Diagnostic Dilemma|Articles in Press

Pandiastolic Antegrade Flow To The Main Pulmonary Artery

Published:February 22, 2023DOI:
      A 6-MONTH-old boy, (weight: 4.8 kg, height: 60 cm), diagnosed with pulmonary atresia and intact ventricular septum, was taken to the operating room for an intracardiac repair. The child previously had undergone pulmonary valve perforation and balloon valvuloplasty. The preoperative transthoracic echocardiogram displayed 2 balanced ventricles and a right ventricle composed of a sinus (inlet) portion, a trabecular part, and a conus (infundibulum). The ventricular septum was intact. A secundum atrial septal defect was present. There was mild tricuspid regurgitation. The right ventricular systolic pressure was 80 mmHg to a systemic systolic arterial pressure of 70 mmHg. The right ventricular outflow tract was severely narrowed, measuring 3.5 mm in diameter. The pulmonary valve was doming, and the annulus was 7.8 mm. The pressure gradient across the right ventricular outflow tract was 82 mmHg. Intraoperatively, resection of the muscular right ventricular outflow tract with reconstruction of the tract using a bovine patch was performed. A pulmonary valvotomy also was completed. Subsequently, the right ventricular pressure was half of the systemic arterial pressure, by invasive measurement, with a 10-mmHg pressure gradient across the pulmonary valve. The child easily separated from cardiopulmonary bypass on milrinone (0.5 µg/kg/min). He was taken to the intensive care unit on mechanical ventilation with stable hemodynamics. On admission to the intensive care unit, the arterial oxygen saturation was >95%, with an inspired oxygen concentration of 60%. Over the next 6 hours, he developed arterial desaturation. The child was treated with a combined ventilation mode of synchronized intermittent mandatory ventilation with pressure control and pressure support, positive end-expiratory pressure of 6 cmH2O, and a fraction of inspired oxygen of 0.8. Transthoracic echocardiography showed the shunt across the atrial septal defect (Fig 1, A and B; Videos 1 and 2). Color-flow Doppler of the hepatic veins showed a reversal of flow corresponding to atrial systole (Fig 2; Video 3). The tricuspid annular plane systolic excursion was 0.627 cm, and the E/A ratio was 0.9 (Fig 3, A and B). The color Doppler blood flow of the right ventricular outflow tract showed flow turbulence beginning below the pulmonary valve, with a peak gradient of 22 mmHg and mild pulmonary regurgitation (Fig 4; Video 4). Right ventricular outflow tract interrogation with continuous-wave Doppler revealed pandiastolic (peak velocity: 84.8 cm/s) antegrade flow toward the pulmonary artery (Fig 5, white arrows). Agitated saline injected into the right internal jugular vein was seen in the atrium and the ventricle, displaying the shunt's nature (Fig 6; Video 5). What is the diagnosis?
      Fig 1
      Fig 1A subcostal 4-chamber transthoracic echocardiography view displaying a right-to-left (A), and a left-to-right (B) shunt across the atrial septal defect.
      Fig 2
      Fig 2Color-flow Doppler of the hepatic veins during diastole (A) and systole (B).
      Fig 3
      Fig 3(A), (B) Tricuspid annular plane systolic excursion and the E/A by pulse-wave Doppler.
      Fig 4
      Fig 4(A), (B) Color-flow Doppler of the right ventricular outflow tract.
      Fig 5
      Fig 5Continuous-wave Doppler interrogation of the right ventricular outflow tract showing pandiastolic antegrade toward the pulmonary artery (white arrows).
      Fig 6
      Fig 6Agitated saline contrast defining the dimension of the right ventricle.

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        • Redington AN
        • Penny D
        • Rigby ML
        • et al.
        Antegrade diastolic pulmonary arterial flow as a marker of right ventricular restriction after complete repair of pulmonary atresia with intact septum and critical pulmonary valve stenosis.
        Cardiol Young. 1992; 2: 382-386
        • Suruga K
        • Toh N
        • Kotani Y
        • et al.
        Residual restrictive right ventricular physiology after one-and-a-half ventricular repair conversion in pulmonary atresia with intact ventricular septum.
        CASE (Phila). 2020; 4: 523-525
        • Sandeep B
        • Huang X
        • Xu F
        • et al.
        Etiology of right ventricular restrictive physiology early after repair of tetralogy of Fallot in pediatric patients.
        J Cardiothorac Surg. 2019; 14: 84
        • Choi JY
        • Kwon HS
        • Yoo BW
        • et al.
        Right ventricular restrictive physiology in repaired tetralogy of Fallot is associated with smaller respiratory variability.
        Int J Cardiol. 2008; 125: 28-35
        • Gatzoulis MA
        • Clark AL
        • Cullen S
        • et al.
        Right ventricular diastolic function 15 to 35 years after repair of tetralogy of Fallot. Restrictive physiology predicts superior exercise performance.
        Circulation. 1995; 91: 1775-1781
        • Awasthy N
        • Bhatt C
        • Iyer KS.
        Pandiastolic antegrade flow in patient with severe right ventricle to pulmonary artery conduit stenosis: An interesting phenomenon.
        Ann Pediatr Cardiol. 2016; 9: 82-84
        • Shekerdemian LS
        • Bush A
        • Shore DF
        • et al.
        Cardiorespiratory responses to negative pressure ventilation after tetralogy of Fallot repair: A hemodynamic tool for patients with a low-output state.
        J Am Coll Cardiol. 1999; 33: 549-555
        • Shekerdemian LS
        • Schulze-Neick I
        • Redington AN
        • et al.
        Negative pressure ventilation as haemodynamic rescue following surgery for congenital heart disease.
        Intensive Care Med. 2000; 26: 93-96