Non invasive anatomy/physiology of coarctation and ...€¦ · Non invasive anatomy/physiology of...
Transcript of Non invasive anatomy/physiology of coarctation and ...€¦ · Non invasive anatomy/physiology of...
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Damien Bonnet Unité médico-chirurgicale de Cardiologie Congénitale et Pédiatrique
Hôpital Universitaire Necker Enfants malades – APHP, Université de Paris Institut Hospitalo-Universitaire IMAGINE
Centre de Référence Maladies Rares Malformations Cardiaques Congénitales Complexes-M3C
Centre de Référence Maladies Rares Maladies Cardiaques Héréditaires- CARDIOGEN
Non invasive anatomy/physiology of coarctation and neonatal management
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Fetal circulation and morphogenesis
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LV
LA
RV
RA
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PA
Desc Aorta
Aortic isthmus
Ductus arteriosus
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Fetal circulation and morphogenesis
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Fetal circulation and morphogenesis
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Fetal circulation and morphogenesis
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Hypoplastic left heart syndrome Aortic atresia
Fetal circulation and morphogenesis
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Extension of ductal tissue into the isthmus
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ASSYMETRY ARTERIAL DUCT
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Clinical aspects of neonatal coarctation
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Aortic valve stenosis Bicuspid aortic valve type 0
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Aortic valve stenosis Bicuspid aortic valve type 1 R-N
Raphe
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Aortic valve stenosis Bicuspid aortic valve type 2
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Accessory mitral valve tissue
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Accessory mitral valve tissue
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Sub-aortic conus
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Supravalvar ring
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Abnormal septal attach of the mitral valve
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Parachute
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Parachute
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Parachute mitral
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Parachute mitral
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Parachute mitral
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Parachute mitral
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Entonnoir
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Outlet VSDPosterior Malalignement
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MAZZUCCO, BORTOLOTTI, STELLIN, ET AL.
Figure 1. (a) Schematic representation of the normal systemic venous connection. For simplicity in this and subse- quent drawings only the left pulmonary veins (LPV) are indicated. (bj Left superior vena cava (LSVC) draining into the coronary sinus (CS). (c) Technique of cannulation of LSVC through the right atrium. (d) Technique of direct ex- tracardiac cannulation of LSVC with a right angle cannula; in this drawing persistent LSVC is associated to a com- mon atrium. IVC = Inferior vena cava; SVC = Superior vena cava.
desaturation. In cases of AV septa1 defects, the existence of a left SVC to the CS is a good indication for positioning the prosthetic septum at the atrial level on the left side of the AV junction or inside the CS itself, along the anterior wall.
which has long been considered as a develop- mental complex known as ‘Raghib complex’.2 Recently, it has been interpreted as a result of the combination of a persistent left SVC together with a defective partitioning of the CS from the LA.3 This malformation, which has been described as ‘unroofed CS’, is produced by the incorporation of the cS into the L~ due to the absence of the Persistent left SVC draining into the left atrium _ _ -.
(LA) This anomaly is most often associated with the
absence of the CS and with a large peculiar ASD,
anterosuperior wall (or ‘roof’) of the CS itself. This anomaly may be complete when a complete in- corporation of the CS is present; in this situation
124 Journal of Cardiac Surgery Vol. 5, No. 2, 1990
LSCV in coronary sinus
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<10% of persisting LSCVXiong Wei al. Circulation. 2010;21:2329-30
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Neonatal coarctation with left ventricular
dysfunction
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Pressure
Volume 8 mmHg
80 mmHg
Pressure volume loop in coarctation
120 mmHg
80 mmHg80 mmHg
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• Pink coarctation
• Arterial duct is closed
• There are signs of heart failure/LV systolic dysfunction
• Yes/No
• The price to pay is systemic hypertension
• Yes/No
• The price to pay is increase LV-TDP
• Yes/No
If one YES : treat coarctation
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If one YES : treat coarctation
• Pink coarctation
• Arterial duct is open with PVR<< SVR
• There are signs of heart failure/LV systolic dysfunction
• Yes/No
• The price to pay is systemic hypertension
• Yes/No
• The price to pay is increase LV-TDP
• Yes/No
If all is No : be careful until AD closure
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+ +/-
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Treat interrupted aortic arch as it is a ducto-dependent defect
• Interrupted aortic arch
• Arterial duct is open with obligatory right to left shunt in systole (PA to Descending Aorta)
• PVR << SVR with diastolic left-to-right shunt (Ao to PA)
• Heart failure is of no importance in the indication
• Systemic hypertension is of no importance
• Increase LV-TDP is of no importance
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Why is there a systolic right-to-left shunt from PA to Aorta ?
• Coarctation of the aorta
• Arterial duct is open with right to left shunt in systole (PA to Descending Aorta)
• PVR << SVR with diastolic left-to-right shunt (Ao to PA)
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Why is there a systolic right-to-left shunt from PA to Aorta ?
• Coarctation of the aorta
• Arterial duct is open with right to left shunt in systole (PA to Descending Aorta)
• PVR << SVR with diastolic left-to-right shunt (Ao to PA)
Failing left ventricle
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Why is there a systolic right-to-left shunt from PA to Aorta ?
• Coarctation of the aorta
• Arterial duct is open with right to left shunt in systole (PA to Descending Aorta)
• PVR << SVR with diastolic left-to-right shunt (Ao to PA)
Small left ventricle with or without aortic stenosis
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+ -
- -
Sub-clavian arteries in coarctation
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- +
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Artère sous-clavière droite rétro-oesphagienne Lusoria
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- -
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Up side down
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TGA-VSD-Coarctation
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TGA-VSD-Coarctation
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Treatment of neonatal coarctation+ +
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Use of PGE1 in coarctation of the aorta
Until what age can PGE1 treatment be initiated to relieve coarctation ?
• The effect of prostaglandin E1 has been determined to be greater when used in patients younger than 96 hours old; the decreased response in older patients suggests that anatomic closure of the ductus arteriosus has occurred.
• However, there have been reported cases of a ‘‘late’’ effect of prostaglandin E1 on the ductus arteriosus.
• In one patient, the effect of prostaglandin E1 on ductal tissue was seen at 7 weeks of age, even with complete anatomical closure of the ductus.
Libermann L et al. Pediatr Cardiol 25:49–52, 2004
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Use of PGE1 in coarctation of the aortaRepair of coarctation with PGE1 increases the risk of re-coarctation
Lehnert A et al. ICTS 2019
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Aortic arch anatomy
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Anatomy of the aortic arch and surgical strategy
There is still controversy regarding the definition of hypoplastic aortic arch.
Physiologically, a 50% reduction of the luminal dimension would have important flow dynamic effect.
Other measures include the transverse arch dimension less than the left carotid artery, the distal arch is less than half the diameter of descending aorta at diaphragm, or the z scores.
The last measure needs to be treated with care; a small change in actual dimension can cause a big change in the z scores especially at the extreme end of the Bell curve.
The practical definition by Karl et al that the dimension (mm) of transverse arch should be the baby weight +1, for example, in a 3 kg baby, the transverse arch is acceptable at 4 mm.
Tsang V et al. Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac Surgery Annual 2019
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Anatomy of the aortic arch and surgical strategy
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70
A B
C D
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Extended end-to-end anastomosis
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Neonatal coarctationComplex defect
-variable physiology
-variable anatomy
that are both the determinant factors for the type of repair
and are also linked with outcomes (early and late).
Tsang V et al. Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac Surgery Annual 2019
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O.Raisky
R.Gaudin
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Collective ignorance is the motivation Curiosity is the strength
Research is the path
Individual experience is the brake Indifference is the weakness
Argument from authority is the threat
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