Persistent truncus arteriosus occurs when, during fetal development, the primitive truncus does not divide into the pulmonary artery and aorta, resulting in a single, large, arterial trunk that overlies a large, malaligned, perimembranous ventricular septal defect. Consequently, a mixture of oxygenated and deoxygenated blood enters systemic, pulmonary, and coronary circulations. Symptoms include cyanosis and heart failure, with poor feeding, diaphoresis, and tachypnea. A normal 1st heart sound (S1) and a loud, single 2nd heart sound (S2) are common; murmurs may vary. Diagnosis is by echocardiography or cardiac catheterization. Medical treatment for heart failure is typically followed by early surgical repair.
Persistent truncus arteriosus (see Fig. 11: Congenital Cardiovascular Anomalies: Truncus arteriosus.) accounts for 1 to 2% of congenital heart anomalies. About 35% of patients have 22q11 deletion syndrome, which includes DiGeorge syndrome and velocardiofacial syndromes.
There are 3 types.
Previously, a type IV was defined, in which arteries supplying blood to the lungs arose from the descending aorta. However, this anomaly is now placed in the category of tetralogy of Fallot with pulmonary atresia.
Other anomalies (eg, truncal valve insufficiency, right aortic arch, interrupted aortic arch, coronary artery anomalies, atrioventricular septal defect) may be present and may contribute to the high surgical mortality rate.
Physiologic consequences of truncus arteriosus include mild cyanosis, significant pulmonary overcirculation, and heart failure (HF).
Symptoms and Signs
Infants usually present with mild cyanosis and symptoms and signs of HF (eg, tachypnea, poor feeding, diaphoresis) in the first few weeks of life. Physical examination may detect a hyperdynamic precordium, increased pulse pressure with bounding pulses, a loud and single 2nd heart sound (S2), and an ejection click. A grade 2 to 4/6 systolic murmur is audible along the left sternal border. A mid-diastolic mitral flow murmur may be audible at the apex when pulmonary blood flow is increased. With truncal valve insufficiency, a high-pitched diastolic decrescendo murmur is audible over the mid left sternal border.
Diagnosis is suspected clinically, supported by chest x-ray and ECG, and established by 2-dimensional echocardiography with color flow and Doppler studies. Cardiac catheterization is occasionally necessary to delineate associated anomalies before surgery, but cardiac MRI or CT angiography may supplant the need for catheterization.
Chest x-ray shows varying degrees of cardiomegaly with increased pulmonary vascular markings, right aortic arch (in about 30%), and relatively high position of pulmonary arteries. ECG commonly shows combined ventricular hypertrophy. Substantial pulmonary overcirculation may produce evidence of left atrial enlargement.
HF is treated vigorously with diuretics, digoxin, and ACE inhibitors, followed by early surgical repair. Prostaglandin infusion is not beneficial.
Surgical management consists of complete repair. The ventricular septal defect is closed so that the left ventricle ejects into the truncal root. A conduit with or without a valve is placed between the right ventricle and the confluence of the pulmonary arteries. Surgical mortality rates have decreased to as low as 10% in recent years. Because the conduit is placed during early infancy, its size becomes inadequate as children grow, and the conduit must be revised during childhood.
Endocarditis prophylaxis is recommended preoperatively but is required only for the first 6 mo after repair unless there is a residual defect adjacent to a surgical patch or prosthetic material.
Last full review/revision March 2010 by Lee B. Beerman, MD