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Mitral valvuloplasty performed 5 y after repair of a sinus venosus ASD was difficult because of a thickened septum, but resulted in improved mitral valve opening and did not lead to ASD. Thus, prior repair of a sinus venosus ASD may not be an absolute contraindication to mitral valvuloplasty.
Embolization and percutaneous retrieval of the Amplatzer septal occluder (ASO) after release have been reported. However, the incidence, the causes of embolization, and the methods for effective retrieval have not been systematically described. In a survey of the ASO company-designated proctors, the incidence of ASO embolization in this group's experience was 0.55% (21 embolizations in 3824 device placements) with a wide range of patient demographics, atrial septal defect (ASD) sizes, and device sizes. Most embolizations occurred because of inadequate rim or undersized devices. Of the 21 embolizations, 15 of the devices were retrieved percutaneously with a gooseneck snare without morbidity or mortality. Six were retrieved at surgery. Of the 21 patients, 12 had ASO closure of their ASDs, and 9 had surgical ASD closure. In vitro, all devices could be retrieved with sheathes 2 Fr sizes larger than their recommended delivery sheath. Any device larger than 26 mm could be retrieved with its delivery sheath. The ability to pull the snared button into a sheath was variable and was assisted by pulling the device from above with a bioptome and by using a rigid notched sheath. Because the incidence of ASO embolization is about 1 in 200 in the most experienced hands, all operators should be prepared with the techniques and equipment required for percutaneous ASO retrieval.
The objectives of this study were to identify possible risk factors that may lead to erosion of the Amplatzer septal occluder (ASO) and recommend ways to minimize future risk. There have been rare occurrences of adverse events with development of pericardial effusion after ASO placement. Identification of high-risk cases, early recognition, and prompt intervention may minimize the future risks of adverse events. In all patients who developed hemodynamic compromise after ASO placement, echocardiograms (pre-, intra-, and postprocedure), atrial septal defect (ASD) size (nonstretched, stretched), size of the device used, cineangiograms, and operative records were reviewed by a panel selected by AGA Medical Corporation. The findings were compared to the premarket approval data obtained from FDA-approved clinical trials that were conducted in the United States, before the device was approved. A total of 28 cases (14 in United States) of adverse events were reported to AGA Medical. All erosions occurred at the dome of the atria, near the aortic root. Deficient aortic rim was seen in 89% and the defect described as high ASD, suggesting deficient superior rim. The device to unstretched ASD ratio was significantly larger in the adverse event group when compared to the FDA trial group. The incidence of device erosion in the United States was 0.1%. The risk of device erosion with ASO is low and complications can be decreased by identifying high-risk patients and following them closely. Patients with deficient aortic rim and/or superior rim may be at higher risk for device erosion. Oversized ASO may increase the risk of erosion. The defect should not be overstretched during balloon sizing. Patients with small pericardial effusion at 24 hr should have closer follow-up.
Closure of interatrial septal defects with percutaneous devices is increasingly common. However, the indications for closure and techniques for device implantation are diverse. We reviewed our first 100 consecutive implants to assess and compare the indications, results, complications, and evolution of techniques for percutaneous patent foramen ovale (PFO) and atrial septal defect (ASD) closure. The mean age of patients was 52 years and 70% were female. Paradoxical embolism was the predominant indication (94%) for PFO closure and significant left-to-right shunt was the most frequent indication (89%) for ASD closure. Implantation success was 94% with major complications in 3 patients (2.8%). Transesophageal echocardiography was utilized in the initial 27 procedures and then replaced by intracardiac echocardiography in subsequent ones, with an associated reduction in procedure and physician time. During 6 months of follow-up, 3 patients were readmitted for atrial arrhythmias (2 patients) and an MRI-negative neurologic event (1 patient). Echocardiography at 6 months in 83% of the PFO patients revealed moderate and severe positive contrast studies for right-to-left shunting in one third of patients, with differences between devices and insertion techniques. This single-center experience with percutaneous device closure of PFO and ASD in adults demonstrates excellent results with few complications.
We report 5-year follow-up data of patients following atrial septal defect (ASD) closure with the Amplatzer septal occluder (ASO). Patients completed a questionnaire related to symptoms pre- and post-ASO implantation. Complete transthoracic echocardiography was used to assess residual atrial septal defect, right ventricular volume overload, and degree of mitral regurgitation. Mean follow-up duration was 4.8 +/- 0.6 years (range, 5.7-3.0 years). Complete closure was observed in all patients. Right ventricular volume overload, present in all patients prior to ASD closure, had resolved in 82% of patients. No mitral valve sequelae were found; 75% of patients were asymptomatic or felt much improved compared to their preclosure symptoms. New onset of migraine-type headaches was encountered in two patients, one for 12 months and one patient persisted with intermittent migrainous episode. In conclusion, we report 100% closure rate of ASD with ASO device, with return of right ventricular size to normal in the majority of patients. New onset of migraine headaches after ASO implantation can persist more than a few months.
Percutaneous closure of an atrial septal defect (ASD) in the elderly with reduced diastolic elasticity of the left ventricle poses a significant management challenge. We report on the case of an 85-year-old patient who was admitted for percutaneous device closure of a moderately large secundum atrial septal defect. Hemodynamic evaluation documented an increase in left atrial pressure from a mean of 12 mm Hg to a mean of 32 mm Hg after balloon test occlusion of the ASD. Two months later, after adequate pretreatment with diuretics and afterload-reducing substances, he underwent successful closure of the ASD using a self-fabricated fenestrated Amplatzer septal occluder, which resulted in a postimplantation left atrial pressure of a mean of 18 mm Hg. Recovery was unremarkable and the fenestration has remained patent for 3 months since implantation of the device. This unique case highlights the feasibility of using a self-fabricated fenestrated Amplatzer septal occluder to close interatrial communications in elderly patients with diastolic dysfunction of the left ventricle.
Little is known about the efficacy and safety of the 40 mm Amplatzer septal occluder (ASO). Thirty-three patients (22 female, 11 male) with a large secundum atrial septal defect (ASD) underwent attempted device closure using the 40 mm ASO at a median age of 40 years (range, 14-81 years) and median weight of 65 kg (range, 48-98 kg). The median size of the ASD measured on 2D transesophageal echocardiography (27 patients) or intracardiac echocardiography (6 patients) was 30.5 mm (range, 24-39 mm) and the median balloon-stretched diameter was 37.7 mm (range, 32-43.7 mm). The median Qp:Qs ratio was 3.2:1 (range, 1.4-6.2). The attempt was unsuccessful in five patients; two had device embolization and one had left atrial wall perforation due to the sheath; all three required emergent surgery. The attempt was successful in the 28 remaining patients, resulting in complete immediate closure in 14 and a trivial residual shunt in 14. Fluoroscopy time ranged from 8.6 to 37.8 min (median, 12.2 min). At 24-hr follow-up, 2D transthoracic echocardiography with color flow Doppler revealed complete closure in 23 patients, and 5 had a trivial residual shunt. There were no complications encountered in patients who received the device. On follow-up, all patients are doing well. We conclude that the 40 mm ASO is safe and effective in most patients with a large ASD up to a diameter of 39 mm. However, the use of this device requires careful attention as the procedure may be unsuccessful or the device may embolize.
We report the case of a rescued 84-year-old patient with atrial septal defect (ASD) who was emergently admitted to our intensive care unit with progressive dyspnea requiring mechanical ventilation for severe anoxia and respiratory arrest. She had no history of congenital heart diseases. ECG and chest X-ray revealed overload of the right atrium and ventricle, and severe increase in pulmonary vascular markings. Transesophageal echocardiography showed a moderately large size ASD (18 x 23 mm(2)). Hemodynamic evaluation documented an increase in PA pressure of 37/16 mm Hg and Q(p)/Q(s) of 2.33. Her systemic condition did not improve following diuretics, cathecholamine, and afterload-reducing substances. She required mechanical ventilation for severe hypoxia. She underwent successful closure of the ASD using an Amplatzer septal occluder on day 17. Hemodynamics and findings on chest X-ray dramatically improved after this procedure. She was discharged from the hospital on foot.
OBJECTIVES: We aim to describe a case with oral-facial-digital syndrome type VI (OFDS VI) or Varadi-Papp syndrome where the only prenatal findings were cleft lip and palate and a primum type atrial septal defect (ASD). METHODS: A 24-year-old pregnant woman, gravida 1 para 0, attended the prenatal clinic for a routine visit at 16 weeks of gestation. Her medical and family history was unremarkable. There was no history of consanguinity, drug or teratogen exposure. Her triple screening test and other routine biochemical and haematological blood tests did not reveal any abnormal results. During routine prenatal sonographic examination at the 16th gestational week, cleft lip and palate including secondary palate on the right side of the face was detected and ASD was suspected. RESULTS: After delivery, prenatally diagnosed cleft lip and palate and primum ASD were confirmed. Postnatally, minimal micrognathia, posteriorly rotated low-set ears, minimal hypertelorism, epicanthal folds, nystagmus, esotropia, broad nasal tip, intraoral frenula and lobed tongue, shawl scrotum and duplicated nail of the index fingers of both hands were also observed. Radiological examination showed partial agenesis of the corpus callosum and partially duplicated terminal phalanx of the index fingers. A diagnosis of Varadi-Papp syndrome was formulated. At one year of age, there was short stature and delayed mental and motor development. CONCLUSION: Understanding the limitations of prenatal ultrasound is very important for the genetic counselling of prospective parents, since major ultrasound findings can be associated with other minor or undetectable features.
A comparative study of right ventricular (RV) function, assessed by echocardiography and angiography, undertaken in 20 patients, 10 of whom had atrial septal defects (ASDs) and 10 had various other heart diseases. All of the measured echocardiographic variables of RV size, apart from RV length, were larger in the patients with ASD. When assessed by multiple regression analysis, the RV M-mode dimension was an independent variable of RV angiographic end-diastolic volume (EDV) in patients without RV volume load (R = 0.92, R2 = 0.85, p < 0.001). In the patients with ASD, echocardiographic RV end-diastolic area was an independent variable of angiographic RVEDV (R = 0.75, R2 = 0.55, p < 0.05), whereas M-mode dimension had a weaker correlation (r = 0.29). The agreement between RV ejection fraction (RVEF) obtained by echocardiography and angiography was moderate in both patient groups. However, fractional area change and fractional length change could not estimate RVEF better. Thus care should be taken to use single measurements and derivatives as the only parameters of RV size and function.
Transmitral flow was studied using Doppler echocardiography with the A/E ratio as a parameter of left ventricular diastolic function in 21 patients (ages 2.5-30.0 years) who had undergone early surgical correction of an isolated secundum type atrial septal defect (ASD) compared to a healthy cohort of 21 subjects. Pre- and postoperative M-mode recordings were compared in 12 of the 21 patients to evaluate the effect of operation on interventricular septal motion (IVS) and left ventricular (LV) and right ventricular (RV) end-diastolic diameter ratio (LVDD/RVDD) as parameters of right ventricular volume overload. No significant difference in A/E ratio was found between the patient and control groups. IVS was shown to normalize in 11 of 12 patients postoperatively and to improve from paradox to flattened in 1 of 12. LVDD/RVDD increased from 1.26 +/- 0.31 to 2.10 +/- 0.51 (p = 0.0008), with no significant difference remaining between the control and patient groups postoperatively. These findings support the conclusion that an intrinsic abnormality of the left ventricle is not responsible for its diastolic dysfunction in patients with ASD who develop left ventricular failure, thereby implicating an acquired abnormality. Mechanical sequelae of right ventricular volume overload were shown to normalize in all patients subsequent to operation in the present study, and therefore cannot be excluded as a cause of left ventricular failure in ASD.
The objective of this literature review is to assess the validity of autistic spectrum disorders (ASD). Twenty papers were identified that adequately investigated the internal or external validity of various subtypes of ASD. At least three groups can be distinguished from autism on clinical grounds; an Asperger syndrome subtype, and two atypical subtypes characterized by low IQ and high IQ. However, the evidence that these clinical distinctions carry inferences with respect to etiology, clinical course, and treatment is only suggestive. Nevertheless, the specification of several ASD subtypes might promote further research and resolve many of the nosologic issues with respect to the classification of pervasive developmental disorders (PDDs).
In order to obtain a method that could predict the in vitro inactivation of an antibiotic in the digestive tract, the non-enzymatic inactivation of 13 beta-lactam antibiotics by human faeces was investigated. Benzylpenicillin, amoxicillin, amoxicillin/clavulanate, cloxacillin, piperacillin, temocillin, cefuroxime, cefamandole, cephradine, cefotaxime, ceftazidime, aztreonam and imipenem were mixed in six graded concentrations with faecal suspensions of 30 healthy volunteers. After incubation the remaining antimicrobial activity was measured by means of a serial dilution method. A relationship between the initial antibiotic concentration (Aia) and the remaining antimicrobial activity after incubation (Asd) was derived, namely: Asd = 1/2[(Aia-K-F)+square root ((Aia-K-F)2 + 4 K Aia)]. The parameters K and F represent the intrinsic dissociation constant and the amount of available bindingsites in the faeces, respectively. Asd values were predicted with a reasonable degree of accuracy for all thirteen antibiotics. Dissociation constants differed significantly between the penicillins and the cephalosporins but F- values did not differ between cephalosporins and penicillins.
In order to assess whether the paradoxical motion of the interventricular septum seen in patients with atrial septal defect (ASD) is due to a true abnormality in septal contraction, eight patients with ASD (age, 1.6-17 years) and eight age-matched control patients were studied using qualitative and quantitative two-dimensional (2D) and M-mode echocardiography. 2-D-echocardiographic images recorded from the parasternal short-axis projection at the level of the papillary muscles and 2D-directed M-mode tracings at this level were obtained. Comprehensive wall motion analysis of the left ventricular (LV) endocardial and epicardial borders was performed using both fixed reference and center of mass (floating reference) models. Our results indicate that interventricular septal wall motion and function are normal in patients with ASD. The apparent "paradoxical" motion is due to excessive anterior motion of the entire left ventricle, and is present only when a fixed reference system is used to assess myocardial motion, but is not present when a center of mass (floating reference system) is employed. Left ventricular function assessed by % area and perimeter change, mean radial shortening fraction, and mean radial wall thickening (2D) as well as LV shortening fraction and septal and posterior wall thickening (M-mode) was not significantly different between the two groups. Standard M-mode tracings can therefore be used to assess LV function despite this apparent abnormal septal motion.
Thirteen infants were found to have atrial septal aneurysms (ASAs) on two-dimensional (2D) echocardiography and their characteristics and natural course have been studied by 2D Doppler echocardiography. Atrial septal aneurysm was accompanied by atrial septal defect (ASD) or other cardiac malformations in 12 of 13 patients, and as an isolated anomaly in one patient. Spontaneous closure of ASD by aneurysmal formation of the interatrial septum was observed in 10 patients. The aneurysms of all 13 patients showed a moderate reduction in size, 14 to 25 months (mean 18 months), after these aneurysms had been first diagnosed and 10 subsequently disappeared. It is likely that ASA occurring in infancy will develop in patients with spontaneous closure of an ASD, and that such an aneurysm has a tendency to regress as the patient grows up.
Urine excretion rates of norepinephrine were measured in 15 children with Tetralogy of Fallot and 25 with atrial septal secundum defects anaesthetized with halothane or morphine before, during and for two hours after surgical correction of their cardiac defects. All patients were paralyzed with d-tubocurarine, the tracheae were intubated and respiration was controlled. Urine was obtained for 90 minutes before induction, during induction, before, during and after bypass and postoperative. Patients with TF had significantly higher pre-operative urine norepinephrine excretion rates than patients with ASD. In TF children anaesthetized with halothane norepinephrine excretion was significantly decreased during induction and during operation but increased post-operatively. Children with ASD and anaesthetized with halothane did not have urine norepinephrine excretion rates that were significantly different from post-operative values until the postoperative period. ASD children anaesthetized with morphine had marked elevations in norepinephrine excretion during induction and all subsequent study periods. On the other hand, morphine anaesthetized TF children did not have a significant increase in urine norepinephrine excretion until bypass had been established. Increased norepinephrine excretion was maintained in these patients during all subsequent study periods. These data, when combined with our results in patients with acquired heart disease, demonstrate that disease can alter norepinephrine responses to morphine anaesthesia. In addition our results suggest that dosage of morphine and morphine blood levels might also modify norepinephrine excretion.
To investigate the role of anaesthetic management in early extubation of the trachea in children after closure of a secundum-type atrial septal defect (ASD II), a retrospective chart review for a two-year period was performed. We identified 36 children who underwent surgical repair of an isolated ASD II. In 19 children (53%) the tracheas were extubated in the operating room immediately after surgery and in 17 patients (47%) the tracheas remained intubated and the lungs were ventilated in the Intensive Care Unit. There was no difference in age (69.5 +/- 33.8 vs 72.9 +/- 45.0 mo) or weight (19.5 +/- 8.1 versus 20.5 +/- 12.7 kg) between the two groups (mean +/- SD). Children in the extubated group had a shorter duration of cardiopulmonary bypass (43.4 +/- 7.8 min) than those remaining intubated (31.7 +/- 12.7 min) (P < 0.05). The children whose tracheas were extubated early received a lower perioperative fentanyl dose (5.9 +/- 6.4 micrograms.kg-1) than those remaining intubated (35.1 +/- 8.5 micrograms.kg-1). Those children in the extubated group had a lower hourly requirement for morphine by infusion (13.6 +/- 5.7 vs 18.2 +/- 5.4 micrograms.kg-1.hr-1) and a shorter stay (20.5 +/- 3.7 versus 29.0 +/- 11.2 hr) in the Intensive Care Unit. Re-intubation of the trachea was not required in any of the children and no deaths occurred. Early extubation after ASD II repair is safe and, given the results of this study, may offer certain advantages over prolonged intubation and ventilation in these children.
We have studied influence of the age related factors on preoperative autologous donation (PAD) of blood in cardic surgery. PAD was undertaken in 246 cases of elective cardiac surgery by means of simple or leap-frog method, starting at approximately 4.5 weeks before operation. It provided 1726 ml of autologous blood storage on the average. Sorting the patients into three groups with age, leading surgical procedures were as follows: closure of the atrial septal defect (ASD) in teen 30s (group L, n = 51), aortic valve replacement (AVR) or mitral valve replacement (MVR) in 40s-50s (group M, n = 83) and 60s and over (group H, n = 112). Coronary artery bypass grafting (CABG) was more common in group H. Percent-freedom from allogeneic blood transfusion was 82.3% in group L, 80.7% in group M and 61.6% in group H, respectively (p < 0.05; L, M vs. H), donated blood volume in group H was significantly less than that of group M (p < 0.05, M: 1987 +/- 63, H: 1610 +/- 60 ml), because blood volume and hemoglobin level before donation tended to be less in group H. Each group did not differ in blood loss during and after operation, which showed a significant positive correlation with operation time and cardiopulmonary bypass (CPB) time. Comparing factors in ASD, CPB time was relatively long, and postoperative blood loss was significantly larger in group H (p < 0.05; L: 432 +/- 71 ml, M: 369 +/- 34 ml, H: 754 +/- 124 ml). This finding suggests that the secondary lesions in age ASD cases adversely affected hemostasis. As to AVR, MVR and CABG, there were no differences in these factors but donated blood volume among three groups. We conclude that elderly patient (60s and over) tends to necessitate allogeneic blood transfusion in cardiac surgery because of the insufficient PAD. Earlier commencement of PAD or concomitant application of erythropoietin will improve this situation.