Situs ambiguus
Situs ambiguus | |
---|---|
Other names | Situs ambiguous, heterotaxy, heterotaxia |
Specialty | Cardiology |
Situs ambiguus is a rare
Individuals with situs inversus or situs solitus do not experience fatal dysfunction of their organ systems, as general
Heterotaxy syndrome with
Situs ambiguus is a growing field of research with findings dating back to 1973.[5]
Signs and symptoms
There are a variety of clinical manifestations of situs ambiguus.
Due to abnormal cardiac development, patients with situs ambiguus usually develop
Right atrial appendage isomerism
Right atrial appendage isomerism, also called right atrial isomerism, is a
Left atrial appendage isomerism
Left atrial appendage isomerism, also called left atrial isomerism, is a cardiac development defect in which the heart has two bilateral left atria and
Conductive nodes and tissues
Abnormal development of the heart results in impaired doubles of conductive nodes, as well as faulty electrical fibers throughout the ventricles. Individuals with right atrial isomerism develop two
Bronchial tree and lungs
Isomerism of the bronchial tree is not typically damaging and presents no significant clinical complications.[7] Pulmonary valve stenosis results in issues of blood flow to the lungs.
Abdominal organs
The liver is typically symmetrical across the left-right axis in patients with situs ambiguus, which is abnormal. A majority of left atrial isomeric patients have defects throughout the biliary tree, which is responsible for bile production, even when the gall bladder is functional and morphologically normal. This biliary atresia can lead to acute problems such as nutrient malabsorption, pale stools, dark urine, and abdominal swelling. If this condition continues without proper treatment, cirrhosis and liver failure become a major concern. Biliary atresia is not usually observed in patients with right atrial isomerism.[2]
Random positioning of the stomach is often one of the first signals of situs ambiguus upon examination. Malrotation of the entire intestinal tract, or improper folding and bulging of the stomach and intestines, results in bowel obstruction. This impairment leads to vomiting, abdominal distension, mucus and blood in the stool. Patients may also experience abdominal pain. Intestinal malrotation is more commonly identified in patients with right atrial isomerism than in those with left atrial isomerism.[citation needed]
Isomeric patients often experience disruptions to splenic development during
Causes
Situs ambiguus has been linked to family history of malformations
Disrupted mitochondria function has also been recently linked to heterotaxy.[14]
Pathophysiology
Molecular and cellular mechanism
Several genes have been identified in normal development of the right-left axis.
The most prevalent and best characterized genetic associations of heterotaxy include:[2]
Type | OMIM
|
Gene | Locus |
---|---|---|---|
HTX1 | 306955 | ZIC3 | Xq26.2 |
HTX2 | 605376 | CFC1
|
2q21.1 |
HTX3 | 606325 | PA26 | 6q21 |
HTX4 | 613751 | ACVR2B | 992 |
HTX5 | 270100 | NODAL
|
10q22.1 |
HTX6 | 614779 | CCDC11 | 18q21.1 |
Classical pathology
- Cardiac looping malformations:
- Deranged abdominal organ asymmetry:
- The stomach and spleen are prone to isolated reversal
- The stomach, liver, and a single adrenal gland are occasionally found in the midline.
- Organ malformations:
- asplenia and polysplenia often lead to sepsis
- More rarely, the head of the pancreas fails to form
- Horseshoe kidneys develop, which can lead to cancer, kidney stones, and/or infection.
- Malrotation errors cause volvulus and/or faulty peritoneal attachments, which completely obstruct the bowel.
- Vascular abnormalities:
- Interrupted inferior vena cava,
- Bilateral superior or inferior venae cavae
- Intrahepatic interruption of the inferior vena cava with connection to the azygos or hemiazygos veins
- Aberrant portal veins.
Bronchial tree and lungs
Pathophysiology in the bronchial tree can be observed by radiography. Under normal development, the bronchial tree consists of two main bronchi that are anatomically different:
- Hyparterial bronchus (below the pulmonary artery): supplies blood to the bi-lobed left lung
- Eparterial bronchus (adjacent to the artery): supplies blood to the tri-lobed right lung
In situs ambiguus, there is a duplication of either the hyparterial or eparterial bronchus. These features are not associated with any significant clinical complications.[19] Mechanisms leading to bronchial duplication are not thoroughly understood.
In pulmonary valve stenosis, there is a reduction in blood flow to the lungs due to an obstruction of the heart at the pulmonic valve. This contributes to cyanosis and pulmonary hypertension.[20]
Diagnosis
For proper diagnosis of situs ambiguus, cardiac and non-cardiac features must be evaluated. Diagnostic criteria for atrial isomerism includes observation of symmetry of thoracic visceral organs upon echocardiogram, arrhythmia upon electrocardiogram, and chest x-ray for confirmation of the heart's location across the left-right axis. Additional radiographic and cross-sectional imaging may be obtained to evaluate both cardiac and non-cardiac manifestations of situs ambiguus. In addition, a series of gastrointestinal tests can be conducted for observation of intestinal malrotation, as well as a scan of the liver and spleen for biliary function.[2]
Diagnostic techniques for cardiac causes
- Echocardiography
- Electrocardiography
- Computed tomography
- Magnetic resonance imaging
- Cardiac catheterization and angiography
- Chest x-ray
Diagnostic techniques for non-cardiac causes
- Computed tomography
- Magnetic resonance imaging
- Splenic function analysis
- Evaluation of biliary anatomy and cholangiogram
- Evaluation of intestinal malrotation
- Pulse oximeter
Other diagnostic features
- Assessment of family history
- Genetic testing
Management
Each of the symptoms of situs ambiguus must be managed with appropriate treatment dependent upon the organ system involved. Intestinal malrotation is treated surgically using the Ladd procedure. This procedure widens a fold in the peritoneum so that the intestines can be placed in non-rotated formation. It is not possible to return the bowel to a normal morphology[21] However, 89% of patients that undergo the Ladd surgery experience a complete resolution of symptoms.
Following cholangiogram, a Kasai procedure is usually performed in cases of biliary atresia. In this surgery, a Y-shaped shunt is used to passage bile from the liver directly to the intestine. If this is unsuccessful, liver transplantation can be considered based on the overall health of the patient. The Kasai procedure is successful in approximately 80% of patients.[22] Following the operation, patients are advised to take fat-soluble vitamins, choleretics, and anti-inflammatory medications.
Right-atrial and left-atrial isomerism and associated pulmonary issues are treated in a series of steps based on the severity of symptoms. Isomeric patients are first treated by inserting a shunt that will move incoming blood through the pulmonary circuit. The Fontan procedure routes blood through the patient's single ventricle, to the lungs, and into systemic circulation. This process is favorable in patients aged 2 to 5 years old. About 20–30% of patients will require a heart transplant.[24] Left-atrial isomeric patients have less severe complications, as they typically have 2 functional ventricles. In this case, they can undergo biventricular repair to form 2 separate ventricles and functional associated valves.
Prognosis
Prognosis for patients with situs ambiguus is quite varied, owed to the spectrum of clinical manifestations.[25] Infants who experience severe cyanosis at birth may die within hours of delivery if medical intervention is not immediate. Alternatively, longevity of neonates with mild cardiac lesions is unaffected.[26] Ten percent of patients born with right atrial isomerism die by the age of 5 without intervention. Improvements in therapies has increased the 5-year survival to 30–74% for right atrial isomeric patients and 65–84% for left atrial isomeric patients based on the cause of their disease.
Research
There have been vast amounts of research on the clinical features, racial disparities, and physiological mechanisms of heterotaxy syndrome dating back to 1973.
Mishra et al. published a review in November 2015 describing current knowledge of cardiac and non-cardiac abnormalities associated with situs ambiguus. The author stresses the importance of genetic testing prior to deciding a prognosis for affected patients.[27] She also proposes prenatal screening and evaluation in cases at risk for development of situs ambiguus.
Recent studies have shown higher rates of heterotaxy syndrome among
The National Birth Defects Prevention study (October 2014) attempted to link clinical presentations of situs ambiguus to demographics in an epidemiological study.[30] This proved a difficult task due to the vast differences in presentation of this disorder. However, the authors are hopeful that finding a link can help inform clinical decision-making, predictive analyses, and future outcomes.
See also
- Chirality (mathematics)
- Ivemark syndrome
- Situs inversus
- Situs solitus
References
- ^ "heterotaxy syndrome". United States National Library of Medicine. Retrieved 23 May 2016.
- ^ a b c d e f g h i Lowenthal, A.; et al. (September 26, 2015). "Anatomy, clinical manifestations and diagnosis of heterotaxy (isomerism of the atrial appendages)". Up To Date. Retrieved November 4, 2015.
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- ^ Lowenthal, Alexander; et al. (October 27, 2015). "Management and outcome of heterotaxy (isomerism of the atrial appendages)". UpToDate. Retrieved December 8, 2015.
- ^ Brandt, Mary; et al. (October 24, 2015). "Intestinal Malrotation". UpToDate. Retrieved December 10, 2015.
- ^ Erlichman, Jessi; et al. (August 3, 2015). "Biliary Atresia". UpToDate. Retrieved December 9, 2015.
- ^ Pasternack, Mark S; et al. (December 11, 2014). "Clinical features and management of sepsis in the asplenic patient". UpToDate. Retrieved December 10, 2015.
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