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PubMed2006

Impact of atrial septal defect closure on right ventricular performance.

BACKGROUND: Atrial septal defect (ASD) closure is one of the most representative cardiac operations, but there have been few assessments of right ventricular (RV) performance during the perioperative period. METHODS AND RESULTS: Using transesophageal echocardiography with automated border detection system, the RV pressure - area (P-A) loops were measured in 6 patients immediately before and after an ASD closure. Multiple RV P-A loops obtained by the inferior vena cava occlusion technique were used to evaluate end-systolic maximal elastance (Ees), preload recruitable stroke work (MEW), external work (EW) and the systolic P-A area (PAA). Ees and MEW are indices of contractility, and PAA represents the total mechanical energy. RV Ees and MEW did not change after the operation (from 3.36 +/- 2.20 to 3.70 +/- 2.04 mmHg/cm2, p = 0.4; and from 10.3 +/- 5.0 to 10.5 +/- 4.5 mmHg, p = 0.8, respectively), whereas EW and PAA were significantly reduced (from 121.4 +/- 77.4 to 48.7 +/- 26.6 mmHg/cm2, p < 0.05; and from 274.8 +/- 212.8 to 92.7 +/- 52.8 mmHg/cm2, p < 0.05, respectively). ASD closure reduced the EW and total mechanical energy of the right ventricle without influencing contractility. CONCLUSIONS: These results indicate that ASD closure preserved RV function and reduced RV myocardial oxygen consumption. Assessment of the RV P-A relationship in the operating room demonstrates the beneficial effects of ASD closure on RV performance.

Adult↗
PubMed1997

Effects of balloon pulmonary valvuloplasty on atrial shunting--a patient with pulmonary valve stenosis and a large secundum atrial septal defect.

Percutaneous balloon valvuloplasty has been established as an effective treatment for pulmonary valve stenosis (PS) in children and adults. However, there are few reports of the use of this technique in patients with other cardiac anomalies. We report the performance of balloon pulmonary valvuloplasty in a 72-year-old woman with a large atrial septal defect (ASD). This patient had a PS with a right ventricular pressure of 108/18 mmHg and a pulmonary arterial pressure of 42/21 mmHg, corresponding to a 66 mmHg pressure gradient. The ASD measured 32 x 27 mm. Balloon pulmonary valvuloplasty reduced the pressure gradient to 5 mmHg immediately after the procedure and to 2 mmHg 40 days after the procedure. The left-to-right shunt ratio was reduced from 17% before to 12% immediately after and to 36% 40 days after the procedure. In contrast, the right-to-left shunt ratio showed a transient increase from 16% before to 28% immediately after the procedure before decreasing to 11% 40 days after the procedure. The arterial blood oxygen tension was 53 Torr before, 46 Torr immediately after and 55 Torr 40 days after the procedure. The grade of heart failure decreased from New York Heart Association class IV before to class II in the chronic stage. These findings indicated that balloon pulmonary valvuloplasty in a patient with ASD transiently increased the right-to-left shunting associated with a decrease in oxygen tension, but that the change in the chronic stage was slight. In our patient with ASD valvuloplasty was useful in relieving the symptoms associated with elevated right ventricular pressure but could not reduce the hypoxemia caused by right-to-left shunting. In conclusion, valvuloplasty in patients with ASD should be considered as a preoperative treatment with the aim of reducing the risk of surgery and to treat symptoms in patients who refuse to undergo surgery.

Aged↗
PubMed2001

Acute stress reactions to everyday stressful life events among sexual abuse survivors with PTSD.

This study examined symptoms of Acute Stress Disorder (ASD), which is often thought of as a precursor to PTSD, among 54 women who already had PTSD for childhood sexual abuse for which they were seeking treatment. We examined the prevalence of ASD symptoms as well as their relationships to trauma symptoms measured by the Trauma Symptom Checklist-40. The ASD diagnosis requires the occurrence of a traumatic life event as well as meeting specific symptoms criteria. We found that fourty-four percent of participants met all symptom criteria for ASD, but only three of these 24 participants described a traumatic life event. Moreover, ASD symptoms were significantly related to trauma symptom scores. These findings suggest that a significant proportion of women with PTSD for childhood sexual abuse may be highly symptomatic for everyday stressful events that would not be experienced as traumatizing to others. Thus, these individuals need assistance in coping with everyday life stressors that do not involve a serious threat or injury in addition to needing help to alleviate their trauma symptoms.

Adaptation, Psychological↗
PubMed2005

Leflunomide and azathioprine combination in refractory adult-onset Still's disease.

OBJECTIVE: To present a case of Adult-onset Still's disease (ASD) in a patient who was successfully treated with leflunomide and azathioprine. CASE SUMMARY: A 24-year-old woman with ASD was initially treated with indomethacin, corticosteroids, and hydroxychloroquine; there was no clinical improvement. Methotrexate was added to the regimen, followed by azathioprine. The patient still experienced disease flares with this treatment, and cyclophosphamide was started. However, because of persisting disease activity, leflunomide combined with azathioprine was given. Only on this regimen was complete disease control achieved, with a normal erythrocyte sedimentation rate as well as normal C-reactive protein and ferritin levels. No recurrences or adverse effects attributable to leflunomide or azathioprine were observed at the one-year follow-up. DISCUSSION: Clinical experience concerning leflunomide and azathioprine combination in ASD is limited. This combination may be modifying the clinical expression of ASD through its effects on T lymphocyte clonal expansion and production of proinflammatory cytokines. CONCLUSIONS: Leflunomide combined with azathioprine appears to be an effective and safe treatment of ASD.

Adult↗
PubMed1999

A qualitative investigation of the organization of traumatic memories.

OBJECTIVE: Previous research has indicated that cohesive organization of traumatic memories may be necessary for the processing and resolution of post-trauma symptoms. The present study aimed to evaluate the qualitative features of memory organization, dissociation and perception of threat in traumatic memories recalled by individuals with and without acute stress disorder (ASD). DESIGN: Survivors of motor vehicle accidents (MVA) with either ASD or no ASD participated in a study on traumatic memories within 12 twelve days of the MVA. METHOD: Participants' audiotaped recollections of their memories of the MVA were coded in terms of disorganized structure, dissociative content and perception of threat. RESULT: The recollections of ASD participants were characterized by disorganization and dissociation more than those of non-ASD participants. CONCLUSION: The current findings suggest that disorganized memory structure may be one process that impedes access to, and modification of, trauma-related cognitive schema.

Adult↗
PubMed2005

Closure of secundum atrial septal defect with autologous right atrial patch: case report.

BACKGROUND: Although various synthetic materials and pericardium have been used for atrial septal defect (ASD) closure, investigators are continuing to search for an ideal material for this procedure. We report and evaluate a case in which autologous right atrial wall tissue was used for ASD closure. CASE: In this case, we closed a secundum ASD of a 22-year-old woman who also had right atrial enlargement due to the defect. After establishing standard bicaval cannulation and total cardiopulmonary bypass, we opened the right atrium with an oblique incision in a superior position to a standard incision. After examining the secundum ASD, we created a flap on the inferior rim of the atrial wall. A stay suture was stitched between the tip of the flap and the superior rim of the defect, and suturing was continued in a clockwise direction thereafter. Considering the size and shape of the defect, we incised the inferior attachment of the flap, and suturing was completed. Remnants of the flap on the inferior rim were resected, and the right atrium was closed in a similar fashion. RESULTS: During an echocardiographic examination, neither a residual shunt nor perigraft thrombosis was seen on the interatrial septum. The patient was discharged with complete recovery. CONCLUSION: Autologous right atrial patch is an ideal material for ASD closure, especially in patients having a large right atrium. A complete coaptation was achieved because of the muscular nature of the right atrial tissue and its thickness, which is a closer match to the atrial septum than other materials.

Adult↗
PubMed1982

Cross-sectional echocardiographic study on atrial septal defect: pre- and postoperative considerations.

The interatrial septum (IAS) has not been readily appreciated by M-mode echocardiography, but cross-sectional echocardiography has the capability of recording the shape and location of the IAS. Thirty-five patients with secundum atrial septal defect (ASD) were studied with cross-sectional echocardiography for detection of the ASD defect and demonstration of the IAS features following ASD closure. The ASD was shown as an echo dropout at the mid-portion of the septum in those patients examined in the present study in the horizontal cross-sections at the fourth intercostal space. The edge of the remaining IAS sharply demarcated and the defect was constantly demonstrated. In the postoperative patients, the IAS was recognized as a smooth series of echoes and the defect was no longer recognized. A notch echo was demonstrated in patients who underwent direct suture of the defect, and two notch echoes were recorded in patients who had a patch closure from a cardiac operation. The size of the defect at cardiac operation ranged from 1.5 to 5.0 cm with an average of 3.3 +/- 0.2 cm. The defect was slightly smaller on cross-sectional echocardiograms than at the time of operation. As the defect grew larger, the right ventricular dimension and the Qp/Qs became larger as well. Postoperatively, the right ventricular dimension was remarkably decreased, and the paradoxical movement of the interventricular septum (IVS) was normalized in the majority of the patients. Cross-sectional echocardiography is useful to diagnose ASD, to measure the size of the IAS defect, and to follow the clinical course.

Adolescent↗
PubMed2005

Neonatal hyperbilirubinemia and risk of autism spectrum disorders.

OBJECTIVE: To investigate the association between neonatal hyperbilirubinemia and autism spectrum disorders (ASD). METHODS: We conducted a large case-control study nested within the cohort of singleton term infants born between 1995 and 1998 at a northern California Kaiser Permanente hospital. Case subjects (n = 338) were children with an ASD diagnosis recorded in Kaiser Permanente outpatient databases; control subjects (n = 1817) were children without an ASD diagnosis, who were randomly sampled and frequency-matched to case subjects according to gender, birth year, and birth hospital. RESULTS: Approximately 28% of case and control subjects received > or =1 bilirubin test in the first 30 days of life. No case-control differences were observed for maximal bilirubin levels of > or =15 mg/dL (10.1% vs 12.1%), > or =20 mg/dL (2.1% vs 2.5%), or > or =25 mg/dL (0.3% vs 0.2%). Compared with children whose maximal neonatal bilirubin levels were <15 mg/dL or not measured, children with any degree of bilirubin level elevation were not at increased risk of ASD, after adjustment for gender, birth facility, maternal age, maternal race/ethnicity, maternal education, and gestational age (for bilirubin levels of 15-19.9 mg/dL: odds ratio: 0.7; 95% confidence interval: 0.5-1.2; for bilirubin levels of 20-24.9 mg/dL: odds ratio: 0.7; 95% confidence interval: 0.3-1.6; for bilirubin levels of > or =25 mg/dL: odds ratio: 1.1; 95% confidence interval: 0.1-11.2). CONCLUSION: These data suggest that neonatal hyperbilirubinemia is not a risk factor for ASD.

Adult↗
PubMed2005

Factors associated with age of diagnosis among children with autism spectrum disorders.

OBJECTIVE: Early diagnosis of children with autism spectrum disorders (ASD) is critical but often delayed until school age. Few studies have identified factors that may delay diagnosis. This study attempted to identify these factors among a community sample of children with ASD. METHODS: Survey data were collected in Pennsylvania from 969 caregivers of children who had ASD and were younger than 21 years regarding their service experiences. Linear regression was used to identify clinical and demographic characteristics associated with age of diagnosis. RESULTS: The average age of diagnosis was 3.1 years for children with autistic disorder, 3.9 years for pervasive developmental disorder not otherwise specified, and 7.2 years for Asperger's disorder. The average age of diagnosis increased 0.2 years for each year of age. Rural children received a diagnosis 0.4 years later than urban children. Near-poor children received a diagnosis 0.9 years later than those with incomes >100% above the poverty level. Children with severe language deficits received a diagnosis an average of 1.2 years earlier than other children. Hand flapping, toe walking, and sustained odd play were associated with a decrease in the age of diagnosis, whereas oversensitivity to pain and hearing impairment were associated with an increase. Children who had 4 or more primary care physicians before diagnosis received a diagnosis 0.5 years later than other children, whereas those whose pediatricians referred them to a specialist received a diagnosis 0.3 years sooner. CONCLUSION: These findings suggest improvements over time in decreasing the age at which children with ASD, especially higher functioning children, receive a diagnosis. They also suggest a lack of resources in rural areas and for near-poor families and the importance of continuous pediatric care and specialty referrals. That only certain ASD-related behaviors, some of which are not required to satisfy diagnostic criteria, decreased the age of diagnosis suggests the importance of continued physician education.

Adolescent↗
PubMed2005

[Atrial septal defects as a risk factor for migraine: a case-control study].

To determine the magnitude of the association between atrial septal defect (ASD) and migraine. We evaluated 101 subjects submitted to transesophageal echocardiography (TEE). They have been asked about headache. Migraine diagnosis was established according the criteria of the International Headache Society (IHS). The subjects were match in cases (ASD carrier) and controls (without ASD). We analyzed the occurrence of migraine, of aura and the frequency of crises in the last month by chi-square test. We matched 34 cases and controls: 82.4% female, the mean age, in years was 38.7 (+/-11.24) and 38.9 (+/-11.17)). Migraine occurred in 79.4% of the cases and in 55.9% of the controls (OR = 4.3) CI = 95% (1.04-8.8), (p = 0.038). Aura occurred in 65.1% (cases) and 40% (controls). It was observed more than three migraine crises in the last month in 76.7% of the cases and 60% of the controls (OR = 1.56) (p = 0.2) (95% CI, 0.6 to 7.6). ASD is a risk factor to migraine with aura in the sample studied. ASD apparently increase the frequency of migraine crises.

Adolescent↗
PubMed1998

[Initial experience in percutaneous closure of interatrial communication with the amplatzer device].

PURPOSE: To evaluate our initial experience with percutaneous closure of secundum type atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS: Seven patients underwent occlusion by anterograde approach, under general anesthesia and transesophageal echocardiography (TEE) guidance. One child had 2 ASD and a patent ductus arteriosus (PDA). The ASD size ranged from 8.7 to 20 mm as measured by TEE. A transthoracic echocardiogram was performed in the morning after the procedure. RESULTS: Eight devices were successfully implanted in 7 patients and the PDA was occluded with a Gianturco coil at the same session. In this patient, there was an episode of supraventricular tachycardia during the occlusion of one ASD which was reverted with adenosin. All patients were discharged the day after, with complete occlusion of all defects. CONCLUSION: The procedure is safe, effective and versatile. It can be applied as an initial alternative to the treatment of selected patients with ASD.

Adolescent↗
PubMed2003

Initial experience in Brazil with the Helex septal occluder for percutaneous occlusion of atrial septal defects.

OBJECTIVE: To evaluate the initial clinical experience with the Helex septal occluder for percutaneous closure of atrial septal defects. METHODS: Ten patients underwent the procedure, 7 patients with ostium secundum atrial septal defects (ASD) with hemodynamic repercussions and 3 patients with pervious foramen ovale (PFO) and a history of stroke. Mean age was 33.8 years and mean weight was 55.4 kg. Mean diameter by transesophageal echocardiography and mean stretched ASD diameter were 11.33 3.3mm, and 15.2 3.8mm, respectively. The Qp/Qs ratio was 1.9 0.3 in patients with ASD. RESULTS: Eleven occluders were placed because a patient with 2 holes needed 2 devices. It was necessary to retrieve and replace 4 devices in 3 patients. We observed immediate residual shunt (< 2mm) in 4 patients with ASD, and in those with patent foramen ovale total occlusion of the defect occurred. No complications were noted, and all patients were discharged on the following day. After 1 month, 2 patients with ASD experienced trivial residual shunts (1mm). In 1 patient, we observed mild prolapse in the proximal disk in the right atrium, without consequences. CONCLUSION: The Helex septal occluder was safe and effective for occluding small to moderate atrial septal defects. Because the implantation technique is demanding, it requires specific training of the operator. Even so, small technical failures may occur in the beginning of the learning curve, but they do not involve patient safety.

Adolescent↗
PubMedDate not supplied

Recombinant avirulent Salmonella vaccine strains with stable maintenance and high level expression of cloned genes in vivo.

Salmonella typhimurium strains with deletion (delta) of the adenylate cyclase (cya) and cyclic AMP receptor protein (crp) genes are avirulent for mice and induce a high level of protective immunity to oral challenge with up to 10,000 times what would be a lethal dose of wild-type virulent S. typhimurium cells. This immunity begins as early as seven days after immunization and lasts for at least four months. S. typhimurium delta cya delta crp mutants stably maintain plasmids and give high-level expression of cloned gene products; in this they appear superior to other avirulent S. typhimurium strains. S. typhimurium delta cya delta crp strains with a delta asd mutation (abolishing production of aspartate beta-semialdehyde dehydrogenase), have an obligate requirement for diaminopimelic acid (DAP). This strain can be used in conjunction with plasmid vectors lacking antibiotic resistance markers but having the wild-type asd+ gene from Streptococcus mutans to complement the delta asd chromosomal mutation. The Asd+ plasmid vector can be used to express a diversity of colonization and virulence antigens from other pathogens. In the delta cya delta crp delta asd S. typhimurium vaccine strain, the plasmid is completely stable in the absence of any exogenous selective pressure either in vitro or in vivo.

Adenylyl Cyclases↗
PubMed2005

Impact of right ventricular size on ECG after percutaneous closure of atrial septal defect with Amplatzer Septal Occluder.

OBJECTIVES: To assess ECG changes after percutaneous atrial septal defect (ASD) closure in children with significant left-to-right shunt. METHODS: Analysis of data of 36 consecutive children with an ASD who had successful percutaneous ASD closure with an Amplatzer Septal Occluder. Assessment comprised echocardiography and ECG the day before and after the procedure and at 1, 6 and 12 months follow-up. RESULTS: The median age (interquartile range) of children was 7.3 (5.3) years. On the day after the procedure the end diastolic diameter of the right ventricle showed already a diminution (34 (12) mm/m2 before intervention vs. 32 (12) mm/m2). ECG changes were first observed at 1 month follow-up (PR interval before intervention 139 (20) ms vs. 132 (20) ms; QRS duration 88 (18) ms vs. 82 (19) ms) and at 6 months follow-up (QRS axis 77 degrees (33) before intervention vs. 72 degrees (53)). With the exception of the QRS duration, ECG intervals and axis were in a normal range in all patients before the procedure. Median QRS duration normalised at 1 year follow-up (83 (8) ms). CONCLUSION: After transcatheter ASD closure, decrease in right ventricular size began rapidly and was followed by reduction of the QRS duration and PR interval within weeks. Shifting to the left of the QRS axis was observed within 6 months follow-up. This study showed that ECG changes due to right ventricular volume overload can regress and normalise after percutaneous ASD closure in children.

Adolescent↗
PubMed2000

Non surgical closure of atrial septal defect using the Amplatzer septal occluder in children--feasibility and early results.

OBJECTIVE: To assess the feasibility and early results of Amplatzer septal occluder in children withy secundim atrial septal defect. SETTING: Tertiary care referral hospital in New Delhi. METHODS: Forty nine children under 12 years of age were diagnosed to be having fossa ovalis atrial septal defect. Forty nine patients underwent detailed 2D-Echocardiography and color Doppler interrogation for the possibility of non-surgical closure of ASD. Sixteen children between age 2.5-12 years (mean 6.5 years) were enrolled into the study. Their weight ranged from 10 kg to 42 kg and there were 9 males and 7 females. The remaining 33 were not considered suitable for device closure in echocardiography and were referred for surgery. RESULTS: All patients had more than 1.8 : 1 shunt. The device was successfully deployed in 13/16 patients. ASD stretched diameter ranged between 13 mm-30 mm (mean 15 mm) and the device size ranged between 14 mm-22 mm. One patient had fenestrated ASD, in this patient the largest of the defect was crossed and closed with 24 mm device resulting in closure of all three defects. We failed in three of our attempts, on one there were deficient inferior margins while in the other two cases the ASD stretched size was such that the device would have encroached upon adjacent structures, hence the procedure was abandoned. All these patients have been operated successfully. Complete abolition of shunt was seen in 38% patients in the immediate post deployment period. At 24 hours complete closure was seen in 12/13 (92%) patients while one patient had trivial residual shunting across the device. This patient also achieved complete closure of atrial shunting when evaluated at three months follow-up. CONCLUSION: Device closure of ASD is emerging as an alternative to surgical closure. However, with the currently available device only a limited number of atrial septal defects can be closed. Long-term studies are required to show sustained benefits and absence of side effects of this device.

Adolescent↗
PubMed2001

Results of surgical repair of ostium primum atrial septal defect in adult patients.

BACKGROUND AND AIM OF THE STUDY: Ostium primum atrial septal defect (ASD I) is very rarely observed in the adults. Although ASD I was first corrected surgically almost 50 years ago, the efficacy of surgical treatment in adults has not been well documented. Thus, the long-term outcome of patients aged over 20 years and having surgical repair of ASD I was examined. METHODS: Fifteen patients (10 males, five females; mean age 31.4+/-13.1 years; range: 20 to 56 years) who had surgical repair of ASD I between 1982 and 2000 were followed. All patients were examined physically and underwent chest radiography, ECG and echocardiography (cross-sectional and Doppler) before and after surgery. Autologous pericardium was used to close the defect in 14 patients, and a direct suture was used in one patient. Mitral valvuloplasty (repair of the cleft) was performed in 12 patients, and De Vega annuloplasty in eight. RESULTS: There were no hospital deaths. In one case a pacemaker was implanted five days after surgery because of complete heart block. Preoperatively, nine patients (60%) were in NYHA classes III and IV; at the end of follow up, 14 (93.3%) were in classes I and II. Preoperatively, 13 patients had sinus rhythm, and one each had atrial fibrillation (AF) and rhythm from the atrioventricular sinus. During follow up, three patients developed AF which was treated successfully with electrical cardioversion. The preoperative mean cardiac volume index of 695 +/- 216 ml/m(2) was reduced significantly after repair to 523 +/- 108 ml/m(2) (p < 0.05). Before surgery, mitral regurgitation was observed (severe in five cases, moderate in seven, mild in three). Postoperatively, a residual intracardiac shunt was identified in one case. Postoperative mitral regurgitation was noted in six patients (moderate in two, mild in four). The right ventricular dimension was decreased significantly, from 5.0 +/- 1.5 mm before surgery to 3.2 +/- 0.6 mm after repair (p < 0.001). CONCLUSION: Patients aged over 20 years with ASD I benefit from surgical repair of the defect.

Adult↗
PubMed2002

Directed forgetting in acute stress disorder.

The rationale underpinning the diagnosis of acute stress disorder is that cognitive mechanisms result in avoidant processing of aversive experiences. This study investigated acutely traumatized participants with either acute stress disorder (ASD; n = 15) or no ASD (n = 14) and nontraumatized comparison participants (n = 16). Participants were administered intermixed presentations on a computer screen of positive, neutral, and trauma-related words that were followed by instructions to either remember or forget each word. On a subsequent recall test, ASD participants displayed poorer recall of to-be-forgotten trauma-related words than did non-ASD participants. Severity of psychopathology was negatively correlated with to-be-remembered positive words. These findings are consistent with the proposal that people who develop ASD display an aptitude for superior forgetting of aversive material.

Acute Disease↗
PubMed2002

Transcatheter closure of secundum atrial septal defects with the Amplatzer occluder in adult patients.

BACKGROUND: Secundum atrial septal defect (ASD) is a common congenital heart disease diagnosed in adulthood. Data regarding the use of the percutaneous occluder device in adult populations are very limited and few studies including the use of the Amplatzer septal occluder (ASO) device in such populations are available. The aim of this study was to evaluAte the immediate and mid-term outcomes of the percutaneous ASD closure with the ASO device in an adult population. METHODS: Between May 1999 and December 2000, 21 adult patients (8 males, 13 females) with a mean age of 44.6 +/- 15.1 years were enrolled for an attempt at ASD closure with the ASO device. RESULTS: Only 18 of the 21 patients underwent implantation of the ASO device, whereas the other 3 patients were submitted to cardiac surgery. The ASO device was successfully implanted in 17 patients (94.4%). The mean maximal ASD transesophageal echocardiography diameter was 14.4 +/- 7.2 mm (range 4-23 mm). The mean stretched defect diameter measured 19.5 +/- 8.4 mm (range 8-34 mm) and the ASO implanted stalk size was 19.8 +/- 8.2 mm (range 8-34 mm). In 2 (11.1%) of the 18 patients a percutaneous transcatheter coronary angioplasty was successfully performed before implantation of the ASO device because of coronary artery disease. At 6 months of follow-up, transesophageal echo examination showed that the device was correctly positioned in all cases. CONCLUSIONS: In adults, transcatheter closure of ASDs with the ASO device is a safe and effective alternative to surgical closure. The immediate and mid-term outcomes are excellent. However, a combined procedure may be necessary.

Adult↗