Pulmonary Venous Flow Research Articles

Pulmonary vein obstruction after catheter ablation in a patient with partial anomalous pulmonary vein connection

A 75-year-old man with symptomatic atrial fibrillation was referred to our hospital for catheter ablation. Preprocedural echocardiogram showed mild-moderate degree mitral regurgitation (MR) and mild tricuspid regurgitation (TR) with transvalvular peak gradient (TVPG) of 27mmHg. The complete isolation of the pulmonary veins was performed by radiofrequency ablation, and the patient was kept in sinus rhythm after the procedure. However, the exertional dyspnea had gradually developed one year after the procedure. Echocardiogram showed severe TR with TVPG 60mmHg. MDCT showed partial anomalous pulmonary vein connection (PAPVC) of the left upper pulmonary vein and the occlusion of left lower pulmonary vein ostium: pulmonary venous flow of the left upper lung was drained into the brachiocephalic vein. The patient underwent surgical correction of PAPVC and annuloplasty of the mitral and tricuspid valve. Although it is unclear whether there is direct causal relationship between PAPVC and PV obstruction, anatomical evaluation of PVs is important in patients undergoing catheter ablation.<Learning objective: Partial anomalous pulmonary vein connection (PAPVC) is rare and often asymptomatic in adults. In the present case, pulmonary vein obstruction occurred after radiofrequency catheter ablation in a patient with PAPVC. Although pulmonary venous flow from only left upper lobe drained into the brachiocephalic vein before ablation, occlusion of the left lower pulmonary vein resulted in right heart failure one year after ablation.>

Surgical treatment of total anomalous pulmonary venous connection under 6 months of age

To discuss the experience of surgical treatment of total anomalous pulmonary venous connection (TAPVC) in infants. The clinic data of 84 cases with TAPVC under 6 months of age underwent surgical treatment at Department of Cardiac Surgery, Guangzhou Women and Children's Medical Center from January 2012 to October 2015 were analyzed retrospectively. There were 58 male and 26 female patients. The patients were aged 1 days to 6 months with a mean of (2.4±2.2) months at surgery, including 22 newborns. Body weight was 1.8 to 6.8 kg with a mean of (4.3±1.2) kg. There were 24 cases of intracardiac type, 46 cases of supracardiac type, 10 cases of infracardiac type and 4 cases of mixed type. There were 26 cases received emergent operation. There were 14 cases used Sutureless technique in operations and 46 cases used conventional methods in the no-intracardiac type cases, and 2 cases enlarged the anastomsis with autologous pericardium. According to the condition, corrective surgeries of other anomalies were performed in the meantime, including 3 Warden operations (right side), 3 bilateral bidirectional Gleen operation, 2 correction of unroofed coronary sinus syndrome, 1 coarctation of aorta correction with deep hypothermic circulation arrest, and 1 repair of ventricular septal defect. The ratio of newborn was higher in Sutureless technique group than in conventional methods group (7/14 vs. 32.6%, χ(2)=4.927, P=0.043), and mean age was less ((1.8±0.4) months vs. (2.4±2.2) months, F=4.257, P=0.042), but there were no difference in body weight, cardiopulmonary bypass time and aorta clamped time between the two groups. Followed up for 1 to 46 months, 10 cases (11.9%) died overall and the mortality of intracardiac (3/10) and mixed (2/4) type were much higher than in intracardiac (4.2%) and supracardiac (13.0%) type. The mortality were no difference between newborn and infants, or whether emergent operation, or Sutureless technique and conventional methods. The maximal pulmonary venous flow velocity was abnormal speed-up >1.8 m/s at 1 week and 1 to 3 months post-operation mostly. The mortality of TAPVC was differed by different types. Intrinsic pulmonary vein stenosis maybe the main cause of mortality. The high quality of anastomsis could reduce the operative mortality.

Study of left ventricular diastolic dysfunction in recently diagnosed hypertensives in Central Nepal

CORRECTION: The conclusion on the PDF of this article was replaced on 17th April 2016. The corrected PDF is now available by clicking on the link below.Background &amp; Objectives: Ectopic Left ventricular diastolic dysfunction is now well established as a cause of left sided heart failure and as a powerful predictor of cardiovascular events. It is attributed mostly to systemic hypertension. The objective of the study was to determine the prevalence of left ventricular diastolic dysfunction in recently diagnosed hypertensives in Nepalese population using echocardiography. Materials &amp; Methods: Two-dimensional echocardiography was performed on 120 newly diagnosed patients of systemic hypertension. Transmitral Doppler indexes of diastolic function, Valsalva maneuver applied to the same mitral inflow pattern, pulsed tissue Doppler of the mitral annulus, deceleration time, isovolumic relaxation time and pulmonary venous flow pattern.Results: The age of the patients in our study ranged from 20 to 84 years with mean age of 50years±14.13 years (standard deviation) and male:female ratio being 1.35:1. Hypertensive patients were highest in age group 45-64 years followed by 25-44 years in both the genders. Majority of the patients had stage 1 hypertension (44.16%) followed by stage 2 HTN in 34.17% and pre-hypertension in 21.67%. The majority of the patients in our study had Grade 1 LVDD (66.67%), 10.83% patients had Grade II LVDD, only 2.50% had non-restrictive Grade III LVDD and none had LVDD-IV. Stage II hypertensives had more LVDD(I+II+III): 39/41-95.12% than stage I hypertensives(39/53-73.58%) and pre-hypertensives (8/26-30.77%). The association between stages of systemic HTN and LVDD was found to be highly statistically significant (p=0.002). Conclusion: Our study showed that left ventricular diastolic dysfunction is a common entity in Nepalese population with systemic hypertension.JCMS Nepal. 2016;12(1):14-18.

Relation of Doppler Tissue Imaging Parameters With Heart Failure Progression in Hypertrophic Cardiomyopathy

Refractory progressive heart failure (HF) is becoming the predominant cause of mortality in nonobstructive hypertrophic cardiomyopathy (HC). To anticipate development of this important and often unpredictable clinical course, we investigated whether left ventricular diastolic dysfunction, assessed by echocardiographic Doppler parameters, could identify a subset of patients with HC without obstruction at rest who would experience progression of HF. Diastolic function parameters, assessed by Doppler tissue imaging (DTI), mitral inflow, and pulmonary venous flow were measured in 274 consecutive adult patients with HC evaluated from 2003 to 2007. DTI and other diastolic and clinical/demographic parameters were measured against the composite end point of HF/death, heart transplantation, or progression to advanced New York Heart Association functional class III/IV symptoms and sudden death (SD)/implantable defibrillator (ICD) interventions. HF end points were reached in 19 of 274 patients (7%) over a follow-up period of 4.0 ± 2.3years. Variables significantly associated with HF outcome by univariate analysis included male gender, initial New York Heart Association class II, lower ejection fraction, and reduced septal and lateral e' mitral annular tissue velocities. Multivariable analysis showed only a reduced lateral e' mitral annular tissue velocity to be independently associated with the composite HF end points (HR 0.77; 95% CI 0.65 to 0.91; p= 0.003). In addition, estimated pulmonary arterial systolic pressure and extensive late gadolinium enhancement by magnetic resonance were also associated with HF outcome (p= 0.04 and p <0.001, respectively). No Doppler (or clinical) variable was associated with SD/appropriate ICD interventions. In conclusion, in HC without outflow obstruction at rest, diastolic dysfunction, evidenced by DTI-reduced lateral e' mitral annular tissue velocity, was associated with adverse long-term HF outcome but was unrelated to SD. This echocardiographic marker provides a potential noninvasive strategy for anticipating progressive HF in this HC patient group.

Total anomalous pulmonary venous return

TAPVR typically presents in early infancy due to excessive pulmonary blood flow and mild cyanosis. Presentation is earlier when there is obstruction to pulmonary venous flow where neonates present with severe cyanosis and cardiogenic shock, surgical repair must be planned immediately. Mixing of well oxygenated blood through the anomalous connection of pulmonary veins with the systemic blood in the right atrium results in similar oxygen saturation in all cardiac chambers and arteries, therefore pre and post ductal oxygen saturations are equal. Increased blood flow across the right heart causes delay in closure of the pulmonary valve, presenting as fixed splitting of second heart sound as well as systolic flow murmur over the pulmonic region. Supra-cardiac drainage of anomalous pulmonary veins to the superior vena cava result in figure-eight or snow man appearance of the cardiac silhouette on CXR.

Accuracy and Internal Consistency of Cardiac Magnetic Resonance Imaging in Measuring Branch Pulmonary Artery Flows in Patients With Conotruncal Anomalies and Branch Pulmonary Artery Stents

Clinicians use branch pulmonary artery (BPA) blood flow distribution to help determine the need for intervention. Although phase-contrast magnetic resonance (PCMR) flow measurements are accurate, this has never been shown in the vicinity of a BPA ferromagnetic stent (FS) which produces significant susceptibility artifact. We retrospectively reviewed 49 consecutive PCMR studies performed from 2005 to 2012 on patients with repaired conotruncal anomalies and either left (n = 29) or right PA (n = 20) stents. Three methods of measuring the stented BPA flow were compared: (1) main PA (MPA) minus nonstented BPA, (2) direct PCMR of stented BPA away from the artifact, and (3) pulmonary venous flows (ipsilateral to stented BPA and derived pulmonary blood flow ratio from bilateral pulmonary venous flows). Internal consistency was tested with the Student t test, linear regression, Bland-Altman analysis, and intraclass correlation (ICC). The mean age was 11.7 ± 6.9 years with 5.8 ± 4.2 years between stent placement and CMR. There was good agreement without significant difference between MPA-derived stented BPA flow (method 1) and direct PCMR of stented BPA (method 2; 41 ± 19% vs 39 ± 19%, p = 0.59; R(2) = 0.84, p <0.001; ICC = 0.96). There was also good agreement between methods 1 and 2 compared to pulmonary venous flows, with the highest correlation occurring between method 2 and ipsilateral pulmonary venous flow (R(2) = 0.90, p <0.001; ICC = 0.97 for MPA-derived-stented BPA flow; R(2) = 0.94, p <0.001; ICC = 0.98 for direct PCMR of stented BPA). Eleven of the 49 patients (22%) underwent interventional catheterization after PCMR. In conclusion, in the vicinity of a BPA FS, accurate measurement of the net fractional pulmonary blood flow ratio is feasible. PCMR adjacent to the stent and ipsilateral pulmonary venous flows provide the most internally consistent data. These data underscore PCMR's utility in managing patients with implanted FS.

Extrapolating echocardiographic determinants of elevated Left Atrial Pressure (LAP) to Cardiac Magnetic Resonance Imaging (CMR) to determine the best CMR correlate of elevated LAP

Background The ratio of the transmitral early inflow wave velocity (E wave velocity) and the velocity of the septal (or lateral) mitral annulus as measured by tissue Doppler (the e’ wave velocity) can be used to estimate left atrial pressure on echocardiographic examination. An elevated E/e’ (more than 15 when using the septal mitral annular velocity) is an established measure of elevated LAP. Furthermore when the left atrial pressure rises, simultaneous changes take place in the pulmonary venous flow. The normal flow pattern in the pulmonary veins consist of a prominent systolic and a smaller diastolic component with the ratio of the peak systolic to diastolic velocities more than 1. With elevated left atrial pressure the ratio drops to below 1.

Velocity time integral for right upper pulmonary vein in VLBW infants with patent ductus arteriosus

OBJECTIVE:Early diagnosis of significant patent ductus arteriosus reduces the risk of clinical worsening in very low birth weight infants. Echocardiographic patent ductus arteriosus shunt flow pattern can be used to predict significant patent ductus arteriosus. Pulmonary venous flow, expressed as vein velocity time integral, is correlated to ductus arteriosus closure. The aim of this study is to investigate the relationship between significant reductions in vein velocity time integral and non-significant patent ductus arteriosus in the first week of life.METHODS:A multicenter, prospective, observational study was conducted to evaluate very low birth weight infants (<1500 g) on respiratory support. Echocardiography was used to evaluate vein velocity time integral on days 1 and 4 of life. The relationship between vein velocity time integral and other parameters was studied.RESULTS:In total, 98 very low birth weight infants on respiratory support were studied. On day 1 of life, vein velocity time integral was similar in patients with open or closed ductus. The mean vein velocity time integral significantly reduced in the first four days of life. On the fourth day of life, there was less of a reduction in patients with patent ductus compared to those with closed patent ductus arteriosus and the difference was significant.CONCLUSIONS:A significant reduction in vein velocity time integral in the first days of life is associated with ductus closure. This parameter correlates well with other echocardiographic parameters and may aid in the diagnosis and management of patent ductus arteriosus.

0540: Relationship between functional capacity and diastolic function in chronic heart failure patients

Dyspnea is the frequent cause of exercise intolerance and physical inactivity among chronic heart failure patients. Diastolic dysfunction has shown significant correlation with exercise capacity. The aim is to study whether there is interaction between left ventricular diastolic dysfunction and functional capacity in our CHF patients. 1613 consecutive ambulatory patients with chronic heart failure were enrolled from 2006 to 2013 and registered in the therapeutic unit of chronic heart failure. Clinical, echocardiographic and biological data were investigated. We divided our patients into 2 groups as follow: group 1with reducing filling pressure (64 years, 67% were male), group 2 with elevated filling pressure (EFP) (69 years, 61% were male). We analyzed New York heart association (NYHA) status and the 6 minutes’ walk test. Assessment of diastolic function as determined by Doppler-derived mitral and pulmonary venous flow velocities recorded by transthoracic pulsed Doppler echocardiography. There was no significant difference in baseline characteristic and ejection fraction. The mean of 6 minutes’ walk in groups were 349 and 212m respectively. Group 2 (EFP) was significantly associated with more NYHA grade III/IV (p<0.00001), inversely associated with NYHA grade I/II (p<0.0001). The 6 minutes’ walk test was shorter in EFP patients than others (P<0.01). There was a significant correlation between diastolic dysfunction and cardiac decompensation (p=0.00001), right ventricular dysfunction (p=0.00001), pulmonary hypertension (p=0.00001), dilated vena cava and higher doses of diuretics (p=0.00001). Also, beta-blockers were inversely associated (P<0.0001). Diastolic dysfunction is significantly associated with impaired functional capacity and dyspnea among CHF patients.

Left atrial strain: a new parameter for assessment of left ventricular filling pressure.

In order to obtain accurate diagnosis, treatment and prognostication in many cardiac conditions, there is a need for assessment of left ventricular (LV) filling pressure. While systole depends on ejection function of LV, diastole and its disturbances influence filling function and pressures. The commonest condition that represents the latter is heart failure with preserved ejection fraction in which LV ejection is maintained, but diastole is disturbed and hence filling pressures are raised. Significant diastolic dysfunction results in raised LV end-diastolic pressure, mean left atrial (LA) pressure and pulmonary capillary wedge pressure, all referred to as LV filling pressures. Left and right heart catheterization has traditionally been used as the gold standard investigation for assessing these pressures. More recently, Doppler echocardiography has taken over such application because of its noninvasive nature and for being patient friendly. A number of indices are used to achieve accurate assessment of filling pressures including: LV pulsed-wave filling velocities (E/A ratio, E wave deceleration time), pulmonary venous flow (S wave and D wave), tissue Doppler imaging (E' wave and E/E' ratio) and LA volume index. LA longitudinal strain derived from speckle tracking echocardiography (STE) is also sensitive in estimating intracavitary pressures. It is angle-independent, thus overcomes Doppler limitations and provides highly reproducible measures of LA deformation. This review examines the application of various Doppler echocardiographic techniques in assessing LV filling pressures, in particular the emerging role of STE in assessing LA pressures in various conditions, e.g., HF, arterial hypertension and atrial fibrillation.

Abstract 14797: Impact of Normalized Pulmonary Vein Flow Pattern After Percutaneous Mitral Valve Repair

Background: Systolic reverse pulmonary venous flow (PVF) assessed with pulsed Doppler echocardiography is a valuable marker of severe mitral regurgitation (MR). However, the relationship between PVF pattern after MR reduction by percutaneous mitral valve repair with MitraClip system and clinical outcome is not well established. We hypothesized that normalized PVF after MitraClip procedure was associated with successful MR reduction and clinical outcome. Method: 146 consecutive patients with symptomatic MR who implanted the MitraClip were studied. The patients were divided into 2 groups on the basis of post-procedural left upper PVF pattern; the normalized group (n = 77) and the non-normalized group (n = 69). The normalized PVF was defined as a ratio of peak systolic to diastolic flow velocity ≧1. Results: In baseline characteristics, the normalized PVF was independently associated with age &lt;75 (liner regression coefficient [B] = 0.521, 95% confidence interval [CI] = 0.146 - 0.822, P = 0.016) and degenerative MR (B = 0.969, 95% CI 0.049 - 0.383, P &lt;.0001). The normalized group demonstrated significantly higher residual MR ≦2 rate than non-normalized group (100% vs. 97.3%, P = 0.003). At a mean of 2.9 ± 1.9 years follow up, the rate of freedom from the composite endpoint (defined as surgery or 2nd MitraClip procedure for mitral valve dysfunction or all cause death) was significantly higher in the normalized group. Mutivariable Cox regression analysis demonstrated that normalized PVF was an independent post-procedural parameter of freedom from composite endpoint (hazard ratio =0.571, 95%CI 0.339 - 0.948, P = 0.03). Conclusion: The normalized PVF after the MitraClip procedure was associated with successful MR reduction and a long-term clinical outcome. Prospective data should be used to validate this.

Scimitar Syndrome a Rare Cause of Isolated Esophgeal Varices

We present a rare case of isolated esophageal varices arising from Scimitar syndrome, an anomalous connection of the right pulmonary vein to the Inferior vena cava (IVC). A 53 year old female with past medical history of Scimitar syndrome repaired at age 20, with dissection of the anomalous right pulmonary vein and connecting it to the right atrium, and then creating an intra-atrial pericardial baffle directing venous flow to the left atrium presented with epigastric pain. She denied history of gastrointestinal bleeding or chest pain. Vital signs and exam were normal. Labs were normal. CT Chest, abdomen and pelvis showed mild mediastinal enlargement, a small right pulmonary artery, loss of right lung volume and diffuse distal esophageal wall prominence. The liver, spleen & pancreas were unremarkable. For epigastric pain, she underwent an EGD showing H.pylori gastritis and grade III esophageal varices in the mid and distal esophagus. She was treated for H. pylori gastritis. Endoscopic US showed esophageal varices, a lymph node in the aortopulmonary region and normal flow in the portal and splenic veins. For further workup of her esophageal varices in the setting of Scimitar syndrome and in the absence of portal hypertension, she underwent a cardiac catheterization. The cardiac catheterization showed normal right atrial and left ventricular end diastolic pressures. Also right pulmonary venous hypertension was noted, with the pulmonary venous collaterals draining into the azygous venous system, intercostal veins and then into the para esophageal venous system producing esophageal varices. Blood flow in the baffle from the right lower pulmonary vein into left atrium was not visualized, suggestive of obstruction of the surgical baffle. The study concluded that the right pulmonary venous flow drained into the systemic circulation via the paraesophageal veins. Scimitar syndrome aka pulmonary venolobar syndrome is a rare congenital heart malformation, with a prevalence of 0.5-1%. It is characterized by partial or complete anomalous drainage of the right pulmonary vein into the IVC, right lung hypoplasia and mediastinal shift. The ‘Scimitar sign' is a curvilinear shadow resembling a curved Turkish sword ‘scimitar' created by an abnormal right pulmonary vein draining into the IVC. The common causes of esophageal varices in an adult are portal vein thrombosis, liver cirrhosis, SVC obstruction, mediastinal tumors, thymoma or chronic fibrosing mediastinitis. Esophageal varices arising from an anomalous pulmonary venous return is very rare. In this case, obstruction of the surgical baffle resulted in esophageal varices without portal hypertension. Patient was referred to surgery for evaluation of right lower lobe pneumonectomy or creation of another surgical baffle which may diminish the esophgeal varices.Figure 1Figure 2Figure 3

Factors associated with systemic to pulmonary arterial collateral flow in single ventricle patients with superior cavopulmonary connections

ObjectiveSystemic to pulmonary arterial collateral flow (CollF) is common in single ventricle patients with superior cavopulmonary connections (SCPC), although associations with CollF are not well understood. We previously described a...

Ultrasonographic Identification of the Pulmonary Veins in Adult Horses

Reasons for performing studyIn man, pulmonary veins (PV) are of major importance in atrial fibrillation pathophysiology as ectopy often originates in atrial myocardial sleeves extending in the PV wall. In addition, PV size on ultrasound is used to assess left atrial volume overload. In horses, PV anatomy and ultrasound have hardly been studied.ObjectivesTo study PV anatomy and establish a standard approach for echocardiographic identification of the PV from a right and left parasternal view.Study designAnatomical and echocardiographic description.MethodsFirstly, post mortem left atrial and PV silicone corrosion casts were made in 10 horses to investigate normal PV anatomy. Secondly, left and right parasternal ultrasound images and silicone casts were made in 3 horses, to compare images and casts.ResultsFour major PV ostia were identified on the casts, draining specific lung areas. From a right parasternal longitudinal view, ostium III was identified between the right atrial wall and right pulmonary artery, and ostium II left‐dorsal to it. From a left parasternal oblique short‐axis view, ostium III, its antrum and side‐branches were used as anatomical landmarks (adjacent to the right atrial wall). Slightly more caudal, ostium II was visualised with, in one horse, its antrum and 2 branches. Ostium I was only seen in one horse, slightly ventral to ostium II. Ostium IV was always identified in cross‐section on a left short‐axis view, left to the pulmonary artery bifurcation.ConclusionsA standard echocardiographic approach allows identification of pulmonary veins in adult horses. Left oblique and short axis views were superior although right long‐axis views also showed ostiums II and III. These data allow reference values to be established for pulmonary venous size and flow, and to investigate new treatment strategies for atrial fibrillation.Ethical animal research: Post mortem study with owner's informed consent; ultrasound with owner's informed consent. Study performed following the local ethical guidelines. Source of funding: Ghent University (institutional). Competing interests: None declared.

Added value of pulmonary venous flow Doppler assessment in patients with preserved ejection fraction and its contribution to the diastolic grading paradigm

To evaluate the prognostic role of pulmonary venous flow parameters and their role in patients with preserved ejection fraction (EF). Pulmonary venous flow parameters were measured in 365 patients in sinus rhythm, without significant mitral disease, and EF >50% (age 64.9 ± 19; 52% female) by a single sonographer. Survival, time to re-admission for heart failure, and to a combined cardiac end point (cardiac death, heart failure, and atrial fibrillation) were retrospectively analysed and correlated to echo parameters. Systolic (S) and diastolic (D) pulmonary vein flow were obtainable in 73% of patients and Ar in 65%. The lower peak S/D ratio and higher ΔAr-A time were associated with higher rate of heart failure readmission (P = 0.03 for both). The S/D integral ratio was the best pulmonary vein flow predictor of heart failure readmissions (P = 0.0009), better than the peak S/D ratio, or ΔA-Ar time (P < 0.01 for both), and independently predicted worse outcome even when adjusted for diastolic grading (using recent guidelines), left ventricle mass index, E/e', and left atrial volume index (P < 0.05 for all). The addition S/D ratio to diastolic grading recognized patients with pseudo-normal filling pattern and S/D ratio >1 with similar clinical outcomes to grade I (P > 0.5), but worse clinical outcomes than in the pseudo-normal patients with lower S/D ratio (P < 0.01). PVFP are obtainable in most patients, add prognostic information on top of routine diastolic parameters, and define an early stage of diastolic dysfunction resembling the pseudo-normal pattern in which S/D ratio is >1, and outcome is excellent.

Improved quantification and mapping of anomalous pulmonary venous flow with four-dimensional phase-contrast MRI and interactive streamline rendering.

Cardiac MRI is routinely performed for quantification of shunt flow in patients with anomalous pulmonary veins, but can be technically-challenging to perform. Four-dimensional phase-contrast (4D-PC) MRI has potential to simplify this exam. We sought to determine whether 4D-PC may be a viable clinical alternative to conventional 2D phase-contrast MR imaging. With institutional review board approval and HIPAA-compliance, we retrospectively identified all patients with anomalous pulmonary veins who underwent cardiac MRI at either 1.5 Tesla (T) or 3T with parallel-imaging compressed-sensing (PI-CS) 4D-PC between April, 2011 and October, 2013. A total of 15 exams were included (10 male, 5 female). Algorithms for interactive streamline visualization were developed and integrated into in-house software. Blood flow was measured at the valves, pulmonary arteries and veins, cavae, and any associated shunts. Pulmonary veins were mapped to their receiving atrial chamber with streamlines. The intraobserver, interobserver, internal consistency of flow measurements, and consistency with conventional MRI were then evaluated with Pearson correlation and Bland-Altman analysis. Triplicate measurements of blood flow from 4D-PC were highly consistent, particularly at the aortic and pulmonary valves (cv 2-3%). Flow measurements were reproducible by a second observer (ρ = 0.986-0.999). Direct measurements of shunt volume from anomalous veins and intracardiac shunts matched indirect estimates from the outflow valves (ρ = 0.966). Measurements of shunt fraction using 4D-PC using any approach were more consistent with ventricular volumetric displacements than conventional 2D-PC (ρ = 0.972-0.991 versus 0.929). Shunt flow may be reliably quantified with 4D-PC MRI, either indirectly or with detailed delineation of flow from multiple shunts. The 4D-PC may be a more accurate alternative to conventional MRI.

Successful transcatheter occlusion of an anomalous pulmonary vein with dual drainage to the left atrium

We describe a case of a scimitar syndrome "variant" where dual drainage existed from the right upper and middle pulmonary veins to the inferior vena cava and left atrium. Device closure of the anomalous vein at the level of the connection to the IVC was successful in achieving diversion of pulmonary venous flow to the left atrium. Vigilance during work-up of anomalous pulmonary venous drainage (whether isolated or associated with other cardiac defects that may be amenable to device closure) is important to define the presence of dual connections to the left atrium, in which case a less-invasive transcatheter approach may be feasible.

Status of Systemic to Pulmonary Arterial Collateral Flow After the Fontan Procedure

The investigators recently validated a method of quantifying systemic-to-pulmonary arterial collateral flow using phase-contrast magnetic resonance imaging velocity mapping. Cross-sectional data suggest decreased collateral flow in patients with total cavopulmonary connections (TCPCs) compared with those with superior cavopulmonary connections (SCPCs). However, no studies have examined serial changes in collateral flow from SCPCs to TCPCs in the same patients. The aim of this study was to examine differences in collateral flow between patients with SCPCs and those with TCPCs. Collateral flow was quantified by 2 independent measures from 250 single-ventricle studies in 219 different patients (115 SCPC and 135 TCPC studies, 31 patients with both) and 18 controls, during routine studies using through-plane phase-contrast magnetic resonance imaging. Collateral flow was indexed to body surface area, aortic flow, and pulmonary venous flow. Regardless of indexing method, SCPC patients had significantly higher collateral flow than TCPC patients (1.64 ± 0.8 vs 1.03 ± 0.8L/min/m(2), p <0.001). In 31 patients who underwent serial examinations, collateral flow as a fraction of aortic flow increased early after TCPC completion. In TCPC patients, indexed collateral flow demonstrated a significant negative correlation with time from TCPC. In conclusion, SCPC and TCPC patients demonstrate substantial collateral flow, with SCPC patients having higher collateral flow than TCPC patients overall. On the basis of the paired subset analysis, collateral flow does not decrease in the short term after TCPC completion and trends toward an increase. In the long term, however, collateral flow decreases over time after TCPC completion.

Evaluation of Fetal Pulmonary Veins During Early Gestation by Pulsed Doppler Ultrasound: A Feasibility Study

AbstractCongenital heart disease (CHD) is the leading cause of infant mortality. Nevertheless, routine prenatal ultrasound only detects 30 %–50 % of CHD cases. Therefore, emphasis should be placed on early predictors of CHD that allow physicians to timely refer high-risk patient to specialized fetal echocardiography, in order to maximize chances of improved outcomes. The fetal venous system has been the focus of attention as a marker of heart function. Yet, there exist inconsistent data about the acquisition of pulmonary venous flow in early pregnancy. This study aims to determine the feasibility of fetal pulmonary venous flow acquisition in early pregnancy, and the association between pulmonary vein (A-wave) flow reversal and the presence of CHD. Total of 211 consecutive pregnant women, between 12 and 15 weeks of gestation, underwent routine obstetric ultrasound along with basic fetal echocardiography including fetal pulmonary venous flow assessment. The pulmonary venous flow velocity waveforms were acquired by either Doppler or Doppler plus enhance flow technique based on equipment availability. All the cases were re-evaluated by specialized fetal echocardiography during late pregnancy to identify congenital heart anomalies. The acquisition of fetal pulmonary vein, between 12 and 15 weeks of gestation, was successfully accomplished in 87.7 % of cases. Five out of seven fetuses with end-diastolic (A-wave) pulmonary venous flow reversal were associated with confirmed cardiac anomaly. In this pilot study, pulmonary venous (A-wave) flow reversal was associated with cardiac anomalies in 86.8 % of cases (p = 0.001). This pilot study proposes that Doppler interrogation of fetal pulmonary vein flow during early pregnancy is feasible. Furthermore, the presence of pulmonary vein (A-wave) reversal might represent a marker of major cardiac anomalies. Further investigation is needed to confirm these findings.

Spectral Doppler interrogation of the pulmonary veins in atrial septal defect.

The various components of the pulmonary venous (PV) flow are linked to physiological and pathological changes that predominantly occur in the left heart. Thus, spectral Doppler interrogation of the PVs provides hemodynamic insight mainly into left-sided cardiac function. An exception to the dependence of PV flow on left heart events occurs in the setting of an atrial septal defect (ASD). The latter causes a portion of the PV blood flow, intended to cross the mitral valve, to be channeled into the more compliant right heart. This phenomenon makes the PV flow more dependent on the left-to-right interatrial shunt. The identification on the PV Doppler of a pattern that suggests uncoupling with left heart hemodynamics should raise the suspicion of an underlying ASD.