Prenatal Diagnosis and Postnatal Outcome of Eight Cases with Criss-Cross Heart - A Multicenter Case Series

OBJECTIVE

 Criss-cross heart (CCH) is a rare congenital cardiac defect defined by crossing of ventricular inflow streams contributing to less than 0.1 % of all congenital heart anomalies. Due to its rarity and complexity, prenatal diagnosis in these patients remains challenging. We sought to describe prenatal findings and postnatal course in eight cases of prenatally diagnosed CCH.

METHODS

 This is a retrospective case series of prenatally diagnosed CCH in three centers between 2010-2017. We reviewed fetal echocardiograms as well as postnatal clinical charts and surgical reports.

RESULTS

 8 cases of CCH were included. The median gestational age at diagnosis was 27 weeks. 7 patients were found with situs solitus, one fetus with situs ambiguous. In all patients, the four-chamber view was abnormal. There was atrioventricular discordance in half of the patients, while all patients showed ventriculoarterial discordance. All patients were found with additional cardiac anomalies, including ventricular septal defect, double outlet right ventricle, right aortic arch, atrial septal defect and pulmonary stenosis. Three patients underwent amniocentesis without pathological findings. All patients were born alive at a median gestational age of 38 + 2 weeks and survived our median follow-up of 181 days.

CONCLUSION

 CCH can be diagnosed prenatally by detailed fetal echocardiography when observing an abnormal four-chamber view with crossing of inflow streams into both ventricles and a lack of parallel orientation of the atrioventricular valve axis due to a clockwise or counterclockwise rotation of the ventricular mass along its axis. With the help of prenatal ultrasound, parental guidance and counselling as well as postnatal pediatric cardiac management can be warranted.

Criss-cross heart with double-outlet right ventricle, subpulmonary ventricular septal defect, and bicuspid pulmonary valve

Criss-cross heart (CCH) is an extremely rare complex congenital heart malformation. It accounts for less than 0.1% of congenital heart diseases. Here, we describe a unique case of CCH with double-outlet right ventricle, huge subpulmonary ventricular septal defect, bicuspid pulmonary valve, and right-hand aortic arch. The anatomic features were observed with echocardiography, and the diagnosis was confirmed at surgery. Many variations of CCH have been described. The present case expands the spectrum of this entity and may provide new insight into this complex anatomy.

Echocardiographic characteristics of the criss-cross heart

OBJECTIVE

To assess the ultrasonic characteristics of the criss-cross heart, and explore the value of echocardiography in the diagnosis of this rare congenital cardiac defect.

METHODS

We reviewed the echocardiographic findings in 4 patients having criss-crossed atrioventricular connections at our hospital, and compared the findings with observations at surgery in 3 of the patients.

RESULTS

In all 4 patients, there was usual atrial arrangement, right hand ventricular topology, and concordant atrioventricular connections. The inlet components of the ventricular mass, however, crossed such that the apical component of the morphologically right ventricle was situated anteriorly and superiorly, and extended to the left relative to the apex of the morphologically left ventricle. The ventriculo-arterial connections were concordant in 1 patient, double outlet from the morphologically right ventricle in 2, and discordant in the other. In all 4 patients, it proved impossible to obtain the standard 4-chamber view showing simultaneously all four chambers and both atrioventricular valves. A series of apical 4-chamber or subcostal coronal views, obtained by tilting the transducer from posterior to anterior, demonstrate initially the connection of the left-sided left atrium and the right-sided left ventricle through the mitral valve. More anterior angulation of the transducer then showed the right-sided right atrium to be connected to the left-sided right ventricle through the tricuspid valve, confirming the presence of twisted atrioventricular connections. Color Doppler imaging displayed the crossing of the atrioventricular connections without mixing of the streams. Short-axis views across the ventricular mass confirmed that the right ventricle was superior, anterior, and to the left of the left ventricle, and demonstrated the horizontal position of the ventricular septum. When viewed subcostally, the distance between the tricuspid valve and the orifice of the inferior vena cava was significantly increased relative to normal findings. The echocardiographic findings were confirmed during surgical interventions in 3 patients, apart from the failure to diagnose one instance of persistent patency of the left superior vena cava.

CONCLUSIONS

The failure to obtain a characteristic 4-chamber view in any cut was diagnostic for recognition of the criss-crossed atrioventricular junctions. Transthoracic echocardiography provides definitive images of this rare arrangement, and accurately defines the associated cardiac abnormalities.

[Echocardiographic evaluation of crisscross heart]

OBJECTIVE

To explore atrioventricular connection and atrioventricular segmental situs in patients with crisscross heart (CCH) and to evaluate the diagnostic value of echocardiography for this anomaly.

METHODS

Ten consecutive patients with crisscross heart were enrolled into this retrospective study. Their echocardiographic data were analyzed and compared with the results of X-ray angiocardiography and 64-slice multi-detector row computed tomography (MDCT) or MRI.

RESULTS

The crossing of atrioventricular valves could be seen in each case by scanning in a subxiphoid or apical 4-chamber view. Both the positive rate and the specificity were 100%. Horizontal ventricular septum was in 9 cases and vertical (sagittal) ventricular septum in 1 case. The segmental set of 8 patients with concordant atrioventricular connection was {S. D. L} in 5 cases, {S. D. D} 1 case, {S. D. S} 1 case and {S. L. D} 1 case. The segmental set of 1 case with discordant atrioventricular connection was {I. D. D} and another 1 case with ambiguous atrioventricular connection was {A. L. L}. In 1 case, the atrioventricular connection was inconsistent with the atrioventricular segmental situs. Ventriculoarterial connections were concordant in 1, DORV in 6, TGA in 2 and C-TGA in 1.

CONCLUSION

Echocardiography is proven quite helpful in diagnosis of CCH, and continuous sweeps in subxiphoid long-axis plane or apical 4-chamber view play a key role. Both the atrioventricular connection and the atrioventricular segmental situs are complicated so that they are not always concordance with each other. It is necessary to account for separately.

Criss-cross heart: report of three cases with double-inlet ventricles diagnosed in utero

Criss-cross heart is a rare congenital cardiac anomaly characterized by crossing of the inflow streams of the two ventricles, due to an apparent twisting of the heart about its long axis and when the axes of the openings of the atrioventricular (AV) valves are not parallel. If unrecognized, this leads to incorrect sequential segmental analysis. We report three cases of double-inlet ventricle with a criss-cross spatial relationship of the AV valves detected on prenatal ultrasound examination at 19-23 weeks' gestation. The sequential diagnosis was confirmed at postmortem examination in two cases and by neonatal echocardiography in the other. Antenatal diagnosis of criss-cross effect of the AV valves is feasible, allowing correct fetal diagnosis and appropriate counseling for this rare form of congenital cardiac disease.

Coronary arteries in crisscross heart

Crisscross heart, or superoinferior ventricles, is a complex and often confusing congenital anomaly. We report a heretofore unreported presentation of "isolated" crisscross heart in situs inversus levocardia, which allows us to more clearly define the typical features of crisscross ventricles. The case of this 41-year-old woman, who had a peculiar coronary anatomy, underscores the concept that coronary artery anatomy is strictly related to the myocardial mass served. In complex congenital heart defects, development of an anterior descending artery is possible (as a primary artery, along with the circumflex and right coronary arteries) only if the ventricular septum develops properly and is aligned with the semilunar valves. We use the present case of crisscross heart to illustrate the spectrum of anomalies that can occur during formation of the cardiac apex; this spectrum ranges from a normal apex, to a diverted apex (as in dextroversion in situs solitus), to a crisscross anomaly.

Fetal echocardiographic features of twisted atrioventricular connections

We present an example of corrected transposition with twisted discordant atrioventricular connections in which both fetal and postnatal echocardiograms were obtained. We correlate the fetal echocardiograms with the postnatal echocardiograms, placing emphasis on the echocardiographic clues to the diagnosis which were present in fetal life. The diagnosis should be suspected when the cardiac chambers and great arteries show an unexpected spatial relationship for the given segmental connections, and when the axes of opening of the atrioventricular valves are not parallel.

Echocardiographic evaluation of hearts with twisted atrioventricular connections (criss-cross heart)

An echocardiographic study was performed on seven patients with twisted atrioventricular connections (criss-cross heart) relative to the usual atrial arrangement. The atrioventricular connections were concordant in five patients and discordant in two. The ventriculoarterial junction was either double-outlet right ventricle (n = 6) or discordant connections (n = 1). Associated cardiac defects were ventricular septal defect (n = 7), pulmonary stenosis (n = 5), straddling tricuspid valve (n = 2), and straddling mitral valve (n = 1). Malalignment between the atrial and ventricular septum was the most important feature of this disease and resulted in altered spatial orientation of the trabecular ventricular septum, and recesses in the ventricles and the right atrium. When assessed by echocardiography, these anatomical features were not invariably recognized in every case, but they were dependent upon the type of atrioventricular connections and the presence of straddling of the atrioventricular valves. Left ventricular recess was the most consistent feature and was present in every patient, regardless of the atrioventricular connections. Right atrial recess was found in four of five patients with concordant atrioventricular connections but was not present in patients with discordant atrioventricular connections. Right ventricular recess was recognized as such in a single patient with concordant atrioventricular connection and straddling mitral valve. The trabecular septum was oriented in a horizontal plane in hearts with concordant atrioventricular connections and without atrioventricular valve straddling. The trabecular septum was oriented semivertically in all other hearts.(ABSTRACT TRUNCATED AT 250 WORDS)

Discordant atrioventricular connexion with concordant ventriculo-arterial connexion (so-called "isolated ventricular inversion") with usual atrial arrangement (situs solitus)

The combination of a discordant atrioventricular connexion with a concordant ventriculo-arterial connexion (so-called "isolated ventricular inversion") is an extremely rare entity described, to the best of our knowledge, on only 15 occasions in patients with usual atrial arrangement. Initial diagnosis at cross-sectional echocardiography has only been reported three times, but the combination has been diagnosed in life on seven occasions, with successful Mustard or Senning operations having been performed in six of these patients. We report a neonate referred with an initial diagnosis of complete transposition, who was correctly diagnosed at cross-sectional echocardiography, and had closure of an associated ventricular septal defect with a Senning procedure in the neonatal period.

Comparative value of transthoracic and transesophageal echocardiography in the assessment of congenital abnormalities of the atrioventricular junction

Information obtained from transthoracic and transesophageal echocardiography (two-dimensional echocardiography with spectral Doppler and color flow imaging) was compared in 17 patients with major congenital abnormalities of the atrioventricular (AV) junction (10 discordant AV connections, 1 criss-cross connection, 5 absent right connections and 1 absent left connection). The findings by either technique were correlated with findings at cardiac catheterization (12 patients) and at surgery (5 patients). In two of six patients with an absent AV connection as defined by transthoracic echocardiography, transesophageal imaging demonstrated an imperforate AV valve. In 11 of 11 patients with a discordant or criss-cross connection, assessment of AV valve and ventricular morphology (by defining the chordal attachments of both AV valves) was possible with transesophageal echocardiography (3 of 11 patients by transthoracic echocardiography); chordal straddling was detected in 1 patient and excluded in 3 others with an associated inlet ventricular septal defect. Anomalous pulmonary venous connection (one patient), atrial septal defect (three patients) and subpulmonary stenosis (five patients) were better assessed by transesophageal imaging, and atrial appendage morphology could be demonstrated in all. The transesophageal technique was less useful in demonstrating the anterior subaortic infundibulum or aortopulmonary shunt (two patients). Although systemic ventricular function could be assessed by either method with use of short-axis M-mode scans, transesophageal pulsed Doppler interrogation of AV valve and pulmonary venous flow patterns provided clues to diastolic dysfunction of the systemic ventricle.

Double outlet right ventricle with discordant atrioventricular connexion: an angiographic analysis of 19 cases

Nineteen patients with double outlet right ventricle and discordant atrioventricular connexion were studied in order to analyze their angiographic anatomy. The discordant atrioventricular connexion was parallel in 18 patients and criss-cross in one. A ventricular septal defect, present in all cases, was perimembranous in ten (50%), muscular in seven (37%), and was part of an atrioventricular septal defect in two. The defect was related spatially to the subaortic outflow in six (29%), to the subpulmonary outflow in 11 (52%), was doubly committed in one and non-committed in two. Long axial and four-chamber views of the ventriculograms were most useful for the angiographic delineation of the basic anatomy of this entity. In patients with abnormally located hearts, variations of the axial views were necessary for proper delineation of the anatomy. It is concluded that modified axial views of ventriculograms are useful for diagnosis of double outlet right ventricle and discordant atrioventricular connexions.

Fontan-type operation for correcting complex congenital defects in a criss-cross heart

Three cases of criss-cross heart with severe and complex congenital defects are reported. Precise preoperative diagnosis of the morphologic abnormalities made it possible to choose an optimal method of surgical treatment: all patients successfully underwent a Fontan-type surgical procedure.

Disharmony between atrioventricular connections and segmental combinations: unusual variants of "crisscross" hearts

Two congenitally malformed hearts are described, one studied in life and the other at autopsy, in which the topology of the ventricular mass was not as expected for the atrioventricular (AV) connection present. In Case 1, studied at autopsy, there was the usual atrial arrangement with a concordant AV connection. The morphologically right ventricle, however, was left-sided and the ventricular mass was of left-hand topology (l loop) rather than the expected right-hand pattern (d loop). In Case 2, studied during life, there was the usual atrial arrangement and a discordant AV connection. Rather than the anticipated left-hand topology (l loop), the ventricular mass was arranged in right-hand fashion (d loop) and the morphologically right ventricle was right-sided. The cases emphasize that for a full description of a congenitally malformed heart, it is often necessary to account for the topology of each segment as well as the connections (or alignment) among the segments.