Tetralogy of Fallot with vertebral defect and left aberrant subclavian artery: a rare occurrence

BACKGROUND

The most prevalent cyanotic congenital heart disease is Tetralogy of Fallot (TOF). It has a variety of presentations and is made up of four anatomic abnormalities. Documented literature shows an incidence of 13-20% of a right aortic arch with an anomalous left subclavian artery among individuals diagnosed with TOF. This is the first case that discusses the rare occurrence of overriding of the aortic arch along with the left aberrant subclavian artery and vertebral defect in a 3-week-old girl. Timely identification and management are pivotal in ensuring the best possible outcomes for these young patients.

CASE PRESENTATION

A 3-week-old female child came with complaints of dyspnea, dysphagia, fatigue, and cyanosis on extreme crying, feeding, and moderate activity. Echocardiography revealed severe pulmonary stenosis with right ventricular dilatation and ventricular septal defect (VSD); a chest computed tomography was performed that revealed four characteristic features of TOF (pulmonary artery stenosis, VSD, right aortic root deviation, and concentric right ventricular hypertrophy) along with overriding of the aortic arch accompanied with the left aberrant subclavian artery (compressing the trachea and infundibulum) and vertebral defect (butterfly vertebra).

CONCLUSIONS

The case of this 3-week-old female infant emphasizes the importance of early and accurate diagnosis in congenital heart diseases, particularly when faced with complex presentations such as the TOF. It serves as a testament to the valuable role of advanced diagnostic imaging techniques in unraveling the complexity of congenital heart conditions.

Tricuspid valve annular tilt for assessment of pre- and post-intervention right ventricular volume in patients undergoing transcatheter pulmonary valve replacement

INTRODUCTION

Transcatheter pulmonary valve replacement serves as a successful alternative to surgical replacement of a right ventricle to pulmonary artery conduit. Guidelines for recommending transcatheter pulmonary valve replacement depend on MRI right ventricular volumes, which have been correlated to the echocardiographic measure of right ventricular annular tilt. We aim to assess whether right ventricular annular tilt can be a clinically useful alternative tool in the acute and long-term periods after transcatheter pulmonary valve replacement to assess right ventricular health.

METHODS

We reviewed 70 patients who underwent transcatheter pulmonary valve replacement at a single institution. Echocardiographic measurements were obtained prior to transcatheter pulmonary valve replacement, immediately after transcatheter pulmonary valve replacement, and within 6 months to 1 year after transcatheter pulmonary valve replacement. Right ventricular annular tilt measures the angle of the tricuspid valve plane relative to the mitral valve plane at end-diastole in the apical four-chamber view. Right ventricular fractional area change, right ventricular systolic strain, tissue Doppler velocity, and tricuspid annular plane systolic excursion Z-scores were obtained using published methods.

RESULTS

Right ventricular annular tilt decreased significantly immediately after transcatheter pulmonary valve replacement (p = 0.0004), and this reduction in right ventricular volume persisted at the mid-term follow-up (p < 0.0001). Fractional area change did not change significantly after transcatheter pulmonary valve replacement while right ventricular global strain improved at mid-term follow-up despite no significant difference immediately after transcatheter pulmonary valve replacement.

CONCLUSIONS

Right ventricular annular tilt decreases both immediately after transcatheter pulmonary valve replacement and at mid-term follow-up. Right ventricular strain also improved after transcatheter pulmonary valve replacement, corresponding to the improved volume load. Right ventricular annular tilt can be considered as an additional echocardiographic factor to assess right ventricular volume and remodeling after transcatheter pulmonary valve replacement.

Comparison of Postoperative, In-Hospital Outcomes After Complete Repair of Tetralogy of Fallot Between 22q11.2 Deletion Syndrome and Trisomy 21

22q11.2 deletion syndrome (22q11) and trisomy 21 (T21) are frequently associated with tetralogy of Fallot (TOF). We hypothesized that there are differences in postoperative length of stay (LOS) and occurrence of postoperative interventions after complete repair of TOF when comparing children with 22q11 to those with T21. Using the Pediatric Health Information System, we performed a retrospective cohort study of patients who underwent complete repair of TOF from 2004 to 2019. Three groups were identified: 22q11, T21, and controls (those without a coded genetic syndrome). Outcomes were postoperative LOS and composite occurrence (yes/no) of at least one postoperative intervention. Bivariate and multivariate comparisons were made among groups; odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the control group as the comparator. There were 6924 subjects (n = 493 22q11, n = 455 T21, n = 5976 controls). In bivariate analysis, 22q11 was associated with a longer LOS compared to T21 (OR 2.37 [2.16, 2.60] vs. 1.25 [1.12, 1.39], p < 0.001), and 22q11 more often underwent postoperative intervention (OR 3.42 [CI 2.56, 4.57] vs. 1.38 [CI 0.91, 2.11]; p < 0.001). In multivariate analysis, 22q11 was also associated with longer LOS (adjusted OR 1.35 [1.26, 1.44] vs. 1.12 [1.04, 1.20]; p < 0.001), but there was no difference in the adjusted odds of postoperative intervention. Children with 22q11 are more likely to experience adverse outcomes after repair of TOF compared to those with T21; the differences are most pronounced for LOS.

Outcomes of adults with repaired tetralogy of Fallot from the national Scottish Cohort

BACKGROUND

The adult population of repaired tetralogy of Fallot is increasing and at risk of pre-mature death and arrhythmia. This study evaluates risk factors for adverse outcome and the effect of pulmonary valve replacement within a national cohort.

METHODS

A retrospective cohort study of 341 adult repaired tetralogy of Fallot (16-72 years) managed through a single national service was undertaken incorporating over 1200 patient-years of follow-up. Demographics, cardiopulmonary exercise testing, cardiac magnetic resonance, reintervention (including pulmonary valve replacement), and clinical events were analysed. The influence of these parameters on a primary outcome (death or arrhythmia) was evaluated.

RESULTS

Compared with an age-/gender-matched population, patients experienced a reduced survival, particularly males over 55 years (standardised mortality ratio : 6.12, 95% CI: 1.64-15.66, p = 0.004). Cox proportional hazards modelling identified increased indexed right ventricle (RV) end-diastolic volume (hazard ratio (HR): 2.86, 95% CI: 1.4-5.85, p = 0.004) and female gender (HR (male): 0.37, 95% CI: 0.14-0.98, p = 0.045) to be predictors significantly associated with the primary outcome. Pulmonary valve replacement undertaken at indexed RV end-diastolic volume = 145 ml/m2 reduced RV volumes and QRS duration but did not improve cardiopulmonary exercise testing nor NYHA class. Pulmonary valve replacement during cohort period was associated with increased risk of primary outcome (HR: 2.82, 95% CI: 1.36-5.86, p = 0.005).

CONCLUSIONS

Although the majority of adult tetralogy of Fallot were asymptomatic in NYHA 1, cardiopulmonary exercise testing revealed important deficits. Tetralogy of Fallot survival was reduced compared to the general population. Female gender and increasing RV end-diastolic volume predicted adverse events. Pulmonary valve replacement reduced RV volumes and QRS duration but did not improve primary outcome.

Quantification of Right Ventricular Electromechanical Dyssynchrony in Relation to Right Ventricular Function and Clinical Outcomes in Children with Repaired Tetralogy of Fallot

BACKGROUND

Electromechanical dyssynchrony occurs ubiquitously following tetralogy of Fallot (TOF) repair, manifesting electrically as a wide QRS duration and mechanically as a right-sided septal/apical flash. Early septal activation and prestretch of the right ventricular (RV) basal lateral wall followed by its postsystolic shortening contributes to inefficient RV mechanics. However, a right-sided septal flash is a dichotomous finding, and the severity of RV dyssynchrony as a continuous spectrum in relationship to RV dysfunction and clinical outcomes in patients with repaired TOF has not been studied. The aim of this study was to quantify the severity of electromechanical dyssynchrony in relation to RV remodeling and clinical outcomes in a pediatric cohort following TOF repair.

METHODS

A retrospective analysis was performed in 81 children with RV volume loading after TOF repair, aged 13.6 ± 2.9 years, and compared with 50 matched control subjects.

RESULTS

Patients had higher RV basal-lateral prestretch and postsystolic strain amplitude and duration, RV mechanical dispersion, and basal lateral-septal wall delay compared with control subjects (P < .001 for all). All intra-RV dyssynchrony timing parameters were associated with reduced cardiac magnetic resonance-derived RV ejection fraction and/or echocardiography-derived RV longitudinal strain. Prestretch duration as a percentage of total shortening time and RV basal lateral-to-midseptal delay were independently associated with RV dysfunction. Postsystolic strain amplitude was higher in patients with ventricular arrhythmias compared with arrhythmia-free patients (7.8% [4.2%-13%] vs 2.0% [0%-12.5%], P = .03).

CONCLUSION

RV prestretch duration, postsystolic strain, and RV lateral-septal delay quantify RV electromechanical dyssynchrony severity and reflect the underlying pathophysiology. The prestretch duration percentage and RV basal lateral-to-midseptal delay were independently associated with RV dysfunction, potentially providing a clinical tool to quantify RV electromechanical dyssynchrony.

Current outcomes and treatment of tetralogy of Fallot

Tetralogy of Fallot (ToF) is the most common type of cyanotic congenital heart disease. Since the first surgical repair in 1954, treatment has continuously improved. The treatment strategies currently used in the treatment of ToF result in excellent long-term survival (30 year survival ranges from 68.5% to 90.5%). However, residual problems such as right ventricular outflow tract obstruction, pulmonary regurgitation, and (ventricular) arrhythmia are common and often require re-interventions. Right ventricular dysfunction can be seen following longstanding pulmonary regurgitation and/or stenosis. Performing pulmonary valve replacement or relief of pulmonary stenosis before irreversible right ventricular dysfunction occurs is important, but determining the optimal timing of pulmonary valve replacement is challenging for several reasons. The biological mechanisms underlying dysfunction of the right ventricle as seen in longstanding pulmonary regurgitation are poorly understood. Different methods of assessing the right ventricle are used to predict impending dysfunction. The atrioventricular, ventriculo-arterial and interventricular interactions of the right ventricle play an important role in right ventricle performance, but are not fully elucidated. In this review we present a brief overview of the history of ToF, describe the treatment strategies currently used, and outline the long-term survival, residual lesions, and re-interventions following repair. We discuss important remaining challenges and present the current state of the art regarding these challenges.

Illustrated Imaging Essay on Congenital Heart Diseases: Multimodality Approach Part III: Cyanotic Heart Diseases and Complex Congenital Anomalies

From the stand point of radiographic analysis most of the complex cyanotic congenital heart diseases (CHD), can be divided into those associated with decreased or increased pulmonary vascularity. Combination of a specific cardiac configuration and status of lung vasculature in a clinical context allows plain film diagnosis to be predicted in some CHD. Correlation of the position of the cardiac apex in relation to the visceral situs is an important information that can be obtained from the plain film. This information helps in gathering information about the atrio-ventricular, ventricular arterial concordance or discordance. Categorization of the cyanotic heart disease based on vascularity is presented below. Thorough understanding of cardiac anatomy by different imaging methods is essential in understanding and interpreting complex cardiac disease. Basic anatomical details and background for interpretation are provided in the previous parts of this presentation.

Right Ventricular Apical Flattening as an Echocardiographic Screening Tool for Right Ventricular Enlargement

Right ventricular dilation is a common complication after tetralogy of Fallot (TOF) repair. Traditional echocardiographic assessments are imprecise due to the RV's location and complex geometry. We propose a novel echocardiographic measurement: RV apical flattening (RVAF) as a screening tool to help identify subjects with severe RV dilation. Patients with repaired TOF who had both echocardiograms and CMR's within 6-month interval at our institution were included in the study. The RVAF was measured in the four-chamber echocardiographic view as the minor length of RV cavity at the level of RV apical endocardium. Subjects were divided into two groups (group I: RVEDVi ≥ 150 ml/m(2) and group II; RVEDVi < 150 ml/m(2)). Echocardiogram and CMR data were compared between groups. A total of 75 subjects were included in the study. Mean age was 12.8 ± 3.6 years. Group I had 36 subjects, and group II had 39 subjects. The mean RVAF was significantly higher in group I (2.7 ± 0.5 cm) compared with group II (1.7 ± 0.4 cm; p < 0.001). There was significant correlation between RVAF and RVEDVi (r = 0.81; p < 0.001). By ROC analysis, an RVAF cutoff value of 2.0 cm had 94 % sensitivity and 77 % specificity in identifying severe RV dilation (area under the curve 0.95). RVAF is a simple and effective echocardiographic screening tool to help identify severe RV dilation. In conjunction with other 2D echocardiographic parameters, this technique would help further refine echocardiography-guided patient selection for timing of CMR and pulmonary valve replacement.

Meningitis and brain abscess: First but fatal presentation in a child with tetralogy of fallot

Brain abscess is a known complication of cyanotic congenital heart diseases. We report the case of a four-year-old girl whose first presentation in the hospital was because of symptoms referable to the neurological system. These symptoms are similar to those seen in cerebral malaria as well as other infections of the central nervous system, e.g. meningitis and encephalitis. Detailed history, painstaking examination, and investigations will however help in differentiating these conditions. In the index case however, the illness was fatal due to the late presentation, which is not uncommon in this environment. In a resource-poor environment such as Nigeria, this is a reminder that proper history taking, clinical examination, and subsequent investigations will aid in early diagnosis and subsequent management of such cases to reduce childhood mortality. It also underscores the need for increased awareness among primary health care providers. .

Children With Tetralogy of Fallot in an Urban Centre in Africa

Introduction: There is a dearth of literature on tetralogy of fallot (TOF) in children in Sub-Saharan Africa. This study up aims to describe the prevalence, clinical profile and associated cardiac anomaly of children diagnosed with TOF documented over an eight year period in a tertiary hospital in South Western Nigeria.

Methods: A prospective review of all consecutive cases of TOF diagnosed with echocardiography at the Lagos State University Teaching Hospital (LASUTH) between January 2007 and December 2014. Data were analyzed using SPSS version 20. Tables and charts were used to depict those variables. Descriptive statistic are presented as percentages or means and standard deviation. Means of normally distributed variables were compared using the student t test and proportions using chi-square test. Skewed distribution were analyzed using appropriate non-parametric tests. Level of significance set at P < 0.05.

Result: The prevalence of TOF among children presenting at LASUTH at the study period was 4.9 per 10 000 while its prevalence among those with congenital heart disease was 16.9%. There was a male predominance and most children presented within 1-5 years of age. Chromosomal abnormalities such as Down syndrome, Turners syndrome and CATCH 22 syndrome were documented in some subjects. Some of the subjects had atypical presentation.

Conclusion: TOF is as common in Nigeria as other parts of the world, there is a need to established cardiac centers to salvage these children. Collaboration from developed countries will be helpful in this resource limited region.