Antenatal assessment and postnatal outcome of fetal echogenic lung lesions: a decade's experience at a tertiary referral hospital.

INTRODUCTION: Fetal echogenic lung lesions (ELL) are the commonest pulmonary pathology diagnosed on antenatal sonography, and include congenital pulmonary airway malformations (CPAMs) and bronchopulmonary sequestrations. This study aimed to evaluate the predictive utility of the CPAM volume ratio (CVR) at presentation in a series of fetuses with ELLs at a tertiary Australian referral hospital. MATERIAL AND METHODS: Retrospective cohort study of all pregnancies with a prenatal diagnosis of an isolated fetal echogenic lung lesion managed at the Royal Women's Hospital, Victoria, Australia, between 2005 and 2015. Data were obtained from electronic ultrasound image databases and medical records. RESULTS: Sixty-five cases were included in the final analysis. The mean gestation at presentation was 22 weeks and 6 d, and the mean CVR was 0.66. Hydrops was evident in four cases at presentation, and did not develop subsequently in any other case. Significant perinatal concerns - fetal/neonatal demise, hydrops, requirement for neonatal intubation/ventilation, or surgery in the first year of life - did not occur with or following a CVR at presentation of <0.45. The survival rate at 1 year was 95%. DISCUSSION: The CVR is a potentially useful tool to assess all fetal ELLs, and not just those presumed to be CPAMs. A CVR at presentation of <0.45 was associated with favourable outcomes.

Dual-source computed tomography for quantitative assessment of tracheobronchial anomaly from type IIA pulmonary artery sling in pediatric patients.

PURPOSE: As an extremely rare abnormity, type IIA pulmonary artery sling (PAS) tracheobronchial anomalies should be differentiated from normal airway for therapeutic decision-making. This study aimed to investigate the quantitative characteristics of type IIA PAS tracheobronchial anomalies using dual-source computed tomography (DSCT). MATERIALS AND METHODS: From January 2009 to December 2016, there were 11 type IIA PAS patients enrolled for analysis and compared with 32 controls. The areas of the trachea, right upper lobar bronchus, left main bronchus, right intermediate bronchus [bridging bronchus (BB) in patients], and subcarinal angle [subpseudocarinal angle in patients] were measured. Measurements other than that for the angle were standardized with body surface area. RESULTS: Significant differences were found between the type IIA PAS patients and controls in terms of DSCT measurements in the trachea (0.51 ±â€¯0.32 cm2/m2 vs. 0.92 ±â€¯0.18 cm2/m2, P < 0.001); left main bronchus (0.29 ±â€¯0.14 cm2/m2 vs. 0.43 ±â€¯0.18 cm2/m2, P = 0.01); right intermediate bronchus [BB in patients] (0.36 ±â€¯0.13 cm2/m2 vs. 0.47 ±â€¯0.12 cm2/m2, P = 0.02); and subcarinal angle [subpseudocarinal angle in patients] (116.27 ±â€¯16.45° vs. 79.41 ±â€¯15.71°, P < 0.001). Receiver operating characteristic analysis further revealed that these parameters may be indicators to differentiate tracheobronchial anomalies due to type IIA PAS from controls (AUC, 0.88-0.98; sensitivity, 81.7%-100%; specificity, 91.7%-100%). CONCLUSIONS: DSCT is an alternative technique to detect tracheobronchial anomalies in pediatric patients with type IIA PAS. It can provide accurate anatomic details for surgeons to determine therapeutic strategies.

Multislice Computed Tomography Assessment of Tracheobronchial Patterns in Partial Anomalous Left Pulmonary Artery.

OBJECTIVE: The aim of this study was to present relationship between partial anomalous left pulmonary artery (PALPA) and the tracheobronchial tree and patterns of the tracheobronchial tree assessed by multislice computed tomography (MSCT). METHODS: Nine patients were assessed by MSCT. The relationships between the tracheobronchial tree and PALPA and different tracheobronchial patterns, location of tracheobronchial stenosis, severity of stenosis, and associated cardiac defects were evaluated. The results of MSCT for these patients were compared with the operative findings. RESULTS: The anatomy of PALPA was clearly identified by MSCT in all 9 patients. Three relationships between PALPA and the tracheobronchial tree were noted. In addition, 3 patterns of tracheobronchial tree anatomy were also demonstrated. The PALPA arose from the right pulmonary artery, forming a pulmonary sling (n = 2). The PALPA, which arose from the proximal right pulmonary artery, went below the tracheal bifurcation and passed anterior (n = 1) or inferior-anterior (n = 6) to the proximal left main bronchus. Three patterns of the tracheobronchial tree were presented with normal (n = 5), normal pattern with right tracheal bronchus (n = 3), and bridging bronchus (n = 1). The rate of tracheobronchial stenosis was 56% (5/9).Five patients underwent operation, and at that time, the relationship between PALPA and the tracheobronchial tree defined on MSCT was confirmed. CONCLUSIONS: The PALPA can be associated with tracheobronchial anomalies and airway compression depending on its orientation to the airway. Noninvasive imaging modalities such as MSCT will be helpful for making further management decisions.

CT assessment of tracheobronchial anomaly in left pulmonary artery sling.

BACKGROUND: The left pulmonary artery sling (LPAS) is a rare vascular anomaly where the left pulmonary artery arises from the right pulmonary artery, passes over the right bronchus, and goes posteriorly between the trachea and esophagus. The LPAS is frequently associated with cardiac and non-cardiac defects including tracheobronchial abnormalities. OBJECTIVE: To evaluate the utility of multislice CT (MSCT) and helical CT (HCT) in diagnosing and defining the tracheobronchial anomaly and anatomic relationships between the trachea and aberrant left pulmonary artery. MATERIALS AND METHODS: MSCT or HCT was performed in 27 children to determine the tracheobronchial anatomy and identify tracheobronchial stenosis. Eighteen children underwent surgery. RESULTS: According to the Wells classification of LPAS, which includes two main types and two subtypes, there were eight cases of type 1A, five cases of type 1B, six cases of type 2A and eight cases of type 2B in this group. Twenty-four of the 27 children had substantial tracheobronchial stenosis. Four died before surgery; the 18 had reanastomosis of the left pulmonary artery. Five children also had tracheoplasty; three died after surgery. CONCLUSION: CT, especially MSCT, is an ideal modality for simultaneously identifying aberrant left pulmonary artery and any associated tracheobronchial anomaly. The Wells classification is useful for operative planning.

Usefulness of magnetic resonance imaging in the assessment of venoatrial connections, atrial morphology, bronchial situs, and other anomalies in right atrial isomerism.

Multiple complex venous and intracardiac anomalies are frequently seen in patients with right atrial isomerism, and complete anatomic information may not always be obtained from combined echocardiography and angiography. Twenty patients with right atrial isomerism were prospectively studied with use of magnetic resonance imaging (MRI); satisfactory imaging was obtained in 18 patients, aged 6 days to 12 years (median 3 months). All patients had undergone echocardiography, cardiac catheterization, and angiocardiography. The purpose of this study was to assess the usefulness of MRI in the evaluation of venoatrial connections, atrial morphology, bronchial situs, and additional anomalies. Bilateral superior venae cavae were documented in 12 patients and anomalous hepatic venous drainage in 11. The pulmonary venous system was imaged in all 18 patients, of whom 12 had total anomalous pulmonary venous connection: 9 supracardiac, 2 infracardiac, and 1 mixed type. Some obstruction to pulmonary venous return was present in 9 of the 12 patients, and the site of obstruction was demonstrated by MRI in 6. Bilateral morphologic right atrial appendages were imaged in 7 patients. Bilateral morphologic right bronchi were identified in 17 patients, asplenia was confirmed in 17 of 18 patients by the absence of splenic tissue on imaging, and hiatal hernia was imaged in 4. Compared with angiography and echocardiography, MRI more clearly defined the pulmonary venous connections in 10 patients with pulmonary venous obstruction. Anomalous hepatic venous connections were better defined by MRI in 2. Therefore, MRI provided valuable supplementary information on the cardiovascular and visceral anomalies in these patients.

A physiologic assessment of segmental bronchial atresia.

A child with congenital atresia of the apical posterior bronchus was followed from birth. The obstructed segment, ventilated through collateral pathways, was documented to be aerated by day 6. At 10 yr of age, the anomalous and adjacent normal segments were resected because of respiratory symptoms. Preoperatively, pulmonary function studies showed a mild obstructive ventilatory defect. Postoperatively, although asymptomatic, the patient's obstruction persisted. Collateral resistance (Rcoll) measured between the atretic and adjacent normal segments of the resected lung was comparable to Rcoll in young adults, but markedly greater than Rcoll for emphysematous lungs. Pathologic examination revealed gross emphysematous changes in the anomalous segment. We conclude that collateral pathways exist early in life and that ventilation of lung distal to congenitally absent airways is slow and may contribute to the development of emphysema; we speculate that this lesion should be resected early in life to permit optimal growth and development of the remaining lung.