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Contrast echocardiography for diagnosis of pulmonary arteriovenous fistulas late after construction of a Glenn anastomosis

Published online by Cambridge University Press:  19 August 2008

Gül Sagin-Saylam  and
Jane Somerville
Gül Sagin-Saylam
Affiliation:
From the Grown-Up Congenital Heart Unit, Royal Brompton National Heart and Lung Hospital, London
Jane Somerville*
Affiliation:
From the Grown-Up Congenital Heart Unit, Royal Brompton National Heart and Lung Hospital, London
*
Dr Jane Somerville, Grown-Up Congenical Heart Unit, Royal Brompton National Heart and Lung Hospital, Sydney Street, London SW3 6NP. Tel: 0171-351 8601; Fax: 0171-351 8201
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Abstract

To demonstrate the use of transthoracic contrast echocardiography in the detection of pulmonary arteriovenous fistulas in patients with a previously constructed anastomosis between the superior caval vein and the right pulmonary artery (Glenn shunt), and to examine their prevalence in this special population, we evaluated prospectively all patients followed up in the Grown-Up Congenital Heart Unit subsequent to construction of a classical or bi-directional Glenn shunt. We studied 12 patients, aged from 21 to 38 (mean 28 ± 4.8) years who had had a previous cavopulmonary shunt in place for a period of 4 to 33 years (mean 24±9 years). All were examined with cross-sectional contrast echocardiography, 11 patients had cardiac catheterisation and angiography, and 6 patients had magnetic resonance imaging. Systemic arterial oxygen saturations at rest, and during exercise using the modified Bruce protocol, were measured in all patients. Contrast echocardiography showed evidence of pulmonary arteriovenous fistulas in 7 of the 12 patients, with appearance of echo contrast in the left atrium 1–8 seconds after peripheral venous injection in the arm. Simultaneous appearance of microbubbles in the right atrium revealed a residual communication between the superior caval vein and the right atrium in 2 patients, and presence of collaterals between the superior and inferior caval veins in one. Cardiac catheterisation and angiography showed obvious fistulas in 4 patients, and revealed suggestive findings in 2. In patients deemed to have pulmonary arteriovenous fistulas on contrast echocardiography, arterial oxygen saturations at rest (51–94%, mean 75±15.3%) and on exercise (23–91%, mean 53±24.2%) were significantly lower compared to patients judged to be without fistulas (p<0.005). Pulmonary hypertension in the contralateral lung was more common in patients with fistulas (mean left pulmonary arterial pressure 22–110 mm Hg, p=0.014). In patients with cavopulmonary anastomoses, pulmonary arteriovenous fistulas occur frequently in the long term (10–33, mean 25.7±8 years), and are associated with worsening systemic arterial desaturation. Contrast echocardiography should be included in the regular evaluation of these patients as a simple and sensitive technique for the detection of pulmonary arteriovenous fistulas, particularly with the devel opment of increasing cyanosis.

Keywords

Fontan circulationfunctionally single ventricletricuspid atresiacavopulmonary anastomosis
Type
Original Articles
Information
Cardiology in the Young , Volume 8 , Issue 2 , April 1998 , pp. 228 - 236
Copyright
Copyright © Cambridge University Press 1998

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References

1.Carlon, CA, Mondini, PG, Marchi, de R.Surgical treatment of some cardiovascular diseases (a new vascular anastomosis). J Tnt Coil Surg 1951; 16: 1–11.Google Scholar
2.Bakuiev, AN, Kolesnikov, SA.Anastomosis of superior vena cava and pulmonary artery in the surgical treatment of certain congenital defects of the heart. J Thorac Surg 1959; 37: 693–702.CrossRefGoogle Scholar
3.Glenn, WWL. Circulatory bypass of the right side of the heart: IV. Shunt between superior vena cava and distal right pulmonary artery-report of clinical application. N Engl J Med 1958; 259: 117–120.CrossRefGoogle ScholarPubMed
4.Kopf, GS, Laks, H, Stansel, HC, Hellenbrand, WE, Kleinman, CS, Tamer, NS.Thirty-year follow-up of superior vena cava-pulmonary artery (Glenn) shunts. J Thorac Cardiovasc Surg 1990; 100: 662–671.CrossRefGoogle ScholarPubMed
5.Hopkins, RA, Armstrong, BE, Serwer, GA, Peterson, RJ, Oldham, HN JrPhysiological rationale for a bidirectional cavopulmonary shunt. A versatile complement to the Fontan principle. J Thorac Cardiovasc Surg 1985; 90: 391–398.CrossRefGoogle Scholar
6.de Leval, MR, Kilner, P, Gewillig, M, Bull, C.Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations. J Thorac Cardiovasc Surg. 1988; 96: 682–695.CrossRefGoogle ScholarPubMed
7.Kawashima, Y, Kitamura, S, Matsuda, H, Shimazaki, Y, Nakano, S, Hirose, H.Total cavopulmonary shunt operation in complex cardiac anomalies. A new operation. J Thorac Cardiovasc Surg 1984; 87: 74–81.CrossRefGoogle ScholarPubMed
8.Glenn, WWL. Superior vena cava-pulmonary artery anastomosis. Ann Thorac Surg 1984; 37: 9–11.Google Scholar
9.McFaul, RC, Tajik, AJ, Mair, DD, Danielson, GK, Seward, JB.Development of pulmonary arteriovenous shunt after superior vena cava-right pulmonary artery (Glenn) anastomosis (report of four cases). Circulation 1977; 55: 212–216.CrossRefGoogle ScholarPubMed
10.Trusler, GA, Williams, WG, Cohen, AJ, Rabinovitch, M, Moes, F, Smallhorn, JF, Coles, JG, Lightfoot, NE, Freedom, RM.The cavopulmonary shunt: evolution of a concept.Circulation 1990; 82(Suppl IV):131–138.Google ScholarPubMed
11.Gramiak, R, Shah, PM, Kramer, DH.Ultrasound cardiography: contrast studies in anatomy and function. Radiology 1969; 92: 939–948.Google Scholar
12.Hernandez, A, Strauss, AW, McKnight, R, Hartmann, AF JrDiagnosis of pulmonary arteriovenous fistula by contrast echocardiography. J Pediatr 1978; 93: 258–261.CrossRefGoogle ScholarPubMed
13.Hare, Van GF, Silverman, NH.Contrast two-dimensional echocardiography in congenital heart disease: techniques, indications and clinical utility. J Am Coll Cardiol 1989; 13: 673–686.Google Scholar
14.Bommer, WJ, Shah, PM, Allen, H, Meltzer, R, Kisslo, J.The safety of contrast echocardiography: report of the committee on contrast echocardiography for the American Society of Echocardiography. J Am Coll Cardiol 1984; 3: 6–13.Google Scholar
15.Meltzer, RS, Tickner, GE, Popp, RL.Why do the lungs clear ultrasonic contrast? Ultrasound Med Biol 1980; 6: 263–269.Google Scholar
16.Feinsrein, SB, Care, Ten FJ, Zwehl, W, Ong, K, Maurer, G, Tei, C, Shah, PM, Meerbaum, S, Corday, E.Two-dimensional contrast echocardiography. I. In vitro development and quantitative analysis of echo contrast agents. J Am Coll Cardiol 1984; 3: 14–20.CrossRefGoogle Scholar
17.Ten Cate, FJ, Feinstein, S, Zwehl, W, Meerbaum, S, Fishbein, M, Shah, PM, Corday, E.Two-dimensional contrast echocardiography. II. Transpulmonary studies. J Am Coll Cardiol 1984; 3: 21–27.Google Scholar
18.Cheatham, JP, Barnharr, DA, Gutgesell, HP.Right pulmonary artery to left atrium communication: an unusual cause of cyanosis in the newborn. Pediatr Cardiol 1982; 2: 149–152.Google Scholar
19.Schmidt, KG, Silverman, NH.Cross-sectional and contrast echocardiography in the diagnosis of interatrial communications through the coronary sinus. Tnt J Cardiol 1987; 16: 193–199.Google Scholar
20.Cloutier, A, Ash, JM, Smallhorn, JF, Williams, WG, Trusler, GA, Rowe, RD, Rabinovitch, M.Abnormal distribution of pulmonary blood flow after the Glenn shunt or Fontan procedure: risk of development of arteriovenous fistulae. Circulation 1985; 72: 471–479.CrossRefGoogle ScholarPubMed
21.Boruchow, TB, Swenson, EW, Elliott, LP, Bartley, TD, Wheat, MW, Schiebler, GL.Study of the mechanisms of shunt failure after superior vena cava-right pulmonary artery anastomosis. J Thorac Cardiovasc Surg 1970; 60: 531–539.CrossRefGoogle ScholarPubMed
22.Mathur, M, Glenn, WWL.Long-term evaluation of cava-pulmonary artery anastomosis. Surgery 1973; 74: 899–916.Google ScholarPubMed
23.Bargeron, LM, Karp, RB, Barcia, A, Kirklin, JW, Hunt, D, Deverall, PB.Late deterioration of patients after superior vena cava to right pulmonary artery anastomosis. Am J Cardiol 1972; 30: 211–216.CrossRefGoogle ScholarPubMed
24.Kawashima, Y, Matsuki, O, Yagihara, T, Matsuda, H.Total cavopulmonary shunt operation. Seminars in Thoracic and Cardiovascular Surgery 1994; 6: 17–20.Google ScholarPubMed
25.Laks, H, Mudd, JG, Standeven, JW, Fagan, L, Willman, VL.Long-term effect of the superior vena cava-pulmonary artery anastomosis on pulmonary blood flow. J Thorac Cardiovasc Surg 1977; 74: 253–260.CrossRefGoogle ScholarPubMed
26.Samanek, M, Oppelt, A, Kasalicky, J, Voriskova, M.Distribution of pulmonary blood flow after cavopulmonary anasromosis (Glenn operation). Br Heart J 1969; 31: 511–516.CrossRefGoogle Scholar
27.Nakazawa, M, Nojima, K, Okuda, H, Imai, Y, Nakanishi, T, Kurosawa, H, Takao, A.Flow dynamics in the main pulmonary artery after the Fontan procedure in patients with tricuspid atresia or single ventricle. Circulation 1987; 75: 1117–1123.Google Scholar