Morphologic Spectrum of Ventriculoarterial Connection in Hearts With Double Inlet Left Ventricle: Implications for Surgical Procedures Hideki Uemura,

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Morphologic Spectrum of Ventriculoarterial Connection in Hearts With Double Inlet Left Ventricle: Implications for Surgical Procedures Hideki Uemura, MD,

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Morphologic Spectrum of Ventriculoarterial Connection in Hearts With Double Inlet Left Ventricle: Implications for Surgical Procedures Hideki Uemura, MD, FRCS, Siew Yen Ho, PhD, Iki Adachi, MD, Toshikatsu Yagihara, MD The Annals of Thoracic Surgery Volume 86, Issue 4, Pages 1321-1327 (October 2008) DOI: 10.1016/j.athoracsur.2008.06.050 Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Diagrams of ventriculoarterial connections in patients and specimens with double inlet left ventricle with the right ventricle leftwards in relation to the dominant left ventricle. The schemas are drawn as seen from the top. The numbers of examples are shown adjacent to each schema. Percentages indicate degree of overriding of the aorta. (Ao = aorta; LV = morphologic left ventricle; PA = pulmonary arterial trunk; RV = morphologic right ventricle; VA = ventriculoarterial connection.) The Annals of Thoracic Surgery 2008 86, 1321-1327DOI: (10.1016/j.athoracsur.2008.06.050) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Diagrams of ventriculoarterial connections in patients and specimens with double inlet left ventricle with the right ventricle rightwards and adjacent to the right atrium. The schemas are drawn as seen from the top. The numbers of examples are shown adjacent to each schema. Percentages indicate degree of overriding of either the aorta or the pulmonary trunk. (Ao = aorta; PA = pulmonary arterial trunk; RV = morphologic right ventricle; LV = morphologic left ventricle; VA = ventriculoarterial connection.) The Annals of Thoracic Surgery 2008 86, 1321-1327DOI: (10.1016/j.athoracsur.2008.06.050) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (a) An example of both great arteries arising from the right-sided morphologic right ventricle. The ventricular septal defect is large, and the outlet septum is oriented perpendicular to the muscular ventricular septum. Panels b, c, and d show examples of unusual ventriculoarterial connections; the aorta arising from the morphologically right ventricle and the pulmonary pathway having membranous atresia. (b) The aorta was anterior to the pulmonary trunk, and the arterial trunks had a parallel arrangement. (c) From the dominant morphologic left ventricle, the imperforate pulmonary valve was seen in relation to the crest of the muscular ventricular septum, while the forceps through the aortic valve indicated that the aortic valvar orifice exclusively originated from the morphologic right ventricle. The outlet septum was markedly attenuated. (d) This view from the pulmonary trunk revealed an imperforate pulmonary valve. (Ao = aorta; AoV = aortic valve; AVV = atrioventricular valve; PT = pulmonary arterial trunk; PV = pulmonary valve; RA = right atrium; RV = morphologic right ventricle.) The Annals of Thoracic Surgery 2008 86, 1321-1327DOI: (10.1016/j.athoracsur.2008.06.050) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Diagrams of obstructions across the aortic or pulmonary pathway in clinical patients. A solitary arrow indicates a restrictive interventricular communication. A broken arrow indicates deviation of the outlet septum. A dual arrow shows a markedly deviated and substantially formed outlet septum. Aortic pathway obstruction includes coarctation of the aorta, interruption of the aortic arch, or subaortic stenosis. (Ao = aorta, LV = morphologic left ventricle; PA = pulmonary arterial trunk; RV = morphologic right ventricle; VA = ventriculoarterial connection.) The Annals of Thoracic Surgery 2008 86, 1321-1327DOI: (10.1016/j.athoracsur.2008.06.050) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Diagrams of ventricular outflow tracts in clinical series in relation to outflow obstructions and surgical procedures used to avoid subaortic stenosis (by either the Damus-Kaye-Stansel anastomosis or enlargement of the interventricular communication). A set of the numbers indicates the number of the surgical procedures used for this purpose from the total number of each pattern of ventriculoarterial connection. Aortic pathway obstruction includes coarctation of the aorta, interruption of the aortic arch, or subaortic stenosis. (Ao = aorta; LV = morphologic left ventricle; PA = pulmonary arterial trunk; RV = morphologic right ventricle.) The Annals of Thoracic Surgery 2008 86, 1321-1327DOI: (10.1016/j.athoracsur.2008.06.050) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions