Atrial septal pacing: a method for pacing both atria simultaneously

By pacing both atria simultaneously, one could reliably predict and optimize left-sided AV timing without concern for IACT. With synchronous depolarization of the atria, reentrant arrhythmias might be suppressed. We studied four male patients (73 +/- 3 years) with paroxysmal atrial fibrillation and symptomatic bradyarrhythmias using TEE and fluoroscopy as guides; a standard active fixation screw-in lead (Medtronic model #4058) was attached to the interatrial septum and a standard tined lead was placed in the ventricle. The generators were Medtronic model 7960. The baseline ECG was compared to the paced ECG and the conduction time were measured to the high right atrium, distal coronary sinus and atrial septum in normal sinus rhythm, atrial septal pacing, and AAT pacing. On the surface ECG, no acceleration or delay in AV conduction was noted during AAI pacing from the interatrial septum as compared with normal sinus rhythm. The mean interatrial conduction time for all 4 patients was 106 +/- 2 ms; the interatrial conduction time measured during AAT pacing utilizing the atrial septal pacing lead was 97 +/- 4 ms (P = NS). During atrial septal pacing, the mean conduction time to the high right atrium was 53 +/- 2 ms. The mean conduction time to the lateral left atrium during atrial septal pacing, was likewise 53 +/- 2 ms. We conclude that it is possible to pace both atria simultaneously from a single site using a standard active fixation lead guided by TEE and fluoroscopy. Such a pacing system allows accurate timing of the left-sided AV delay.     

Increased excretion of urinary transforming growth factor beta 1 in patients with diabetic nephropathy

Two cases of double outlet right ventricle with restrictive ventricular septal defect are described. This is an uncommon presentation that causes left ventricular dysfunction because of left ventricular outflow tract obstruction. The presence of an intact atrial septum leads to severe pulmonary hypertension, which tends to aggravate the right ventricular output. In the presence of a normal left ventricle, the authors suggest the possibility of enlargement of the ventricular septal defect in order to perform a biventricular repair. The association of a supramitral valve ring in both cases, and the isolation of the left subclavian artery and an aortopulmonary fenestration in one of these cases, are also discussed. In addition we explore factors that cause restrictive ventricular septal defects as well as the mechanisms that may lead to spontaneous closure of ventricular septal defect in a double outlet right ventricle.     

Transvasal closure of interatrial defects using the Babic double-umbrella occluder system

The purpose of the study was to assess the feasibility and safety of closure of atrial septal defects and patent foramen ovale by means of a new interventional technique. Transvasal closure of ostium secundum atrial septal defect and patent foramen ovale was performed in 18 patients using an occluder system for atrial septal defects. Two patients had undergone unsuccessful direct surgical closure years before. Implantation and follow-up were controlled using radiographic views both with and without contrast injection, transthoracic and multiplane transesophageal echocardiographic imaging, color Doppler sonography, and computed tomography. The defect was closed in 16 patients using 19 procedures. Removal of the devices through the sheath was indicated in 4 patients because of placement failure. Intraprocedural complications were ventricular fibrillation in one patient and fixation of the device in Chiari's network in an additional one. During 7-26 months follow-up occluder damage was seen in two patients and perforation of the left atrium in one patient. Thickening on the occluder surface was observed in two patients. There was no death. The system for closure of atrial septal defect is feasible and safe in patients with defects < or = 27 mm in diameter. Long-term observation of outcome is limited yet.     

Biatrial myxoma: a rare cardiac tumor

A previously healthy 48-year-old man presented to the hospital with a transient ischemic attack. Echocardiography revealed a large left atrial tumor with a second tumor in the right atrium. Surgical excision revealed a large left atrial myxoma with extension through the interatrial septum into the right atrium.     

Diagnosis of endocardial cushion defect with cross-sectional and M-mode scanning echocardiography. Differentiation from secundum atrial septal defect

Twelve cases of endocardial cushion defect were studied before and after operation with ultrasono-cardiotomography (tomography) cross-sectional echocardiography, two-dimensional echocardiography, B-scan echocardiography) and M-mode scan along a horizontal section of the heart. For comparison, 20 healthy subjects, 18 cases of mitral valvular disease, 4 cases of congestive cardiomyopathy, 1 case of partial anomalous pulmonary venous drainage, and 25 cases of atrial septal defect of secundum type were also examined with the same technique. In cases without cardiac malformation, the echo of the anterior mitral valve was usually continuous medially with that of the interatrial septum in the horizontal plane at the level of the membranous septum. This feature was clearly recorded in all cases with right heart enlargement. In ostium secundum atrial septal defect the echo of the anterior mitral valve continued into that of the interatrial septum. An echo interruption was shown, indicating the defect itself to be in the middle part of the interatrial septum. In all the cases of endocardial cushion defect which we examined discontinuity was shown between the echo of the anterior mitral valve and that of the interatrial septum. This discontinuity was interpreted as indicating the defect itself. The mitral valve ring echo was close to the basal end of that of the interventricular septum, possibly reflecting an abnormal attachment of the mitral valve. In all cases, after operation, the echo of the artificial interatrial septum was recorded, continuous with that of the anterior mitral valve. The features of the echocardiographic sweep from the anterior mitral valve to the interatrial septum were thus different in the three groups. These echocardiographic differences are thought to correspond to the anatomical differences between the normal, atrial septal defect of secundum type, and endocardial cushion defect, and are essential features differentiating them from each other.     

Identification of a human heart FABP pseudogene located on chromosome 13

Between June 1992 and January 1996, 27 patients aged 3.9 to 74 years with an ostium secundum (22 patients) or patent foramen ovale with right-to-left shunts (5 patients) underwent percutaneous closure of their atrial septal defects with the Sideris occluder. After a thromboembolic complication, transesophageal echocardiography was performed routinely after the procedure in 15 patients between 1 month and 2 years, and in 6 patients on the 15th day. Two patients died, on the 2nd day and 21st month, of non-related causes. After an average follow-up of 33 months, 59% of patients had complete occlusion of the atrial septal defects or only a minimal residual shunt. Displacement of the prosthesis was defects or only a minimal residual shunt. Displacement of the prosthesis was observed in 7 cases with no relationship to size: 4 parallel to the septum with reappearance or increase in shunt, 3 with tilting of the prosthesis. All of these patients had a large residual defect compared with 20% with a normally positioned prosthesis (p < 0.05). Tilting of the occluder was associated with left atrial thrombosis (present in 40% of these patients), complicated by systemic embolism in one case: there were no cases of left atrial thrombus in the 9 with complete occlusion and the 5 patients with an isolated residual defect (p < 0.05). Occlusion of atrial septal defect with the Sideris device is effective and a safe method in the majority of cases. However, a badly positioned prosthesis with a residual shunt should be extracted as seen as possible or within three weeks if displacement is observed at control echocardiography.     

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.     

Unroofed coronary sinus syndrome

Unroofed coronary sinus syndrome or coronary sinus septal defect is a rare congenital cardiac anomaly. We performed corrective operations in 9 patients with such condition. Of them, seven patients had the completely unroofed coronary sinus and persistent left superior vena cava (PLSVC) directly draining into the left atrium (LA). One patient had PLSVC and the partially unroofed terminal portion of the coronary sinus (CS), or sinus ostium open into LA. Another patient had total anomalous pulmonary vein connection and the partially unroofed mid-portion of CS without PLSVC. The operative methods of the unroofed coronary sinus included: ligating PLSVC and repairing ostium primum or secundum atrial septal defects in 4 cases; creating an intra-atrial tunnel from PLSVC to the right atrium (RA) and repairing the atrial septal defect in 2 cases; reconstructing the intra-atrial septal with a patch as a baffle to guide PLSVC or sinus ostium respectively towards RA in 2 cases; enlarging the defect on the coronary sinus roof and repairing the atrial septal defect of the coronary sinus type in one case. No patient died in this group. Because unroofed coronary sinus syndrome has atypical clinical manifestation and usually complicates varied congenital anomalies, its preoperative diagnosis is very difficult in some times and may draw the reliable support from echocardiography and catheterization. The operative program and method must depend not only upon its type but also upon PLSVC presence of absence, and communication between PLSVC and RSVC.     

Diversion of the inferior vena cava into the left atrium after repair of atrial septal defect with partial anomalous pulmonary venous drainage

An 11-year-old female had operative repair of atrial septal defect associated with partial anomalous pulmonary venous drainage by direct suture at 6-year-old. Postoperatively, cyanosis and nodal bradycardia were noted by physical exercise. During 5 years thereafter, the symptoms were gradually aggravated accompanying. Cardiac catheterization revealed diversion of the inferior vena cava into the left atrium. Oxygen sampling showed right to left shunt of 22% at the atrial level. At reoperation, orifice of the inferior vena cava into the right atrium became narrow 5 mm in diameter. After enlargement of the orifice, the atrial septum was created with a Gore-Tex patch to redirect the inferior vena cava to the right atrium. Post operative course was uneventful with disappearance of the cyanosis. The patient is up and well now 9 years after reoperation.     

Uptake of pre-emergent herbicides by corn: distribution in plants and soil

We experienced an uncommon case of coronary sinus atrial septal defect, which was not associated with a left superior vena cava (LSVC). A 29-year-old woman, who experienced fatigue during moderate exercises, was found to have the atrial septal defect located in the lower part of the septum by echocardiography preoperatively. On operation, the coronary sinus ASD was diagnosed. The ostium of coronary sinus was located in the left atrium. This type is classified as partially unroofed coronary sinus without LSVC. Our case, in the absence of the LSVC, was repaired by simple closure of the coronary sinus ASD, so the coronary veins drained into the left atrium. Postoperative course was uneventful.     

Right atrial isolation for atrial fibrillation associated with atrial septal defect

Two patients with atrial fibrillation associated with an atrial septal defect underwent simultaneous surgical correction of the atrial septal defect and right atrial isolation. The right atrium was surgically isolated while the continuity with the sinoatrial node was preserved in the remainder of the heart. After the operation, the patients maintained normal sinus rhythm for 99 and 65 months. Thus, right atrial isolation offers an alternative to the current surgical treatment for atrial fibrillation associated with an atrial septal defect.     

The management of severe subaortic stenosis, ventricular septal defect, and aortic arch obstruction in the neonate

Neonates with ventricular septal defect and aortic arch obstruction frequently have subaortic stenosis resulting from posterior deviation of the infundibular septum. Because the aortic anulus is often hypoplastic, making direct resection of the infundibular septum through the standard transaortic approach difficult, the optimal method of repair is uncertain. From September 1989 through November 1991, seven patients with ventricular septal defect, coarctation (n = 4), or interrupted aortic arch (n = 3) and severe subaortic stenosis underwent repair with use of a technique that included transatrial resection of the infundibular septum. Their ages ranged from 5 to 63 days (median 15 days) and weights from 1.3 to 5.4 kg (mean 3.1 kg). Only one patient was older than 1 month. The systolic and diastolic ratios of the diameter of the left ventricular outflow tract to that of the descending aorta were 0.53 +/- 0.09 mm (standard deviation) and 0.73 +/- 0.11, respectively. At operation, the posteriorly displaced infundibular septum was partially removed through a right atrial approach by resecting the superior margin of the ventricular septal defect up to the aortic anulus. The resulting enlarged ventricular septal defect was then closed with a patch to widen the subaortic area. In each patient the aortic arch was repaired by direct anastomosis. All patients survived operation; there was one late death from noncardiac causes 3 months after repair. The survivors remain well from 3 to 14 months after repair (mean 8 months). All are in sinus rhythm and none has a residual ventricular septal defect. One patient underwent successful balloon dilation of a residual aortic arch gradient late after repair. No patient has significant residual subaortic stenosis, although one has valvular aortic stenosis. This series suggests that in neonates with ventricular septal defect and severe subaortic stenosis resulting from posterior deviation of the infundibular septum, direct relief can be satisfactorily accomplished from a right atrial approach. This method provides effective widening of the left ventricular outflow tract and is superior to palliative techniques or conduit procedures.     

Atrial septal displacement for repair of anomalous pulmonary venous return into the right atrium

BACKGROUND: In the repair of anomalous connection of the pulmonary veins to the right atrium, the use of a baffle of pericardium to divert the pulmonary venous blood into the left atrium could cause pulmonary venous obstruction as a result of thickening of the pericardial patch. Anomalous pulmonary venous drainage to the right atrium caused by malposition of the atrial septum primum can be repaired by displacing the shifted septum primum to the normal position. METHODS: In 5 patients with total (n=2) or partial (n=3) anomalous pulmonary venous drainage into the right atrium, the septum primum was shifted toward the left atrium and the pulmonary veins drained into the anatomic right atrium despite their normal connection with the posterior wall of the left atrium. This method consisted of incision of the posterior edge of the atrial septum primum and displacement of the incised atrial septum between the anomalous pulmonary veins and both venae cavae. No patch was used. RESULTS: Postoperative echocardiography showed a wide pathway from the pulmonary veins to the left atrium with no stenotic portions. No atrial arrhythmias occurred after the operation. CONCLUSIONS: This technique may be advantageous because it allows for future growth of the route of the pulmonary venous pathway and avoids postoperative supraventricular arrhythmias.     

Pulsatile total cavopulmonary shunt for hypoplastic right heart syndrome with abnormal systemic venous return--a case report

A pulsatile total cavopulmonary shunt was successfully performed on a 5-year-old girl with hypoplastic right heart syndrome associated with abnormal systemic venous return; at the same time, modified mitral valve replacement was performed for mitral regurgitation. The right atrium, tricuspid valve and right ventricle were all extremely dimunitive. The diameter of the tricuspid valve was 50% of normal and the volume of the right ventricle was 8.6% of normal. In addition, there were severe subpumonary stenosis, a restrictive ventricular septal defect (VSD) and an atrial septal defect (ASD). The bilateral superior venae cavae (SVCs) and the hepatic vein drained to the left atrium, and the inferior vena cava was infrahepatically interrupted with a hemiazygos connection to the left superior vena cava. At the operation, each SVC was anastomosed end-to-side to each branch of the pulmonary artery (PA). The restrictive ventricular septal defect and stenotic subpulmonary lesion were left. The diameter of the ASD was reduced from 12 mm to 7 mm. The main PA was neither divided nor banded. The pulsatile blood flow from the left heart to the PA was regurated by a native restrictive VSD and stenotic subpulmonary lesion, and that from the right heart via the ASD was limited by reducing the size of the ASD. These described anatomic arrangements produced adequate antegrade pulsatile flow in the PA, which might prevent the development of pulmonary arteriovenous fistulae and, besides permit transfer of drainage of the hepatic vein from the left to the right atrium via the ASD in future.     

Temperature of the sclera during diathermocoagulation carried out in patients with retinal detachment

Regional coronary blood flow was measured by injecting radioactive microspheres (15 mum +/- 5 in diameter) into the left atrium of anesthetized ponies with surgically prepared open thorax before and during occlusion of the coronary arteries. The normal blood flow to the myocardium of the interventricular septum and the left ventricular wall were highest, followed in decreasing order by the right ventricular wall, the interatrial septum, the atrial walls, and the valves. Measurement of transmural blood flow in the normal left ventricle yielded a mean endocardial/epicardial flow ratio of 1.36 in the free wall. The left ventricular flow ratio was 1.33 in the septal wall. The percentage of the left ventricular myocardium made ischemic during occlusion of the right coronary artery or of the left coronary artery (cranial descending and circumflex arteries) was approximately equal. Blood flow to the ischemic areas of the left ventricle after occlusion of coronary arteries ranged from 3.8 to 20.6% of the normal flow. A disproportionate decrease in flow to the endocardial regions of the left ventricle was also observed in ischemic areas (mean inner/outer left ventricular wall flow ratio was 68.89% of the normal flow ratio).     

Handedness assessment inventory

A 6 year old boy with a large atrial septal defect, partial anomalous pulmonary venous drainage and unrecognized anomalous insertion of the inferior vena cava into the left atrium had cyanosis after closure of the atrial defect. Repeat study revealed direct drainage of the inferior vena cava into the left atrium with moderate arterial oxygen desaturation. At repeat operation an unusual positioning of the inferior vena cava was seen. After reopening of the atrial defect, the pulmonary venous and systemic venous drainage anomalies were identified. A Dacron patch was inserted so as to divert flow to the proper atrium. Repeat catheterization 3 months after operation revealed a normal heart with no obstruction; arterial oxygen saturation was normal. The child has continued to do well 3 years after operation.     

Lipomatous hypertrophy of the atrial septum: diagnosis with fat suppressed MR imaging

We present a case of a 50-year-old female evaluated for a 1-year history of numbness of the first and second toe of the right foot. Echocardiography performed in order to exclude cardiovascular compromise revealed a granular mass originating from the posterior part of the interatrial septum. On subsequent magnetic resonance imaging (MRI) with fat suppression sequences, the final diagnosis of lipomatous hypertrophy of the interatrial septum, a benign and underrecognized condition characterized by septal accumulation of fatty tissue, was made. Although no previous reports have focused on this, tailored cardiac MR with fat suppression sequences proved to be an excellent noninvasive method in assessing an accurate diagnosis and in differentiating lipomatous hypertrophy of the atrial septum from other cardiac neoplasms.     

Renovascular disease: the fifth frontier

BACKGROUND: Coronary sinus type atrial defect is the result of an incomplete formation of the atriovenous fold. This is a rare anomaly that in a very few cases took advantage of echocardiographic diagnosis before surgery. We report on a case of coronary sinus type atrial septal defect diagnosed by means of transthoracic and transesophageal echocardiography. PATIENT: A 65 year old woman who was admitted to hospital for evaluation of dyspnea and pre-syncope. A diagnosis of secundum type atrial septal defect had been achieved few months before. METHOD DESCRIPTION: Color Doppler transthoracic echocardiography demonstrated evidence of left-to-right shunt through the coronary sinus-left atrium common wall, while transesophageal echocardiography showed a defect in the coronary sinus roof in its terminal portion, proximal to the atrial septum. At that level the shunt flow was demonstrated by the presence of a negative contrast after contrast injection. Both transthoracic and transesophageal contrast echocardiographies demonstrated the persistence of a left superior vena cava draining into the enlarged coronary sinus: the existence of a right-to-left shunt at the coronary sinus level suggested by transthoracic echocardiographic examination was not confirmed by transesophageal echocardiography. CONCLUSIONS: This is one of the few reported cases of coronary sinus type atrial defect diagnosed noninvasively and the diagnostic usefulness of both transthoracic and transesophageal echocardiographic approaches is stressed.     

IGF system components as prognostic markers in breast cancer

Device closure of oval fossa atrial septal defects with the Amplatzer Septal Occluder was performed in 26 patients ranging in age from 0.89 to 60.44 years. In eight additional patients no device implant was performed because of the presence of multiple defects or because the defect was of a size unsuitable for closure with the devices currently available. The stretched diameter of the defects that were closed ranged from 4 to 23 mm (mean 14+/-5.4 mm) and device sizes ranged from 4 to 24 mm. Two devices were unstable, of which one embolized to the right atrium after release. Both devices were retrieved at the same procedure. One of these patients subsequently underwent a successful device closure of his defect using a larger (24-mm) device. Three patients had multiple defects, which were successfully closed with a single device. At 1-month follow-up 23/26 (88%) and at 3-month follow-up 22/24 (92%) patients had complete closure of their defects, while two had residual shunts. One further patient who had complete closure of his defect at 1-month post-implant had his device removed and his atrial septal defect patched surgically 8 weeks after device closure. This was done as a result of the development of a vegetation affecting the device after an episode of septicaemia, which was not related to the cardiac problems. There was no procedure-related morbidity or mortality and all patients remain well at the present time.     

Neuropsychological function in adults with attention-deficit hyperactivity disorder

Pacemaker therapy in patients with atrial fibrillation means the best current pacemaker therapy for patients with bradycardias with the aim to avoid the onset of atrial fibrillation and to establish DDD pacing despite of a history of atrial tachyarrhythmias. The newer application of pacing is the suppression of atrial arrhythmias in patients with medical refractory atrial tachyarrhythmias. Patients with slow ventricular rates and permanent atrial fibrillation should receive a VVI-pacemaker, if the bradycardias causes syncope, dizziness or a decrease of their exercise tolerance. In case of chronotropic incompetence the pacemaker should provide rate responsive pacing. Patients with sick sinus syndrome should receive an atrial (AAI) or dual-chamber (DDD) pacemaker, because patients with these in contrast to VVI-pacemakers develop less often atrial fibrillation and subsequent complications such as atrial thromboembolism. A dual-chamber or VDD-pacemaker--the latter connected to a VDD-single-lead--is indicated in patients with advanced AV-block. Atrial fibrillation occurs in 3 to 6% of the patients with no history of arrythmia and is, if pacemakers have no automatic mode switch, an often reason to program the devices to the VVI-pacing mode. Nowadays, most DDD(R)-pacemakers provide an automatic mode switch: During an atrial tachycardia the pacemaker switches to a VVI/VVIR mode and restores the initial DDD(R)-pacing mode with termination of the arrhythmia. In respect to the newer applications, one approach to prevent atrial tachyarrhythmias is permanent atrial pacing. As lower pacing rates of 80 to 90 ppm are usually needed and many patients hardly tolerate these pacing rates, new algorithms are under clinical investigation. Another approach is the simultaneous depolarization of the right and left atrium. Biatrial pacing is performed with one lead in the high right atrium and another lead in the coronary sinus. Another solution is bifocal atrial pacing with leads placed in the high right atrium and in the coronary sinus ostium. One effect of the new pacing techniques is to shorten interatrial conduction times. Therefore, biatrial pacing has become a therapy to prevent atrial arrhythmias deriving from delayed interatrial conduction times. As atrial reentry circuits seem to be important in atrial fibrillation, multisite atrial pacing is also performed in patients with medical refractory paroxysmal atrial fibrillation. Preliminary results suggest a more effective prevention of atrial fibrillation; nevertheless, these techniques should be still restricted to patients enrolled in clinical studies.