CI RCULATION
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2. An echo-free space dorsal to what appears to be posterior left atrial wall was also found in our two patients. However we have been able to record such membrane-like, strong and regular echoes in normal newborns such as shown in figure 2 A. On the right (B) is shown for comparison the echocardiogram of our 13-day-old patient with infradiaphragmatic TAPVC. The posterior echo-free space looks similar in both cases. This finding would then appear to have little specificity. We can only speculate as to the origin of this echo in the normal; it could possibly be due to a dilated right pulmonary vein. This echo appears to be different from the weak and irregular echoes which can be recorded occasionally ventral to the posterior wall of the left atrium in normal subjects. 3. In addition, we found in our second case (TAPVC to the portal vein) an echo-free space dorsal to the left ventricle (fig. 1 A). Because of the absence of pericardial effusion at surgery, we believe that it could be the echocardiographic representation of the anomalous vein descending vertically behind the heart. This feature, associated with an echo-free space dorsal to the left atrium, could perhaps be more specific of an infradiaphragmatic type of TAPVC. In summary, we would like to emphasize that the echocardiographic diagnosis of TAPVC is not as easy in the newborn period as it can be at a later age; signs of RVDVO may be lacking, and one must be careful in interpreting an echo-free space dorsal to the left atrium. A. Bozio, M.D. A. Davignon, M.D. Ste-Justine Hospital for Children Montreal, Quebec, Canada
References 1. Paquet M, Gutgesell H: Echocardiographic features of total anomalous pulmonary venous connection. Circulation 51: 599, 1975 2. Solinger R, Elbl F, Minhas K: Echocardiography in the normal neonate. Circulation 47: 108, 1973 3. Nadas AS, Fyler DC: Pediatric Cardiology. Philadelphia, W. B. Saunders Company, 1972 4. Godman M, Tham P, Kidd BSL: Echocardiography in the evolution of the cyanotic newborn infant. Br Heart J 36: 154, 1974 5. Glaser J, Whitman J, Liebman J: The differential diagnosis of total anomalous pulmonary venous drainage in infancy by echocardiography. Circulation 46 (suppl II): 11-38, 1972
The authors reply: To the Editor: Dr. Bozio and Davignon's comments regarding the diagnosis of total anomalous pulmonary venous connection (TAPVC) by echocardiography are well taken. Based on the population of patients we had studied at that time, we stated that "the criteria presented in this study appear to be specific for TAPVC ... and should allow an early diagnosis in infants with this condition."' Since then we also have become aware of the difficulties in making this diagnosis by echo in newborns. We have now studied two newborns with TAPVC. One had infradiaphragmatic drainage, and we suggested the diagnosis from the echo; the other had drainage directly to the right atrium without a common pulmonary venous chamber, and no echo-free space could be identified behind the left atrium. Both patients had normal septal motion. Thus, our experience also confirms the findings of Godman et al.' that signs of right ventricular volume overload are usually missing in patients who present in the newborn period. It also stresses the fact that, as we stated in the paper, a normal echo does not rule out the diagnosis. We have also been faced with the problem of finding an echo-free space dorsal to the left atrium in normal newborns. In trying to solve that problem in a given patient it is important to realize that the echo is but one of many tools that the cardiologist possesses in the evaluation of the newborn, and thus one should not rely exclusively on it to make a diagnosis.
VOL. 53, No. 6, JUNE 1976
We feel that knowledge of these potential pitfalls allows for a more judicious use of echocardiography in the evaluation of infants and children. Marc Paquet, M.D. Institut de Cardiologie de Quebec
Quebec, Canada Howard P. Gutgesell, M.D. Baylor College of Medicine Houston, Texas 77025
References 1. Paquet M, Gutgesell H: Echocardiographic features of total anomalous pulmonary venous connection. Circulation 51: 599, 1975 2. Godman M, Tham P, Kidd BSL: Echocardiography in the evaluation of the cyanotic newborn infant. Br Heart J 36: 154, 1974
Left Circumflex Coronary Artery in SCS To the Editor: In the September 1975 issue of Circulation,' Gentzler and his coworkers found only two of nineteen patients with prolapsing mitral valves to have an atrioventricular branch of the left circumflex coronary. In contrast, they found 74 of 78 control patients to have a branch of the left circumflex coronary in the atrioventricular groove. They concluded that this absence of a left circumflex coronary artery in the distribution of the atrioventricular groove was a congenital anomaly and responsible for segmental myocardial dysfunction in some patients with the systolic click syndrome. We examined 100 consecutive selective coronary arteriograms from patients who did not have evidence of prolapsing of the mitral valve (control patients) and 100 consecutive selective coronary arteriograms from patients with proven prolapsing mitral valves by biplane cineangiography. The branching pattern of the left circumflex coronary artery was compared in these two groups of patients. The following types were identified: TYPE 0: A branching pattern described by Gentzler et al. for patients with systolic click syndrome. That is, there was no AV branch past the first large marginal branch of the circumflex coronary. TYPE I: Patients with a small atrioventricular branch past either the first or second marginal branches from the left circumflex artery. TYPE II: Patients with a large atrioventricular branch of the left circumflex artery which gave off one or two marginal branches and at least one posterior lateral branch. TYPE III: Patients who had a so-called "dominant" left coronary circulation with the posterior descending artery arising from the left circumflex vessel. The distribution in our 100 control patients and 100 patients with prolapsing mitral valve are noted in table 1. The four anatomic TABLE 1. Normals LCA
TYPE TYPE TYPE TYPE
N= 100
0 I II III
Prolapsing mitral valve
23 22 41 14
N = 100
21 21
48 10
patterns are distributed among the two groups in a nearly identical manner. Specifically, the prevalence of the Type 0 pattern (absent AV branch) is at least as prevalent in the control group as in patients with prolapsing mitral valve. Furthermore, in patients with this pattern the right coronary artery provided multiple posterolateral branches to the left ventricle. We are, therefore, unable to confirm
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Letter: Left circumflex coronary artery in SCS. R H Peter, V S Behar, Y Kong, J A Kisslo and J R Margolis Circulation. 1976;53:1042-1043 doi: 10.1161/01.CIR.53.6.1042 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1976 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/53/6/1042.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
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1042
2. An echo-free space dorsal to what appears to be posterior left atrial wall was also found in our two patients. However we have been able to record such membrane-like, strong and regular echoes in normal newborns such as shown in figure 2 A. On the right (B) is shown for comparison the echocardiogram of our 13-day-old patient with infradiaphragmatic TAPVC. The posterior echo-free space looks similar in both cases. This finding would then appear to have little specificity. We can only speculate as to the origin of this echo in the normal; it could possibly be due to a dilated right pulmonary vein. This echo appears to be different from the weak and irregular echoes which can be recorded occasionally ventral to the posterior wall of the left atrium in normal subjects. 3. In addition, we found in our second case (TAPVC to the portal vein) an echo-free space dorsal to the left ventricle (fig. 1 A). Because of the absence of pericardial effusion at surgery, we believe that it could be the echocardiographic representation of the anomalous vein descending vertically behind the heart. This feature, associated with an echo-free space dorsal to the left atrium, could perhaps be more specific of an infradiaphragmatic type of TAPVC. In summary, we would like to emphasize that the echocardiographic diagnosis of TAPVC is not as easy in the newborn period as it can be at a later age; signs of RVDVO may be lacking, and one must be careful in interpreting an echo-free space dorsal to the left atrium. A. Bozio, M.D. A. Davignon, M.D. Ste-Justine Hospital for Children Montreal, Quebec, Canada
References 1. Paquet M, Gutgesell H: Echocardiographic features of total anomalous pulmonary venous connection. Circulation 51: 599, 1975 2. Solinger R, Elbl F, Minhas K: Echocardiography in the normal neonate. Circulation 47: 108, 1973 3. Nadas AS, Fyler DC: Pediatric Cardiology. Philadelphia, W. B. Saunders Company, 1972 4. Godman M, Tham P, Kidd BSL: Echocardiography in the evolution of the cyanotic newborn infant. Br Heart J 36: 154, 1974 5. Glaser J, Whitman J, Liebman J: The differential diagnosis of total anomalous pulmonary venous drainage in infancy by echocardiography. Circulation 46 (suppl II): 11-38, 1972
The authors reply: To the Editor: Dr. Bozio and Davignon's comments regarding the diagnosis of total anomalous pulmonary venous connection (TAPVC) by echocardiography are well taken. Based on the population of patients we had studied at that time, we stated that "the criteria presented in this study appear to be specific for TAPVC ... and should allow an early diagnosis in infants with this condition."' Since then we also have become aware of the difficulties in making this diagnosis by echo in newborns. We have now studied two newborns with TAPVC. One had infradiaphragmatic drainage, and we suggested the diagnosis from the echo; the other had drainage directly to the right atrium without a common pulmonary venous chamber, and no echo-free space could be identified behind the left atrium. Both patients had normal septal motion. Thus, our experience also confirms the findings of Godman et al.' that signs of right ventricular volume overload are usually missing in patients who present in the newborn period. It also stresses the fact that, as we stated in the paper, a normal echo does not rule out the diagnosis. We have also been faced with the problem of finding an echo-free space dorsal to the left atrium in normal newborns. In trying to solve that problem in a given patient it is important to realize that the echo is but one of many tools that the cardiologist possesses in the evaluation of the newborn, and thus one should not rely exclusively on it to make a diagnosis.
VOL. 53, No. 6, JUNE 1976
We feel that knowledge of these potential pitfalls allows for a more judicious use of echocardiography in the evaluation of infants and children. Marc Paquet, M.D. Institut de Cardiologie de Quebec
Quebec, Canada Howard P. Gutgesell, M.D. Baylor College of Medicine Houston, Texas 77025
References 1. Paquet M, Gutgesell H: Echocardiographic features of total anomalous pulmonary venous connection. Circulation 51: 599, 1975 2. Godman M, Tham P, Kidd BSL: Echocardiography in the evaluation of the cyanotic newborn infant. Br Heart J 36: 154, 1974
Left Circumflex Coronary Artery in SCS To the Editor: In the September 1975 issue of Circulation,' Gentzler and his coworkers found only two of nineteen patients with prolapsing mitral valves to have an atrioventricular branch of the left circumflex coronary. In contrast, they found 74 of 78 control patients to have a branch of the left circumflex coronary in the atrioventricular groove. They concluded that this absence of a left circumflex coronary artery in the distribution of the atrioventricular groove was a congenital anomaly and responsible for segmental myocardial dysfunction in some patients with the systolic click syndrome. We examined 100 consecutive selective coronary arteriograms from patients who did not have evidence of prolapsing of the mitral valve (control patients) and 100 consecutive selective coronary arteriograms from patients with proven prolapsing mitral valves by biplane cineangiography. The branching pattern of the left circumflex coronary artery was compared in these two groups of patients. The following types were identified: TYPE 0: A branching pattern described by Gentzler et al. for patients with systolic click syndrome. That is, there was no AV branch past the first large marginal branch of the circumflex coronary. TYPE I: Patients with a small atrioventricular branch past either the first or second marginal branches from the left circumflex artery. TYPE II: Patients with a large atrioventricular branch of the left circumflex artery which gave off one or two marginal branches and at least one posterior lateral branch. TYPE III: Patients who had a so-called "dominant" left coronary circulation with the posterior descending artery arising from the left circumflex vessel. The distribution in our 100 control patients and 100 patients with prolapsing mitral valve are noted in table 1. The four anatomic TABLE 1. Normals LCA
TYPE TYPE TYPE TYPE
N= 100
0 I II III
Prolapsing mitral valve
23 22 41 14
N = 100
21 21
48 10
patterns are distributed among the two groups in a nearly identical manner. Specifically, the prevalence of the Type 0 pattern (absent AV branch) is at least as prevalent in the control group as in patients with prolapsing mitral valve. Furthermore, in patients with this pattern the right coronary artery provided multiple posterolateral branches to the left ventricle. We are, therefore, unable to confirm
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on April 30, 2015
Letter: Left circumflex coronary artery in SCS. R H Peter, V S Behar, Y Kong, J A Kisslo and J R Margolis Circulation. 1976;53:1042-1043 doi: 10.1161/01.CIR.53.6.1042 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1976 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/53/6/1042.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on April 30, 2015
