Which two ventricles cannot be used for a biventricular repair

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Presentation transcript:

Which two ventricles cannot be used for a biventricular repair Which two ventricles cannot be used for a biventricular repair? Echocardiographic assessment Norman H Silverman, MD, Doff B McElhinney, MD The Annals of Thoracic Surgery Volume 66, Issue 2, Pages 634-640 (August 1998) DOI: 10.1016/S0003-4975(98)00573-6

Fig 1 Apical four-chamber view in a patient with a hypoplastic right ventricle with intact ventricular septum and diminutive tricuspid valve. The left atrium (LA), left ventricle (LV), right atrium (RA), and right ventricle (RV) are displayed. The arrows indicate the annuli of the mitral and tricuspid valves. The scale marker (left-hand panel) indicates 1 cm, with the tricuspid annulus approximating 5 mm, yielding a Z value of the tricuspid valve of −2.5. The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)

Fig 2 (Left) Image taken in an apical four-chamber view with caudal angulation. (Right) A view with cranial angulation of the pulmonary artery and its bifurcation into the right and left pulmonary artery (arrows). The chambers of the heart, as abbreviated in Figure 1, as well as the annulus of the very diminutive tricuspid valve are identified. The right ventricle is extremely hypertrophic, with a small inlet portion and a slit-like outlet portion proximal to the pulmonary artery identified on the right. The bifurcation of the pulmonary artery can be seen to the left of the ascending aorta (AO). The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)

Fig 3 A series of images in a patient with Ebstein’s malformation and pulmonary atresia. (Top) Subcostal sagittal view demonstrating the inferior vena cava (IVC), a very large Eustachian valve (EV) in the right atrium (RA), and the mural leaflet (ML) of the tricuspid valve. The aorta (Ao) is seen above. The area between the mural leaflet of the tricuspid valve and the Eustachian valve shows the atrioventricular groove to which the mural leaflet is normally attached in this view. The displacement between the attachment to the ventricular wall on the diaphragmatic surface and the atrioventricular groove demonstrates the marked displacement of the mural leaflet. The area confined to the right ventricle in this example is almost exclusively atrialized right ventricle (ARV). (Middle) Subcostal coronal view orthogonal to the previous frame. The area between the atrioventricular groove and the attachment of the mural leaflet again demonstrates the marked displacement of the leaflet. The anterior leaflet is adherent to the right ventricular wall, and can be seen occupying the subpulmonary area. The arrows indicate the attached anterosuperior leaflet of the tricuspid valve. (Bottom) An apical four-chamber view in the same patient. Here the left atrium (LA) and left ventricle (LV) can be easily identified. The anterosuperior leaflet (AL) can be seen from the normal position of the atrioventricular valve groove and is adherent to the right ventricular wall (arrows). The septal leaflet is entirely adherent to the ventricular wall and can be seen separated from the endocardium only toward the apex of the ventricle. The Eustachian valve can also be identified. The position normally occupied by the right ventricle is atrialized right ventricle. (PA = pulmonary artery.) The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)

Fig 4 (Left) Apical four-chamber view in a patient with moderately severe Ebstein’s malformation who had previously undergone annuloplasty with a Carpentier ring elsewhere, but presented with recurrent/residual moderate-severe tricuspid regurgitation. (Right) Systolic Doppler color-flow image from the same view demonstrates marked tricuspid regurgitation, as judged by a very broad jet. (Bottom) After removal of the ring, reconstruction of the tricuspid valve, and bidirectional Glenn at our institution, the tricuspid regurgitation is reduced to two small jets, one seen at the coaptation point between the septal and anterior leaflets, and the other arising more posteriorly between the septal and mural leaflets. The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)

Fig 5 This apical four-chamber view was taken from an infant with pulmonary atresia after right ventricular outflow reconstruction. The sizes of the right ventricular and tricuspid annulus are reasonable, but there is substantial tricuspid regurgitation. Bidirectional Glenn procedure and tricuspid annuloplasty reduced the degree of regurgitation and improved the quality of life for this patient. The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)

Fig 6 (Top left) A patient with a hypoplastic right ventricle (RV) and intact ventricular septum, demonstrating the presence of ventriculocoronary connections and retrograde flow into the right coronary artery. The color-flow map also demonstrates disturbed flow as a result of the patent ductus arteriosus within the pulmonary artery (PA), the normal-sized left ventricle (LV), and the right atrium (RA). The ventriculocoronary connection can be seen coming from the diaphragmatic surface of the right ventricle and passing immediately and directly into the coronary artery (arrows). (Bottom left) This subcostal image of a different patient demonstrates a ventriculocoronary connection (S) between the cavity of the right ventricle and the surface of the heart. Note that the Nyquist limit or velocity scale on the left-hand side has been turned down to accentuate lower velocity flow. (Top right) Here the anterior ventriculocoronary connection (VCC) is seen draining from the right ventricular outflow and toward the left coronary artery. (Bottom right) A pulsed-wave Doppler spectrum in the right coronary artery in the patient seen in the top left panel. This demonstrates systolic flow away from the transducer (ie, toward the aortic end of the coronary artery) with prograde flow into the coronary artery only for a short period of diastole. This finding has been appreciated only when there is a direct connection between the coronary artery and ventricle. (AO = aorta.) The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)

Fig 7 (A) Apical four-chamber view of a straddling tricuspid valve. The arrows indicate the tendinous cords crossing the ventricular septum (S) through the septal defect from the right atrium (RA) into the left ventricle (LV). This patient underwent ventricular septation with transplantation of the cordal apparatus into the right ventricle (RV) and a bidirectional Glenn procedure. (B) Apical four-chamber view of another patient with straddling of the right atrioventricular valve across the ventricular septum and into the left ventricle. Doppler color flow demonstrates almost complete absence of inflow into the hypoplastic outlet chamber (v), with all right atrial and left atrial flow draining into the larger left ventricle. (Ao = descending aorta; LA = left atrium; PV = pulmonary vein.) The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)

Fig 8 This patient with a small left ventricle was considered inadequate for a biventricular repair and underwent a Norwood procedure. (Top) Parasternal long-axis view demonstrating the diminutive aorta (AO), left atrium (LA), and left ventricle (LV), which has evidence of endocardial fibroelastosis and thickening of the tendinous cords supporting the mitral valve leaflets. (Bottom) This apical four-chamber view demonstrates the hypoplastic nature of the left-heart structures. The right ventricle is apex-forming. The mitral annulus is less than 6 mm. (RA = right atrium; RV = right ventricle.) The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)

Fig 9 (A) This image is from a fetus of 36 weeks’ gestation who presented initially at 26 weeks. There was disparate growth in the right and left ventricles over the course of gestation, with a progressive increase in right ventricular size, appropriate for age, but with less than adequate growth of the left ventricle. At birth, this patient had an extremely diminutive left ventricle, and a Norwood procedure was performed. (B) This frame demonstrates a shunt from the left (LA) to right (RA) atrium through the foramen ovale. (LV = left ventricle; RV = right ventricle.) The Annals of Thoracic Surgery 1998 66, 634-640DOI: (10.1016/S0003-4975(98)00573-6)