Clinical Significance of Partial Anomalous Pulmonary Venous Connections (Isolated and Atrial Septal Defect Associated) Determined by Cardiovascular Magnetic Resonance

BACKGROUND

Partial anomalous venous connections (PAPVC) are associated with left to right shunting and right heart dilatation. Identification of PAPVC has increased with widespread use of cross-sectional imaging modalities. However, management strategies are mostly based on expert opinion given the scarcity of data from large series. We aimed to define types and significance of isolated and atrial septal defect (ASD) associated PAPVC detected by cardiovascular magnetic resonance.

METHODS

We retrospectively reviewed our cardiovascular magnetic resonance database from 2002 to 2018 to identify isolated or ASD-associated PAPVC cases.

RESULTS

A total of 215 patients (median age 46 years; range, 6-83) with isolated or ASD-associated PAPVC were identified among 102 135 clinical cardiovascular magnetic resonance studies. Of these, 104 were isolated and 111 were associated with an ASD. Anomalous connection of right upper pulmonary vein was the most common single venous anomaly (99/215), but in the isolated PAPVC group there were more anomalous left than right upper pulmonary veins (39 versus 34). The Qp/Qs was significantly higher for isolated anomalous single right upper pulmonary vein than left upper pulmonary vein (1.6 versus 1.4 respectively; P=0.01) as were right ventricular end-diastolic volumes (113.7±30.9 versus 90 [57-157] mL/m2, P=0.004). In the PAPVC with an ASD group, sinus venosus ASDs (82%) were associated with right-sided PAPVCs while both right and left-sided venous anomalies were seen in secundum ASDs (18%). In a substantial number of patients (30 out of 91) with sinus venosus ASDs, PAPVCs were more complex and involved more than a single anomalous right upper pulmonary vein; and in 5 patients with ASD, PAPVC was identified only after the ASD closure.

CONCLUSIONS

This large series provides descriptive and hemodynamic features for isolated and ASD-associated PAPVCs. Anomalous isolated right upper pulmonary vein may cause a significant shunt (Qp/Qs >1.5). PAPVC associated with sinus venosus and secundum ASDs might be more complex than a single anomalous pulmonary vein and missed before ASD correction.

Right Ventricular Flow Dynamics in Dilated Right Ventricles: Energy Loss Estimation Based on Blood Speckle Tracking Echocardiography-A Pilot Study in Children

Using blood speckle tracking (BST) based on high-frame-rate echocardiography (HFRE), we compared right ventricle (RV) flow dynamics in children with atrial septal defects (ASDs) and repaired tetralogy of Fallot (rTOF). Fifty-seven children with rTOF with severe pulmonary insufficiency (PI) (n = 21), large ASDs (n = 11) and healthy controls (CTL, n = 25) were included. Using a flow phantom, we studied the effects of imaging plane and smoothing parameters on 2-D energy loss (EL). RV diastolic EL was similar in ASD and rTOF, but both were greater than in CTL. Locations of high EL were similar in all groups in systole, occurring in the RV outflow tract and around the tricuspid valve leaflets in early diastole. An additional apical early diastolic area of EL was noted in rTOF, corresponding to colliding tricuspid inflow and PI. The flow phantom revealed that EL varied with imaging plane and smoothing settings but that the EL trend was preserved if kept consistent.

Transthoracic echocardiography monitoring during atrial septal defect and ventricular septal defect device closures using a three-dimensional printed transducer holder

Transthoracic echocardiography (TTE) is noninvasive but can only be performed intermittently during fluoroscopy. In a prior study, we created a transducer holder device to allow for hemodynamic monitoring in the intensive care unit. The current study is the first instance of the use of a three-dimensional (3D)-printed TTE transducer holder, which is easily customized and personalized to a previous transducer holder at relatively low cost and short production time, to enable continuous TTE monitoring during device closure of an atrial septal defect (ASD) and ventricular septal defect (VSD). There were 14 ASD patients and 9 VSD patients scheduled to undergo device closure. The study's real-time TTE monitoring was performed by using a 3D-printed transducer holder over the course of the entire implantation procedure. There were 23 patients who successfully underwent septal closures using the 3D-printed holder that enabled real-time images over the entire procedure. The median duration for real-time TTE guidance was 15 minutes for the ASD and 36 minutes for the VSD and the median fluoroscopy time was 11 minutes for the ASD and 30 minutes for the VSD. One migrating VSD occluder and one case of aortic regurgitation after occluder deployment were noted by real-time TTE monitoring during the procedure. Our novel 3D-printed transducer holder can provide transesophageal echocardiography-like real-time imaging during device closure of an ASD and a VSD and may become a new alternative method in ASD and VSD closures. It can also prevent radiation exposure for the intervention team who would otherwise need to perform TTE during live fluoroscopy.

Favorable changes of left ventricular function in the circumferential direction following transcatheter atrial septal defect closure: a strain imaging study

To clarify the impact on left ventricular (LV) function of percutaneous atrial septal defect (ASD) closure in adult patients. Echocardiograms of 46 patients (52 ± 18 years) who underwent ASD closure with a significant left-to-right shunt obtained before and 1 month after the procedure were retrospectively analyzed. Functional parameters were obtained by 2-dimensional speckle-tracking imaging. Global longitudinal strain and strain rate at early diastole (SRe) was calculated from the three standard apical views, while circumferential and radial parameters were calculated from basal, middle, and apical LV short-axis views. Along with a diminished right ventricular (RV) volume, the LV volume and ejection fraction increased (end-diastolic volume: 61 ± 12 to 76 ± 15 mL, p < 0.001; and 63% ± 4 to 64% ± 4% p = 0.03; respectively). Both global strain and SRe was augmented only in the circumferential direction (- 16.2% ± 2.9% to - 19.8% ± 2.8%; and 1.07 ± 0.29 to 1.34 ± 0.28 s^-1, both p < 0.001). Augmentation of circumferential SRe correlated with both the changes in and the pre-procedural value of diastolic LV eccentricity index (r = - 0.57, p < 0.001; and r = 0.37, p = 0.01; respectively), a morphological parameter of RV volume overload. Following ASD closure in adults, both LV systolic and diastolic function could favorably change in the circumferential direction, and the degree of diastolic functional change is associated with RV volume overload, i.e., severity of ventricular interdependence.

Persistent Hypoxemia in a Teen With Down Syndrome

Upchurch A, Sharma S, Hadigal S, Wagner M, Berry R. Persistent hypoxemia in a teen with down syndrome. J Clin Sleep Med. 2019;15(10):1547–1549.

Assessment of the Right and Left Atrial Functions at Midterm After Surgical and Device Atrial Septal Defect Closure: A 2-Dimensional Speckle-Tracking Echocardiographic Study

OBJECTIVES

The available literature lacks data on the comparison of the functions of the right atrium (RA) and left atrium (LA) between surgical atrial septal defect (ASD) closure and percutaneous device ASD closure at follow-up durations of longer than 1 year. We sought to evaluate the RA and LA functions in patients who underwent surgical or device ASD closure between 1 and 5 years postprocedurally.

METHODS

The study population included 30 patients who underwent device ASD closure and 30 who underwent surgical ASD closure, who were matched for the procedural time, age, and sex, in addition to 30 control participants. The RA and LA functions were evaluated with 2-dimensional speckle-tracking echocardiography.

RESULTS

The LA systolic and early diastolic strain and strain rate values and the RA early diastolic strain rate in the device closure group were more likely to be abnormal than in the control group. The RA systolic and late diastolic strain and strain rate values, the RA early diastolic strain rate, and the LA early diastolic strain in the surgical closure group were more likely to be abnormal than in the control group. The RA systolic strain and strain rate in the surgical closure group were more likely to be abnormal than in the device closure group.

CONCLUSIONS

The LA reservoir and conduit functions and the RA contraction function in the patients who underwent device ASD closure and all of the RA functions and the LA conduit function in the patients who underwent surgical ASD closure were more likely to be abnormal than those in the control participants. The RA reservoir function in the surgical closure group was more likely to be abnormal than that in the device closure group.

Validation of intracardiac shunt using thoracic bioimpedance and inert gas rebreathing in adults before and after percutaneous closure of atrial septal defect in a cardiology research unit: study protocol

INTRODUCTION

Intrathoracic shunt quantification is a major factor for appropriate clinical management of heart and pulmonary diseases. Intracardiac shunts quantified by pulmonary to systemic output ratio (Qp/Qs) are generally assessed by Doppler echocardiography, MRI or catheterisation. Recently, some authors have suggested the concomitant use of thoracic bioimpedance (TB) and inert gas rebreathing (IGR) techniques for shunt quantification. The purpose of this study is to validate the use of this approach under conditions where shunt fraction is directly quantified such as in patients with isolated atrial septal defect (ASD).

METHODS AND ANALYSIS

This trial is a prospective, observational single-centre, non-blinded study of adults seen for percutaneous closure of ASD. Qp/Qs ratio will be directly measured by Doppler echocardiography and direct Fick. IGR and TB will be used simultaneously to measure the cardiac output before and after closure: the ratio of outputs measured by IGR and TB reflecting the shunt fraction. The primary outcome will be the comparison of shunt values measured by TB-IGR and Doppler echocardiography.

ETHICS AND DISSEMINATION

The study has been approved by an independent Research Ethics Committee (2017-A03149-44 Fr) and registered as an official clinical trial. The results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03437148; Pre-results.

Morphological variations of the interatrial septum in ovine heart

Smooth septum interatrial septum, patent foramen ovale (PFO) channel and atrial septal pouches (SPs) are commonly described variants in humans. Recent discoveries on the clinical significance of left-sided SP may encourage the creation of new strategies and devices for the management of SPs. However, these strategies may first be tested in the ovine model before implementation in humans. Unfortunately, little is known about the presence of SPs in ovine. In this study a total of 60 ovine (Ovis aries) hearts were examined. The interatrial septum morphology was assessed and the PFO channel and SPs were measured. The most commonly occurring variant were PFO channels (25.0%) with channel lengths of 5.4±2.3 mm. Smooth septums were observed in 18.3% of hearts. In the remaining cases, septums had a left septal ridge (15.0%), left SP (11.7%), left septal bridge (10.0%), right SP (10.0%), or had both a right SP and left septal ridge (10.0%). No double SPs were observed. The mean right SP depth was 3.4 ± 1.2 mm, and its mean ostium width and height were 7.9±1.8 mm and 2.8±1.0, respectively. For the left SP, the mean depth was 6.0±1.7mm, the ostium width was 7.9±2.4mm, and the ostium height was 4.1±1.6mm (range: 2.3-6.4mm). In conclusion the interatrial septum of ovine hearts exhibit morphologies that are more similar to humans than they are to swine, which should be taken into account during experimental studies. The presence of a left SP in sheep hearts make ovine models a promising alternative to the human heart for developing left-sided SP management devices and techniques.

Platypnea-Orthodeoxia: A Case of Unexplained Hypoxia

INTRODUCTION

Platypnea-orthodeoxia syndrome is a rare clinical syndrome defined by worsening deoxygenation and dyspnea when changing to an upright sitting or standing position. It is seen in 3 different clinical scenarios: intracardiac shunts, pulmonary arteriovenous shunts, and ventilation/perfusion mismatch in the lungs.

CASE

An 82-year-old woman with a history of nonischemic cardiomyopathy with reduced ejection fraction was admitted with dyspnea and hypoxemia. She was found to have atrial septal defect with right to left shunting in the setting of normal right atrial pressures.

DISCUSSION

Platypnea-orthodeoxia syndrome is a clinical syndrome where, in the setting of an interatrial communication, a right to left shunt can occur without elevated pulmonary or right atrial pressure, resulting in significant hypoxia.

CONCLUSION

Platypnea-orthodeoxia syndrome is a clinical condition that is being recognized more frequently due to more accurate diagnosis, and its treatment can alleviate symptomatic hypoxemia.

Lutembacher syndrome with mitral valve calcification in a 31-year old male

Lutembacher syndrome is characterized by a congenital ostium secundum atrial septal defect and an acquired mitral valve stenosis. We present a similar case in a 31-year old male who came in with orthopnoea, central cyanosis and pedal oedema. Examination revealed cardiac murmurs in tricuspid and apical regions. Chest x-ray showed signs of pulmonary congestion and ventricular enlargement. Electrocardiogaphy (ECG) revealed right axis deviation and right bundle branch block along with atrial fibrillation and Transthoracic Echocardiography (TTE) showed abnormal valves (mitral stenosis with calcification and tricuspid regurgitation) and dilated cardiac chambers. The patient was consequently treated with beta-blockers and diuretics and scheduled for valvular and septal repair via open heart surgery. The purpose of this case report is to assist cardiologists in diagnosing this syndrome accurately on the basis of symptoms and investigations.

Simultaneous Closure of a Left Atrial Appendage through an Atrial Septal Defect and the Atrial Septal Defect

Left atrial appendage (LAA) occlusion can be employed as an alternative treatment to oral anticoagulation in patients with atrial fibrillation to prevent embolic events. Atrial septal defect (ASD) may be related with right heart dysfunction and allow paradoxical embolism to occur. However, occlusion of both LAA through atrial access with ostium secundum ASD and ASD in the same setting is unusual. Therefore, we report a case in which a LAA and an ASD was sequentially occluded.

Arrhythmias in Patients with Atrial Defects

Atrial arrhythmias are common in patients with atrial septal defects. A myriad of factors are responsible for these that include remodeling related to the defect and scar created by the repair or closure. An understanding of potential arrhythmias, along with entrainment and high-density activation mapping can result in accurate diagnosis and successful ablation. Atrial fibrillation is being seen increasingly after patent foramen ovale closure and may be the primary etiology of recurrent stroke in these patients.

Safety and efficacy of transthoracic versus transesophageal echocardiography in transcatheter closure of atrial septal defects. Reporting a single center experience from Saudi Arabia

Objectives:

To assess the safety and effectiveness of transthoracic echocardiography (TTE) in monitoring transcatheter closure of atrial septal defect (ASD), in comparison with conventional technique using transesophageal echocardiography (TEE).

Methods:

A retrospective review of all cases of transcatheter closure of isolated ostium secundum ASDs operated from 2005 to 2015, at the Pediatric Interventional Cardiology Department, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia. Exclusion criteria included age ≤3 years at the time of the procedure and rim size ≤3 mm. Patients were divided into 2 groups: TTE and TEE group. Demographic and clinical baseline data, procedure data, and outcomes were compared between the 2 groups.

Results:

We included 77 cases: 45 in TTE group and 28 in TEE (mean ± standard deviation age=8.18 ± 5.85 versus 17.68 ± 14.88), with no significant difference in ASD size, rim adequacy, or other anatomical difficulties. All (100%) patients in TEE group underwent general anesthesia, versus 8.9% in TTE group. Device deployment was comparably successful (97.8% versus 92.9%, p=0.554); while procedure time (76.27 ± 31.80 versus 119.85 ± 19.90 minutes, p<0.001) and fluoroscopy time (11.29 ± 9.04 versus 18.73 ± 11.54 minutes, p=0.003) were significantly reduced in TTE versus TEE. Prevalence of postprocedural complications was comparable in the 2 groups.

Conclusion:

Transthoracic echocardiography has non-inferior efficacy in device deployment with reference to TEE and superior safety features including significant reduction of procedure and fluoroscopy times and lesser use of general anesthesia.

Perinatal outcomes and congenital heart defect prognosis in 53313 non-selected perinatal infants

Objective

To evaluate perinatal outcomes and congenital heart defect (CHD) prognosis in a non-selected population.

Methods

The population-based surveillance data used in this assessment of CHDs were based on birth defect surveillance data collected from 2010–2012 in Liuyang City, China. Infants living with CHDs were followed up for 5 years to determine their prognosis. Prevalence, prenatal diagnosis, perinatal outcomes, and total and type-specific prognosis data were assessed using SPSS 18.0.

Results

In total, 190 CHD cases were identified among the 53313 included perinatal infants (PIs), indicating a CHD prevalence of 35.64 per 10000 PIs in this non-selected population. The five most frequently identified types of CHDs were ventricular septal defects (VSDs, 38.95%), atrial septal defects (ASDs, 15.79%), cardiomegaly (7.89%), tetralogy of Fallot (TOF, 5.79%), and atrioventricular septal defects (AVSDs, 5.26%). Of the 190 CHD cases, 110 (57.89%) were diagnosed prenatally, 30 (15.79%) were diagnosed with associated malformations, and 69 (36.32%) resulted in termination of pregnancy (TOP). Moreover, 15 (7.89%) PIs died within 7 days after delivery, and 42 (22.10%) died within 1 year. In contrast, 79 (41.58%) were still alive after 5 years. When TOP cases were included, the 5-year survival rate of PIs with prenatally detected CHDs was lower than that of PIs with postnatally detected CHDs (25.45% vs. 63.75%). The CHD subtype associated with the highest rate of infant (less than 1 year old) mortality was transposition of the great arteries (100%). The subtypes associated with higher 5-year survival rates were patent ductus arteriosus (80%), ASD (63.33%), VSD (52.70%) and AVSD (50%).

Conclusions

The rates of prenatal CHD detection and TOP were high in this study population, and the 5-year survival rate of PIs with CHDs was low. The government should strengthen efforts to educate pediatricians regarding this issue and provide financial assistance to improve the prognosis of infants living with CHDs, especially during the first year of life.

Dynamic characteristic mechanism of atrial septal defect using real-time three-dimensional echocardiography and evaluation of right ventricular functions

The dynamic characteristics of the area of the atrial septal defect (ASD) were evaluated using the technique of real-time three-dimensional echocardiography (RT 3DE), the potential factors responsible for the dynamic characteristics of the area of ASD were observed, and the overall and local volume and functions of the patients with ASD were measured. RT 3DE was performed on the 27 normal controls and 28 patients with ASD. Based on the three-dimensional data workstations, the area of ASD was measured at P wave vertex, R wave vertex, T wave starting point, and T wave terminal point and in the T-P section. The right atrial volume in the same time phase of the cardiac cycle and the motion displacement distance of the tricuspid annulus in the corresponding period were measured. The measured value of the area of ASD was analyzed. The changes in the right atrial volume and the motion displacement distance of the tricuspid annulus in the normal control group and the ASD group were compared. The right ventricular ejection fractions in the normal control group and the ASD group were compared using the RT 3DE long-axis eight-plane (LA 8-plane) method. Real-time three-dimensional volume imaging was performed in the normal control group and ASD group (n=30). The right ventricular inflow tract, outflow tract, cardiac apex muscular trabecula dilatation, end-systolic volume, overall dilatation, end-systolic volume, and appropriate local and overall ejection fractions in both two groups were measured with the four-dimensional right ventricular quantitative analysis method (4D RVQ) and compared. The overall right ventricular volume and the ejection fraction measured by the LA 8-plane method and 4D RVQ were subjected to a related analysis. Dynamic changes occurred to the area of ASD in the cardiac cycle. The rules for dynamic changes in the area of ASD and the rules for changes in the right atrial volume in the cardiac cycle were consistent. The maximum value of the changes in the right atrial volume occurred in the end-systolic period when the peak of the curve appeared. The minimum value of the changes occurred in the end-systolic period and was located at the lowest point of the volume variation curve. The area variation curve for ASD and the motion variation curve for the tricuspid annulus in the cardiac cycle were the same. The displacement of the tricuspid annulus exhibited directionality. The measured values of the area of ASD at P wave vertex, R wave vertex, T wave starting point, T wave terminal point and in the T-P section were properly correlated with the right atrial volume (P<0.001). The area of ASD and the motion displacement distance of the tricuspid annulus were negatively correlated (P<0.05). The right atrial volumes in the ASD group in the cardiac cycle in various time phases increased significantly as compared with those in the normal control group (P=0.0001). The motion displacement distance of the tricuspid annulus decreased significantly in the ASD group as compared with that in the normal control group (P=0.043). The right ventricular ejection fraction in the ASD group was lower than that in the normal control group (P=0.032). The ejection fraction of the cardiac apex trabecula of the ASD patients was significantly lower than the ejection fractions of the right ventricular outflow tract and inflow tract and overall ejection fraction. The difference was statistically significant (P=0.005). The right ventricular local and overall dilatation and end-systolic volumes in the ASD group increased significantly as compared with those in the normal control group (P=0.031). The aRVEF and the overall ejection fraction decreased in the ASD group as compared with those in the normal control group (P=0.0005). The dynamic changes in the area of ASD and the motion curves for the right atrial volume and tricuspid annulus have the same dynamic characteristics. RT 3DE can be used to accurately evaluate the local and overall volume and functions of the right ventricle. The local and overall volume loads of the right ventricle in the ASD patients increase significantly as compared with those of the normal people. The right ventricular cardiac apex and the overall systolic function decrease.

Prediction of early-onset atrial tachyarrhythmia after successful trans-catheter device closure of atrial septal defect

Atrial tachyarrhythmia is a well-known long-term complication of atrial septal defect (ASD) in adults, even after successful trans-catheter closure. However, the risk factors for early-onset atrial tachyarrhythmia after trans-catheter closure remain unclear. This retrospective study enrolled adults with secundum ASD undergoing trans-catheter closure from January 2000 to March 2014. We analyzed the clinical characteristics of patients and assessed risk factors for new-onset atrial tachyarrhythmia defined as a composite of atrial fibrillation or flutter (AF/AFL) after ASD closure. We enrolled a total of 427 patients; 123 were male (28.8%) and the median age was 37.0 (interquartile range [IQR]: 18.3-49.0). Nineteen (4.4%) patients had documented atrial tachyarrhythmia during the follow-up period (median: 11.4 months [IQR: 5.4-24]). Patients with transient AF/AFL during closure showed a greater incidence of new-onset atrial tachyarrhythmia during the follow-up period than patients with consistent sinus rhythm during closure (27.3% vs 3.8%; P = 0.01). Most new-onset atrial tachyarrhythmias were documented within 6 months (median: 2.6 [IQR: 1.2-4.1] months) of closure. In the multivariate analysis, the risk for new-onset atrial tachyarrhythmia was significant in patients with AF/AFL during closure (hazard ratio [HR]: 9.90, 95% confidence interval [CI]: 2.86-34.20; P < 0.001), deficient posteroinferior rim (HR: 5.48, 95% CI: 1.15-25.72; P = 0.04), and age of closure over 48 years (HR: 3.30, 95% CI: 1.30-8.38; P = 0.01). In conclusion, transient AF/AFL during trans-catheter closure of ASD as well as deficient posteroinferior rim and age of closure over 48 years may be useful for predicting early new-onset atrial tachyarrhythmia after device closure.

Management of potential gas embolus during closure of an atrial septal defect in a three-year-old

Gas embolism occurring in adult patients supported with cardiopulmonary bypass is usually associated with mechanical complications. Management of gas embolism is less often described for the pediatric or neonatal patient. Measures to counteract gas embolism must be undertaken immediately if a satisfactory outcome is to be achieved. Here, the management of a three-year-old female patient, who was undergoing repair of a secundum atrial septal defect when the aortic cannula became dislodged and air entered the aorta, is described. Immediate implementation of an air embolism protocol, including (among other maneuvers) removal of air from the circuit, retrograde cerebral perfusion via the superior vena cava, and induction of cerebral hypothermia, may have aided in an acceptable outcome.

Contributors to and impact of residual shunting after device closure of atrial septal defects

BACKGROUND

The prevalence of residual shunt in patients after device closure of atrial septal defect and its impact on long-term outcome has not been previously defined.

METHODS

From a prospective, single-institution registry of 408 patients, we selected individuals with agitated saline studies performed 1 year after closure. Baseline echocardiographic, invasive hemodynamic, and comorbidity data were compared to identify contributors to residual shunt. Survival was determined by review of the medical records and the Social Security Death Index. Survival analysis according to shunt included construction of Kaplan-Meier curves and Cox proportional hazards modeling.

RESULTS

Among 213 analyzed patients, 27% were men and age at repair was 47 ± 17 years. Thirty patients (14%) had residual shunt at 1 year. Residual shunt was more common with Helex (22%) and CardioSEAL/STARFlex (40%) occluder devices than Amplatzer devices (9%; P = .005). Residual shunts were more common in whites (79% vs 46%, P = .004). At 7.3 ± 3.3 years of follow-up, 13 (6%) of patients had died, including 8 (5%) with Amplatzer, 5 (25%) with CardioSEAL/STARFlex, and 0 with Helex devices. Patients with residual shunting had a higher hazard of death (20% vs 4%, P = .001; hazard ratio 4.95 [1.59-14.90]). In an exploratory multivariable analysis, residual shunting, age, hypertension, coronary artery disease, and diastolic dysfunction were associated with death.

CONCLUSIONS

Residual shunt after atrial septal defect device closure is common and adversely impacts long-term survival.

Left Ventricular Non-compaction in Holt-Oram Syndrome

Holt-Oram Syndrome is an autosomal dominant condition with complete penetrance and which involves upper limb skeletal and cardiac abnormalities. The latter can be structural defects or involve the conduction system. This report details the occurrence of left ventricular non-compaction in multiple family members with Holt-Oram Syndrome. It is recommended that patients with the Holt-Oram Syndrome be considered for comprehensive cardiac evaluation to exclude non-compaction cardiomyopathy as this may have significant prognostic implications.

Longitudinal evaluation of P-wave dispersion and P-wave maximum in children after transcatheter device closure of secundum atrial septal defect

Transcatheter device closure of the secundum atrial septal defect (ASD) in children prevents atrial arrhythmias in older age. However, the benefits of favourable atrial electrocardiographic markers in these children remain elusive. We aimed to review the electrocardiographic markers of atrial activity in a longitudinal fashion. We retrospectively reviewed longitudinal data of all children who underwent transcatheter device closure at the National University Hospital between 2004 and 2013. The inclusion criteria included the presence of a secundum-type ASD with left to right shunt and evidence of increased right ventricular volume load (Q p/Q s ratio >1.5 and/or right ventricular dilatation). A total of 25 patients with a mean follow-up of 44.7 ± 33.47 (7.3-117.4) months were included. P maximum and P dispersion decreased at 2 months, P amplitude at 1 week and remained so until last follow-up. A positive trend was seen with a correlation coefficient of +0.12 for P maximum, +0.08 for P dispersion and 0.34 for P amplitude. There was a higher baseline P amplitude and P dispersion in patients who were older than 10 years and a non-significant trend to support an increase in both P maximum (71.0 ± 8.8 vs. 73.2 ± 12.7), P dispersion (17.0 ± 6.5 vs. 22.0 ± 11.3) and P amplitude (0.88 ± 0.25 vs. 1.02 ± 0.23) in patients with an ASD more than 15 mm compared with an ASD <15 mm. There is reduction in both P maximum and P dispersion as early as 2 months, which persisted on follow-up. Earlier closure may result in more favourable electrocardiographic results.

Isolated Atrial Septal Defect Complicated by Tricuspid Valve Infective Endocarditis

Infective endocarditis (IE) associated with atrial septal defect (ASD) is extremely rare. However, tricuspid regurgitation (TR) secondary to right ventricular overload is a potential cause of IE, and once it occurs, the development of a paradoxical embolism may lead to fatal complications. We herein report the case of a 50-year-old woman who was admitted due to a persistent fever resistant to antibiotics. Echocardiography showed secundum ASD, moderate TR and a mobile vegetation measuring 15×10 mm attached to the tricuspid valve. Given the risk of developing a paradoxical embolism, urgent surgery was successfully performed.

Recurrent Stroke/TIA in Cryptogenic Stroke Patients with Patent Foramen Ovale

Background:

Patent foramen ovale (PFO) is present in 40% of patients with cryptogenic stroke and may be associated with paradoxical emboli to the brain. Therapeutic options include antiplatelet agents, anticoagulation, percutaneous device and surgical closure. We assessed the hypothesis that there are differences in rates of recurrent TIA or stroke between patients in the four treatment groups.

Methods:

Patients presenting from January 1997 with cryptogenic stroke or TIA and PFO were followed prospectively until June 2003. Treatment choice was made on an individual case basis. The primary outcome was recurrent stroke. The secondary outcome was a composite of stroke, TIA, and vascular death.

Results:

Baseline. Our cohort consisted of 121 patients; 64 (53%) were men. Median age was 43 years. Sixty-nine percent presented with stroke and 31% with TIA. One or more vascular risk factor was present in 40%. Atrial septal aneurysm (ASA) was present in 24%. Treatment consisted of antiplatelet agents (34%), anticoagulation (17%), device (39%) and surgical closure (11%). Follow-up. Recurrent events occurred in 16 patients (9 antiplatelet, 3 anticoagulation, 4 device closure); 7 were strokes, 9 were TIA. Comparing individual treatments there was a trend toward more strokes in the antiplatelet arm (p=0.072); a significant difference was seen for the composite endpoint (p=0.012). Comparing closure versus combined medical therapy groups, a significant difference was seen for primary (p=0.014) and secondary (p=0.008) outcomes, favoring closure. Age and pre-study event predicted outcome.

Conclusion:

Patent foramen ovale closure was associated with fewer recurrent events. Complications of surgical and device closure were self-limited.

Outcome of patients undergoing open heart surgery at the Uganda heart institute, Mulago hospital complex

BACKGROUND

Heart disease is a disabling condition and necessary surgical intervention is often lacking in many developing countries. Training of the superspecialties abroad is largely limited to observation with little or no opportunity for hands on experience. An approach in which open heart surgeries are conducted locally by visiting teams enabling skills transfer to the local team and helps build to build capacity has been adopted at the Uganda Heart Institute (UHI).

OBJECTIVES

We reviewed the progress of open heart surgery at the UHI and evaluated the postoperative outcomes and challenges faced in conducting open heart surgery in a developing country.

METHODS

Medical records of patients undergoing open heart surgery at the UHI from October 2007 to June 2012 were reviewed.

RESULTS

A total of 124 patients underwent open heart surgery during the study period. The commonest conditions were: venticular septal defects (VSDs) 34.7% (43/124), Atrial septal defects (ASDs) 34.7% (43/124) and tetralogy of fallot (TOF) in 10.5% (13/124). Non governmental organizations (NGOs) funded 96.8% (120/124) of the operations, and in only 4 patients (3.2%) families paid for the surgeries. There was increasing complexity in cases operated upon from predominantly ASDs and VSDs at the beginning to more complex cases like TOFs and TAPVR. The local team independently operated 19 patients (15.3%). Postoperative morbidity was low with arrhythmias, left ventricular dysfunction and re-operations being the commonest seen. Post operative sepsis occurred in only 2 cases (1.6%). The overall mortality rate was 3.2.

CONCLUSION

Open heart surgery though expensive is feasible in a developing country. With increased direct funding from governments and local charities to support open heart surgeries, more cardiac patients access surgical treatment locally.

Shunt flow evaluation in congenital heart disease based on two-dimensional speckle tracking

High-frame-rate ultrasound speckle tracking was used for quantification of peak velocity in shunt flows resulting from septal defects in congenital heart disease. In a duplex acquisition scheme implemented on a research scanner, unfocused transmit beams and full parallel receive beamforming were used to achieve a frame rate of 107 frames/s for full field-of-view flow images with high accuracy, while also ensuring high-quality focused B-mode tissue imaging. The setup was evaluated in vivo for neonates with atrial and ventricular septal defects. The shunt position was automatically tracked in B-mode images and further used in blood speckle tracking to obtain calibrated shunt flow velocities throughout the cardiac cycle. Validation toward color flow imaging and pulsed wave Doppler with manual angle correction indicated that blood speckle tracking could provide accurate estimates of shunt flow velocities. The approach was less biased by clutter filtering compared with color flow imaging and was able to provide velocity estimates beyond the Nyquist range. Possible placements of sample volumes (and angle corrections) for conventional Doppler resulted in a peak shunt velocity variations of 0.49-0.56 m/s for the ventricular septal defect of patient 1 and 0.38-0.58 m/s for the atrial septal defect of patient 2. In comparison, the peak velocities found from speckle tracking were 0.77 and 0.33 m/s for patients 1 and 2, respectively. Results indicated that complex intraventricular flow velocity patterns could be quantified using high-frame-rate speckle tracking of both blood and tissue movement. This could potentially help increase diagnostic accuracy and decrease inter-observer variability when measuring peak velocity in shunt flows.

Conduction abnormality and arrhythmia after transcatheter closure of atrial septal defect

BACKGROUND

The aim of this study was to prospectively perform ambulatory 24-h ECG monitoring to assess the effects of transcatheter closure of atrial septal defect (ASD).

METHODS AND RESULTS

A total of 235 consecutive subjects (female, n=163; male, n=72; age, 44.6±14.4 years) were enrolled in the study, who were due undergo ASD closure. Holter monitoring was performed before procedure and at 1, 6 and 12 months of follow-up. During the procedure transient supraventricular arrhythmia occurred in 8 patients (3.4%), and bradycardia in 3 (1.3%). In 3 patients (1.3%) an episode of atrial fibrillation occurred in the first hour after the procedure. In 8 patients (3.4%) transient first-degree atrioventricular block was noted. A significant increase in number of supraventricular extrasystoles (SVES)/24 h was noted 1 month after the procedure (P<0.001). On multiple forward stepwise regression analysis, device size and fluoroscopy time had an influence on increase in number of SVES seen 1 month after the procedure (P<0.001).

CONCLUSIONS

Transcatheter closure of ASD is associated with a transient increase in supraventricular premature beats and a small risk of conduction abnormalities and paroxysmal atrial fibrillation in early follow-up. Transcatheter closure of ASD does not reduce arrhythmia that appears prior to ASD closure. Larger device size and longer procedure time are associated with increased risk of supraventricular arrhythmia on early follow-up.

[Dilated cardiomyopathy caused by p.E446K mutation in SCN5A gene]

Dilated cardiomyopathy (DCM) is myocardial disorder characterized by progressive heart chambers enlargement and impairment of myocardial contractility. This disorder is the most common cause of advanced heart failure requiring the heart transplantation. The prevalence of the disease is 36.5 per 100 000 in population. About 20-30% of cases are familial. Disease is genetically heterogenous, there more than 100 genes when mutated can give rise a DCM. In 2004, the role of SCN5A gene mutations was shown in origin of DCM with cardiac conduction defects and arrhythmias. In this work we present a clinical case of dilated cardiomyopathy with cardiac arrhythmias and p.E446K mutation in SCN5A gene. We have observed DCM with mild left ventricular hypertrophy, progressive AV block, atrial fibrillation and congenital heart defect (atrium septal defect) in two generations. The congenital heart defect did not co-segregate with SCN5A mutation and DCM.

Atrial septal defects

Atrial septal defects are the third most common type of congenital heart disease. Included in this group of malformations are several types of atrial communications that allow shunting of blood between the systemic and the pulmonary circulations. Most children with isolated atrial septal defects are free of symptoms, but the rates of exercise intolerance, atrial tachyarrhythmias, right ventricular dysfunction, and pulmonary hypertension increase with advancing age and life expectancy is reduced in adults with untreated defects. The risk of development of pulmonary vascular disease, a potentially lethal complication, is higher in female patients and in older adults with untreated defects. Surgical closure is safe and effective and when done before age 25 years is associated with normal life expectancy. Transcatheter closure offers a less invasive alternative for patients with a secundum defect who fulfil anatomical and size criteria. In this Seminar we review the causes, anatomy, pathophysiology, treatment, and outcomes of atrial septal defects in children and adult patients in whom this defect is the primary cardiac anomaly.

Automatic moment segmentation and peak detection analysis of heart sound pattern via short-time modified Hilbert transform

This paper proposes a novel automatic method for the moment segmentation and peak detection analysis of heart sound (HS) pattern, with special attention to the characteristics of the envelopes of HS and considering the properties of the Hilbert transform (HT). The moment segmentation and peak location are accomplished in two steps. First, by applying the Viola integral waveform method in the time domain, the envelope (E(T)) of the HS signal is obtained with an emphasis on the first heart sound (S1) and the second heart sound (S2). Then, based on the characteristics of the E(T) and the properties of the HT of the convex and concave functions, a novel method, the short-time modified Hilbert transform (STMHT), is proposed to automatically locate the moment segmentation and peak points for the HS by the zero crossing points of the STMHT. A fast algorithm for calculating the STMHT of E(T) can be expressed by multiplying the E(T) by an equivalent window (W(E)). According to the range of heart beats and based on the numerical experiments and the important parameters of the STMHT, a moving window width of N=1s is validated for locating the moment segmentation and peak points for HS. The proposed moment segmentation and peak location procedure method is validated by sounds from Michigan HS database and sounds from clinical heart diseases, such as a ventricular septal defect (VSD), an aortic septal defect (ASD), Tetralogy of Fallot (TOF), rheumatic heart disease (RHD), and so on. As a result, for the sounds where S2 can be separated from S1, the average accuracies achieved for the peak of S1 (AP₁), the peak of S2 (AP₂), the moment segmentation points from S1 to S2 (AT₁₂) and the cardiac cycle (ACC) are 98.53%, 98.31% and 98.36% and 97.37%, respectively. For the sounds where S1 cannot be separated from S2, the average accuracies achieved for the peak of S1 and S2 (AP₁₂) and the cardiac cycle ACC are 100% and 96.69%.

Follow-up of P dispersion after transcatheter closure of an atrial septal defect in children

OBJECTIVES

To determine in paediatric patients with atrial septal defects whether differences in P wave dispersion occurred with transcatheter closures using the Amplatzer septal occluder.

METHOD

A total of 31 children who had undergone transcatheter closures were evaluated. P maximum, P minimum, and P dispersion were measured with 12-lead surface electrocardiography, before the procedure and one week, one month, three months, six months and one year following the procedure. SPSS 10 was used for statistical analysis.

RESULTS

There were 23 (74.2%) females and 8 (25.8%) males with an overall mean age of 7.5 +/- 4.1 years and mean weight of 26.2 +/- 16.9 kg. The P maximum and P minimum measurements differed between patients during the follow-up period. Both measurements decreased with time. However, P dispersion was not significantly different throughout the follow-up period (before the procedure P maximum 95.4 +/- 15.6 ms, P minimum 64.5 +/- 15.4 ms, and P dispersion 30.8 +/- 11.4 ms; one year later, P maximum 76.1 +/- 14.6 ms, P minimum 47.1 +/- 12.1 ms, and P dispersion 29.1 +/- 9.1 ms).

CONCLUSION

Over time, there are no P dispersion differences in transcatheter closures using the Amplatzer septal occluder.

Influence of percutaneous atrial septal defect closure on inter- and intra-ventricular mechanical dyssynchrony in adults: evaluation of strain pattern

Previous studies using speckle-tracking echocardiography (STE) for quantifying the functions of the right and left ventricles (RV and LV, respectively) in the presence of percutaneous atrial septal defect (ASD) closure have focused on the peak systolic strain (PSS). This study investigated changes in the mechanical dyssynchrony of ventricular contraction before and after ASD closure, issues that have been little addressed in the literature. Thirty-one adults with ASD were studied using two-dimensional STE before and 24 h after ASD closure. Thirty-one healthy age- and sex-matched subjects were recruited as controls. Global and segmental PSS values from the longitudinal, circumferential, and radial directions were analyzed. The time to peak systolic strain (PSST) and the standard deviation of the time to peak strain (SDT) among segments in each direction were calculated, to investigate the inter- and intra-ventricular mechanical dyssynchrony in these patients and improvements after closure. Compared to the control group, patients with ASD had higher RV free-wall longitudinal systolic strain, with increased PSST and SDT. The SDT values of the LV longitudinal and circumferential strains were also increased. By 24 h after ASD closure, the RV free-wall longitudinal strain and its PSST and SDT had reverted to normal levels. The LV circumferential strain was increased, and its SDT was decreased. The contraction period of the RV and myocardial contraction dyssynchrony in the RV and LV were increased in ASD patients. The inter- and intra-ventricular mechanical utilities were improved after percutaneous closure of the ASD.

[Superior vena cava blood flow measurements for results prognosing of a bidirectional cava-pulmonary anastomosis in correction of hemodynamics parameters in patients with hypoplastic right ventricle]

The method of prediction the enability of closure atrial septal defect before operation or in pre-bypass period during the one and one-half ventricle repair of CHD with hypoplastic right ventricle was presented. The method is based on comparison of the initial blood flow on superior vena cava (SVC) and right-to-left shunt at atrial level. Defect can be closed if flow on SVC and shunt flow are approximately equal. According to prognosis in 16 of 37 patients defect was closed. After operation there were not signes congestive heart insufficiensy and cyanosis. This approach allowes to avoid reoperations at least in half of patients. If shunt flow exceeds flow on SVC, defect must be left open.

Circulating ghrelin was negatively correlated with pulmonary arterial pressure in atrial septal defect patients

BACKGROUND

Ghrelin was found to attenuate the magnitude of pulmonary arterial hypertension and pulmonary vascular remodeling in rats. The objective of this study was to explore the fasting plasma ghrelin level and the relationships between ghrelin and pulmonary arterial pressure (PAP) in atrial septal defect (ASD) patients with pulmonary arterial hypertension (PAH).

METHODS

Fasting plasma ghrelin, obestatin, and insulin levels were measured by enzyme linked immunosorbent assay (ELISA) method in ASD patients with or without PAH according to the manufacturer's instructions. Insulin resistance was calculated by the homeostasis model of assessment for insulin resistance (HOMA-IR) approach, calculated as fasting insulin (microunits/ml)× fasting blood glucose (mmol/L)/22.5. Comparisons between the parameters of patients with PAH and those of patients with normal PAP were performed with an unpaired Student's t test. The relationships between ghrelin and various clinical parameters were examined by bivariate correlations and multiple regression analysis.

RESULTS

We found that the fasting plasma ghrelin level and the ratio of ghrelin to obestatin were significantly lower in the PAH group compared with the control group ((582.4±12.8) pg/ml vs. (1045.2±95.5) pg/ml, P < 0.05 and 30.5±4.9 vs. 70.0±9.7, P < 0.01). The fasting plasma obestatin level was higher in the PAH group compared with the control group, but the difference between them was not significant ((23.2±3.1) pg/ml vs. (16.3±1.6) pg/ml, P > 0.05). In a multiple regression model analysis, only mean PAP was an independent predictor of ghrelin and the ratio of ghrelin to obestatin (standardized coefficient = -0.737, P < 0.001 and standardized coefficient = -0.588, P = 0.006, respectively).

CONCLUSION

Ghrelin is negatively correlated with mean PAP and this suggests that circulating ghrelin might predict the severity of pulmonary hypertension in ASD patients with PAH.

Improvement in cardiac structure and functions early after transcatheter closure of secundum atrial septal defect in children and adolescents

We sought to assess the effects of transcatheter closure of atrial septal defect (ASD) on right and left ventricular form and functions, as well as atrial volumes and pulmonary venous flows. We enrolled 25 patients (mean age: 9.02) prospectively who underwent successful transcatheter closure of secundum ASD. We performed transthoracic echocardiography, including two-dimensional, pulsed wave Doppler, M-mode echocardiography, and tissue Doppler imaging before the procedure and 1 day, 1 month, 3 months and 6 months after the procedure. Serum brain natriuretic peptide (BNP) levels were measured prior to the procedure, and 1 day, 1 month, and 3 months there after. Mitral inflow early diastolic wave increased significantly, while isovolumetric relaxation time and deceleration time did not change during the follow-up. The E/E' was also increased significantly during follow-up. After the closure, right ventricular size and right atrial volume reduced, while left ventricular size increased significantly. There was a statistically significant improvement in left and right ventricular Tei indices. Pulmonary vein systolic velocity and the ratio of systolic to diastolic wave decreased, while atrial reversal wave (ARW) velocity increased immediately after the procedure. Although the concentration of BNP was increased on the first day after the procedure, its levels reduced and had reached the pre-procedure values at 1 month of follow-up. In the study, a significant improvement in the right and left ventricular functions was detected after transcatheter closure of secundum ASD in the short-term follow-up. In addition, we found a significant reduction in right heart sizes with corresponding global functional improvement in the right ventricle after the procedure.

Transcatheter closure of atrial septal defects in adolescents and adults: technique and difficulties

AIM

to evaluate the results of transcatheter closure of atrial septal defect (ASD) in adolescents and adult.

METHODS

a case series of patients undergoing transcatheter closure of ASD in RS Cipto Mangunkusumo, Jakarta during 2002 -2013. Transesophageal echocardiography, hemodynamic study, and angiography were performed before the procedure. Oxygen test was done if PA pressure was more than 2/3 of aortic pressure, followed by an occlusion test if no response observed to determine whether the device could be released.

RESULTS

we enrolled 54 patients, of whom 26% were adolescents and 3% were males. Median body weight was 49 (26-75) kg and ASD size was 21 (9.4-39.6) mm. The procedure was done under general anesthesia in 26% of patients. Oxygen test was applied in 11% patients and occlusion test in 2% of patient. Transcatheter closure of ASD was successful in all patients using common technique (31%), right pulmonary vein-assisted (65%), left pulmonary assisted (2%), and cutting long sheath (2%). There was neither residual ASD nor complications observed. Mean fluoroscopy and procedure time were 29 (SD 18) and 109 (SD 36) minutes, respectively. Median hospital stay was 1 (1-3) day.

CONCLUSION

transcatheter closure of ASD in adolescents and adults is safe and effective.

[Age-related diagnostic features of congenital atrial septal defect in adults according to the data of radiodiagnostic studies]

OBJECTIVE

To reveal diagnostic features in atrial septal defect (ASD) in different age groups; to define a role of X-ray study in the diagnosis of ASD.

MATERIAL AND METHODS

Forty-eight patients (16 men and 32 women) aged 15 to 71 years with ASD at different sites were examined. All the patients underwent chest X-ray, echocardiography, and cardiac phase-contrast magnetic resonance imaging (MRI). The examinees were divided into 2 age groups: 1) less than 40 years (n = 18) and 2) more than 40 years (n = 30). The groups were compared using quantitative and alternative signs and they did not significantly differ in the volume of intracardiac shunt and in the size of the defect. The X-ray and MRI indicators reflecting the calibers of pulmonary arteries were also compared in patient groups with different pulmonary artery systolic pressures (PASP) (< 35, 36-60, and > 60 mm Hg).

RESULTS

The older age group more frequently showed signs of heart failure, valvular regurgitation, and an atypical X-ray pattern. The sizes of atria, pulmonary artery and its branches, and PASP were also increased in the older age group. The patient group with high PASP (> 60 mm Hg) significantly differed from the others in all the indicators analyzed. Normal PASP and moderate pulmonary hypertension groups greatly differed only in the Moore index.

CONCLUSION

Chest X-ray reflects rather precisely the hemodynamic type of the defect. High pulmonary hypertension has clear X-ray and MRI manifestations. The specificity of X-ray in the diagnosis of PASP is lower in the older age group due to the higher rate of an atypical X-ray pattern. Radiology is important in detecting pulmonary venous hypertension in patients with PASP. Pulmonary venous hypertension is indicative of elevated pressure in the left atrium and pulmonary veins and arises from different causes: shunt inversion, restrictive defect, mitral valve comorbidity, and left ventricular systolic and diastolic dysfunction.

Tel Hashomer camptodactyly syndrome: a case report

Tel Hashomer camptodactyly syndrome (THCS) is a rare autosomal recessive camptodactyly with muscular involvement. The manifestations of THCS other than camptodactyly are clubbed feet, thenar and hypothenar hypoplasia, abnormal palmar creases and dermatoglyphic ridges, spina bifida and mitral valve prolapse. The syndrome was first described by Goodman et al in 1972 and thereafter two further cases with similar phenotype were seen. Herein, we present another case report and review of the literature of other syndromes associated with camptodactyly and mitral valve prolapse. Further cases with this syndrome need to be reported for mapping of the candidate loci. This will help in planning management and genetic counselling.

Feasibility and safety of transthoracic echocardiography-guided transcatheter closure of atrial septal defects with deficient superior-anterior rims

Although previous studies showed that transthoracic echocardiography (TTE) can be used to guide transcatheter closure of atrial septal defect (ASD), whether TTE can be used to guide transcatheter closure of secundum ASD with a deficient superior-anterior rim is unknown and this critical issue was addressed in the present study. A total of 280 patients with secundum ASD who underwent transcatheter ASD closure were recruited and divided into groups A and B depending on ASD superior-anterior rim>4 mm (n = 118) or ≤4 mm (n = 162). TTE was used to guide Amplatzer-type septal occluder (ASO) positioning and assess residual shunt. Procedure success was defined as no, trivial and small residual shunt immediately after the procedure as assessed by color Doppler flow imaging. Group A and group B did not differ in complication rate (8.55% vs.7.55%), procedure success rate (98.3% vs. 95.0%) or complete closure rate immediately after the procedure (89.7% vs. 89.3%) or at 6-month follow-up (98.3% vs. 96.8%). The mean procedure and fluoroscopy time in group B were much longer than those in group A. In conclusion, the absence of a sufficient superior-anterior rim in patients undergoing percutaneous closure of secundum-type ASDs using fluoroscopic and TTE guidance is associated with slightly greater device malposition and migration as well as increased procedural and fluoroscopic times, but the overall complication rate did not differ with TTE guidance when compared to historical controls that used TEE guidance.

[Migraine and cadiac shunts - is there a link?]

Recently an association between migraine and cardiac shunts (e.g. through a patent foramen ovale, PFO) has been described. There is evidence from mostly retrospective case series that PFO closure can significantly improve migraine. On the other hand an increase in attack frequency or de novo migraine after percutaneous closure of an atrial septal defect has been described. Animal experiments showed that microemboli in the cerebral circulation can trigger a cortical spreading depression, which is believed the pathophysiological substrate of migraine aura. A randomized controlled trial that investigated PFO closure for treatment resistant migraine with aura was negative. It is currently discussed whether certain subgroups, who have a high risk for paradoxical embolism, might improve after PFO closer.

A tale of two balloons: assessment of hemodynamics with atrial septal defect temporary balloon occlusion

We describe two cases in which temporary balloon occlusion (TBO) was used to determine the suitability of atrial septal defect (ASD) closure. These cases underscore the utility of TBO in select patients undergoing percutaneous closure of ASDs.

[Visualization of right atrial flow patterns and quantification of pulmonary to systemic flow ratio in patients with atrial septal defect by vector flow mapping]

OBJECTIVE

To evaluate the ability of vector flow mapping (VFM) in visualizing right atrial flow and quantifying pulmonary to systemic flow ratio in patients with atrial septal defect (ASD).

METHODS

VFM was performed on 30 patients with ASD and 50 healthy volunteers. The pulmonary to systemic flow ratio (Qp/Qs) was calculated using VFM and spectral doppler compared with that obtained through oximetric data derived from cardiac catheterization.

RESULTS

Blood streams from superior and inferior caval veins did not collide but turned forward, contributing to a forward clockwise vortex during systole on the subcostal bi-atrial plane in the healthy volunteers. The vortex was disrupted continuously by a left to right shunt in the patients with ASD during the hole cardiac cycle. The Qp/Qs measured by VFM was less angle-dependent in all the cases than the other methods. The mean value of Qp/Qs of the healthy volunteers calculated by apical three-chamber view and apical five-chamber view ranged from 0.84:1 to 1.15:1, which is consistent with the theoretical value 1 of no left to right shunts. The values of Qp/Qs of patients with ASD measured by VFM and spectral doppler showed no significant differences with those obtained through oximetric data [(2.18 +/- 0.48) vs. (2.29 +/- 0.76), P = 0.29; (2.30 +/- 0.91) vs. (2.29 +/- 0.76), P = 0.86]. However, the Qp/Qs value measured by VFM had a better correlation with the oximetric data than that measured by spectral doppler (r = 0.71, P < 0.001 vs. r = 0.38, P < 0.05). The inter-observer and intraobserver variability of Qp/Qs measured by VFM was 9.84% and 9.86% respectively.

CONCLUSION

VFM can visualize right atrial flow field in patients with ASD and quantify Qp/Qs in a more accurate way than spectral dopler.

Continuous spinal anaesthesia for a total hip arthroplasty in a patient with an atrial septal defect

Atrial septal defect (ASD) is often diagnosed and repaired during childhood. Nevertheless, it is the most common congenital cardiac defect seen in adults. ASD is characterized by a left-to-right intracardiac shunt and pulmonary hypertension. Pulmonary hypertension increases perioperative risks of morbidity and mortality. We report the anaesthetic management of a 68-year-old woman with an unrepaired ASD, who underwent a total hip arthroplasty under continuous spinal anaesthesia.

AMPLATZER Septal Occluder failure resulting in paradoxical cerebral embolism

Patent foramen ovale and atrial septal defect are risk factors for paradoxical embolism and subsequent cerebral ischemic events. The transseptal passage of emboli from the right to the left cardiac chambers appears to play an important role. The therapeutic options are medical therapy (anti-aggregation or anticoagulation), surgical closure, or transcatheter closure. Transcatheter closure of atrial septal defects affords the advantage of closing an atrial defect without the associated morbidity of open-heart surgery and the bleeding sequelae of oral anticoagulation. After closure, however, the presence of a residual shunt is independently associated with an increased risk of recurrent ischemic events. Newer devices, such as the AMPLATZER Septal Occluder, have decreased the risk of residual shunting and thromboembolic events. In addition, they have a very low risk of device dislodgement, migration, and embolization.We describe the case of a 60-year-old woman with Ebstein anomaly and recurrent ischemic strokes who presented with acute ischemic infarcts and paradoxical embolism 3 years after undergoing transcatheter closure of an atrial septal defect. A right-to-left shunt through a displaced AMPLATZER Septal Occluder was detected. Pulmonary hypertension and resultant right ventricular failure and right atrial dilation could have contributed to the persistent shunting and paradoxical embolism.To our knowledge, the delayed dysfunction of an AMPLATZER Septal Occluder has not been reported. In addition to describing the patient's case, we review the relevant medical literature.