Perioperative and Anesthetic Considerations in Truncus Arteriosus.

Truncus arteriosus is a congenital cardiac lesion in which failure of embryonic truncal septation results in a single semilunar valve and single arterial trunk providing both pulmonary and systemic circulations. Most patients with this lesion are symptomatic in the neonatal period with cyanosis and/or congestive heart failure and undergo complete repair in the first weeks of life. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with truncus arteriosus.

Prenatal diagnosis of the fetal common arterial trunk. A case series.

Fetal common arterial trunk is an anomaly represented by a unique arterial trunk that arouses from the base of the heart, and gives birth to systemic branches, both pulmonary and coronary, frequently associated with a ventricular septal defect (VSD) and has a poor prognosis. We present a series of 17 cases diagnosed in our tertiary center with different types of fetal common arterial trunk, its associated disorders, the evolution of the pregnancies, and of the neonates. We concluded that our cases support the fact that a complete intrauterine evaluation of each case of the common arterial trunk is impossible. The postnatal prognosis of the cases from our center was fatal, similar to most reports of the literature.

Reduced dosage of ß-catenin provides significant rescue of cardiac outflow tract anomalies in a Tbx1 conditional null mouse model of 22q11.2 deletion syndrome.

The 22q11.2 deletion syndrome (22q11.2DS; velo-cardio-facial syndrome; DiGeorge syndrome) is a congenital anomaly disorder in which haploinsufficiency of TBX1, encoding a T-box transcription factor, is the major candidate for cardiac outflow tract (OFT) malformations. Inactivation of Tbx1 in the anterior heart field (AHF) mesoderm in the mouse results in premature expression of pro-differentiation genes and a persistent truncus arteriosus (PTA) in which septation does not form between the aorta and pulmonary trunk. Canonical Wnt/ß-catenin has major roles in cardiac OFT development that may act upstream of Tbx1. Consistent with an antagonistic relationship, we found the opposite gene expression changes occurred in the AHF in ß-catenin loss of function embryos compared to Tbx1 loss of function embryos, providing an opportunity to test for genetic rescue. When both alleles of Tbx1 and one allele of ß-catenin were inactivated in the Mef2c-AHF-Cre domain, 61% of them (n = 34) showed partial or complete rescue of the PTA defect. Upregulated genes that were oppositely changed in expression in individual mutant embryos were normalized in significantly rescued embryos. Further, ß-catenin was increased in expression when Tbx1 was inactivated, suggesting that there may be a negative feedback loop between canonical Wnt and Tbx1 in the AHF to allow the formation of the OFT. We suggest that alteration of this balance may contribute to variable expressivity in 22q11.2DS.

[Embryology of the heart walls]. / Embryologie des cloisons du cœur.

Although anatomically simple structures, the atrial septum and the ventricular septum have complex embryological origins. Recent findings in molecular biology allowed better comprehension of their formation. As soon as the heart tube is formed, cells migrate from several cardiogenic fields to take part in the septation. Elongation, ballooning, and later inflexion of the heart tube create chamber separating grooves, facing the future septa. The systemic venous tributaries conflate at the venous pole of the heart; it will partially involute while contributing to the atrial septum. The primary atrial septum grows from the atrial roof towards the atrioventricular canal. It fuses there with the atrioventricular cushions, while its upper margin breaks down to form the ostium secundum. Then a deep fold develops from the atrial roof and partly covers the ostium secundum, leaving a flap-like interatrial communication through the oval foramen. It will close at birth. The interventricular septum has three embryological origins. The ventricular septum primum, created during the ballooning process, origins from the primary heart tube. It will form the trabecular septum and the inlet septum. The interventricular ring, surrounding the interventricular foramen, will participate in the inlet septum and also form the atrioventricular conduction axis. The outflow cushions will separate the outflow tract in the aorta and pulmonary artery, and grow to create the outlet septum. After merging with the atrioventricular cushions, they will also be part of the membranous septum.

Conotruncal cardiac defects: a clinical imaging perspective.

Conotruncal cardiac defects make up a significant portion of congenital heart disease. For proper diagnosis and subsequent care of patients with these defects, different and sometimes multiple imaging modalities are needed at various stages of care. This article reviews the characteristics of some of the most common conotruncal defects and the imaging options available along with the advantages and disadvantages of each. Intricate knowledge of the capabilities of each modality will aid the practitioner in making optimal clinical decisions.

Prenatal sonographic appearance of truncus arteriosus on wide-band Doppler imaging.

Persistent truncus arteriosus is an uncommon congenital cardiac anomaly. In most patients, this condition is not diagnosed prior to birth. We report a case in which this uncommon cardiac anomaly was diagnosed prenatally using wide-band Doppler imaging. When diagnosing fetal truncus arteriosus, sonologists should carefully search for the origin of the main pulmonary artery and for its 2 branches. Our experience suggests that wide-band Doppler imaging facilitates the prenatal diagnosis of truncus arteriosus.

Cardiac outflow tract: a review of some embryogenetic aspects of the conotruncal region of the heart.

A review concerning some embryogenetic aspects of the cardiac outflow tract is presented. Two main topics are discussed: the truncal septation and the secondary heart field. In the context of the septation of the truncus arteriosus, the development of the arterial valves is largely discussed, particularly in reference to the sinuses of Valsalva. Emphasis is also given to the fate of the external myocardial wall of the truncus arteriosus, as this primordial myocardial surface disappears later in the development. Molecular genetics data concerning Sox4 and NF-Atc transcription factors are correlated in the present review with rare forms of truncus malformations encountered in human pathology. The roles exerted by the secondary heart field and the neural crest on the development and growth of the conotruncal musculature are largely discussed. Reported experimental ablations of both secondary heart field and neural crest, showed conotruncal defects such as persistent truncus arteriosus, tetralogy of Fallot, and double-outlet right ventricle, which were considered as the result of a short outflow tract causing, ultimately, a lack of conotruncal rotation. In this regard, some morphologic correlations are carried out, in the present review, between these experimental animal models and human malformations, and it is thought that this sort of conotruncal defects cannot be explained always in terms of conotruncal hypoplasia. Finally, influence of Pitx2c, a left-right laterality signaling gene, on the modulation of the conotruncal rotation, as most recently reported, is emphasized in terms of very likely multifactorial contributions in the embryogenesis of the conotruncal region of the heart.

Histological study of the proximal and distal segments of the embryonic outflow tract and great arteries.

The normal development of the ventricular outlets and proximal region of the great arteries is a controversial subject. It is known that the conus, truncus arteriosus (truncus), and aortic sac participate; however, there are some doubts as to the actual prospective fate of the truncus. Some authors propose that it gives origin to the proximal region of the great arteries and that the myocardial cells of its wall become smooth muscle. Nevertheless, others think that the truncus only forms the arterial valve apparatus and that therefore the myocardial cells transform into fibroblasts. As a first approach to beginning to elucidate which process occurs, the aim of this article was to study the histological changes in the wall of these components of the developing heart in chick embryos whose hearts had been labeled at the truncoconal boundary at stage 22HH, tracing the changes up to stage 36HH. Also, the histological constitution of the wall of the pulmonary arterial trunk and its valve apparatus were studied in the posthatching and adult hearts of chickens and rats. The conus and truncus walls were always encircled by a myocardial sleeve from the outset of their development. Between stages 26HH to 28HH, the truncal myocardial cells adjacent to the mesenchymal tissue of the ridges began to lose cell-to-cell contacts and invaded the extracellular matrix. At stage 24HH, the aortic sac began to project into the pericardial cavity and became divided into two channels by the aortic-pulmonary septum at stage 26HH. The wall of the aortic sac is mostly constituted by a compact mesenchymal tissue. Initially, it does not have smooth muscle but this starts to appear at stage 30HH. The insertion ring of the valves, a broad structure, was formed by mesenchymal tissue. Both structures were always covered by a myocardial sleeve. The leaflets developed from the truncal ridges, the segment immediately proximal to the aortic sac. Our results indicate that the proximal region of the pulmonary and aortic arteries do not originate from the truncus arteriosus; rather, we found that they take origin from the aortic sac. Thus, our findings agree with the proposal that the myocardial cells of the external sleeve of the truncus become fibroblastic and suggest that the insertion ring of the arterial valves has a dual origin: fibroblasts produced by truncal myocardial transdiferentiation and the mesenchymal tissue of the proximal region of the truncal ridges, while the leaflets have their origin from the truncal ridges. We discuss the fact that, because the truncus arteriosus does not give origin to the trunks of the aortic and pulmonary arteries, it may be necessary to modify terminology. Based on our results, together with the new findings obtained by in vivo labeling, immunostaining, a chimeric approach, and ultrastructural studies, we propose a developmental model that correlates the fate of the conus, truncus, and aortic sac with the normal morphogenesis of the ventricular outlet tracts and the trunks of the great arteries. (c) 2005 Wiley-Liss, Inc.

Differentiation of the cardiac outflow tract components in alevins of the sturgeon Acipenser naccarii (Osteichthyes, Acipenseriformes): implications for heart evolution.

Previous work showed that in the adult sturgeon an intrapericardial, nonmyocardial segment is interposed between the conus arteriosus of the heart and the ventral aorta. The present report illustrates the ontogeny of this intermediate segment in Acipenser naccarii. The sample studied consisted of 178 alevins between 1 and 24 days posthatching. They were examined using light and electron microscopy. Our observations indicate that the entire cardiac outflow tract displays a myocardial character during early development. Between the fourth and sixth days posthatching, the distal portion of the cardiac outflow tract undergoes a phenotypical transition, from a myocardial to a smooth muscle-like phenotype. The length of this region with regard to the whole outflow tract increases only moderately during subsequent developmental stages, becoming more and more cellularized. The cells soon organize into a pattern that resembles that of the arterial wall. Elastin appears at this site by the seventh day posthatching. Therefore, two distinct components, proximal and distal, can be recognized from the fourth day posthatching in the cardiac outflow tract of A. naccarii. The proximal component is the conus arteriosus, characterized by its myocardial nature and the presence of endocardial cushions. The distal component transforms into the intrapericardial, nonmyocardial segment mentioned above, which is unequivocally of cardiac origin. We propose to designate this segment the "bulbus arteriosus" because it is morphogenetically equivalent to the bulbus arteriosus of teleosts. The present findings, together with data from the literature, point to the possibility that cells from the cardiac neural crest are involved in the phenotypical transition that takes place at the distal portion of the cardiac outflow tract, resulting in the appearance of the bulbus arteriosus. Moreover, they suggest that the cardiac outflow tract came to be formed by a bulbus arteriosus and a conus arteriosus from an early period of the vertebrate evolutionary story. Finally, we hypothesize that the embryonic truncus of birds and mammals is homologous to the bulbus arteriosus of fish.

Local and regional variations in myofibrillar patterns in looping rat hearts.

BACKGROUND: In chickens, cytodifferentiation, right side dominance in myofibril development, and variations in myofibrillar patterns in different areas and layers of the myocardial wall exist which have been implicated in the process of heart looping. Little comparable information is available for developing myofibrillar patterns in the early development of mammalian hearts. METHODS: We have used transmission electron microscopy (TEM), confocal scanning laser microscopy (CSLM), and 3-D reconstruction techniques also present in the looping hearts of embryonic day (ED) 9.5 to 11.5 rat hearts. RESULTS: Local and regional variations and right side dominance in myofibrillar patterns were shown during looping in 9.5 through 11.5 days of development in embryonic rat heart. At 9.5 days of development, myofibrils near the lumen of the myocardial wall were primarily in circumferential bands while near the pericardial surface they were primarily in longitudinal bands. In older embryos, regional variations in myofibrillar organization was found in areas associated with the cardiac cushions, trabeculae, and myocardial wall of the developing heart chambers. Based on sarcomeric structure, myofibrils in the ventricle and outflow tract were more advanced than those found in the atrial wall. CONCLUSIONS: The local and regional patterns of myofibrils in looping rat hearts are similar to those which have been found in developing chicken hearts. This study and others indicate cytodifferentiation and development of the contractile apparatus has a crucial role in the process of heart looping.

Central cardiovascular shunts in the perinatal marsupial.

BACKGROUND: Marsupials are born at an early stage of development after a short period of gestation. In this study the nature and timing of closure of the central cardiovascular shunts was investigated. METHODS: Light and scanning electron microscopy were used to determine changes in central cardiovascular shunts in eight marsupial species with gestation periods of between 12.5 and 36.5 days and birth weights ranging from 12.5 mg to 740 mg. Laboratory mice with a birth weight of about 1,000 mg and a gestation period of 21 days were included for comparison. RESULTS: Marsupials have a ductus arteriosus and an interatrial communication. The former closes rapidly after birth in the marsupial; however the interatrial communication is in the form of a fenestrated septum, which closes as a result of tissue proliferation over a period of days after birth. An additional central shunt, an interventricular foramen, was found to persist in three species for a short time after birth. In one species, the eastern native cat, Dasyurus viverrinus, which has a gestation period of about 19 days and low birth weight of about 12.5 mg, in addition to the two common shunts there was a large interventricular communication and septation of the outflow tract was incomplete. CONCLUSION: In adapting from intra-uterine life, it seems that marsupials have adopted different, but equally effective strategies, with regard to the circulatory system.

Ontogeny of vessel wall components in the outflow tract of the chick.

During development of the outflow tract, the walls of the truncus arteriosus change from a diffuse extracellular matrix (ECM) surrounded by an extension of the myocardium to alternating laminae of smooth muscle and elastic connective tissue. The transition rapidly follows septation, when mesenchyme associated with the endothelium differentiates. Using immunocytochemical methods with antibodies to components of the tunica media and the tunica adventitia we have analysed the differentiation of the vessel walls of the outflow tract of the chick. The tunica media marker, elastin, forms laminae in a radial sequence, beginning at the outer margin of the truncus mesenchyme. Conversely, smooth muscle myosin is first expressed in cells associated with the endothelium. Laminin is expressed as a cell surface component throughout the development of the outflow tract. Matrix fibronectin distribution is correlated with the regions that will form the tunica media and apparently forms a radial gradient which is highest near the endothelium. Markers for the tunica adventitia, collagen I and VI, are expressed first at the peripheries of the newly formed tunica media, and collagen VI expression spreads radially through the tunica media. Thus, the vessel wall components appear within the mesenchyme of the truncus arteriosus in opposed radial gradients of differentiation. The tunica media cells acquire secretory and contractile phenotypes independently and may be responding to different stimuli in their expression of these features.

Experimental study of the development of the truncus arteriosus of the chick embryo heart. I. Time of appearance.

The time of appearance of the truncus arteriosus was studied in the chick embryo using an in ovo labeling technique. Three hundred embryos at stages 13-18 of Hamburger and Hamilton were selectively labeled at the distal end of the heart tube, using gelatine-india ink label; 122 of these embryos were reincubated and 111 of them reached stages 25-28. In these stages the final location of the label was determined. Only 95 of these embryos showed both a normal heart and a label located in it. The remaining embryos were discarded due to abnormal cardiac morphology or because the label was not found. Embryos labeled at stages 13-14 had label in the conus in 42.8% of the cases and in the boundary between the conus and the truncus arteriosus in 57.1% of the cases. Label placed at stages 15-16 was located in the conus in 6.1% of the cases, in the boundary between the conus and the truncus arteriosus in 44.8% of the cases, and in the truncus arteriosus in 48.9% of the cases. Finally, label placed at stages 17-18 was located in the boundary between the conus and the truncus arteriosus in 18.7% of the cases and in the truncus arteriosus in 81.2% of the cases. Our results permit us to conclude that the truncus arteriosus appears in the chick embryo as early as stages 15-16 of Hamburger and Hamilton (50-56 hours of incubation).

Development of the ventriculoarterial segment of the human embryonic heart: a morphometrics study.

In the literature, discussions continue on the question whether the distal portion of the cardiac outlet segment (ventriculoarterial portion, outflow tract of the embryonic heart) is subject to a shortening (absorption, retraction) during development. In 28 human embryos ranging from 4-42 mm crown-rump length, stereological estimates of volume fractions and surface densities were used to calculate the diameter and the length of the distal outlet segment and their changes during development. A significant increase was found in the wall thickness of this segment, whereas its length remained about the same. An actual shortening was not found. It is concluded that the relative change in proportions is the cause of the disagreements. It is further concluded that there is still a mechanical role for the aorticopulmonary septum in maintaining the length of the outlet segment during growth of this region.

Decrease in calcitonin-containing cells in truncus arteriosus.

Experimental studies in chick embryos have demonstrated that truncus arteriosus (TA), a form of conotruncal cardiac defect, is due to abnormalities in the cranial neural crest. However, no data are available to support this hypothesis in humans with isolated TA. In the present study, the assessment of calcitonin immunoreactive cells (C-cells) has been employed to evaluate whether or not the proportion of thyroid cells derived from the cranial neural crest is normal in patients with isolated TA. Thyroid sections from 15 such patients in which no other extracardiac malformations were neither clinically nor pathologically found, and from 11 control age-matched patients were studied immunohistochemically at autopsy in order to determine the number and distribution of calcitonin-containing cells. The volume density of C-cells (0.888%) and the number of C-cells per follicle (0.991) was significantly lower in patients with TA than in control patients (3.475%, and 2.367, respectively). The decrease of neural crest-derived cells in the thyroid of patients with "isolated" TA documents more extent abnormalities than clinically suspected and supports the hypothesis of neural crest disturbance as the pathogenetic factor responsible for this heart malformation.

The Splotch (Sp1H) and Splotch-delayed (Spd) alleles: differential phenotypic effects on neural crest and limb musculature.

Homozygous mutants of the murine Splotch (Sp1H) and the Splotch-delayed (Spd) alleles show different phenotypes with respect to neural crest derivatives and their longevity. In this report, Sp1H/Sp1H, Spd/Spd and Sp1H/Spd mouse mutant embryos were examined histologically in serial sections on day 13.5 of gestation. All Spd/Spd and Sp1H/Spd embryos showed a similarly dramatic reduction of the muscle primordia in the limbs that had previously been observed in Sp1H homozygotes. The neural crest-derived spinal ganglia and Schwann cells showed major defects in Sp1H homozygotes and lesser defects in Spd homozygote, with Sp1H/Spd embryos being intermediary. Also, the neural crest-derived septum of the truncus arteriosus was formed in almost none of the Sp1H homozygotes, in roughly half of the Sp1H/Spd double heterozygotes and in all of the Spd homozygotes. Aortic conus malformations were observed in all mutants. The paternal origin of the Sp1H allele in the Sp1H/Spd embryos had no influence on the resulting phenotype. These observations demonstrate that the neural tube defect and the limb muscle defect are the common denominator of both the Splotch and the Splotch-delayed phenotype. The extent of the neural crest defects in the mutant compounds apparently depends on the Splotch alleles involved.

Fetal cardiovascular morphology of truncus arteriosus with or without truncal valve insufficiency in the rat.

BACKGROUND: Recent advances in fetal echocardiography have necessitated further study on fetal in situ cardiovascular morphology of truncus arteriosus and the effects of truncal valve insufficiency. METHODS AND RESULTS: We studied 55 fetal rats with truncus arteriosus among 300 fetuses from 40 virgin females treated with 200 mg fertilysin on the 10th day of pregnancy. After rapid whole-body freezing on the 21st day, the fetuses were studied by means of serial cross-sectional photographs of the frozen thorax. Thirty-five fetuses with a normal heart treated with fertilysin served as controls. Truncus arteriosus was characterized by a large ventricular septal defect, a solitary artery (truncus arteriosus) overriding the ventricular septum, the right and left pulmonary arteries originating from the truncus arteriosus with or without a common trunk (main pulmonary artery), and absent ductus arteriosus. Fetuses with truncal valve insufficiency had thick truncal valves, a large truncus arteriosus, and large ventricles. The subgroup of 12 fetuses with a large truncus (truncal diameter greater than 160% of the ascending aorta diameter in the controls) showed significantly greater values for right ventricular volume (200% of control) and mass (120% of control), left ventricular volume (170% of control) and mass (110% of control), right (120% of control) and left (110% of control) atrial volume, and pericardial fluid (140% of control) than the controls. These changes were less prominent and ventricular volumes were not increased in the remaining subgroup with a truncal diameter of 160% or less of aorta diameter in the controls. CONCLUSIONS: In fetal truncus arteriosus, truncal valve insufficiency was associated with increased ventricular volume load and incomplete cardiac compensation in rats.

Development of the musculoelastic septation complex in the avian truncus arteriosus.

It is now well established that cells from the cardiac neural crest (CNC) are essential for normal conotruncal septation. The truncal septation complex consists of the aorticopulmonary (AP) septum and the myocardial sheath of the truncus. The principal role of the CNC cells during septation appears to be their differentiation into the elastogenic smooth muscle that forms the AP septum proper. The objective of this study was to integrate serial reconstruction and specific histochemical markers in order to provide a unified analysis of the relationships between the CNC and the other components of the truncal septation complex. The development of the septation complex was compared normal embryos vs. embryos from which the CNC had been surgically ablated. Embryos from each group were harvested after incubation periods of 4-8 days (Hamburger-Hamilton stages 23-34). Histochemical procedures were performed for positive identification of the elastic matrix and smooth muscle alpha-actin; the presence of these proteins was used as the criterion for "septal cells" and to define the boundaries of the septum. The results indicate that the shape, components, boundaries, and degree of organization of the septation complex may be different from previous descriptions. Furthermore, all of the components of the truncal septation complex are dysgenic in the absence of the CNC. Of special significance in the absence of CNC. Of special significance in the absence of CNC are: 1) the failure of the myocardial sheath to retract; 2) the apparently random distribution of surrogate ectomesenchyme; and 3) the impairment of truncal elastogenesis. These results indicate that the cells of neural crest origin interact with the surrounding mesenchyme during septation and that the entire septation complex depends upon the presence of the neural crest cells for normal development.

Immunofluorescent localization of tenascin during the morphogenesis of the outflow tract of the chick embryo heart.

The cono-truncus constitutes a complex segment of the developing heart that gives rise to the outflow tract of the ventricles and root of the pulmonary and aortic arteries. Numerous studies have revealed that the extracellular matrix plays a relevant role in most morphogenetic processes modulating cell behaviour. By means of immunofluorescence, we studied the distribution and possible involvement of tenascin during morphogenesis of the conus and truncus in chick embryo hearts between days 4.5-10 of incubation. Tenascin is an extracellular matrix glycoprotein with a significant role in morphogenesis and cell and tissue differentiation. Our results reveal a specific distribution of tenascin in the areas of the cono-truncus undergoing significant structural changes during morphogenesis of this cardiac segment, appearing mainly in the mesenchymal layer subjacent to the myocardial layer, the cono-truncal ridges and the aorto-pulmonary septum. The distribution of tenascin was compared and contrasted with that of collagen type I, which constitutes a further component of the extracellular matrix common to most developing connective tissues.