Pulmonary artery dissection secondary to ventricular septal defect and pulmonary valve stenosis

The aortic short axis view demonstrated the widening of the pulmonary artery and the membrane-like echo in the pulmonary artery divided it into true lumen and false lumen. And the flow of the ruptured openings on the band-like echo was clearly revealed by Color Doppler.

Percutaneous pulmonary valve implantation in a patient with congenitally corrected transposition of the great arteries: a case report

BACKGROUND

Percutaneous pulmonary valve implantation has become an attractive method of dysfunctional right ventricle outflow tract treatment.

CASE PRESENTATION

We describe a unique case of a 20-year-old Caucasian male patient with a complex cyanotic heart defect, namely pulmonary atresia, with congenitally corrected transposition of the great arteries and ventricular septal defect after Rastelli-like surgery at the age of 5 years with homograft use. At the age of 20 years, the patient needed percutaneous pulmonary valve implantation owing to homograft dysfunction. Despite unusual course of the coronary arteries, balloon testing in the landing zone of the right ventricle outflow tract excluded potential coronary artery compression. Then, after presentation, a Melody valve was implanted successfully in the pulmonary valve position. The 8-year follow-up was uneventful.

CONCLUSION

This is likely the first description of a percutaneous pulmonary valve implantation in such anatomy. Such a procedure is feasible; however, it requires exceptional caution owing to the anomalous coronary arteries course, which can be the reason for their compression.

Impact of pulmonary stenosis on right ventricular global longitudinal strain in repaired tetralogy of Fallot patients post transcatheter pulmonary valve replacement

BACKGROUND

Mixed pulmonary disease with pulmonary regurgitation (PR) and stenosis (PS) in repaired tetralogy of Fallot (rTOF) can negatively impact ventricular health. Myocardial strain has been shown to be more sensitive at detecting occult ventricular dysfunction compared to right ventricular ejection fraction (RV EF). We hypothesize that rTOF patients with predominant PS will have lower RV global longitudinal strain (RV GLS) prior to and post-transcatheter pulmonary valve replacement (TPVR).

METHODS

A retrospective cohort of rTOF patients who underwent cardiac magnetic resonance (CMR) and cardiac catheterization for right ventricular pressure (RVSP) measurement were analyzed at three time points: before valve implantation, at discharge and within 18 months post-TPVR. Patients were dichotomized into three groups based on RVSP: 0%-49%, 50%-74%, and >75%. RV GLS and left ventricular (LV) GLS by speckle tracking echocardiography (STE) were obtained from the apical 4-chamber using TomTec software (TOMTEC IS, Germany).

RESULTS

Forty-eight patients were included. Every 14.3% increase in preimplantation RVSP above 28% was associated with an absolute magnitude 1% lower RV GLS (p = .001). Preimplantation RVSP when 75% or higher had 3.36% worse RV GLS than the lowest bin (p = .014). Overall, average RV strain magnitude was higher when preimplantation RVSP was less than 50% and had greater improvement over the three time points. Higher post implantation RVSP correlated with lower strain magnitude.

CONCLUSION

Patients with significant PS (>50%) may benefit from earlier PVR and not depend solely on RV size and EF. Myocardial strain may be a more sensitive marker of function; however, larger, prospective studies are needed.

Natural history of aortic root dilatation and pathologic aortic regurgitation in tetralogy of Fallot and its morphological variants

OBJECTIVE

We sought to characterize the natural history of aortic root dilatation and aortic regurgitation in tetralogy of Fallot (TOF).

METHODS

A single-center review of patients who underwent TOF repair from January 1960 to December 2022 was performed. Morphology was categorized as TOF-pulmonary stenosis or TOF-variant (including TOF-pulmonary atresia and TOF-pulmonary atresia-major aortopulmonary collateral arteries). Echocardiographically determined diameters and derived z scores were measured at the annulus, sinus of Valsalva, and sinotubular junction immediately before TOF repair and throughout follow-up. Linear mixed-effects models assessed trends in dimensions over time.

RESULTS

Of 2205 patients who underwent primary repair of TOF at a median age of 4.9 months (interquartile range, 2.3-20.5 months) and survived to discharge, 1608 (72.9%) patients had TOF-pulmonary stenosis and 597 (27.1%) patients had TOF-variant. At a median postoperative follow-up of 14.4 years (interquartile range, 3.3-27.6 years; range, 0.1-62.6 years), 313 (14.2%) patients had mild or greater aortic regurgitation and 34 (1.5%) patients required an aortic valve or root intervention. The overall mean rates of annular, sinus of Valsalva, and sinotubular junction growth were 0.5 ± 0.2, 0.6 ± 0.3, and 0.7 ± 0.5 mm/year, respectively. Root z scores remained stable with time. At baseline, patients with TOF-variant had larger diameters and z scores at the annulus, sinus of Valsalva, and sinotubular junction, compared with patients with TOF-pulmonary stenosis (all P values < .05). Over time, patients with TOF-variant demonstrated relatively greater annular (P = .020), sinus of Valsalva (P < .001), and sinotubular junction (P < .001) dilatation. Patients with ≥75th percentile root growth rates had a higher incidence of mild or greater aortic regurgitation (P < .001), moderate or greater aortic regurgitation (P < .001), and aortic valve repair or replacement (P = .045).

CONCLUSIONS

Patients with TOF-variant are at comparatively greater risk of pathologic root dilatation over time, warranting closer longitudinal follow-up.

Electrocardiographic manifestations of pulmonary stenosis versus pulmonary hypertension

BACKGROUND

Right ventricular hypertrophy can be caused by conditions such as pulmonary stenosis and pulmonary hypertension. ECG is a readily available and affordable test, the aim of this study was the evaluation of the electrocardiographic aspects of pulmonary stenosis, and pulmonary hypertension.

METHODS

A list of patients diagnosed with isolated pulmonary stenosis and pulmonary hypertension patients hospitalized and treated between 2019 and 2021 were extracted from the hospital archives. Furthermore, the ECG of the patients was analyzed in terms of the prevalence of the variables in the study using FECG Caliper software. Finally, the data of 93 patients (in both groups) were analyzed.

RESULTS

In this study, 46 patients were in the severe pulmonary stenosis group, and 49 were in the severe or moderate-to-severe pulmonary hypertension group. The heart rate in the pulmonary hypertension group was significantly higher. R/S > 1 in precordial leads differs between the two groups and higher amplitude R wave in V1(p-value = 0.05). in the pulmonary stenosis group. While in the pulmonary hypertension group, R wave growth occurs later, and this ratio is greater than one after V4. Bundle block in the form of RBBB(p-value <0.001) and maximum QRS duration is more in the pulmonary stenosis group(p-value = 0.001).

CONCLUSION

Our findings show the different strains of the right ventricle in two groups. It can be concluded that the effects of severe pulmonary stenosis on the ECG are more on the QRS wave and in the form of a block, while severe pulmonary hypertension affects the ST segment and T wave.

Cardiovascular Characteristics and Progressions of Hypertrophic Cardiomyopathy and Pulmonary Stenosis in RASopathy Syndrome in the Genomic Era

INTRODUCTION

To investigate cardiovascular characteristics and progressions of hypertrophic cardiomyopathy (HCM) and pulmonary stenosis (PS) and determine whether any genotype-phenotype correlations exist in patients with gene-confirmed RASopathy syndrome.

STUDY DESIGN

Eighty patients (male, 55%) confirmed as having RASopathy syndrome by genetic testing at a single tertiary center were enrolled. Subjects' medical and echocardiography records were reviewed and the changes in the z scores of left ventricular wall thickness (LVWT) and the degree of PS over time were examined during follow-up of 5.7 ± 3.1 and 7.5 ± 5.2 years, respectively.

RESULTS

The most common RASopathy gene identified was PTPN11 (56%), followed by RAF1 (10%). Eighty-five percent of patients had cardiovascular diseases, wherein 42% had HCM, and 38% PS. Mean maximal LVWT z score on the initial echocardiography (mean age 5.0 ± 6.0 years) was 3.4 ± 1.3 (median 2.8, range 2.1-6.6) in the HCM group. Overall, the maximal LVWT increased with time, especially in the HCM group (z = 3.4 ± 1.3 to 3.7 ± 1.6, P = .008) and RAF1-variant group (z = 3.7 ± 1.7 to 4.6 ± 1.8, P = .031). Five patients newly developed HCM during the study period. Genotype-phenotype correlation was significant for HCM (P = .002); 31% of patients with PTPN11 and 88% with RAF1 variants had HCM. PS did not progress in this study cohort.

CONCLUSIONS

In this study, progression of ventricular hypertrophy was seen in a significant number of patients with genotype correlation. Thus, long-term follow up of cardiovascular problems in patients with RASopathy is necessary.

Blood cyst of the pulmonary valve causing right ventricular outflow tract obstruction: A case report

Blood cysts are rare cardiac tumors, often involve the atrioventricular valves. Blood cysts are usually small and tend to be clinically silent. Here, we report a case of blood cyst adhered to the junction of the pulmonary valve and the right ventricular outflow, causing severe outflow obstruction. This case was initially misdiagnosed as pulmonary valve stenosis by transthoracic echocardiography (TTE) and even underwent percutaneous balloon pulmonary valvuloplasty (PBPV). As the right ventricle-to-pulmonary artery peak gradient did not decrease after PBPV procedure, the boy underwent TTE again and the diagnosis was corrected as blood cyst. The cystic mass was successfully resected subsequently, and the boy recovered well.

3q29 microdeletion syndrome associated with developmental delay and pulmonary stenosis: a case report

BACKGROUND

3q29 microdeletion syndrome (OMIM 609425), first described in 2005, is a rare copy number variation (CNV), accompanied by various neurodevelopmental and psychiatric problems. Phenotypic features of the syndrome have not been fully characterized due to the new definition and rarity. Facial dysmorphology, musculoskeletal anomalies, cardiovascular abnormalities, gastrointestinal abnormalities, and dental abnormalities can be seen.

CASE

A 28-month-old male patient was brought to the child and adolescent psychiatry clinic with a complaint of speech delay. He had mild dysmorphic symptoms. He was also sensitive to voice and often covered his ears. Balloon valvuloplasty was performed on the postnatal 28th day due to severe pulmonary stenosis. While karyotype was found to be normal, in array-Comparative genomic hybridization (aCGH), copy loss was detected in the long arm of chromosome 3 (arr[hg19] 3q29[196,209,689-197,601,344]x1), which contains approximately 1.4 Mb harboring 30 genes. Genetic counseling was given to the family of the patient who was diagnosed with 3q29 microdeletion syndrome.

CONCLUSIONS

In conclusion, we present 3q29 microdeletion syndrome with global developmental delay (GDD), dysmorphic face, hyperacusis, scoliosis, and severe pulmonary stenosis. Performing genetic analysis in patients with developmental delay and congenital heart disease (CHD) for which the cause cannot be explained will prevent these rare diseases from being missed, and the characteristics of the diseases will be better characterized with the reported cases.

OUP accepted manuscript

Association between hypoplastic left heart syndrome and valvular pulmonary stenosis is very rare. Severity of valvular pulmonary stenosis in this setting limits management options. Consequently, patients with this condition are considered poor candidates for Norwood stage one reconstruction. Herein, we describe a newborn with hypoplastic left heart syndrome and significantly dysplastic pulmonary valve who successfully underwent the Norwood procedure with neoaortic valve reconstruction. Therefore, the Norwood procedure with neoaortic valve reconstruction might be an option for this difficult condition.

Anesthetic Management of a Parturient With Double-Outlet Right Ventricle Obstruction and Pulmonary Stenosis Scheduled for Cesarean Delivery: Case Report and Review of Literature

Double-outlet right ventricle (DORV) is a rare cardiac condition in which both the aorta and pulmonary artery arise from the right ventricle, resulting in parallel systemic and pulmonary circulations. Usually, DORV is present with ventricular septal defect; however, the location of the ventricular septal defect and presence of pulmonary stenosis (PS) result in various physiological features and subtypes of DORV. Because DORV without PS causes congestive cardiac failure and DORV with PS results in cyanotic heart disease, anesthesia management varies widely according to the resultant physiological characteristics. Reports of anesthesia management in a parturient with DORV undergoing cesarean delivery is scarce because of the low incidence of DORV and the discouragement of these patients to conceive. Only 8 known previous such cases are reported, and almost all these patients were administered regional anesthesia. Here we describe a parturient with DORV, to whom general anesthesia was administered because of incidental antiphospholipid syndrome with low platelets. To the best of our knowledge, this scenario has not been described previously.

Sub-pulmonic stenosis caused by a right ventricular outflow tract vegetation in a children with restricted ventricular septal defect

Infective endocarditis involving the right heart is rarely observed in the pediatric population. Echocardiography plays an important role in its diagnosis, and surgery is indicated in patients with heart failure and persistent sepsis not responding to medical treatment. Here, we report a rare case of restricted ventricular septal defect complicated by a vegetation developed in the right ventricular outflow tract and causing sub-pulmonic stenosis in a 3-year-old male child.

[Giant Pulmonary Artery Aneurysm Associated with Pulmonary Valve Regurgitation and Stenosis Due to Quadricuspid Pulmonary Valve:Report of a Case]

A 64-year-old woman was diagnosed with dilatation of the pulmonary artery and pulmonary valve stenosis approximately 10 years ago. At the age of 63, she developed hemoptysis and was referred to our hospital. The pulmonary trunk was enlarged to 63 mm with moderate pulmonary valve insufficiency. The transpulmonary valve pressure gradient was 25 mmHg;thus, surgery was performed. A median sternotomy revealed a markedly dilated pulmonary trunk growing into the pericardial cavity. After opening the patient's pulmonary trunk to check the pulmonary valve, a thickened and shortened quadricuspid valve was observed. We replaced the pulmonary valve with a bioprosthetic valve and used a vascular prosthesis to reconstruct the pulmonary artery. The postoperative course was uneventful, and she was discharged 22 days after the surgery. Histopathological examination of the pulmonary artery aneurysm wall revealed cystic medial necrosis.

Novel coronary artery anomaly in a French bulldog with pulmonary stenosis

A 9-month-old French Bulldog with pulmonary stenosis (PS) underwent transthoracic echocardiography (TTE) and electrocardiogram-gated coronary computed tomography angiography (ECG-CCTA) for presurgical planning of pulmonary balloon valvuloplasty (PBV). Transthoracic echocardiography revealed severe PS and identified two distinct coronary ostia (left and right). Electrocardiogram-gated coronary computed tomography angiography showed a circumpulmonary course of the interventricular paraconal coronary artery, which abnormally originated from the right coronary artery. Based on this case report, the echocardiographic identification of two coronary ostia does not rule out a coronary artery anomaly with circumpulmonary course (as previously hypothesized), and coronary computed tomography angiography may be recommended for presurgical planning of PBV in French Bulldogs.

Pulmonary Artery Aneurysm Associated with Bicuspid Pulmonary Valve

A 73-year-old Japanese man was admitted with an asymptomatic pulmonary artery aneurysm. However, chest X-ray and contrast-enhanced thoracic computed tomography revealed a protrusion at the second left branch that in fact was a pulmonary artery aneurysm with a diameter of 50 mm. Transesophageal echocardiography showed a bicuspid pulmonary valve, and cardiac catheterization revealed pulmonary stenosis with a pressure gradient of 45 mmHg, but no other heart diseases were noted. An extremely rare pulmonary artery aneurysm associated with an isolated bicuspid pulmonary valve was diagnosed.

Full Development of Consequences of Congenital Pulmonic Stenosis in Eighty-Four Years

Described herein is an 84-year-old woman, the oldest reported, with severe pulmonic stenosis who underwent a highly successful pulmonic valvotomy at age 77 and highly unsuccessfully attempted percutaneous pulmonic valve implantation at age 84. During the 84 years she developed nearly all clinical and morphologic consequences of pulmonic stenosis, including heavy calcification of the pulmonic valve, heavy calcification of the tricuspid valve annulus, severe right ventricular wall thickening without ventricular cavity dilation, aneurysm of the pulmonary truck, multiple focal ventricular wall scars without narrowing of the epicardial coronary arteries, wall thickening and luminal narrowing of the intramural coronary arteries, and extremely low 12-lead QRS electrocardiographic voltage.

Valve-Sparing or Valve Reconstruction Options in Tetralogy of Fallot Surgery

This review deals with a relatively new field in congenital heart surgery, valve preservation or, in cases of more severe pulmonary valve stenosis or dysplasia, valve reconstruction during tetralogy of Fallot repair. We describe the stepwise approach utilized, starting with simple maneuvers such as commissurotomy and valve dilation for mild pulmonary stenosis to commissurotomy and intraoperative balloon dilation for moderate stenosis, and finally transection of the annulus and valve reconstruction using a patch that acts as a modified monocusp. Results are presented and have been gratifying.

[A Case of Combined Spinal-Epidural Anesthesia for Cesarean Section in a Patient with Right Heart Failure due to Supravalvular Pulmonary Stenosis after Jatene Operation]

In a 30-year-old pregnant woman with supravalvular pulmonary stenosis after Jatene operation, the right ventricular and pulmonary artery pressure were 54/4 and 30/10 mmHg respectively in the non-pregnant condition. She was hospitalized due to pregnancy induced hypertension at 37 weeks of gestation. At the end of pregnancy, right ventricular failure occurred due to the increased circulatory plasma volume. Induc- tion of delivery was started at 37 weeks 6 days. How- ever, emergency cesarean section was planned because of maternal fatigue and uterine inertia. It was expected that airway management might be difficult because of obesity and full stomach. We chose combined spinal and epidural anesthesia. To avoid rapid reduction of systemic vascular resistance, we selected 0.5% isobaric bupivacaine 1.9 ml and fentanyl 10 gg for spinal anesthesia. Because inadequate analge- sia might worsen right ventricular failure, we added epidural anesthesia. The loss of cold sensation had reached at the fifth thoracic dermatomal level. The hemodynamics was stable without vasopressors. The continuous infusion of 0.2% ropivacaine from epidural catheter was started immediately after the delivery of the baby. As the result of choosing the appropriate anesthesia method, type and amount of local anesthetic, we succeeded in anesthetic management of this patient with right ventricular failure.

Differential Impact of Pulmonary Regurgitation on Patients With Surgically Repaired Pulmonary Stenosis Versus Tetralogy of Fallot

Patients with repaired pulmonary stenosis (PS) or tetralogy of Fallot (TOF) both develop pulmonary regurgitation (PR) leading to right ventricular (RV) dilatation and dysfunction. We aimed to characterize differential effects of chronic PR in these populations. Patients with surgically repaired PS were matched 1:2 by age and PR fraction with patients with TOF. Patients with previous pulmonary valve replacement were excluded. Cardiovascular magnetic resonance data were compared; peak longitudinal and circumferential systolic strain by feature tracking were compared to evaluate differential contribution of the RV sinus and outflow tract, respectively. PS (n = 24, 41 ± 13 years old) and TOF (n = 47, 39 ± 13 years old) patients did not differ in RV end-diastolic volume (153 ± 45 vs 154 ± 45 ml/m(2), p = 0.99) or diastolic function. However, patients with PS had preserved RV ejection fraction (54.3 ± 4.4% vs 48.0 ± 7.1%, p <0.0001). Differences were greater in RV circumferential (-15.8 ± 3.3 vs -11.8 ± 3.4, p <0.0001) than longitudinal strain (-18.0 ± 3.8 vs -15.9 ± 3.8, p = 0.04), with particular decrease in the infundibulum (-17.4 ± 7.5 vs -6.8 ± 6.3, p <0.0001). Late gadolinium enhancement in the RV outflow tract was more frequent in patients with TOF (70.2% vs 45.8%, p = 0.001). In conclusion, surgical repair of PS leads to similar RV dilatation and diastolic dysfunction compared to patients with TOF, but differential effects on ventricular systolic function, largely related to differences in the outflow tract. With different patterns of scarring and ventricular remodeling, further study is needed to clarify whether criteria for pulmonary valve replacement in patients with PS should differ from those with TOF.

[Pulmonary stenosis and atrial septal defect: a rare association in the elderly]

We report the case of an elderly woman with persistent unrepaired atrial septal defect and moderate pulmonary stenosis. The diagnostic work-up and the echocardiographic findings of such a rare case are reported, along with a brief description of heart failure pathophysiology in this grown-up congenital heart disease.To the best of our knowledge, this is the first case with the greater longevity in an elderly patient with unrepaired atrial septal defect and pulmonary stenosis ever reported in the literature.

Severe pulmonary arterial hypertension in an adult patient with total anomalous pulmonary venous connection operated in infancy

The goal of total anomalous pulmonary venous connection repair is to obtain an unobstructed communication between the pulmonary veins and the left atrium and removing intracardiac shunting. However, pulmonary venous obstruction orstenosis may be seen in 5-10% of patients, is usually evident in the first 6 months following surgery and may lead to pulmonary congestion, pulmonary arterial hypertension, and late mortality. In such cases, early intervention may be indicated before irreversible secondary changes occur. We present the case and the therapeutic approach of an adolescent patient with total anomalous pulmonary venous drainage to the superior vena cava operated in infancy who developed pulmonary venous obstruction and secondary severe pulmonary arterial hypertension.

Root translocation in congenitally corrected transposition of the great arteries with ventricular septal defect and pulmonary stenosis, and other lesions

The pulmonary root translocation (PRT) procedure has been used to correct ventriculoarterial discordance or malposition of great arteries since 1994. It was part of the surgical repair of 62 consecutive patients presenting with congenitally corrected transposition of the great arteries (CCTGA) with ventricular septal defect (VSD) and pulmonary stenosis (PS), or other complex congenital heart disease with malposition of the great arteries, VSD, and PS. PRT was performed as follows: removal of the pulmonary artery (PA) with the pulmonary valve from its abnormal position, closure of the consequent hole with an autologous pericardial patch, resection of some conal septum, creation of an intraventricular tunnel connecting the left ventricle to the aorta, and construction of a new right ventricular outflow tract using the translocated PA. In patients presenting with important pulmonary valve stenosis, the pulmonary artery was enlarged with a monocusp valve pericardial patch. The Senning procedure was used with some modification to complete the anatomical repair in CCTGA patients. Overall in-hospital and long-term mortality were 4.8% and 3.4%, respectively. PRT appears to be a good surgical alternative for patients presenting with CCTGA with VSD and PS, and other lesions involving malposition of the great arteries, VSD, and PS.

Large size VSD with pulmonary stenosis

Defect in the ventricular septum with obstruction to right ventricular outflow tract encompass a wide anatomic, physiological and clinical spectrum. Large ventricular septal defects occur with pulmonary stenosis that varies from mild to severe to complete (pulmonary atresia). Very large VSD (size 6.4 cm, in our case) with severe PS is a rare CHD and without surgical correction only 10% patient can survive beyond 20 year of age. With the help of noninvasive investigation (Echocardiography) we can diagnose CHD very easily.

Surgery impacts right atrial function in tetralogy of Fallot

OBJECTIVE

To analyze the impact of surgery and pericardial integrity on right atrial function and total heart volume variation in the setting of pulmonary valve insufficiency.

METHODS

Right atrial function and total heart volume variation were analyzed in 2 subgroups of patients with pulmonary valve insufficiency compared with healthy controls: group 1 with surgically repaired tetralogy of Fallot (n = 20 patients) and group 2 after balloon angioplasty of pulmonary valve stenosis in patients with isolated valve disease without surgery (n = 7 patients). Volumetric analysis of magnetic resonance imaging data revealed parameters of atrial function (reservoir, conduit, and pump functions and cyclic volume change) and of total heart volume (end-diastolic and end-systolic total heart volume and the variation). Statistical analysis included uncorrected and corrected pairwise comparisons and the calculation of groupwise Pearson correlation coefficients.

RESULTS

In group 1 with a pulmonary regurgitation fraction of 31.0% ± 14.9%, right atrial function was clearly impaired, with reduced reservoir and elevated conduit function, and total heart volume variation was elevated to 13.9% ± 3.4%. In group 2 with a pulmonary regurgitation fraction of 22.8% ± 6.9%, the values were close to normal, with unaffected atrial function and a total heart volume variation of 9.9% ± 3.3%.

CONCLUSIONS

The hydrodynamic effect of pulmonary valve insufficiency alone is likely not the only reason for impaired right atrial function and elevated total heart volume variation in patients with tetralogy of Fallot; it is rather the scar in the right atrium, the injured pericardium, and the disease itself that are responsible for the energetically unfavorable alterations.

[Percutaneous treatment of pulmonary artery stenoses]

Pulmonary artery stenoses are a common problem in pediatric cardiology. They may interfere with the growth and development of the lung and cause pressure overload on the right heart and by increasing pulmonary arterial valvular insufficiency, also volume overload on the right ventricle. This may predispose the patient to cardiac failure, limitation of exercise tolerance and arrhythmias. Percutaneous treatment of pulmonary artery stenoses has undergone significant development over the last 20 years. Above all, the development of high pressure balloon catheters and stents has made treatment results better.

Bicuspid pulmonary valve with atrial septal defect leading to pulmonary aneurysm

Pulmonary artery aneurysms are rare. We describe 2 adult patients with pulmonary artery aneurysm with normal pulmonary pressure associated with bicuspid pulmonary valve and atrial septal defect. One patient presented with moderate pulmonary valve stenosis and was treated with open surgery; the other patient had a small atrial septal defect and mild pulmonary valve insufficiency and is periodically still being evaluated. Hemodynamic alterations associated with a pulmonary artery aneurysm are described; the influence of additional volume overload and intrinsic wall abnormalities in pulmonary valvular lesions as potential triggers for the development of these aneurysms are analyzed and therapeutic strategies are discussed.

Hypoplastic right-heart syndrome presenting as multiple miscarriages

Reversible causes of miscarriage are many, but they affect only 1% of women who are trying to conceive. Herein, we describe the case of a 23-year-old woman who presented for evaluation of repeated miscarriages and was found to have hypoxemia and erythrocytosis. Further evaluation revealed hypoplastic right-heart syndrome with an intracardiac shunt. She underwent hybrid repair with pulmonary valve balloon valvuloplasty, followed by surgery to perform atrial septal defect closure and a Glenn anastomosis. The erythrocytosis and hypoxemia resolved, and she was able to conceive and deliver a healthy baby at term 2 years later. This is a unique case of a rare congenital heart defect that went unnoticed until adulthood, when attempts at pregnancy failed because of the associated hypoxemia. Timely and appropriate treatment led to a successful pregnancy after repeated miscarriages. This case exemplifies the need for a comprehensive medical evaluation of every woman with a history of multiple miscarriages to determine whether a reversible cause exists.

[Repair of congenital heart disease in an adult with septal defects and pulmonary stenosis: anesthetic management]

A 66-year-old man with complex congenital heart defects (atrial septal defects, with incomplete cor triatriatum, an aneurysmal sac in the membranous septum, ventricular communication and pulmonary valve stenosis) was scheduled for surgery for progressive dyspnea even at rest. During anesthetic induction, effort was made to avoid increased shunting. Surgery consisted of resection of the cor triatriatum membrane, closure of communications with pericardial patches, pulmonary valve replacement, replacement of the root with a porcine root, and pulmonary artery aneurysmorrhaphy. Severely decreased contractility developed while the patient was still in the operating room; inotropic support with adrenaline and dobutamine was required. Extubation was completed in the postoperative recovery unit with no further complications. Echocardiography showed a left-ventricular ejection fraction of 45%. We found few published reports of cases of complex congenital heart disease treated surgically in adulthood. In such cases, cardiac pathophysiology must be carefully considered, and maneuvers that increase systemic resistance or right-ventricular ejection fraction should be avoided. Postoperative pulmonary vascular resistance should be kept as low as possible.

[Isolated pulmonary supravalvular stenosis accompanied by pulmonary artery aneurysm]

We present a 19-year-old asymptomatic female patient in whom isolated pulmonary supravalvular stenosis and pulmonary artery aneurysm were incidentally detected. On cardiologic examination, a systolic murmur was heard over the lungs, right axis deviation was seen on the electrocardiogram, and marked appearance of the pulmonary artery was noted on the chest X-ray. On transthoracic echocardiography, the pulmonary artery trunk was found to be wider than normal, and there were mild pulmonary and tricuspid regurgitation. Color Doppler examination showed a turbulent flow 2 cm distal to the pulmonary valve. Transesophageal echocardiography showed a supravalvular membranous structure and a proximal pulmonary artery aneurysm. The pulmonary artery trunk was measured as 40 mm at the widest part. Thoracic computed tomography revealed that the proximal pulmonary artery aneurysm was localized to the pulmonary artery trunk and measured 41 mm. As the patient was asymptomatic and there were no signs of aneurysmatic compression or a left-to-right shunt, and due to the presence of a relatively low gradient (16 mmHg) across the stenotic area, she was scheduled to regular radiologic control.

Increasing the accuracy of lung perfusion scintigraphy in children with bidirectional Glenn circulation

BACKGROUND

In children who have undergone a bidirectional Glenn procedure without antegrade or additional pulmonary blood flow, we have often noted a discrepancy between apparent lung perfusion on scintigraphy and superior vena cava angiography when evaluating right and left pulmonary blood flow. We found a tendency for radionuclide, tracer 99mTc-MAA, when administered through a single upper extremity vein, to preferentially accumulate in the ipsilateral lung.

OBJECTIVE

In the present study, we examined whether the ratio of right-to-left pulmonary flow varied when 99mTc-MAA was administered via either the right upper or the left upper extremity vein.

MATERIALS AND METHODS

We studied six children (median age 1.3 ± 0.23 years) who underwent a bidirectional Glenn before total cavopulmonary connection. Five children who underwent biventricular repair served as a control. Perfusion scintigraphy using 99mTc-labeled macroaggregated albumin (99mTc-MAA) was performed in all children. First, we injected radionuclide via the right upper extremity and calculated the pulmonary accumulation in both lungs (R-image). Second, we injected the same dose of radionuclide via the left upper extremity and calculated the pulmonary accumulation (B-image), which represented the resulting administration via both upper extremities. The lung accumulation that resulted from radionuclide administration via the left upper extremity (L-image) was determined by subtracting the R-image from the B-image. We evaluated the right-to-total pulmonary blood flow ratio (radionuclide accumulation in right lung / radionuclide accumulation in both lungs) in the R-, L- and B-images.

RESULTS

The right-to-total pulmonary blood flow ratios in the R-, L- and B-images were 815 ± 15.3%, 39.8 ± 11.7% and 61.3 ± 11.8%, respectively, and there were significant differences among the three images (P < 0.01). On the other hand, in the control group, the right-to-total pulmonary blood flow ratios in the R-, L- and B-images were 59.3 ± 22.4%, 57.8 ± 26.4% and 58.8 ± 23.7%, respectively, and there was no significant difference.

CONCLUSION

In children with bidirectional Glenn circulation without antegrade or additional pulmonary blood flow, the venous blood of each arm tends to flow into the ipsilateral lung. The administration of radionuclide via both arms is important for accurate evaluation of lung perfusion scintigraphy in children who have undergone a bidirectional Glenn procedure.

Surgical management of ventricular septal defect with pulmonary stenosis with idiopathic thrombocytopenic purpura

Patients with idiopathic thrombocytopenic pupura (ITP), when under goes any cardiac surgery face an increased risk of postoperative haemorrhagic complications. A 28 years old female patient with idiopathic thrombocytopenic purpura(ITP) and Ventricular septal defect (VSD) with pulmonary stenosis (PS) was operated. We treated her with oral steroid for three weeks immediately before surgery. During surgery under extracorporeal circulation bleeding was controlled meticulously and she was administered methyl prednisolone, injection hydrocortisone, fresh frozen plasma, platelets and whole blood. Steroid was continued postoperatively for two weeks. She did not suffer from any haemorrhagic complication and her recovery was uneventful. Congenital heart disease with idiopathic thrombocytopenic purpura can be operated for heart surgery if appropriate pre, intra and postoperative measures are taken. DOI: 10.3329/bmrcb.v36i3.6665Bangladesh Med Res Counc Bull 2010; 36: 101-103

Pulmonary stenosis as a predisposing factor for infective endocarditis in a patient with Noonan syndrome

Noonan syndrome is an autosomal dominant dysmorphic syndrome. Pulmonary stenosis is the most common cardiac anomaly in Noonan patients, with an incidence of 60%. A 9-year-old girl was referred to our institution with pericardial effusion. Transthoracic echocardiography indeed confirmed massive pericardial effusion and revealed, further, valvular and arterial pulmonary vegetations that accompanied a dysplastic tricuspid pulmonary valve. We decided to perform emergency pericardial tube drainage and to continue the anti-biotic regimen for 2 more weeks before undertaking open-heart surgery. After 2 weeks, the patient underwent an operation wherein the valvular vegetations were excised and a pulmonary valve commissurotomy was performed, yielding a competent pulmonary valve with 3 distinct but moderately dysplastic cusps. In addition to the pulmonary valve, the main, left, and right pulmonary arteries were filled with mobile vegetations, which were removed during the procedure. In this patient, a dysplastic and stenotic pulmonary valve may have contributed to the progression of endocarditis and to the growth of vegetations that occupied the pulmonary arteries. In conclusion, we hypothesize that although pulmonary stenosis is not considered a common predisposing factor for infective endocarditis, it can contribute to the progression of infective endocarditis in Noonan patients.

Keutel syndrome in a patient presenting with hearing loss

Keutel syndrome (KS) is a rare autosomal recessive disease which is mainly characterised by abnormal cartilage calcification, peripheral pulmonary artery stenosis, sensorineural and conductive hearing loss, brachytelephalangism, and midface hypoplasia. Here, we present and discuss a Keutel syndrome patient with hearing loss born to consanguineous parents (first cousins), along with all the characteristic features of KS.

[Therapeutic effect of Cheatham-Platinum stent implantation for vessel stenosis associated with congenital heart disease in children and adolescents]

OBJECTIVE

Although NuMED Cheatham-Platinum (CP) stent was specifically designed to treat vascular obstructions associated with congenital heart disease (CHD), its application in pediatric patients is relatively uncommon, especially in the pulmonary artery stenosis. The aim of this study was to evaluate the immediate-, early- and intermediate-term results of CP stent implantation in the treatment of vessel stenosis associated with CHD in children and adolescents.

METHODS

From August 2005 to May 2007, 5 consecutive patients (3 boys and 2 girls) diagnosed as vascular stenosis associated with CHD underwent CP stent implantation in our institution. One patient had native coarctation of the aorta (CoA) and four patients had pulmonary artery stenosis. The median age and weight of patients were 12 years (range 4 - 15 years) and 24 kg (range 20 - 51 kg), respectively. The CP stent and NuMED Balloon-in-Balloon catheter were selected according to digital subtracted angiography measurements. After checking for correct position by angiography, the inner balloon and outer balloon inflated successively to expand the stent to desired diameter.

RESULTS

Totally 6 stent placement procedures were performed and 8 CP stents (8-zig, 22 - 39 mm in length) were implanted in these 5 patients. All stents but one in a case of right pulmonary artery stenosis were immediately successfully placed in the target lesions without displacement during the procedures. For this case, a repeat procedure was performed and a second CP stent was reimplanted successfully 11 months later. After the procedure, the systolic pressure gradient across the stenosis decreased from (43.43 +/- 25.61) mm Hg (1 mm Hg = 0.133 kPa) to (3.29 +/- 3.09) mm Hg (t = 4.320, P < 0.01) and the narrowest diameter of the stenotic vessels increased from (6.86 +/- 2.04) mm to (13.44 +/- 4.02) mm (t = -4.508, P < 0.01). The percentage of pulmonary artery flow to the ipsilateral lung increased from 11.0% and 13.0% to 47.5% and 52.2% after the procedure in 2 cases of unilateral pulmonary artery branch stenosis, respectively. The ratio of right ventricular to aortic systolic pressure decreased from 62.3% and 72.2% to 27.0% and 33.3% in 2 cases of bilateral branch pulmonary artery stenosis, respectively. Upper limb blood pressure of one case of native CoA dropped greatly from 206/133 mm Hg to 156/95 mm Hg. During a median follow-up of 20 months (range 13 - 34 months), the results have been stable without complications except 2 stents which developed intrastent restenosis 6 months after the procedure.

CONCLUSION

Our experience suggests that the CP stent implantation is safe and feasible for the treatment of vessel stenosis associated with CHD in children and adolescents. The immediate-, early- and interim results are encouraging, but long-term results remain to be further evaluated and demand many more cases to be studied.

Dextrocardia and corrected transposition of the great arteries (I,D,D) in a case of Kartagener's syndrome: a unique association

Kartagener's syndrome (KS) usually includes mirror-image dextrocardia. The incidence of congenital heart disease in KS is comparable with that in the general population. This paper reports on a case of Kartagener's syndrome associated with dextrocardia, corrected transposition of the great arteries (I,D,D), ventricular septal defect, and valvar pulmonary stenosis in an 8-year-old girl.

A giant main pulmonary artery aneurysm associated with infundibular pulmonary stenosis

We report a case of a giant pulmonary artery aneurysm associated with infundibular pulmonary stenosis. Echocardiography disclosed markedly enlarged main pulmonary artery, but no left to right shunt flow at levels of the atrial septum, ventricular septum and the pulmonary artery. Continuous wave Doppler revealed a maximum velocity of 1.5 m/s which corresponded to the pressure gradient between the right ventricle and the pulmonary artery of 9.5 mmHg. Contrast-enhanced multidetector-row computed tomography with a 16-slice scanner revealed pulmonary artery aneurysm with the maximum diameter of 67 mm on axial image.

Shunt operations improved thrombocytopenia in a patient with congenital cyanotic heart disease

Cardiac and vascular intervention in thrombocytopenic congenitally cyanotic patients is more dangerous. Thrombocytopenia in these patients is related to immune thrombocytopenia, polycythemia, hyperviscosity, pseudothrombocytopenia, and drugs. Herein we report on a thrombocytopenic 8-year-old girl with tricuspid valve atresia and pulmonary valve stenosis admitted for catheterization. Thrombocytopenia (21,000/mm3) and shunt occlusion was noticed. Thrombocytopenia did not recover after intravenous immunoglobulin (IVIG) and phlebotomy therapies. During preparation for surgery, she suffered cardiopulmonary arrest. A Gore-tex graft was placed in the right pulmonary artery and truncus brachiocephalicus. After surgery, her platelet count spontaneously increased to within the normal range (178,000/mm3 to 250,000/mm3). After resuscitation, she had right-sided hemiplegia sequelae, though there were no hemorrhagic findings on cranial magnetic resonance imaging (MRI) or computed tomography (CT) scans. Two months after surgery, the Blalock-Taussig (BT) shunt blood flow decreased, thrombocyte count dropped, and peripheral cyanosis reappeared. A Fontan operation was performed without hemorrhagic events, and after surgery the thrombocyte count reached 330,000/mm3. We suggest that if a patient with cyanotic heart disease has thrombocytopenia and there is no apparent cause, hypoxia-related thrombocytopenia must be considered. After reoxygenation by shunt or corrective surgeries, thrombocyte count and functions will recover.

Comparative computational fluid dynamic study of two distal Contegra conduit anastomoses

A computational fluid dynamic (CFD) study compared two configurations of distal anastomosis of 12 mm Contegra conduit: conventional 'circular' vs. oblique 'elliptical' anastomosis extended on the left PA, evaluating pressure and velocity profiles, and shear stress, from PA origin to the bifurcation. 'Elliptical' anastomosis provides larger (=54% difference) cross-sectional area than 'circular' anastomosis. Velocity contours showed important stagnation at PA bifurcation in 'circular' anastomosis and minimal in 'elliptical' configuration, where fluid flow occurred preferentially in left PA. Pressure contours showed peak pressure zone at bifurcation in 'circular' anastomosis, while 'elliptical' exhibited more uniform pressure distribution. Shear stress distribution was more homogeneous in 'elliptical' than in 'circular' anastomosis. At bifurcation and in right PA artery velocity and pressure were higher for 'circular' than 'elliptical' anastomosis, while in left PA velocity was much higher for 'elliptical' anastomosis. CFD study demonstrates more homogeneous pressure, velocity and shear stress distributions for 'elliptical' compared to 'circular' anastomosis at PA bifurcation, and preferential flow in left PA. CFD results suggest that clinical application of 'elliptical' anastomosis, with cross-sectional area larger than conventional 'circular' anastomosis, may reduce incidence and degree of distal stenosis, particularly for small size conduits.