to the nonhomogeneity of the left ventricular wall motion in the first few days of life, standard single-dimension shortening fraction provided an unreliable measure of global left ventricular performance before day 4. Thus, systolic right ventricular hypertension at a level sufficient to distort the left ventricular configuration is present until day 4 or 5 of life, resulting in altered left ventricular regional wall motion. As a result, usual M mode echocardiographic assessment of left ventricular function is unreliable in this age group.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of coronary artery anatomy by two-dimensional echocardiography in patients with transposition of the great arteries

With the increasing popularity of the Jatene procedure for the treatment of common or D-transposition of the great arteries (D-TGA), the preoperative definition of coronary artery anatomy in D-TGA has assumed great importance. Consequently, the reliability of two-dimensional echocardiography for determining the coronary artery anatomy was studied in 32 infants with D-TGA. Surgical observation of the coronary anatomy was used to assess the accuracy of the echocardiographic diagnosis. The coronary arteries were visualized in 29 of 32 patients (90%), predominantly with the use of parasternal and apical views. In the three remaining patients visualization of the coronary arteries was inadequate to allow determination of their anatomy. The coronary artery anatomy was correctly predicted in 25 of the 29 patients in whom the coronary arteries were visualized. The anatomic patterns included usual coronary anatomy for D-TGA (n = 16), left circumflex coronary from the right coronary artery (n = 6), single right coronary artery (n = 1), single left coronary artery (n = 1), and inverted origin of the coronary arteries (n = 1). The errors in the remaining four patients were (1) false-negative diagnosis of origin of the left circumflex coronary from the right coronary artery (n = 1); (2) false-positive diagnosis of origin of the left circumflex coronary from the right coronary artery (n = 1), and (3) diagnosis of origin of the left circumflex coronary from the right coronary artery when the correct diagnosis was single right coronary artery (n = 2).(ABSTRACT TRUNCATED AT 250 WORDS)

Regional and global left ventricular function in infants with anomalous origin of the left coronary artery from the pulmonary trunk: preoperative and postoperative assessment

Anomalous origin of the left coronary artery from the pulmonary trunk (ALCA) remains a diagnostic as well as a therapeutic problem. The purposes of this study were: (1) to analyze left ventricular mechanics, including regional wall motion, in infants with ALCA, (2) to determine if the pattern of wall motion in infants with ALCA distinguishes these patients from those with congestive cardiomyopathy of other causes, and (3) to evaluate the potential for recovery of left ventricular function after successful restoration of a dual coronary artery system. Left ventricular mechanics were studied before and serially after surgery in six infants (2 to 13 months old) with ALCA. Fifteen age-matched normal subjects and seven age-matched patients with idiopathic congestive cardiomyopathy were also studied for comparison. Preoperatively, the end-diastolic volume in infants with ALCA was about four times larger than normal and did not differ from that in infants with CM; the myocardial volume was also about three times larger than normal, similar to that in the patients with CM. The myocardial volume/end-diastolic volume ratio was extremely low in patients with ALCA and in those with CM. The infants with ALCA did not exhibit specific segmental wall motion abnormalities but rather had global hypokinesis indistinguishable from that in the patients with CM. After successful repair, end-diastolic volume index rapidly decreased, reaching near normal values by 7 to 22 months after surgery, while myocardial volume index decreased at a slower rate, leading to an early phase of "overshoot hypertrophy," but reaching normal values by 7 to 22 months after surgery.+

Two-dimensional echocardiographic anatomy in crisscross heart

The anatomy of crisscross heart was studied in 14 patients, aged 2 days to 26 years, using 2-dimensional (2-D) echocardiography. The visceroatrial situs was solitus in all 14 patients. Crossing of the atrioventricular (AV) valves could be seen in each case by scanning in a subxiphoid or apical 4-chamber view. The subpulmonary infundibulum was deficient in 13 of the 14 patients, resulting in approximation of the pulmonary and tricuspid valves. Subpulmonary stenosis, seen in 11 patients, resulted from proximity of the infundibular septum, the tricuspid valve and the subpulmonary infundibular free wall. A subaortic infundibulum, present in all cases, was well developed in 13 patients, who had malposition of the great arteries, and was short in 1 patient, with nearly normally related great arteries. In cases that conformed to the inverse loop rule (segmental combination (S,D,L) or (S,L,D)), the pulmonary valve was posterior to the tricuspid valve and wedged between the AV valves. In 3 patients (double outlet right ventricle (S,D,L)) the mitral valve straddled into a large, left-sided subaortic infundibulum. In both patients with arterial malposition who did not follow the inverse loop rule, the pulmonary trunk was anterior to the tricuspid valve and well separated from the mitral valve. In patients with crisscross heart the ventricles appeared to have been rotated about their long axes without concomitant motion of the AV valve anuli, producing actual crossing of the ventricular inflow tracts. The right ventricular sinus was significantly smaller and the infundibulum significantly larger in the patients with crisscross heart than in age-matched control subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Obstruction of right ventricular inflow and outflow in corrected transposition of the great arteries (S,L,L): two-dimensional echocardiographic diagnosis

Obstruction of systemic ventricular inflow and outflow is considered uncommon in corrected transposition of the great arteries (S,L,L). Between 1979 and 1985, 42 patients with corrected transposition and two ventricles and atrioventricular valves underwent two-dimensional echocardiography. Obstruction of right ventricular inflow and outflow was present and diagnosed by two-dimensional echocardiography in 5 of the 42 patients. A supratricuspid stenosing ring, recognized in the apical or subxiphoid four chamber view as a bright, linear structure on the left atrial side of the tricuspid valve, occurred in two patients. Subaortic obstruction due to infundibular hypertrophy with or without displaced muscle bundles was seen in three patients. Subxiphoid long- and short-axis views and parasternal long-axis views best displayed these features. Aortic coarctation was present in four cases and could be diagnosed using modified suprasternal notch views. Thus, systemic ventricular inflow and outflow obstruction may be more common in corrected transposition than previously believed (occurring in up to 10 to 15% of patients). The mechanisms producing the obstruction appear to be characteristic of the left atrium and right ventricle irrespective of location or connections. Echocardiography appears to be an excellent technique for diagnosing these associated lesions in corrected transposition.