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Early Diastolic Clicks After the Fontan Procedure for Double 304 Br Heart J 1990;63:304-7 Early diastolic clicks after the Fontan procedure for double inlet left ventricle: anatomical and physiological correlates Br Heart J: first published as 10.1136/hrt.63.5.304 on 1 May 1990. Downloaded from Andrew N Redlngton, Kit-Yee Chan, Julene S Carvalho, Elliot A Shinebourne Abstract inlet ventricle with two atrioventricular M mode echocardiograms and simultan- valves. All had previously undergone a Fontan eous phonocardiograms were recorded type procedure with direct atriopulmonary in four patients with early diastolic anastomosis. In two patients a valved clicks on auscultation. All had double homograft was interposed between the right inlet left ventricle and had undergone atrium and pulmonary artery. Each patient the Fontan procedure with closure of the had the right atrioventricular valve closed by right atrioventricular valve orifice by an either a single or double layer of Dacron cloth artifical patch. The phonocardiogram sewn into the floor of the right atrium. The confirmed a high frequency sound main pulmonary artery was tied off in all. occurring 60-90 ms after aortic valve Cross sectional, M mode, and pulsed wave closure and coinciding with the time of Doppler echocardiograms with simultaneous maximal excursion of the atrioven- electrocardiogram and phonocardiogram were tricular valve patch towards the ven- recorded on a Hewlett-Packard 77020A tricular mass. One patient had coexist- ultrasound system. The phonocardiogram was ing congenital complete heart block. recorded over the point on the chest where the The M mode echocardiogram showed diastolic click was best heart on auscultation, i'reversed") motion of the patch towards usually in the fourth left intercostal space the right atrium during atrial contrac- close to the sternum. M mode echocar- tion. Doppler flow studies showed that diograms from the left atrioventricular valve, coincident with this motion there was the aortic valve, and the patch over the right forward flow in the pulmonary artery atrioventricular valve were recorded with the with augmentation when atrial contrac- simultaneous electrocardiogram and phono- tion coincided with ventricular systole. cardiogram. In one patient, who had The early diastolic click in these congenital complete heart block, an M mode patlents was explained by abrupt cessa- recording was made of the transverse diameter http://heart.bmj.com/ tion of the motion of the atrioventricular of the right atrium viewed from a subcostal valve patch towards the ventricular position. Pulsed wave Doppler flow mass in early diastale. In one patient measurements in the superior and inferior atrial contraction led to a reversl of this vense cavae (caval veins) and the proximal left motion and was associated with forward pulmonary artery were also recorded in this flow in the pultnonary artery. patient. All recordings were made with a Honeywell (Ecoline 22) strip chart recorder at a paper speed of 100 mm/s. on October 2, 2021 by guest. Protected copyright. For many patients with complex congenital heart disease the only surgical optlon for long term palliation is the Fontan operation' or one of its modifications.2 While most survivors are Results clinically well after these procedures, abnor- The phonocardiogram confirmed the presence mal physical signs such as cyanosis, arrhyth- of an early diastolic click in each patient. This mnia, fluiid retention, and heart murmurs are was recorded as a high frequency sound occur- common. Indeed, in a recent review they were ring 60-90 ms after the initial high frequency found in 62%, of patients.' We report four oscillations associated with aortic valve closure, patients in whom the previ'ously unreported the timing ofwhich was confirmed from the M auscultatory stgn of an early diastollic click was mode echocardiogram of the aortic valve. heard. Sirmultaneous M mode echocardio- There was an inconsistent relation between the Department of Psediatric Cardiology, graphy and phonocardiographty showed the sound and left atrioventricular valve motion Brnprte Hospital, origin of this sournd. (fig 1). In each patient, however, the onset of Lonida the sound coincided with the time at which the A N Redingtn right atrioventricular valve patch had reached K-Y Chan X Carviah Patients and methods its maximal excursion in early ventricular t Shinbourne Four patients (aged 4-18 years) with loud diastole (fig 2). CoitCs-pothdnte to early diastolic clicking sounds noted on The patient with congenital complete heart Dr Andrew N Aedrngtoni block was studied in further 3 Deprtffhnt do-Paedaatric . routine auscultation underwent detailed detail. Figure tardiek3gy, .rompton investigation by echophonocardiography. All shows a recording of the motion of the right H"pkitai Fuibh\n Road, solitus with the usual atrioventricular valve patch and its relation to Lohd%mis5W-3 HP. patients had situs atrial arrangement. The atrioventricular connection the P wave of the electrocardiogram and sub- A2*a jaugr:yaeta brt1opl9blO was univen-tricular, all patients having double sequent atrial contraction. It is clear from this Early diastolic clicks after the Fontan procedurefor double inlet left ventricle: anatomical andphysiological correlates 305 Figure 1 M mode recordings takenfrom the 1. ,: t right atrioventricular valve (RAVV) patch EC f top panel) and the left atrioventricular valve ECG (left A VV, bottom panel) ... in the same The PCG~ patient. Br Heart J: first published as 10.1136/hrt.63.5.304 on 1 May 1990. Downloaded from early diastolic click PCG.: (EDC) coincides with the patch abrupt cessation of movement of the patch RAVV Right iowards the ventricle in patch atrium early diastole and is not related to the motion of the left atrioventricular valve. FA.T _ ECG, electrocardiogram; PCG, phonocardiogram. zAA ff-A-lA ---I "'.1.101. llw---",.'-'.'.,.m,-':- I ...... .. -7., F.,. ... ... - ----- '! A-T.L tECG. I6W... 11,111-111 T .000 owas WW. ECG P CG w^"'M 4s NIEO .i-1.. EDC.: PCG .:!I .. t v.*Ane0.......... [- RAV V _.6 ........... S_ S~~~~~~~~~~~~~~~~~~~~~~~~~~~..:v .......... Leftt AVV pFigure2 Mi'mode reccordings of the right atrioventricular valve (RAVV) patch in two patients. In both the early diastiolic click (EDC) occurred approximately 80 ms cafter closure of the aortic valve. ECG, electrocardiogre am; PCG, phonocardiogram. http://heart.bmj.com/ recording that atrial contraction was associated systole there was flow away from the atrium, with movement of the patch away from the with "reversed" flow in the venae cavae (caval ventricular mass and towards the right atrium. veins) and forward flow in the proximal left When this occurred in early diastole there was a pulmonary artery after the P wave of the prolongation of the interval between aortic electrocardiogram. Interestingly, this flow was valve closure and the early diastolic click (fig augmented when the P wave coincided with or 3(A)). This motion presumably reflects a pres- was close in timing to the QRS complex. The the atrium sure change between ventricle and atrium. M mode recording from right on October 2, 2021 by guest. Protected copyright. Some light was shed on the nature of this showed that the transverse diameter decreased pressure change when the atrial dimension and with atrial systole with the atrial septum mov- pulsed wave Doppler flow recordings were ing towards the right atrium after the P wave examined. Figure 4 shows that during atrial (fig 4). v v v f ....*s V... VL I. ...... Iv ECG ------ p-lnhf atrium-. A.,.0, l~~~~~~~~~~~~~~~~~~~~~~~~~~W..-w-F W---. Figure 3 M mode recording of the right atrioventricular valve patch in the patient with congenital complete heart block. The P wave of the electrocardiogram (ECG) is marked along the top. When the P wave occurred in diastole the patch moved awayfrom the ventricle towards the right atrium (marked with arrows). The early diastolic click (EDC) was delayed when atrial contraction occurred towards the end ofsystole (A). ECG, electrocardiogram; PCG, phonocardiogram. 306 Redington, Chan, Carvalho, Shinebourne Figure 4 Pulsed wave p ppp variable relation between atrial and ventricular Doppler recordings in the . contraction in this patient. Figure 3 shows that proximal left pulmonary .f.- ..._. artery (top panel) and other than during ventricular systole, the P inferior vena cava (IVC, t wave of the electrocardiogram was followed by middle panel) from the Right motion of the patch away from the ventricular patient with complete atrium heart block. The bottom Pulmonary ~~~~~~~~~~mass and towards the right atrium. This is the f~~~~~ ~~~~~~~ ~~~~ ~ ~~~ .........v~ ~~~~% g s Br Heart J: first published as 10.1136/hrt.63.5.304 on 1 May 1990. Downloaded from panel shows the M mode artery .v opposite to what might be expected and recording of the transverse presumably reflects a pressure transient be- diameter of the right tween the left ventricle and right atrium. It is atrium. (The P wave of the electrocardiogram is clear from fig 4 that the right atrium is empty, marked by an arrow at the ing at this time; the transverse dimension top of each recording-see decreases and there is flow away from the right text for details.) atrium in the venae cavae (caval veins) and pulmonary artery. Furthermore this flow is augmented when atrial and ventricular systole are synchronous (when the atrioventricular Ivc valve patch is already maximally displaced RA '7 > ; S ' towards the right atrium). It is clear, therefore, that right atrial contraction is contributing to forward flow in the pulmonary artery. This is consistent with previous studies that have shown the effect of atrial contraction910 al- though its haemodynamic importance has been l I 1 doubted." It is difficult to explain the motion of the atrioventricular valve patch away from the left ventricle during atrial systole under these circumstances, however. The M mode recordings of the left atrioventricular valve confirmed that it opens shortly after the P wave Right s.zXX@$Ra on the electrocardiogram. It is possible that atrium active contraction of the left atrium leads to an abrupt rise in left ventricular pressure so that right atrial pressure is exceeded, so pushing the patch towards the right atrium.
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