Atrial septal aneurysm: a new classification in two hundred five adults

Atrial septal aneurysm is a localized "saccular" deformity, generally at the level of the fossa ovalis, which protrudes to the right or the left atrium or both. For 39 months we prospectively analyzed 205 consecutive patients in whom atrial septal aneurysm was diagnosed echocardiographically. The direction and movement of atrial septal aneurysms were carefully studied in multiple views, and, according to our findings, we now propose a new classification: type 1R if the bulging is in the right atrium only, type 2L if the bulging is in the left atrium only, type 3RL if the major excursion bulges to the right atrium and the lesser excursion bulges toward the left, type 4LR if the maximal excursion of the atrial septal aneurysm is toward the left atrium with a lesser excursion toward the right atrium, type 5 if the atrial septal aneurysm movement is bidirectional and equidistant to both atria during the cardiorespiratory cycle. We found an incidence of 1.9%, a mean age of 63 years (25 to 97 years), a female/male ratio of 2:1, valvular regurgitation 74%, hypertension 64%, left ventricular hypertrophy 38%, coronary heart disease 32%, patent foramen ovale 32%, pulmonary hypertension 31%, stroke 20%, dysrhythmias 16%, valvular prolapse 15%, and atrial septal defect 3%. No differences were found between mobile and motionless types of atrial septal aneurysm. However, differences were found between predominantly left bulging or right bulging atrial septal aneurysm (134 versus 57 patients), as well as other variables. All types of atrial septal aneurysm have particular clinical or echocardiographic characteristics. The new classification is a complete, simple, and practical form. Atrial septal aneurysm is associated with congenital and acquired heart diseases but also can present as an isolated abnormality.     

Evaluation of right ventricular systolic pressure during incremental exercise by Doppler echocardiography in adults with atrial septal defect

STUDY OBJECTIVES: Pulmonary hypertension is the most important complication in patients with atrial septal defect (ASD), but its role in limiting exercise has not been examined. This study sought to evaluate exercise performance in adults with ASD and determine the contribution of elevated pulmonary artery pressure in limiting exercise capacity. DESIGN: We used Doppler echocardiography during exercise in 10 adults (aged 34 to 70 years) with isolated ASD (New York Heart Association class I, II) and an equal number of matched control subjects. Incremental exercise was performed on an electrically braked upright cycle ergometer. Expired gases and VE were measured breath-by-breath. Two-dimensional and Doppler echocardiographic images were obtained at rest prior to exercise to determine ASD size, stroke volume (SV), shunt ratio (Qp:Qs), right ventricular outflow tract (RVOT) size, and right ventricular systolic pressure at rest (RVSPr). Doppler echocardiography was repeated at peak exercise to measure right ventricular systolic pressure during exercise (RVSPex). RESULTS: Resting echocardiography revealed that RVOT was larger (21+/-4 vs 35+/-8 mm, mean+/-SD; p=0.0009) and RVSPr tended to be higher (17+/-8 vs 31+/-8 mm Hg; p=0.08) in ASD; however, left ventricular SV was not different (64+/-23 vs 58+/-23 mL; p>0.05), compared with control subjects. Despite normal resting left ventricular function, ASD patients had a significant reduction in maximum oxygen uptake (VO2max) (22.9+/-5.4 vs 17.3+/-4.2 mL/kg/min; p=0.005). RVSPex was higher (19+/-8 vs 51+/-10 mm Hg; p=0.001) and the mean RVSP-VO2 slope (1+/-2 vs 18+/-3 mm Hg/L/min; p=0.003) and intercept (17+/-4 vs 27+/-4 mm Hg; p=0.05) were higher in the ASD group. VO2max correlated inversely with both RVSPr (r=-0.69; p=0.007) and RVSPex (r=-0.67; p=0.01). CONCLUSION: These findings suggest that adults with ASD have reduced exercise performance, which may be associated with an abnormal increase in pulmonary artery pressure during exercise.     

Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect: an alternative approach

BACKGROUND: Minimally invasive cardiac surgical techniques recently have been applied in the management of a variety of intracardiac lesions. METHODS: Fourteen patients (6 boys and 8 girls; age, 8.9 +/- 5.5 years; body weight, 29.0 +/- 13.5 kg) were operated on using minimally invasive cardiac surgical techniques for the closure of a ventricular septal defect (subarterial in 11 patients and perimembranous in 3 patients). The operations were performed through a left anterior minithoracotomy and were guided by video-assisted endoscopic techniques under femorofemoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The right ventricular outflow tract was entered after pericardiotomy was performed. RESULTS: Closure of the defect (directly in 4 patients and by patch in 10 patients) was performed successfully in all patients. A right ventricular outflow tract obstruction and ruptured sinus of Valsalva aneurysm also were repaired in 1 patient each. The duration of cardiopulmonary bypass was 41 +/- 10 minutes (range, 28 to 100 minutes) and the total operative time was 2.2 +/- 0.8 hours (range, 1.3 to 3.5 hours). All the patients recovered rapidly from their operation and had an uneventful postoperative course. Follow-up (mean, 6.2 months; range, 6 to 9 months) was complete in all patients. There were no late deaths. Transthoracic echocardiographic examination showed no residual shunt and no aortic regurgitation in all patients. CONCLUSIONS: Our experience demonstrates that minimally invasive cardiac surgical techniques are technically feasible and an alternative option for the repair of a ventricular septal defect.     

Impact of ultrafiltration on blood use for atrial septal defect closure in infants and children

BACKGROUND: Infants and children undergoing open cardiac operations have a high incidence of blood product transfusion. Ultrafiltration has been shown to reverse hemodilution and improve myocardial function and hemodynamics after cardiopulmonary bypass (CPB). METHODS: The effect of ultrafiltration on the amount of blood transfusion and hospital charge in 39 consecutive patients who underwent elective atrial septal defect repair was examined. Patients in group I (n=26) had a conventional cardiopulmonary circuit prime with blood, whereas 13 patients had bloodless prime (group II). Ultrafiltration was used immediately after weaning from CPB in group II. The patients in group I received blood products after discontinuation of CPB to achieve a hematocrit of 30%. The amount of blood product used, hematocrit immediately after CPB and on arrival in intensive care unit, postoperative hemodynamics and saturations, total operating room charge, blood charge, hospital stay, and hospital charge were compared. RESULTS: Mean body weight (15.8 kg in group I versus 17.5 kg in group II) and preoperative hematocrit values (35.6% in group I versus 34.2% in group II) were similar. Mean hematocrit immediately after CPB was 22% and 14% in group I and II, respectively (p < 0.0001). The mean hematocrit upon arrival to the intensive care unit was 34% in group I and 22% in group II (p < 0.0001). The amount of blood product transfusion was 32 mL/kg in group I and 3 mL/kg in group II patients (p < 0.0001). The patients in group II had significantly less blood bank charges; however, operating room charges and total hospital charges were similar between the two groups. CONCLUSIONS: Elective atrial septal defect repair was performed with no blood product transfusion without increased morbidity or hospital stay. Ultrafiltration can be used to reverse hemodilution resulting from a bloodless CPB prime without an increase in hospital charge.     

Electrocardiographic abnormalities in hypothyroidism before and after exercise

Eleven men and 50 women with severe hypothyroidism were studied. All patients had a serum PBI less than 3.0 mug/100 ml, 131I 24 hours uptake less than 13% and a a photomotogram contraction and half relaxation time of 380 msec or more. Before exercise the mean +/- SE heart rate was 68.39 +/- 3.26/min, the PR interval 17.08 +/- 0.37 csec, the QRS voltage (sum of the QRS amplitude in leads I, II and III) 16.44 +/- 0.89 mm (10mm = 1.0 mV) and the T wave amplitude 0.06 +/- 0.15 mm. A significant correlation (p less than 0.05) existed between the PBI values and the QRS voltage. Following exercise there was a significant acceleration of the heart rate (+ 23.39/min, p less than 0.001), shortening of the PR interval (-0.66 csec, p less than 0.02) and T wave elevation (+ 0.40 mm, p less than 0.001). ST segment changes were not observed in any case. Replacement treatment in 7 cases resulted in a significant change in the resting heart rate (+ 11.86/min. p less than 0.025), PR interval (-3.28 mm, p less than 0.025) and T wave height (+ 2.50 mm, p less than 0.01). These findings suggest that exercise may be used in the differentiation between hypothyroidism and coronary heart disease. The theoretical importance of these findings is also discussed. An increase in cardiac energy demands during exercise may be the cause for some of the ECG changes observed on exertion.     

Immune parameters in athletes before and after strenuous exercise

Secretory IgA levels were studied in nationally ranked Nordic skiers before and after the national cross-country races held in February 1981. Comparing the skiers with age-matched controls, there was significantly lower level of salivary IgA before the race. Concentrations of IgA decreased further following the competition (50 kn for males; 20 km for females) to very low levels. There also were a significant increase in the percentage of B lymphocytes and a decrease in the null population (non-T, non-B) in the athletes after the race compared with the controls. The mechanism responsible for these changes is unknown, but the low salivary IgA levels may result from depletion of nasal fluid and/or malfunction of the mucosal plasma cells due to a decrease temperature in the mucous membranes. We speculated that a temporary antibody deficiency on the mucosal surface might lead to a susceptibility to acquiring viral and bacterial infections, especially during the interval immediately following strenuous exercise.     

Atrial arrhythmias in adults after repair of tetralogy of Fallot. Correlations with clinical, exercise, and echocardiographic findings

BACKGROUND: The long-term success of intracardiac repair of tetralogy of Fallot is hampered by the occurrence of arrhythmias. Numerous studies have stressed the potential role of ventricular arrhythmias. However, the importance of other arrhythmias in the morbidity of these patients appears to be underestimated. Furthermore, most follow-up studies have been limited to children or adolescents, whereas many patients have reached adulthood after earlier repair of tetralogy of Fallot. The aim of the present study was to determine the incidence of atrial fibrillation, atrial flutter, and other supraventricular arrhythmias in adult patients after intracardiac repair for tetralogy of Fallot and their correlation with surgical and clinical findings. METHODS AND RESULTS: The study group consisted of 53 consecutive patients referred to the Thoraxcenter adult congenital heart disease clinic. They underwent repair at a mean age of 9.1 years (range, 0.7 to 55 years). The median age at the time of study was 23.2 years (range, 15 to 57 years; mean age, 26.6 years), and the mean duration of follow-up of 17.5 years (range, 1.4 to 32 years) after surgery. Records were reviewed extensively for evidence of arrhythmias. The follow-up study included routine 12-lead ECG, 24-hour continuous ambulatory monitoring, and echocardiography, and 46 patients underwent exercise testing. Sinus node dysfunction was recorded in 19 patients (36%), of whom 4 required a permanent pacemaker. Atrial fibrillation or flutter was found in 12 patients, and other supraventricular tachycardias were found in 6. The former were more frequently of older age at follow-up. Antiarrhythmic therapy and cardioversion were typically directed at control of atrial (and not ventricular) tachyarrhythmias. Ten patients (19%) showed nonsustained ventricular tachycardia; they were older at initial surgery and older at follow-up and had more intracardiac repairs and longer cardiopulmonary bypass times. CONCLUSIONS: Despite an emphasis on ventricular ectopy in past series, the main sources of morbidity in adult patients after surgical correction of tetralogy of Fallot emanated from atrial arrhythmias, which were present in one third of the patients.     

Physical activity before and after exercise in women with chronic fatigue syndrome

Placenta growth factor (PlGF) is a homodimeric glycoprotein, 46-50 kDa in size, belonging to the vascular endothelial growth factor (VEGF) sub-family. It exists as two isoforms, PlGF-1 and -2, the latter having a heparin-binding domain. Like VEGF, it is a potent angiogenic factor; however, PlGF homodimers interact with the VEGF receptor Flt-1 (fms-like tyrosine kinase), but not with the kinase domain-containing region (KDR). Since PlGF is made by the human placenta and extravillous trophoblast (EV-T) cells of the human placenta express Flt-1 in situ, these cells may be responsive to PlGF. Therefore, this study examined whether first trimester EVT cells propagated in vitro expressed the mRNA or the protein of Flt-1 and PlGF, and whether exogenous PlGF-1 had any effect on EVT cell proliferation, migration or invasiveness. Immunocytochemical and RT-PCR analyses revealed that both normal and SV40 Tag-immortalized EVT cells expressed the protein and mRNA for Flt-1, but not for PlGF-1 or -2. Exogenous PlGF-1 stimulated proliferation (measured by 3H-thymidine uptake) of normal EVT cells in a concentration-dependent manner, but only in the presence of excess heparan sulphate proteoglycans (HSPGs). These results raise two possibilities: that exogenous PlGF-1 (in spite of having a low affinity for heparin) was sequestered away from its receptor because of binding to heparan sulphate proteoglycans on the EVT cell surface or the ECM, or that HSPGs could modify the interaction between Flt-1 and PlGF. PlGF-1, in the presence or absence of HSPGs, however, had no effect on EVT migration or invasiveness, when measured with a transwell invasion (in the presence of Matrigel) or migration (in the absence of Matrigel) assay. These findings place PlGF amongst a large group of growth factors that promote EVT cell proliferation without influencing their migratory or invasive behaviours, and suggest that PlGF-Flt-1 interactions may be regulated by HSPGs in situ.     

Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults

To ascertain the outcome of childhood vesicoureteric reflux (VUR), 226 adults (37 males), mean age 27 years, were studied after 10-35 years, extended to 41 years by postal questionnaire in 161. At presentation (mean age 5 years) all had VUR (grade III-V in 68) and urinary tract infection (UTI); there was renal scarring in 85 (acquired before referral in 11 and during follow-up in 1), hypertension in 6 and impaired renal function in 5. They were managed and followed prospectively by one paediatrician; 63% of these children remained free from UTI; VUR persisted in 63 and had resolved in 69% of 193 children managed medically. At follow-up, 61% of adults had remained free from infection; 17 adults had hypertension and/or raised plasma creatinine, 16 with scarred kidneys. Their deterioration was predictable because of scar type, blood pressure or plasma creatinine levels in childhood. No new scars developed after puberty. Renal growth rates were unaffected by initial severity or persistence of VUR. On the later questionnaire, 9 further adults, mean age 38 years, had moderate hypertension. The adults with complications were those with extensive renal scarring and/or at least borderline hypertension in childhood. Those with VUR, but no scarring, and managed carefully in childhood, did not suffer serious consequences as adults. There is a need for early recognition and treatment of children with VUR and UTI to limit scar development.     

Atrial septal defect with tricuspid valve regurgitation and heart failure in early childhood: report of a case with successful surgical management consisting of special patch closure technique and use of polydioxanone suture for the tricuspid annuloplasty

A management of surgery for infant having a small left ventricular cavity associated with atrial septal defect and tricuspid valve regurgitation was presented. A right upper part of the defect was remained in open during a patch closure of ASD and this portion was temporarily sutured by prolene stayed extracardialy through Waterston's groove. During 20 minutes after weaning from the cardiopulmonary bypass, left heart failure did not appear and then it was completely closed. DeVega's method was employed for the tricuspid valve regurgitation using a absorbale Polydioxanone suture, because of a growth of the sutured annulus. Postoperative course was uneventful and trivial tricuspid valve regurgitation was recognized in angiocardiographic studies performed in 2 weeks and 6 months after operation.     

Repeated vital capacity manoeuvres after cardiopulmonary bypass: effects on lung function in a pig model

Respiratory failure following cardiopulmonary bypass (CPB) is a major complication after cardiac surgery. A vital capacity inflation of the lungs, performed before the end of CPB, may improve gas exchange, but the necessity to repeat it is unclear. Therefore, we studied 18 pigs undergoing hypothermic CPB. A vital capacity manoeuvre (VCM) was performed in two groups and consisted of inflating the lungs for 15 s to 40 cm H2O at the end of CPB. In one group, VCM was repeated every hour. The third group served as controls. Atelectasis was studied by CT scan. Intrapulmonary shunt increased after bypass in the controls and improved spontaneously 3 h later without returning to baseline values. From 3 to 6 h after CPB, there was no more improvement and more than 10% atelectasis remained at 6 h. In contrast, the two groups treated before termination of CPB with VCM showed only minor atelectasis and no abnormal changes in gas exchange directly after bypass or later. We conclude that the protective effect of VCM remained for 6 h after bypass, and there was no extra benefit on gas exchange by repeating the VCM.     

Effects of differing intensities and formats of 12 months of exercise training on psychological outcomes in older adults.

The 12-mo effects of exercise training on psychological outcomes in adults (aged 50–65 yrs) were evaluated. Ss (N?=?357) were randomly assigned to assessment-only control or to higher intensity group, higher intensity home, or lower intensity home exercise training. Exercisers showed reductions in perceived stress and anxiety in relation to controls. Reductions in stress were particularly notable in smokers. Regardless of program assignment, greater exercise participation was significantly related to less anxiety and fewer depressive symptoms, independent of changes in fitness or body weight. It is concluded that neither a group format nor vigorous activity was essential in attaining psychological benefits from exercise training in healthy adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term change in exercise capacity, body mass, and pulmonary function in adults with cystic fibrosis

STUDY OBJECTIVES: Cross-sectional studies in patients with cystic fibrosis (CF) have shown that exercise capacity is correlated with pulmonary function and body mass. We have examined whether the same relationships are seen longitudinally in adults with CF. DESIGN: Subjects who first performed progressive maximal cycle ergometry between 1986 and 1989 were retested using an identical protocol a mean of 6.3 years later. PARTICIPANTS AND SETTING: Adults with CF attending a regional center. MEASUREMENTS AND RESULTS: The principal exercise measures were peak oxygen uptake (VO2peak), ventilation (VEpeak), oxygen saturation, and heart rate. Spirometry, weight, and height were also recorded at each time point. At baseline, subjects had a mean age of 19.8 years, body mass index (BMI) of 19.0, FEV1 of 69% predicted, VO2peak of 1.56 L/min, and VEpeak of 48.9 L/min. At repeated testing after a mean interval of 6.3 years, the FEV1 had fallen significantly to 54% predicted (p < 0.001) and the BMI had risen significantly to a mean of 20.9 (p < 0.001). There were no significant differences in VO2peak or VEpeak, although VEpeak was a significantly higher proportion (72% vs 61%) of predicted maximal voluntary ventilation. CONCLUSIONS: Adults with mild to moderate pulmonary dysfunction were able to increase body mass and maintain VO2peak despite a declining FEV1. VO2peak was not reduced by the decrease in FEV1 because VEpeak was unaffected. Improved nutrition may have contributed to maintaining fitness.     

Psychoneurotic characteristics of patients with anorexia nervosa before and after treatment and at follow-up 4-7 years later

In normotensive (NR) and spontaneously hypertensive rats (SHR) the cardiac vagal component of baroreceptor reflex was checked before and after intravenous infusion of clonidine (25-30 microgram/kg). 1) The decrease of heart rate due to the arterial baroreceptor reflex was the same in NR and in SHR. 2) Intravenous injection of clonidine produced much greater decrease of the heart rate in SHR than in NR. 3) After administration of clonidine the stimulation of arterial baroreceptors decreased the heart rate to the same low level in NR and SHR. In these conditions the maximal neurogenic slowing of the heart rate was probably achieved. 4) Atropine abolished almost completly heart rate change following baroreceptor stimulation or/and clonidine administration.     

Acute renal failure in blacks and Indians in South Africa--comparison after 10 years

Acute renal failure (ARF) has changed in its aetiology in developed Western countries. This study compares our experiences of the aetiology and incidence of ARF a decade after a previously recorded paper in the literature. The data of 226 patients with a diagnosis of ARF during a 3-year period from 1986 to 1988 was analysed. ARF in our study occurred at a younger age. Medical causes of ARF remain the dominant subgroup. There were female patients presenting with ARF associated with self-induced abortions. Toxins of a herbal variety and infections remain the commonest aetiological factors in the medical subgroup. Infections have replaced nephrotoxins as being the principal medical cause. There has been no major change in the incidence or aetiology of ARF over a decade. The prevention of ARF in blacks in sub-Saharan Africa is primarily concerned with the eradication of nephrotoxins and infections and a laxity in the abortion laws of the country. Only by an improvement in education, nutrition, socio-economic status and sanitation can one eradicate or diminish ARF in developing countries.     

Effects of exercising before versus after eating on dieting and exercise evaluations: A preliminary investigation.

Psychological processes may play a role in the evaluation of the effectiveness of exercise and subsequent food intake. In order to further investigate this phenomenon, the effects of the timing of exercise relative to an eating opportunity were evaluated. Female undergraduate participants who were of average weight and did not exercise regularly were randomly assigned to one of three conditions (exercise before eating [n = 10], exercise after eating [n = 11], or no exercise [n = 12]). Expectations of the effectiveness of the exercise, value of dieting, and intake were assessed. Participants who exercised after eating had higher expectations of the effectiveness of the exercise than those who exercised before eating, while those who exercised before eating reported valuing dieting more than controls. No effects on intake emerged; therefore, there appears to be a disconnect between dieting appraisals and actual eating behaviour. The results are discussed in relation to theories on conflicting goals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Growth hormone versus placebo treatment for one year in growth hormone deficient adults: increase in exercise capacity and normalization of body composition

OBJECTIVE: Studies with GH substitution in GH-deficient (GHD) adults lasting more than 6 months have so far been uncontrolled. End-points such as physical fitness and body composition may be subject to a considerable placebo effect which weakens the validity of open studies. We therefore tested GH (2 IU/m2 per day) versus placebo treatment for 12 months. DESIGN: Twenty-nine patients (mean age 45.5 +/- 2.0 years) with adult-onset GHD were studied in a double-blind, parallel design. Measurements of body composition by means of conventional anthropometry, bioelectrical impedance (BIA), CT scan and DEXA scan, exercise capacity, and isometric muscle strength were performed at baseline and after 12 months treatment. For body composition measurements a control group of 39 healthy, age and sex-matched subjects was included. RESULTS: Sum of skinfolds (SKF) at 4 sites decreased significantly after GH treatment. Total body fat (TBF) as assessed by DEXA and BIA was elevated at baseline but normalized after GH. TBF assessed by SKF revealed significantly higher levels compared to DEXA and BIA, although all estimates intercorrelated closely. Visceral and subcutaneous abdominal fat decreased by 25 and 17%, respectively after GH (P < 0.01) to levels no longer different from the control group. CT of the mid thigh revealed a significant reduction in fat tissue and a significant increase in muscle volume after GH treatment, both of which resulted in a normalization of the muscle: fat ratio (%) (placebo: 58:42 (baseline) vs 58:42 (12 months); GH: 66:34 (baseline) vs 72:28 (12 months) (P = 0.002); normal subjects: 67:33 (P < 0.05 when compared to 12 months placebo data)). Total body resistance and resistance relative to muscle volume decreased significantly after GH treatment suggesting over-hydration as compared to normal subjects. Exercise capacity (kJ) increased significantly after GH treatment (placebo: 54.7 +/- 9.8 (baseline) vs 51.6 +/- 8.2 (12 months); GH: 64.9 +/- 13.3 (baseline) vs 73.5 +/- 13.6 (12 months) (P < 0.05)). Isometric quadriceps strength increased after GH but no treatment effect could be detected owing to a small increase in the placebo group. Serum IGF-I levels (microgram/l) were low baseline and increased markedly after GH treatment to a level exceeding that of normal subjects (270 +/- 31 (12 months GH) vs 156 +/- 8 (normal subjects (P < 0.01)). The levels of serum electrolytes and HbA1c remained unchanged. The number of adverse effects were higher in the GH group after 3 months, but not after 6 and 12 months. CONCLUSIONS: (1) The reduction in excess visceral fat during GH substitution is pronounced and sustained; (2) beneficial effects on total body fat, muscle volume and physical fitness can be reproduced during prolonged placebo-controlled conditions; (3) uncontrolled data on muscle strength must be interpreted with caution; (4) a daily GH substitution dose of 2 IU/m2 seems too high in many adult patients.