Echocardiographic evaluation of the systemic ventricle after atrial switch procedure. The usefulness of subcostal imaging

Background: Subcostal planes allow demonstration of the entire right ventricular cavity and are frequently used in patients with congenital heart disease; however, their clinical utility in the evaluation of systemic right ventricular function after atrial switch procedure for complete transposition has never been verified in adolescent and adult patients. Methods: In unselected patients with simple transposition who had had an atrial switch performed between 1982 and 1990, echocardiographic and myocardial perfusion imaging were performed. Systolic function of the right ventricle was assessed from the subcostal window, and the right ventricular area change was calculated. Right ventricular systolic function was defined as impaired when the right ventricular area change was equal to or less than 0.35. Results: Sixty [43 male and 17 female, mean age (standard deviation) 14.9 (4.5) years] patients were included in the analysis. Echocardiographic right ventricular area change ranged from 0.14 to 0.66 [0.42 (0.12)]. Twenty-one patients (35%) had significant impairment of right ventricular systolic function [0.29 (0.06)]. Right ventricular area change equal to or less than 0.35 detected moderate-to-severe perfusion abnormalities with 78% sensitivity and 62% specificity. Conclusions: Right ventricular area change evaluated from the subcostal plane provides significant clinical information in patients with complete transposition. A cutoff value of 0.35 can be used as an indication of right ventricular impairment associated with significant perfusion abnormalities. (Cardiol J 2008; 15: 156-161

Factors associated with the presence of tricuspid valve regurgitation in patients with systemic right ventricles following atrial switch

Background: The development of significant tricuspid regurgitation (TR) is associated with an unfavorable clinical outcome in patients with systemic right ventricles. Increased knowledge about the factors contributing to its presence would help prevent its progression. Methods: This was a retrospective analysis of the factors predictive of significant TR in 60 patients with systemic right ventricles following an atrial switch procedure for complete transposition of the great arteries. Data from echocardiographic examinations, exercise radionuclide angiography, and myocardial perfusion imaging were analyzed. Results: Significant TR was present in 20% of patients. Compared to patients without significant TR, patients with significant TR were older at the time of surgery (p ≤ 0.001), with a higher body mass index (p ≤ 0.005), lower right ventricular ejection fraction (RVEF; p ≤ 0.01), higher exercise perfusion abnormalities score on radionuclide angiography (p ≤ 0.03), and higher systolic blood pressure (p ≤ 0.02). At univariate logistic regression analysis systolic blood pressure (p = 0.03), increasing age at surgery (p = 0.01), and RVEF (p = 0.02), were predictors of significant tricuspid regurgitation. The latter two remained significant at multivariate analysis. Conclusions: Patients operated upon later in life, with decreased RVEF and higher blood pressure, are at risk of significant tricuspid regurgitation and therefore warrant special attention. Prospective studies are needed to ascertain whether appropriate pharmacological intervention would prevent the development and/or progression of TR in these patients. (Cardiol J 2010; 17, 1: 29-34

Giant Intrapericardial Myxoma Adjacent to the Left Main Coronary Artery

A 62-years-old woman was admitted to the hospital because of chronic cough, expectoration of thick mucus, hoarseness and tightness in the precordial area. Computed Tomography (CT) examination revealed the presence of a giant intrapericardial tumor with the dimensions of 80 × 38 × 32 mm. It was located anteriorly and laterally to the left atrium, posteriorly to the pulmonary trunk and the ascending aorta. This hypodense change modeled the left atrium without evidence of invasion. CT coronary angiography and 3-dimensional reconstruction were applied to enable precise planning of cardiac surgery. CT evaluation confirmed that it is possible to remove the tumor without damage to the adjacent left main coronary artery. The patient underwent cardiac surgery with sternotomy and cardiopulmonary bypass. A cohesive, smooth, vascularized tumor pedunculated to the left atrial epicardium was visualized. The location and dimensions corresponded to those determined by CT scan examination. The entire tumor was successfully dissected together with adjacent adipose and fibrous tissue. Histological evaluation revealed the presence of myxoid cells, blood vessels, degenerative changes, and microcalcifications embedded in profuse hyalinized stroma. Those histological features enabled identification of the intrapericardial tumor as a myxoma. Follow-up CT examination did not demonstrate any signs of recurrence of the myxoma. According to our knowledge, a myxoma located inside the pericardial sac has never been described before