Annals of Pediatric Cardiology
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    -  Chikkagoudar KN
    -  Koneti NR
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LETTER TO EDITOR  
Ahead of print publication
Anatomically corrected malposition of great arteries: A nidus for the left ventricular outflow tract obstruction


1 Department of Pediatric Cardiology, Care Hospitals, Hyderabad, Telangana, India
2 Department of Pediatric Cardiology, Rainbow Children Heart Institute, Hyderabad, Telangana, India

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How to cite this URL:
Gupta P, Chikkagoudar KN, Koneti NR. Anatomically corrected malposition of great arteries: A nidus for the left ventricular outflow tract obstruction. Ann Pediatr Card [Epub ahead of print] [cited 2019 Dec 12]. Available from: http://www.annalspc.com/preprintarticle.asp?id=271501




Sir,

We would like to bring to your notice an interesting case of anatomically corrected malposition of great arteries (ACMGA) presented with left ventricular outflow tract obstruction (LVOTO) few years after transcatheter closure of perimembranous ventricular septal defect (PmVSD).

A 3-year-old boy diagnosed to have moderate PmVSD with ACMGA underwent transcatheter closure using 6/4 Amplatzer duct occluder II (ADO II) from retrograde (arterial) approach.[1] The child was given Aspirin 3 mg/kg for 6 months and kept on regular follow-up.

Transthoracic echocardiography on 2-year follow-up showed developing LVOTO due to hypertrophy of subaortic conus, which progressed to severe degree with a peak gradient of 70 mmHg [Figure 1]a. The obstruction was 1 cm below the previously deployed ADO II device. Computerized tomography angiography was done which confirmed the findings of LVOTO [Figure 1]b. The child underwent surgical resection of LVOTO under transesophageal guidance [Figure 1]d. Postoperative assessment revealed no gradient in the LVOT. The child is asymptomatic, and no recurrence of LVOTO seen during the follow-up.
Figure 1: (a) Transthoracic echocardiographic Doppler assessment across left ventricular outflow tract showing peak gradient of 70 mmHg (b) computed tomography angiogram showing narrowed left ventricular outflow tract obstruction and device is below the obstruction (white broad arrow) (c) left ventricular angiogram in anteroposterior projection showing elongated left ventricular outflow tract (d) intraoperative picture showing the obstructing conus (white arrow) and device (broken arrow)

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The embryological basis for this condition was described by Goor et al. as isolated inversion of conus which results in inversion of conal musculature together with the great arteries.[2] The posterior left ventricle connects to the anterior aorta resulting in an elongated LVOT as seen in the angiogram of our case [Figure 1]c. This pushes the pulmonary artery (PA) posterior and right to the aorta. The abnormal spatial orientation of PA with respect to the right ventricle makes it difficult for the catheter to enter PA from the right atrium. There are four types of ACMGA described by Van Praagh. Type 1 (S, D, L) situs solitus, d-loop ventricle, left and anterior aorta; Type 2 (S, L, D) situs solitus, l-loop ventricle, right and anterior aorta; Type 3 (I, L, D) situs inversus, l-loop ventricle, right and anterior aorta; and Type 4 (I, D, L) situs inversus, d-loop ventricles, left and anterior aorta.[3] The most common type of ACMGA is Type 1, as in our case. Types 1 and 3 are physiologically corrected, whereas Type 2 and Type 4 have transposition physiology. In all types of ACMGA, the aorta is anterior to the PA and supported by a muscular subaortic infundibulum despite ventriculoarterial concordance. As a result, there is a high incidence of subaortic obstruction in this condition. Other associated anomalies are ventricular septal defect (VSD), right ventricular outflow tract obstruction, right ventricular hypoplasia, juxtaposed atrial appendage, and right aortic arch. VSD, right arch, and juxtaposed appendage were present in our case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Koneti NR, Penumatsa R, Arramraju S, Vadlamudi K, Sreeram NS. Retrograde transcatheter closure of ventricular septal defect in children using Amplatzer Duct occluder II device. J Am Coll Cardiol 2012;59 Suppl 13: E814.  Back to cited text no. 1
    
2.
Goor DA, Dische R, Lillehei CW. The conotruncus. I. Its normal inversion and conus absorption. Circulation 1972;46:375-84.  Back to cited text no. 2
    
3.
Van Praagh R, Durnin RE, Jockin H, Wagner HR, Korns M, Garabedian H, et al. Anatomically corrected malposition of the great arteries (S, D, L). Circulation 1975;51:20-31.  Back to cited text no. 3
    

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Correspondence Address:
Nageswara Rao Koneti,
Department of Pediatric Cardiology, Rainbow Children Heart Institute, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/apc.APC_160_19



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