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Biomedical subjects

R H Anderson

Publications and source records attributed to R H Anderson.

At least 163 records · Page 9Linked to original sources

The structure of the mouse heart in late fetal stages.

Because of the opportunities for genetic manipulation, the mouse has become the major species for models of human disease. Recently, targeted and insertional mutations have induced many novel models of developmental abnormality, including several of congenital heart defects. Interpretation and use of such models requires a precise understanding of the similarities and differences between mouse and human in terms of cardiac development and structure. To this end, we have characterised the late fetal mouse heart using scanning electron microscopy and serial histological sections. Right atrial anatomy is dominated by the venous valves, which separate the orifices of the caval veins from the musculature of the primary atrium. Their structure and location suggest that the pulmonary vein is unlikely to develop from the venous sinus. The pectinated wall of the appendage serves to distinguish the morphologically right atrium, in that it runs around the atrioventricular junction, from the left atrium in which this vestibular region is smooth-walled. The persistence of the left superior caval vein draining to the right atrium, along with a solitary opening for the pulmonary vein in the left atrium, distinguishes the atrial anatomy of the mouse from that of the human. The flap valve of the oval foramen is extensive and represents the embryonic primary atrial septum. The superior rim of the foramen is an infolding of the atrial roof, as has been described in the human, showing that, contrary to orthodox opinion, there is no extensive formation of a secondary atrial septum. The region of the membranous septum seen in the human heart is a relatively thick structure in the late fetal mouse, and is located exclusively in an atrioventricular position. Unlike the human, there is little distinction between the apical trabeculations of the left and right ventricles of the mouse heart.

Animals↗

How should we optimally describe complex congenitally malformed hearts?

BACKGROUND: There is still no agreement on how best to describe the arrangement of complex congenitally malformed hearts. Some favor a system using short coded segmental combinations. Others favor a more descriptive approach. METHODS AND RESULTS: I have reviewed my own experience in examining congenitally malformed hearts. This shows that it is possible to select in all such hearts the most constant anatomic components to define the morphology of the atrial and ventricular chambers and the arterial trunks. These components are the appendages for the atriums, the apical trabecular regions for the ventricles, and the branching pattern for the arterial trunks. Thereafter, it is possible in all hearts to base description on the fashion in which the chambers and trunks are or are not joined together, describing separately any pertinent additional morphologic features or abnormal relationships. CONCLUSIONS: By using this simple descriptive approach, which owes nothing to concepts of development, it is possible to give a basic description of each heart, and predict the location of the conduction tissues, even if the heart in question has never previously been encountered.

Heart Defects, Congenital↗

The coronary arteries in hearts with discordant atrioventricular connections.

Gross morphologic study of 14 hearts with congenitally corrected transposition or discordant atrioventricular connections and double-outlet right ventricle or pulmonary atresia disclosed consistently the origins of the coronary arteries from two aortic sinuses. With usual atrial arrangement, the artery arising in sinus 1 (right-hand facing), as seen from the noncoronary aortic sinus, supplied the morphologically right ventricle. Coronary blood supply to the morphologically left ventricle usually came from sinus 2 (left-hand facing), although in two hearts the circumflex branch was a continuation of the artery from sinus 1. The sinus nodal artery arose from the circumflex coronary artery, and histologic studies of two hearts demonstrated that blood supply to the anterior atrioventricular node also came from this vessel. Early branching and entrapment in fat or right ventricular muscle, as well as malalignment of aortic and pulmonary sinuses, occurred frequently. These findings may have implications for coronary arterial transfer in the double switch operation in hearts with discordant atrioventricular connections.

Adolescent↗

Surgical anatomy of the coronary circulation in hearts with discordant atrioventricular connections.

We examined the arrangement of the coronary arterial and cardiac venous systems in 46 specimens with discordant atrioventricular connections so as to identify any structural abnormalities and to consider their surgical implications in terms of anatomical biventricular repair. Grossly abnormal arterial courses were seen in 11 hearts (24%). A substantial branch supplying the morphologically right ventricular outflow tract, which could restrict a ventriculotomy, was found in 61% of cases. The coronary sinus received all the morphologically right ventricular veins, as well as the posterior interventricular vein, in 40 hearts, this pattern being in contrast to the pattern in the normal heart. The morphologically left ventricular and anterior interventricular veins, all of which drain via the coronary sinus in the normal heart, were frequently connected independently to the morphologically right atrium in the specimens with discordant connections, the drainage occurring through the spaces between the pectinate muscles. These direct drainages are at risk of potential damage either by extensive intra-atrial maneuvers or by postoperative intraatrial thrombosis. It is predicted, therefore, that surgical results can be improved still further when account is taken of this vascular anatomy of the heart itself.

Cadaver↗

The nature of the annular attachment of a common atrioventricular valve in hearts with isomeric atrial appendages.

OBJECTIVE: To clarify the precise anatomic arrangement of the annular attachment of a common atrioventricular valve in the setting of visceral heterotaxy. METHODS: One hundred and twelve autopsied specimens with isomeric atrial appendages were studied. RESULTS: Annular hinge points with a planar orientation were found in only 7 hearts. All others showed a nonplanar and undulating arrangement, including 7 with Ebsteins's malformation. When the posterior half of the valvar attachment was taken as a reference plane, the anterior part deviated superiorly, the distance from the plane to the anterior point being 6.7 +/- 4.9% of the circumferential length of the annulus. The ratio of the antero-posterior diameter to the width of the annulus was smaller in hearts with biventricular connections (0.77 +/- 0.15) than in those with double inlet ventricle (0.89 +/- 0.17, P < 0.001). Reflecting this, the ratio of superior deviation of the anterior valvar annulus compared to the antero-posterior diameter was greater in hearts with biventricular atrioventricular connections (P = 0.016), particularly in those with isomeric right appendages. No significant differences were found when the data was analyzed according to variations in ventricular morphology. CONCLUSIONS: The precise evaluation of the annular structure of a common atrioventricular valve may well prove to be of clinical significance so as optimally to achieve valvar annuloplasty.

Ebstein Anomaly↗

Atresia or absence of the left-sided atrioventricular connection in the fetus: echocardiographic diagnosis and outcome.

Our objective was to describe the appearance of atresia of the left-sided atrioventricular valve on the four-chamber view of the fetal heart. Twenty-four cases of atresia of the left-sided atrioventricular connection were detected over a 2-year period. Cases were analyzed according to the appearance of the four-chamber view and the connections of the great arteries. All cases were referred because the left-sided ventricle was smaller than the right. There were five different groups of cardiac anomaly detected. Associated findings varied according to the diagnostic group. It was concluded that it is possible to identify atresia of the left-sided atrioventricular connection accurately during obstetric ultrasound examination by evaluation of the four-chamber view. However, the appearance of this view varies with the diagnosis. Each diagnostic group has different implications in terms of associated extracardiac malformations and postnatal management.

Diagnosis, Differential↗

Ventricular myoarchitecture in tetralogy of Fallot.

BACKGROUND: Little attention has been paid to the architecture of the muscle fibres of the ventricular walls in congenitally malformed hearts. In this study the gross pattern of myocardial fibres in normal hearts was compared with that in cases of tetralogy of Fallot. METHODS AND RESULTS: After morphological examination nine specimens with tetralogy were dissected to study the ventricular myoarchitecture. Changes were found in the shape of the malformed ventricles. The ventricular walls were arranged in layers in all hearts. Superficial and deep layers were present in both ventricles, with the superficial layer showing a more oblique orientation in the specimens with tetralogy than in normal hearts. Modifications of muscle fibre that were related to the type of malformation were seen in the deep layer. A middle layer was present in the left ventricles of normal hearts and specimens with tetralogy: this showed a horizontal orientation in both groups. In contrast, a middle layer was found in the right ventricle only in specimens showing tetralogy. CONCLUSIONS: The malformed hearts showed modifications in ventricular shape, in the arrangement of muscle in the right ventricle, and in the overall myoarchitecture. These changes could well be the consequence of the same agent (or agents) that caused the structural defect.

Adolescent↗

The development of the atrioventricular junction in the human heart.

The histogenesis of the separation between atrial and ventricular myocardium at the atrioventricular junction in the developing human heart has been investigated immunohistochemically by using monoclonal antibodies specific for atrioventricular cushion tissue, mesenchymal cells, atrial and ventricular myocardium, and myocardium of the primary ring. It was found that the insulation between the muscle masses of atrium and ventricle is established by the fusion of the tissues of the atrioventricular sulcus (located at the epicardial side of the junctional myocardium) with those of the atrioventricular cushions (located at the endocardial side of the junctional myocardium). This process takes place at the ventricular margin of the myocardium of the atrioventricular canal. The separation of atrial and ventricular myocardium starts at approximately 7 weeks of development in the anteromedial portion of the right atrioventricular junction and is largely completed around the 12th week of development. The only remaining myocardial continuity between atrial and ventricular myocardium is the atrioventricular axis of conduction. Our findings show that the nonmuscular part of the developing leaflets of the atrioventricular valves derives from the atrioventricular cushions and that the tissues of the atrioventricular groove do not contribute to the development of these leaflets.

Bundle of His↗

A quantitative study of nerve distribution in the conduction system of the guinea pig heart.

Quantitative measurements of relative nerve density were achieved using computer-assisted image analysis of immunohistochemically and histochemically defined nerves in the conduction system of the guinea pig heart. All regions of the conduction system possessed a similar density of nerve fibres and fascicles displaying immunoreactivity for the general neuronal marker protein gene product 9.5 (PGP 9.5), and this was 3 to 4-fold higher than in the adjacent myocardium. Acetylcholinesterase (AChE) positive and tyrosine hydroxylase (TH)-immunoreactive nerves were the main subtypes identified in the sinus and atrioventricular nodes, representing 40-45% of the stained area occupied by PGP 9.5-immunoreactive nerves. AChE-positive nerves were the dominant subtype identified in the left and right bundle branches, but were equal in proportion to TH-immunoreactive nerves in the penetrating bundle. Neuropeptide Y-immunoreactive nerves represented the main peptide-containing subpopulation in the nodal tissues, displaying a similar pattern of distribution and relative density to those nerves demonstrating TH immunoreactivity. Substance P and calcitonin gene-related polypeptide immunoreactive nerves were present throughout the conduction system and represented the main peptide-containing subpopulation in the ventricular conduction tissues. Nerve fibres showing immunoreactivity for either somatostatin or vasoactive intestinal polypeptide exhibited distinct patterns of distribution and comprised a relatively minor component of the innervation. The innervation of the guinea pig conduction tissues thus exhibits a uniform distribution and it comprises putative parasympathetic nerves and intrinsic neurons (AChE positive), sympathetic efferent nerves (NPY and TH-immunoreactive nerves) as well as other peptide-containing nerves, some of which (substance P and calcitonin gene-related polypeptide) are considered to represent afferent nerves. The distribution and density of nerve subpopulations in the guinea pig conduction system differ from those observed in the human conduction system, which suggests that the guinea pig may be an inappropriate model for comparative functional studies.

Animals↗

Surgical implications in hearts with isomeric atrial appendages.

As we have tried to demonstrate in this chapter, extensive understanding of morphology is necessary for successful definitive repair in individual patients with isomeric atrial appendages, as well as for the further evolution of optimal surgical strategies. Obviously different from patients with the usual atrial arrangement, those with isomeric atrial appendages have specific morphologic features that may underscore the clinical problems frequently found in this setting. Surgical strategies as well as individual operative procedures should be established on the basis of knowledge regarding those features presently demonstrated, namely, ventricular structures, the atrioventricular valves, the coronary circulation, and so on. Further investigations will certainly provide other aspects of which we are at present unaware.

Coronary Circulation↗

Anatomy of the aortic root with particular emphasis on options for its surgical enlargement.

BACKGROUND AND AIMS OF THE STUDY: The aortic root is a frequent site of surgical intervention, both in adults and children, yet there is ambiguity about the precise nature and relation of the various structures composing the aortic root. The present review aims to clarify these ambiguities and to explain the morphological basis of surgical procedures for enlargement of the aortic root. MATERIALS AND METHODS: Using autopsied specimens of normal hearts, the morphology of the attachment of the leaflets, the interleaflet triangles and the circular ventriculo-arterial junction of the aortic root were studied in detail, paying special regard to fibrous and muscular continuity, relation to the atrioventricular conduction axis, and the coronary arterial branching. Surgical dissections and incisions required for enlargement of the aortic root were simulated in these specimens. RESULTS: It was evident that the locus of attachment of aortic valvar leaflets takes the form of three (semilunar) crescents. This attachment is not circular, as the word 'annulus' suggests, neither does it correspond to the anatomical ventriculo-arterial junction. During implantation of a mechanical valve in the aortic position, a circular prosthetic valve ring is sutured on to the attachments of the native valvar leaflets. This must entail some distortion when the sutures are tied. Analysis of autopsied specimens showed that, on completion of the process of suturing, the location of the prosthetic valve is close to the anatomic ventriculo-arterial junction-one of the true annular regions of the aortic root. CONCLUSIONS: The continuity of the aortic valvar leaflets and the interleaflet triangles with structures such as the aortic (anterior) leaflet of the mitral valve posteriorly, and with the muscular ventricular septum anteriorly, provide an opportunity for surgeons to enlarge the aortic root by widening of the anatomic ventriculo-arterial junction.

Adult↗

Pathologic elucidation of the echocardiographic features of Ebstein's malformation of the morphologically tricuspid valve in discordant atrioventricular connections.

We defined the morphology of the left atrioventricular valve in Ebstein's malformation associated with congenitally corrected transposition to elucidate the approach to diagnosis by echocardiography. We found 14 unequivocal cases out of a total of 3,720 specimens. We noted the atrial arrangement, displacement, and nature of the tricuspid leaflets, and axis of the plane of the tricuspid orifice. We constructed ratios of volume of the atrialized to the functional right ventricle, and of the right to left ventricle, as well as distances of the septal attachments of the atrioventricular junctions to the respective ventricular apices. Three specimens had abnormalities of cardiac position, and 8 had ventricular septal defect. The tricuspid valve plane was rotated 47 +/- 21 degrees from its usual position into the ventricle. The tricuspid valvar tissue was variably attached to the underlying myocardium, with the most severely affected lesion being the mural leaflet followed by the septal leaflet, and the anterior leaflet attachment the least affected. Abnormalities of the tendinous cords and the effective valvar orifice occurred in 3 specimens. The ratio of the atrialized to the functional right ventricular volume was 0.74 +/- 0.49; the ratio of the fetal right to left ventricular volume was 1.18:1 +/- 0.70:1. These data suggest that plastic repairs of the right ventricle would leave a small functional right ventricle, but that valve replacement could restore the volume of the ventricle. Thus, the plane of displacement of the valve in corrected transposition appears less amenable to 4-chamber echocardiography than other forms of Ebstein's malformation. Changes in the echocardiographic planes should display the morphology and also provide some hemodynamic information.

Adult↗

Use of the bidirectional Glenn procedure in the presence of forward flow from the ventricles to the pulmonary arteries.

BACKGROUND: Relative regression of the pulmonary arterial size has been reported after a conventional bidirectional Glenn procedure. Maintaining a supplemental pulmonary flow could be of surgical value unless the option also militates against the efficacy of the partial right heart bypass. METHODS AND RESULTS: Twenty-seven patients considered unsuitable for a Fontan-type procedure underwent a bidirectional Glenn procedure in the presence of forward flow from the ventricles to the pulmonary arteries, the flow being maintained through the pulmonary trunk in 22 or a systemic-to-pulmonary shunt in 5. There was one surgical death due to atrioventricular valvular regurgitation. Subsequently, 9 patients have successfully undergone a total cavopulmonary connection 2.6 +/- 1.9 years after the initial procedure. Preoperative and postoperative catheterizations revealed changes in arterial oxygen saturation (75 +/- 11% compared with 83 +/- 7%, P < .001) and end-diastolic volumes of the systemic ventricles (from 238 +/- 92% to 188 +/- 97% of the expected normal volume, P < .01), whereas no difference was detected in the mean cross-sectional area of the right and left pulmonary arteries compared with the expected normal value for the right pulmonary artery (from 76 +/- 21% to 81 +/- 20%) or in the ventricular ejection fraction (from 53 +/- 8% to 50 +/- 14%). The relative regression or growth of the pulmonary arterial size was statistically related to the size of the channel for forward flow. CONCLUSIONS: Maintenance of forward flow from the ventricle provides a feasible means, when performing a bidirectional Glenn procedure, of protecting against regression of pulmonary arterial size as well as off-loading the ventricles and improving arterial oxygen saturation.

Adolescent↗