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interesting and complex changes in the normal physiology of Ebstein’s anomaly of the tricuspid valve (TV) is a well-
the heart. Each patient must be considered individually, described congenital malformation3 in which the septal leaflet
because small differences in septal defect size or pathway of the TV is conjoined to the septal surface well below the
obstruction may have an enormous impact on the overall valve annulus into the body of the right ventricle (RV; Figure
effectiveness of the circulation and on management of the 1). The other 2 leaflets of the valve elongate to coapt with the
patient. For the purposes of this article, only the most abnormal septal leaflet, displacing the resulting coaptation
common types of complex CHD will be considered (those point into the RV outflow tract.
that are most likely to be seen in the adult cardiologist’s
office). However, the principles of flow and resistance, as Pathophysiology
reviewed in the prior 2 portions of this series and as related There are 2 significant hemodynamic outcomes of the mal-
below, are easily generalized to give the practicing physician formation. First, coaptation is rarely adequate, so most
insight into the physiological consequences of a myriad of patients have at least moderate TV regurgitation. Second, the
rare cardiac malformations. effective RV chamber size is reduced (and the right atrial
Adults with complex CHD can be divided into 2 groups: [RA] size increased) by a magnitude that corresponds to the
those who have not previously had an intervention and those displacement of the TV. The small size of the RV diminishes
who have. The former will present with new-onset symptoms its filling capacity, which results in increased impedance to
in adulthood or may be identified as a result of a physical filling. RA filling pressures are elevated, exacerbated by the
examination with a new physician, an abnormal ECG, or tricuspid regurgitation. In more severe cases, venous conges-
before they begin a new job. Children in the latter group who tion may result. The frequent association of an atrial septal
From the Center for Interventional Vascular Therapy (R.J.S.), Cardiovascular Research Foundation, Columbia University Medical Center, New York,
NY; Department of Pediatrics and Medicine (Z.M.H.), Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center,
Chicago, Ill; and Department of Pediatrics (J.F.R.), Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC.
This article is Part III in a 3-part series. Part I appeared in the February 26, 2008, issue (Circulation. 2008;117:1090 –1099) and Part II appeared in
the March 4, 2008, issue (Circulation. 2008;117:1228 –1237).
Correspondence to Robert J. Sommer, MD, Director, Invasive Adult Congenital Heart Disease, Assistant Professor of Clinical Medicine and Pediatrics,
Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY 10032. E-mail CHDDoctor@aol.com
(Circulation. 2008;117:1340-1350.)
© 2008 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.107.714428
1340
Sommer et al Complex Congenital Heart Disease 1341
cardiac output is increased and the RV is asked to accept the atrial communication should likely be left open. The
more volume). tradeoff of low cardiac output for full oxygen saturation is
often not beneficial for the patient, because tissue oxygen
Natural History delivery (the product of oxygen content and cardiac output) is
Clinical symptoms are highly variable and are related prin- usually less after elimination of the shunt, as has been demon-
cipally to the degree of TV displacement. With mild disease, strated with a number of other congenital malformations.6
the patient may be asymptomatic, and the diagnosis may be In the unusual case of an adult patient presenting with a
discovered incidentally during an echocardiogram performed small RV volume, tricuspid regurgitation, and true right-sided
for other reasons. The patient may present with a murmur of heart failure symptoms, surgical reconstruction or replace-
tricuspid regurgitation or with supraventricular tachycardia ment of the TV in the annular position is probably the best
(accessory bypass tracts are a common association4). With option.7 An alternative surgical approach, which has been
more severe valve displacement and an intact atrial septum, used primarily in children, is the “11/2 ventricle repair,” in
the patient may present with exercise intolerance. Although which a bidirectional Glenn shunt is performed (superior
the small RV may be able to produce a normal resting output, vena cava disconnected from the RA and anastomosed
it is preload limited, which limits its stroke volume. As directly to the right pulmonary artery). This allows the blood
demands increase on the “maxed out” RV, left ventricular returning from the upper body to drain directly to the lungs
(LV) preload requirements will not be met, which limits and back to the LV, whereas the small RV is unloaded and
systemic cardiac output. Signs of systemic venous congestion needs to handle only return from the inferior vena cava.8 As
may be present with exertion. a rule, most patients with Ebstein’s anomaly and significant
The more common presentation is that of a patient who symptoms due to hypoplasia of the RV will have undergone
also has an ASD or PFO. These patients may also present prior surgery as children, receiving either restorative valve
with exercise intolerance. However, with an atrial communi- surgery or single-ventricle repairs.
cation, when RV capacitance becomes inadequate and RA
pressure rises with exertion, the patient will develop a L-Transposition of the Great Arteries
right-to-left shunt at the atrial level. In contrast to the patient (Physiologically “Corrected” Transposition)
with an intact septum, when RV output cannot meet the L-transposition of the great arteries (L-TGA) is the result of
preload requirements of the LV, the right-to-left shunt aug- abnormal ventricular looping of the developing fetal heart, in
ments/normalizes LV preload and output, at the expense of which the primitive ventricle moves to the right and the
systemic arterial hypoxemia. In this population, even though bulbus cordis moves to the left.9 Because these structures are
resting oxygen saturation may be normal at rest, exercise the precursors of the LV and RV, respectively, the morpho-
1342 Circulation March 11, 2008
correct fusion with the growing muscular ventricular septum, cyanotic, profoundly exercise intolerant, and polycythemic16
narrowing the pathway from RV to pulmonary artery and and are at risk of arterial occlusion, hemoptysis, cerebral
enlarging the aortic root such that it extends over the RV abscess, and other life-threatening issues. When a complete
outflow tract. The RV hypertrophy is a secondary response to repair is anatomically and physiologically possible, correc-
increased afterload. Obstructions in the branch pulmonary tion of the defect provides the patient with a vastly superior
arteries, coronary anomalies, a right-sided aortic arch, and quality of life, although the surgery carries somewhat higher
additional VSDs are common additional associations. mortality and morbidity in the adult than in the child.17
In tetralogy of Fallot, systemic and pulmonary venous Palliative procedures such as aorta-to–pulmonary artery
return, the RA and LA, the atrial septum, and the AV valves shunts and transcatheter balloon dilation of the RV outflow
are typically normal. Blood ejected from the ventricles has 2 tract may improve arterial saturation and reduce symptoms as
possible pathways: through the anatomically aligned outflow a result; however, experience with these palliations is princi-
tract or through the VSD to the opposite outflow. The pally in children. Acute increases in pulmonary blood flow
direction and magnitude of blood flow from each ventricle correspondingly increase pulmonary venous return, which
will be determined by the relative resistance of each pathway. places an acute volume load on the LV. The less compliant
With subpulmonary valvar obstruction, hypoplasia of the LV of the adult may not handle the volume load as easily as
pulmonary valve, narrowing of the main pulmonary artery the pediatric ventricle, and new symptoms of congestive heart
trunk, and the frequently associated branch pulmonary artery failure are possible.
stenoses, the pathway from the RV to the lungs in tetralogy of
Fallot is typically a high-resistance pathway (the net resis- Tetralogy of Fallot With Pulmonary Atresia
tance of obstructions in series is the sum of the individual In the most severe cases of spiral septum malalignment, the
resistors). The combination of a high-resistance pulmonary pulmonary valve may be atretic, or the main pulmonary artery
pathway and a nonrestrictive VSD creates the hemodynamic trunk may not form at all.8 In some of these newborns, the
conditions for significant right-to-left shunting at the ventric- ductus arteriosus may be the only source of pulmonary blood
ular level, which results in systemic arterial desaturation. flow (blood flows from the high-resistance aorta to the
lower-resistance pulmonary arteries). In the first few days of
Natural History life, as the ductus begins to close, these patients will become
The resistance of the pulmonary path is extremely variable profoundly cyanotic and will require medical intervention
from 1 patient to the next. If the obstructive lesions are mild, (prostaglandin E1) to maintain ductal patency, followed by a
the net resistance to pulmonary flow will be low compared surgical reconstruction of the RV outflow tract.
1344 Circulation March 11, 2008
patients who underwent an arterial switch, survival was 91% functional class I. Patients who have had only palliative
at 10 years, with 96% of patients unlimited in their physical shunts remain cyanotic and have many of the long-term
activity, and 99% taking no medication.32 Most clinical issues issues of their counterparts who have not undergone repair
after the operation are the result of surgical residua from the (see above); however, in patients who have never undergone
initial operation in infancy. complete repair, longstanding or multiple shunt procedures
Coronary lesions are rare, with myocardial ischemia very may severely distort or interrupt the branch pulmonary
uncommon after reimplantation of the vessels. In a series of arteries and may preclude more definitive repairs.
755 arterial switch procedures, coronary perfusion issues With a completed tetralogy of Fallot repair, normal cardiac
were detected in 34 children, with documented ischemia in physiology is restored. However, a number of hemodynamic
only 19.33 There are no data available yet on the risk of issues may be seen in adults who have undergone surgical
coronary complications later in adulthood. correction as children, including residual RV outflow ob-
The other major clinical issue after the arterial switch is struction, residual obstruction in the branch pulmonary arter-
related to anatomic distortion of the great vessels. Residual ies, residual shunts (at atrial, ventricular, or arterial levels),
supravalvar stenosis at the aortic and pulmonary reanastomo- significant right-sided valvar insufficiency, aortic insuffi-
sis sites may be seen,34 but clinically significant obstructions ciency, dilated and poorly contractile ventricles,42– 45 heart
are most often resolved in the pediatric age group with block, and reentrant ventricular arrhythmia due to scarring in
transcatheter or surgical therapy. Progressive dilatation and the ventricles.46 Sudden cardiac death may occur in patients
valvar insufficiency of the reconstructed aortic root may be with residual disease and may be predictable with electro-
problematic and may necessitate valve replacement later in physiological evaluation.47 Antitachycardia pacing may ben-
life.35 Branch pulmonary artery stenosis may result from efit some patients who are established to be at greatest risk for
pulling the main pulmonary artery trunk forward to anasto- life-threatening arrhythmia.48
mose it to the former aortic root.36 This may be a clinically Most often, adult tetralogy of Fallot patients present with
important afterload for the RV or may significantly redistrib- new-onset or increasing exercise intolerance and must be
ute pulmonary blood flow from 1 lung to the other if the evaluated to rule out both potentially important surgical
degree of obstruction of the branches is unequal. These residua and ventricular myocardial issues. RV dilatation and
obstructive lesions have been treated successfully in the dysfunction are common in this group and are most often
pediatric population with balloon and stent angioplasty.37 related to long-standing pulmonary regurgitation in patients
Because arterial switch patients are now reaching adulthood who have had surgical manipulation of the valve. With
in growing numbers, the long-term outcome of Jatene’s dilatation of the RV and the tricuspid annulus, tricuspid
Downloaded from http://ahajournals.org by on October 1, 2018
operation continues to be unveiled. regurgitation may be secondary but certainly compounds the
issue of RV volume overload. The RV with preserved systolic
“Natural History” After Surgical Intervention for function typically responds well to pulmonary valve replace-
Tetralogy of Fallot ment in many patients,49 with or without concurrent TV
In the late 1940s, before the era of open heart surgical repairs, repair. LV dysfunction is common in patients who underwent
palliative shunts were developed to carry blood directly from surgery before 1970 and is most often related to suboptimal
the aorta to the pulmonary artery, bypassing the obstruction in myocardial protection during surgery or to injury of unsus-
the RV outflow tract.38 The Blalock-Taussig shunt (subcla- pected anomalous coronary branches. MRI has proven ex-
vian artery to pulmonary artery), the Waterston shunt (direct tremely valuable in the quantitative assessment of ventricular
anastomosis of ascending aorta to right pulmonary artery), and valvar function in this population of patients who are
and the Potts shunt (direct anastomosis of descending aorta to typically difficult to image with transthoracic echocardiogra-
left pulmonary artery) were common in the 1950s and 1960s phy50 due to surgical scarring and anatomic distortion. Pa-
and enabled survival to adolescence and adulthood. Shunts tients who are free of clinical symptoms are frequently lost to
were later used in the short-term palliation of neonates with follow-up, but ongoing care and screening are essential
severe cyanosis, so that complete open heart repairs could be because the population remains at risk for ventricular dys-
performed more safely in an older/larger child. function, ventricular arrhythmia, and, in some cases, sudden
Complete surgical repair of tetralogy of Fallot separates death.
systemic and pulmonary venous return and creates unob-
structed flow to both great arteries. Closure of the VSD is The Adult Patient With Single-Ventricle
accomplished with an angled patch that directs LV flow to the Physiology (Fontan Operation)
aorta. Repair of the RV outflow tract and pulmonary arteries Patients with functional single ventricles, those with absent or
may entail subvalvar muscle resection, pulmonary valvot- hypoplastic pumping chambers, absent or hypoplastic AV
omy, transannular patching to enlarge a hypoplastic valve valves, or complex VSDs that cannot be closed, are reaching
annulus, and patch angioplasty of the main or branch pulmo- adulthood in large numbers for the first time. Simple pallia-
nary arteries. Currently, corrective surgery is typically per- tions such as shunts or pulmonary artery banding were
formed in the first year of life.39 With good surgical results, initially performed to maintain quality of life for a few years
survival and quality of life have been excellent. In a retro- in patients with appropriate anatomy. Long-term survival was
spective analysis from the Mayo Clinic, 86% of patients were not seen until the introduction in 1971 of the Fontan opera-
alive at 32 years,40 and in a series of 151 patients from tion,51 a more definitive palliative approach in which the
Toronto, Canada,41 94% were in New York Heart Association systemic venous return is rerouted to completely bypass the
Sommer et al Complex Congenital Heart Disease 1347
efficient than when mixed arterial blood is delivered to the (IVC) flow is rerouted through external conduit directly to pulmo-
pulmonary artery, and the fraction of “blue” blood in the nary artery. Systemic venous blood (black arrows) flows to
lungs; only pulmonary venous blood is pumped to aorta (Ao;
ventricle is smaller, which results in higher systemic oxygen white arrow). RPA indicates right pulmonary artery; LPA, left
saturations after the Glenn shunt (85% to 90%) than after the pulmonary artery.
initial palliation. Finally, volume loading of the ventricle is
eliminated because it pumps blood only to the systemic “Natural History” of a Fontan Circulation
circulation. Today, children with Fontan physiology are reaching adult-
The final stage of the palliation, the Fontan operation, hood in unprecedented numbers. Initially after the surgery,
redirects inferior vena caval flow away from the atrium to the ⬎90% of patients are in New York Heart Association class I
pulmonary arteries,53 leaving only pulmonary venous blood or II,54 with marked improvements in exercise capacity
to be pumped by the ventricle to the aorta (Figure 6). These (compared with their preoperative state) due to improved
patients become fully saturated after the surgery. Despite the tissue oxygen delivery. Unlike patients with repairs of simple
complete separation of systemic and pulmonary venous defects such as patent ductus arteriosus or ASD, Fontan
blood, Fontan physiology is distinct from that of the normal patients experience ongoing attrition even after decades of
heart. symptom-free survival. This is due to ventricular failure;
In contrast to a 2-ventricle circulation, in which blood is breakdown and growth-related senescence of constructed
pumped through 2 parallel circuits by separate pumps, the pathways; the development of atrial arrhythmia; fluid reten-
single functional ventricle in a Fontan circulation must tion and electrolyte disturbances; low cardiac output; and
generate enough energy to push blood through both the thrombotic and thromboembolic issues. The classic paper by
systemic and pulmonary vascular beds consecutively. There Fontan et al55 in the early 1990s proved the palliative, rather
is no energy added by a second ventricle to help push blood than reparative, nature of the procedure. In that series, after
through the lungs. Flow from the systemic veins, through the 12 years, only 70% of “perfect” Fontan patients were alive,
lungs and back to the ventricle, is entirely passive (Figure 7). and fewer than half of the survivors remained in New York
Low resistance in this pathway is therefore critical. Anatomic Heart Association class I or II.
obstructions in the pulmonary vasculature, elevation of pul- Advances in the pre-Fontan management of these children,
monary vascular resistance, competitive arterial flow into the including staging of surgical reconstruction and improved
lungs, AV valve stenosis or regurgitation, elevation of ven- surgical techniques, are likely to have resulted in better late
tricular end-diastolic pressure, or rhythm disturbances with outcomes since the Fontan paper was published, but it is clear
loss of AV synchrony may create critical impedance to flow. that the procedure will never be curative in nature.56 Although
1348 Circulation March 11, 2008
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