Echocardiographic factors discriminating biventricular versus univentricular approach in the foetus with borderline left ventricle

2014 ◽  
Vol 25 (5) ◽  
pp. 941-950 ◽  
Author(s):  
David W. Jantzen ◽  
Sarah K. Gelehrter ◽  
Sunkyung Yu ◽  
Janet E. Donohue ◽  
Carlen G. Fifer
Keyword(s):  
Mitral Valve ◽  
Left Ventricle ◽  
Single Ventricle ◽  
Left Ventricular ◽  
Z Score ◽  
Biventricular Repair ◽  
Z Scores ◽  
Valve Annulus ◽  
Single Ventricle Palliation ◽  
Dimension Ratio

AbstractBackground: The term “borderline left ventricle” describes a small left heart that may be inadequate to provide systemic cardiac output and implies the potential need for a single-ventricle palliation. The aim of this study was to identify foetal echocardiographic features that help discriminate which infants will undergo single-ventricle palliation versus biventricular repair to aid in prenatal counselling. Methods: The foetal database at our institution was searched to identify all foetuses with borderline left ventricle, as determined subjectively by a foetal cardiologist, from 2000 to 2011. The foetal images were retrospectively analysed for morphologic and physiologic features to determine which best predicted the postnatal surgical choice. Results: Of 39 foetuses identified with borderline left ventricle, 15 were planned for a univentricular approach, and 24 were planned for a biventricular approach. There were significant differences between the two outcome groups in the Z-scores of the mitral valve annulus, left ventricular end-diastolic dimension, aortic valve annulus, and ascending aorta diameter (p<0.05). With respect to discriminating univentricular outcomes, cut-offs of mitral valve Z-score ⩽−1.9 and tricuspid:mitral valve ratio ⩾1.5 were extremely sensitive (100%), whereas a right:left ventricular end-diastolic dimension ratio ⩾2.1 provided the highest specificity (95.8%). Conclusion: In foetuses with borderline left ventricle, a mitral valve Z-score ⩾−1.9 or a tricuspid:mitral valve ratio ⩽1.5 suggests a high probability of biventricular repair, whereas a right:left ventricular end-diastolic dimension ratio ⩾2.1 confers a likelihood of single-ventricle palliation.

The hybrid procedure for the borderline left ventricle

2010 ◽  
Vol 21 (1) ◽  
pp. 26-30 ◽  
Author(s):  
Christopher K. Davis ◽  
Peter Pastuszko ◽  
John Lamberti ◽  
John Moore ◽  
Frank Hanley ◽  
...  
Keyword(s):  
Left Ventricle ◽  
Single Ventricle ◽  
Scoring Systems ◽  
Ventricular Volume ◽  
Left Ventricular ◽  
Hybrid Procedure ◽  
Left Ventricular Volumes ◽  
Left Heart ◽  
Biventricular Repair ◽  
Definitive Repair

AbstractIntroductionIn patients with varying degrees of left heart hypoplasia, it is often difficult to determine whether the left heart structures are adequate in size to support biventricular circulation. Historically, the decision to pursue a single ventricle or biventricular repair needed to be made early and was often irreversible. The hybrid procedure may be a better initial approach for patients with borderline left ventricles.MethodsWe describe a series of four patients with various congenital cardiac malformations, all of whom had borderline left ventricles. Based on pre-operative echocardiograms, several scoring systems and left ventricle volumes were used to predict the optimal type of repair. A left ventricular volume of 20 millilitres per square metre was used as the minimum cut-off value for adequacy of biventricular repair.ResultsThe left ventricular volumes for the patients were 17.1, 23.7, 25.4, and 25.8 millilitres per square metre. In none of the four patients were the calculations unanimous in the recommendation to pursue either type of repair. All patients underwent the hybrid procedure and then eventual single ventricle palliation (two patients) or biventricular repair (two patients). All survived with a mean follow-up of 18 plus or minus 3.9 months.ConclusionsThe hybrid procedure may be the best option in patients with a borderline left ventricle. It can serve as a bridge to a more definitive repair when patients are older, larger, and for whom the decision between single ventricle and biventricular repair can be more easily made.

scholarly journals Maternal hyperoxygenation and foetal cardiac MRI in the assessment of the borderline left ventricle

2014 ◽  
Vol 25 (6) ◽  
pp. 1214-1217 ◽  
Author(s):  
Sharon Borik ◽  
Christopher K. Macgowan ◽  
Mike Seed
Keyword(s):  
Left Ventricle ◽  
Phase Contrast ◽  
Single Ventricle ◽  
Venous Return ◽  
Postnatal Growth ◽  
Left Ventricular ◽  
Pulmonary Vasodilation ◽  
Left Ventricular Output ◽  
Atrial Shunt ◽  
Single Ventricle Palliation

AbstractUsing phase-contrast MRI in a foetus with borderline left ventricular hypoplasia at 37 weeks’ gestation we showed an increase in pulmonary blood flow during maternal hyperoxygenation. The associated increase in venous return to the left atrium, however, resulted in reversal of the atrial shunt, with no improvement in left ventricular output. The child initially underwent single ventricle palliation with a neonatal hybrid procedure, but following postnatal growth of the left ventricle tolerated conversion to a biventricular circulation at 5 months of age. We conclude that when there is significant restriction of filling or outflow obstruction across the left heart, neither prenatal nor postnatal acute pulmonary vasodilation can augment left ventricular output enough to support a biventricular circulation. Chronic pulmonary vasodilation may stimulate the growth of the left-sided structures allowing biventricular repair, raising the intriguing question of whether chronic maternal oxygen therapy might obviate the need for neonatal single ventricle pallation in the setting of borderline left ventricular hypoplasia.

scholarly journals The Early “Unnatural” History Following Surgical Repair of Ventricular Septal Defects

2019 ◽  
Vol 12 (4) ◽  
pp. 121-124
Author(s):  
Sathish M. Chikkabyrappa ◽  
Justin T. Tretter ◽  
Arpan R. Doshi ◽  
Sujatha Buddhe ◽  
Puneet Bhatla ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Surgical Repair ◽  
Left Ventricular ◽  
Patch Repair ◽  
Qualitative Assessment ◽  
Z Score ◽  
Septal Defects ◽  
Valve Annulus ◽  
Annulus Diameter

Introduction Surgical outcomes for simple ventricular septaldefects (VSD) have been excellent in the past three decades. Forthis project, the timing of resolution of left-sided dilation and mitralregurgitation (MR) following VSD repair was assessed. Methods Echocardiographic data surrounding surgery of 42 consecutivechildren who underwent surgical patch repair of a VSD werereviewed. The echocardiograms were reviewed up to a mean of 12months post-operatively (range 9 - 14 months). Quantitative dataindexed to body surface area including left atrial (LA) volume, mitralvalve annulus diameter, and left ventricular end-diastolic dimension(LVEDD) was analyzed. Results The majority of our pre-surgical cohort had only trace(44%) or no MR (31%), with a small proportion having mild (16%)or moderate MR (9%). No patients had moderate or greater MR followingrepair at follow-up. The median mitral valve annular Z-scorewas 1.8 (SD 1.6; range: -1.2 to 4.1) pre-operatively, improving to a 0.6(range: -1.7 to 2.4; p < 0.001) at follow-up. LA dilation was present in70% of patients, with a median LA volume Z-score of 1.1 (range: -2.6to 15.5), decreasing to 13% median Z-score -1.2 (range: -3.5 to 2.9; p< 0.001) at follow-up. LV dilation was present in 81% of pre-operativepatients with a median LVEDD Z-score of 3.0 (range: -2.0 to 7.9).There was significant improvement in qualitative assessment of LVenlargement (25%) with a median LVEDD Z-score of 0.5 (range:-2.1 to 2.9; p < 0.001) at follow-up. Discharge echocardiogram wasperformed at a mean of 5.7 days (range: 3 - 12 days) following surgery. Conclusions Normalization of LA, mitral valve annulus, and LV sizeoccurred within the first three months in the majority of patients, withsignificant changes occurring within the first post-operative weekfollowing surgical repair for VSD.

scholarly journals Surgical Outcomes of Biventricular Repair for Hypoplastic Left Ventricle With Congenital Mitral Valve Stenosis

2019 ◽  
Vol 10 (1) ◽  
pp. 11-17 ◽  
Author(s):  
Masatoshi Shimada ◽  
Takaya Hoashi ◽  
Tomohiro Nakata ◽  
Hideto Ozawa ◽  
Kenichi Kurosaki ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Mitral Valve ◽  
Left Ventricle ◽  
Left Ventricular Mass ◽  
Surgical Intervention ◽  
Left Ventricular ◽  
Mitral Valve Stenosis ◽  
Biventricular Repair ◽  
Hypoplastic Left Ventricle ◽  
Ventricular Mass

Objective: Surgical outcomes of biventricular repair for hearts with hypoplastic left ventricle with congenital mitral valve stenosis are described. Serial changes of left ventricular geometry and clinical features after biventricular repair were reviewed. Methods: Eight patients with hypoplastic left ventricle and congenital mitral valve stenosis who underwent first surgical intervention for biventricular circulation in neonatal or infantile period between 2001 and 2014 comprise the study population. Serial change in left ventricular end-diastolic diameter, left ventricular mass index, and relative wall thickness after biventricular repair were evaluated by two-dimensional echocardiography. Results: The median Z-scores of left ventricular end-diastolic diameter and mitral valve diameter before the first surgical intervention were −3.0 (range, −4.8 to −2.0) and −1.0 (−2.9 to 2.1), respectively. Mitral valves were surgically treated in five patients; they were replaced in two and repaired in three patients. Left ventricular end-diastolic diameter Z-score at five years after biventricular repair was 0.1 (−3.0 to 1.0), which was significantly larger than before first surgical intervention ( P = .005). Left ventricular mass index, on the other hand, did not change, but relative wall thickness significantly decreased ( P = .009). Postoperative catheter study showed pulmonary hypertension with high left ventricular end-diastolic pressure in more than half of survivors. Conclusions: Left ventricle increased in size after the biventricular repair with appropriate mitral valve procedures before progression of pulmonary hypertension. Left ventricular mass, however, did not accompany the increase. Some patients may have suffered from mild, but certain restrictive left ventricular physiology and subsequent pulmonary hypertension as the result of abnormal remodeling process of the myocardium.

Optimal Z-Score Use in Surgical Decision-Making in Pulmonary Atresia With Intact Ventricular Septum

2017 ◽  
Vol 8 (3) ◽  
pp. 385-388 ◽  
Author(s):  
Mark Nelson Awori ◽  
Nikita P. Mehta ◽  
Frederick O. Mitema ◽  
Naomi Kebba
Keyword(s):  
Tricuspid Valve ◽  
Pulmonary Atresia ◽  
Ventricular Septum ◽  
Data Sets ◽  
Intact Ventricular Septum ◽  
Z Score ◽  
Biventricular Repair ◽  
Tricuspid Valve Annulus ◽  
Z Scores ◽  
Valve Annulus

Objectives: In the surgical treatment of pulmonary atresia with intact ventricular septum, the size of the tricuspid valve annulus (as measured by z-scores) has emerged as a significant factor in deciding which repair to perform. Various tricuspid valve annulus z-scores are reported as “cutoffs” for successful biventricular repair. We aimed to determine whether the use of different z-score data sets contributed to the gross variation in “cutoffs” for successful biventricular repair reported in the literature. Methods: A single search was made of PubMed using the “advanced” setting with the following search terms: pulmonary, atresia, intact, septum, z, and score. The filters “title” and “title/abstract” were used for the first four and last two terms, respectively; the instruction “AND” combined all terms. Articles that identified which z-score data set was used in patients with biventricular repairs were included. Results: From 13 articles, 1,392 patients were studied, 410 (29.5%) of which achieved biventricular repair. Three z-score data sets were quoted; mean tricuspid valve annulus z-scores in biventricular repair patients ranged between −0.53 and −5.1. After correcting for discrepancies between z-score data sets, no study reported a mean tricuspid valve annulus z-score <−2.8 in biventricular repair patients and 83.3% reported mean tricuspid valve annuli z-scores >−1.7. Conclusion: The use of varied tricuspid valve annuli z-score data sets may have contributed to gross variations in reported “cutoffs” for successful biventricular repair. This could lead to inappropriate surgical pathway allocation.

scholarly journals Critical Ebstein’s anomaly with circular shunt: from successful fetal therapy with non-steroidal anti-inflammatory drugs to biventricular repair using Da Silva cone technique

2021 ◽  
pp. 1-4
Author(s):  
Lilian M. Lopes ◽  
Rodrigo F. Bezerra ◽  
Jose Pedro da Silva ◽  
Luciana da Fonseca da Silva
Keyword(s):  
Single Ventricle ◽  
Ductus Arteriosus ◽  
Ebstein’S Anomaly ◽  
Biventricular Repair ◽  
Fetal Demise ◽  
Ebstein's Anomaly ◽  
Gestational Week ◽  
Inflammatory Drugs ◽  
Anti Inflammatory ◽  
Single Ventricle Palliation

Abstract We report an innovative treatment strategy for fetal Ebstein’s anomaly with a circular shunt. We used transplacental non-steroidal anti-inflammatory drugs, at the 29th gestational week, to constrict the ductus arteriosus avoiding fetal demise. We addressed the critical neonate with an urgent Starnes procedure. Finally, instead of following the usual single-ventricle palliation pathway after the Starnes procedure, we achieved successful two-ventricle repair with the cone technique at 5 month old.

Numerical Study on Diastolic Left Ventricular Hemodynamics Using Motion Models of Mitral Valve With/Without Edge-to-Edge Repair

2010 ◽  
Author(s):  
Yingying Hu ◽  
Liang Shi ◽  
Siva Parameswaran ◽  
Sergey A. Smirnov ◽  
Zhaoming He
Keyword(s):  
Shear Stress ◽  
Mitral Valve ◽  
Left Ventricle ◽  
Platelet Activation ◽  
Numerical Study ◽  
Left Ventricular ◽  
High Shear ◽  
High Shear Stress ◽  
Orifice Area ◽  
Motion Models

Edge-to-edge repair (ETER) is a newly developed technique to correct such mitral valve (MV) malfunctions as regurgitation [1,2]. This technique changes MV geometric configuration by suturing the anterior and posterior leaflets at central or commissural edges, and consequently alters MV and left ventricle (LV) dynamics. For instance, stress in the MV elevated due to ETER may cause leaflets tearing near suture. Little has been known about shear stress on the MV and LV walls under MV ETER conditions, where high shear stress might cause platelet activation or hemolysis [3]. When ETER is done at the central leaflet edges, it generates two MV orifices, leads to two deflected jets, and completely changes vortices in the LV. ETER also reduces the orifice area, and increases jet velocity and transmitral pressure [1,2,4]. Flow patterns in the LV and ETER effects on the LV and MV functions have not been understood well.

Origin of regional pressure gradients in the left ventricle during early diastole

1995 ◽  
Vol 268 (2) ◽  
pp. H550-H557 ◽  
Author(s):  
S. D. Nikolic ◽  
M. P. Feneley ◽  
O. E. Pajaro ◽  
J. S. Rankin ◽  
E. L. Yellin
Keyword(s):  
Mitral Valve ◽  
Left Ventricle ◽  
Dynamic Geometry ◽  
Major Axis ◽  
Left Ventricular ◽  
Elastic Recoil ◽  
Systolic Volume ◽  
Early Diastole ◽  
Shape Changes ◽  
Isovolumic Relaxation

Left ventricular (LV) pressure (P)-diameter, LVP-area, or LVP-volume relationships used to evaluate LV diastolic function assume uniform LV wall motion and constant LVP. Contrary to these assumptions, there are significant differences in ventricular dynamic geometry and in LV pressures measured simultaneously in different parts of the LV, particularly during early diastole. We instrumented six anesthetized open-chest dogs with three pairs of orthogonal ultrasonic crystals (anterior-posterior and septal-free wall minor axes, and base-apex major axis) and two micromanometers (in the apex and in the LV base). The mitral valve occluder was implanted during standard cardiopulmonary bypass in the mitral annulus. Data were recorded during 11 transient vena caval occlusions. The mitral valve was occluded for 1 beat every 6–8 beats during each vena caval occlusion to produce nonfilling diastole. With the decrease of the LV end-systolic volume (Ves) below the equilibrium volume Veq (volume of the completely relaxed LV at LVP = 0); the minimum negative LVP in nonfilling beats increases, the shape of the ventricle is more ellipsoidal in both filling and nonfilling beats, and the base-to-apex pressure gradient at the time of LVP minimum increases regardless of the presence or absence of filling. Thus heterogeneous myocardial stresses during isovolumic relaxation and early diastole result in ventricular shape changes, intraventricular redistribution of chamber volume, local accelerations of blood, and associated intraventricular LVP gradients. The role of elastic recoil assumes greater importance at Ves smaller than Veq, when the left ventricle becomes more ellipsoidal in shape during isovolumic relaxation, leading, in turn, to greater shape changes and greater LVP gradient.

Do Pediatric Sickle Cell Disease Patients Develop Diastolic Dysfunction?.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3195-3195
Author(s):  
Mark V. Zilberman ◽  
Wei Du ◽  
Wanda J. Whitten-Surney ◽  
Sharada A. Sarnaik
Keyword(s):  
Mitral Valve ◽  
Sickle Cell Disease ◽  
Tissue Doppler ◽  
Left Ventricular ◽  
Volume Index ◽  
Cell Disease ◽  
Mitral Inflow ◽  
Lv Mass ◽  
Z Scores ◽  
Mass Volume

Abstract Sickle cell disease (SCD) is a known cause of chronic volume overload. Although systolic dysfunction is rare, as many as 80% of adult patients with SCD have an echocardiographic mitral valve inflow pattern suggestive of abnormal left ventricular (LV) diastolic function (DF). DF has not been studied in pediatric SCD patients. Therefore, the objective of this study was to evaluate DF in pediatric SCD patients using echocardiographic velocities of mitral inflow and tissue Doppler (TDI) indices. Echocardiograms were performed in 79 SCD patients (ages 2 – 18 years), and 84 controls matched for age and race. LV and left atrial (LA) volumes, LV mass, early (E) and late (A) mitral inflow velocities, and TDI velocities at the septal and lateral aspects of the mitral valve were obtained. LV dilatation was defined as LV end-diastolic dimension more then 2 standard deviations above the median (z-value &gt;2). LV hypertrophy was defined as LV mass/volume index&gt;1.15 g/ml. For SCD patients, average hemoglobin (Hb) levels for the year prior to the study were recorded. Data were analyzed using t-test and Spearman correlation analysis. Of 79 SCD subjects, 32 (43%) had LV dilatation, 11(14.9%) had LV hypertrophy and 3 had both. LV z-scores were inversely related to Hb (r −0.62, p&lt;0.0001) but unrelated to age. The early mitral inflow velocities E were negatively correlated with Hb levels(r − 0.34, p&lt;0.04) and were positively correlated with LV z-scores (r 0.41, p&lt;0.04) reflecting pre-load dependency of mitral inflow indices. DTI diastolic velocities were unrelated to Hg or LV size reflecting pre-load independent nature of these indices. DTI systolic velocities S’ correlated positively with LV mass/volume index (r 0.28, p&lt;0.02). SCD patients had significantly larger LV and LA volumes than controls (p&lt;0.01). The early E and late A mitral inflow velocities were higher in the SCD group than the control, although the differences were not statistically significant. DTI indices did not differ between SCD patients and the control. Conclusion: Despite high incidence of left ventricular dilatation, pediatric SCD patients don’t demonstrate diastolic dysfunction when evaluated using pre-load independent echocardiographic tissue Doppler indices.

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