Surgical management of ascending aortic pseudoaneurysm in a 2-year-old boy: a case report.

BACKGROUND: Aortic pseudoaneurysms are rare but life-threatening complications usually seen after cardiac surgery. The causes could be multifactorial such as infection or trauma. CASE PRESENTATION: We report the surgical management of a postoperative pseudoaneurysm of the ascending aorta caused by methicillin-resistant Staphylococcus aureus in a 2-year-old Middle Eastern boy who had undergone ventricular septal defect closure, subaortic membrane resection, and pulmonary artery de-banding. He was immediately operated on for resection of the aneurysm. A computed tomography scan at 2 months following surgery showed no aneurysm. Antibiotics were continued for 6 weeks and our patient was discharged with negative blood cultures. CONCLUSION: Early diagnosis and appropriate treatment of such rare complication can be lifesaving.

Feasibility of cardiac resynchronization therapy in a patient with complex congenital heart disease and dextrocardia, facilitated by cardiac computed tomography and coronary sinus venography.

We describe a case with pacemaker implantation for cardiac resynchronization therapy (CRT) in a patient with complex congenital heart disease, facilitated by cardiac computed tomography (CT) and coronary sinus (CS) venography. A 37-year-old male presented with congenitally corrected transposition of the great arteries and mesocardia, along with a history of two open heart surgeries (closure of atrial septal defects and a ventricular septal defect, and pulmonary valvectomy at age 7; mechanical tricuspid valve replacement at age 13). He showed symptoms of progressive heart failure (NYHA class III) with significant impairment of the systemic right ventricular function. He also developed permanent atrial fibrillation with a junctional rhythm at a rate of 45 beats per minute. Biventricular pacing without an atrial lead was considered to be the best option available. CRT implantation was facilitated by proper identification of CS anatomy utilizing cardiac CT and CS venography and was performed without any complications. At follow up, a postero-anterior chest X-ray showed the final position of the right-sided ventricular (left ventricular morphology) lead pointing to the apex and the left ventricular lead at the posterolateral aspect of the systemic ventricle (right ventricular morphology).

Aortopulmonary collaterals after bidirectional cavopulmonary connection or Fontan completion: quantification with MRI.

BACKGROUND: Aortopulmonary collaterals (APCs) have been associated with increased morbidity after the Fontan operation. We aimed to quantify APC flow after bidirectional cavopulmonary connections and Fontan completions, using phase-contrast MRI, and to identify risk factors for the development of APCs. METHODS AND RESULTS: APC blood flow was quantifiable in 24 of 36 retrospectively analyzed MRI studies. Sixteen studies were performed after the bidirectional cavopulmonary connections (group A) and 8 after the Fontan operation (group B). APC blood flow was calculated by subtracting the blood flow volume through the pulmonary arteries from that through the pulmonary veins. The ratio of pulmonary to systemic blood flow (Qp/Qs) was 0.93+/-0.26 in group A and 1.27+/-0.16 in group B. APC flow was 1.42 (0.58 to 3.83) L/min/m(2) and 0.82 (0.50 to 1.81) L/min/m(2) in groups A and B, respectively. The mean inaccuracies corresponded to 7.9+/-14.5% and 7.1+/-13.6% of ascending aortic flow in groups A and B, respectively. Qp/Qs was negatively correlated with a younger age at the time of the bidirectional cavopulmonary connections operation (r=0.62, P=0.01) and positively correlated with the age at the time of the Fontan completion (r=0.81, P=0.01). Patients with a previous right-sided modified Blalock-Taussig shunt had more collateral flow to the right lung than those without. CONCLUSIONS: APC blood flow can be noninvasively measured in bidirectional cavopulmonary connections and Fontan patients, using MRI in the majority of patients and results in a significant left-to-right shunt.

Phase-contrast magnetic resonance quantification of normal pulmonary venous return.

PURPOSE: To assess the feasibility of phase-contrast magnetic resonance (PCMR) in quantifying the pulmonary venous return in normal subjects. MATERIALS AND METHODS: PCMR was performed in 12 healthy adult volunteers (mean age 38 years, range 27-60 years; 9 men; body surface area 1.81+/-0.15 m2) for the ascending and descending aorta, caval veins, main and branch pulmonary arteries, and pulmonary veins. Two readers independently quantified blood flow in all subjects. RESULTS: Intraobserver differences were -2.0% (95% confidence interval [CI]: -9.9% to 5.9%), -4.5% (95% CI: -15.6% to 6.5%), and -0.7% (95% CI: -4.5% to 3.0%) for all vessels, pulmonary veins, and other great vessels, respectively. Interobserver differences were -2.0% (95% CI: -10.6% to 6.6%), -3.1% (95% CI: -16.0% to 9.9%), and -1.4% (95% CI: -6.4% to 3.5%) for all vessels, pulmonary veins, and other great vessels, respectively. Pulmonary venous flow volume showed high correlations with the volumes of the pulmonary arterial flow, systemic arterial flow, and systemic venous flow (r=0.76-0.92, P<0.005). CONCLUSION: Flow quantification of normal pulmonary venous return using PCMR is feasible with high reproducibility and accuracy.

Anatomical and functional evaluation of pulmonary veins in children by magnetic resonance imaging.

Pulmonary vein pathologies often present a diagnostic challenge. Among the different imaging modalities used for the evaluation of pulmonary veins, magnetic resonance is the most comprehensive in assessing anatomy and pathophysiology at the same time. Bright blood cine sequences and contrast-enhanced magnetic resonance angiography outline the course and connections of the pulmonary veins. Phase-contrast velocity mapping measures flow patterns, velocities, and volumes throughout the pulmonary circulation. This paper reviews contemporary utilization of magnetic resonance in the evaluation of pulmonary venous abnormalities in children, based on our experience over the last 5 years and on that of other investigators. We summarize how magnetic resonance imaging enhances our understanding of pulmonary vein physiology and how it can influence the diagnostic approach to children and adults with a pulmonary venous pathology, and we discuss its limitations.

The relationship between scimitar syndrome, so-called scimitar variant, meandering right pulmonary vein, horseshoe lung and pulmonary arterial sling.

We report a case in which a meandering right pulmonary vein connecting to the left atrium is associated with hypoplasia of the right lung, horseshoe lung, abnormal pulmonary lobation, and abnormal branching of the pulmonary arteries. We discuss its relationship to the so-called scimitar variant, and to the scimitar syndrome itself.