Transcatheter closure of atrial septal defects within the oval fossa: medium-term results in children using the 'ASDOS'-technique

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of the ASDOS-technique (Sulzer-Osypka GmbH, Germany) for transcatheter closure of atrial septal defects within the oval fossa. BACKGROUND: Although several attempts have been made to occlude defects within the oval fossa by transcatheter techniques, none of these has gained general acceptance. METHODS: Patients with a defect in the oval fossa measuring equal to or less than 20 mm diameter, with a residual septal rim of 5 mm or greater, body weight greater than 10 kg, with clinical indications for surgical closure were considered for transcatheter closure. Follow-up investigations were performed at discharge, after 1, 3, 6 and 9 months, as well as after 1 and 2 years. RESULTS: Of 78 patients considered for closure, a device was inserted in 41 patients (53%), with success being achieved in 40 patients (98%). The ages ranged from 1.1 to 15 years (7.8 +/- 1.92 years), the 'stretched' diameter of the defect from 10 to 20 mm (14.7 +/- 2.60 mm), and the diameters of the inserted devices from 25 to 45 mm (33.2 +/- 5.43 mm). Transient impairment of atrioventricular conduction occured in 4 patients. During the follow-up of 23.0 +/- 5.6 months elective surgical closure of a residual shunt was performed 26 months after insertion of the device in one patient. None of the other patients required surgery, hospitalisation or medical treatment, and none is requiring further treatment of the defect within the oval fossa. Fracture of one arm of the device occurred in 4 patients, but the fractured arms are in an unchanged and stable position after a period of at least 19 months. CONCLUSIONS: Our medium-term data show that transcatheter closure in children of defects within the oval fossa can be performed with a high efficacy and safety using the ASDOS-device.     

Dynamic three-dimensional echocardiographic reconstruction of congenital cardiac septation defects

DNA and FISH (fluorescence in situ hybridization) analysis were carried out in 12 patients with stigmata of Turner syndrome to determine whether the Supernumerary Marker Chromosome (SMC) found cytogenetically in each of these patients was derived from the Y chromosome. The presence of a Y chromosome in these patients may predispose them to develop gonadoblastoma. PCR-Southern blot analysis, followed by FISH, was used to detect the presence of Y chromosome material. The Sex determining Region Y (SRY), Testis Specific Protein Y-encoded (TSPY) and Y-chromosome RNA Recognition Motif (YRRM) genes, which map at Yp11.31, Yp11.1-11.2 and Yp11.2/Yq11.21-11.23, respectively, were selected as markers, because they span the whole Y chromosome, and more importantly, they are considered to be involved in the development of gonadoblastoma. It was shown that in 12 patients, all of whom had an SMC, the SMC of 11 was derived from the Y chromosome. Furthermore, the presence of the SRY, TSPY and YRRM gene sequences was determined and FISH analysis confirmed the Y origin of the SMCs. The methodology described in this report is a rapid, reliable and sensitive approach which may be easily applied to determine the Y origin of an SMC carried in Turner syndrome. The identification of an SMC is important for the clinical management and prognostic counseling of these patients with Turner syndrome.     

Transcatheter closure of atrial septal defect

Isolated secundum atrial septal defect is one of the most common congenital heart defects. Surgical closure is the treatment of choice but is associated with a chest scar, some morbidity and a relatively long recovery and the use of cardiopulmonary bypass. Transcatheter closure of secundum atrial septal defect is therefore an attractive approach. 3 children, aged 5-10 years, underwent successful transcatheter closure of moderate to large central atrial septal defects with the Cardioseal device. The procedures were performed under x-ray and transesophageal echocardiographic guidance. Our initial experience, and that of others, indicates that transcatheter occlusion of secundum atrial septal defects is safe and effective and can be an appropriate alternative in approximately 60% of patients.     

Transcatheter closure of patent ductus arteriosus in children and adults

AIM: To describe the initial New Zealand experience of transcatheter patent ductus arteriosus closure in adults and children. METHODS: Twenty-three children beyond infancy and four adults with isolated patent ductus arteriosus were selected for transcatheter umbrella closure. Rashkind umbrellas were placed across the patent ductus arteriosus through a percutaneously inserted long venous sheath using the Mullins technique. RESULTS: In 25 of the 27 patients a Rashkind umbrella was placed accurately. In two patients the umbrella could not be placed accurately: in one the procedure was abandoned uneventfully and in one the umbrella embolised to the right pulmonary artery necessitating surgical removal of the device and patent ductus arteriosus closure. There were no other significant complications. A second umbrella insertion is planned in two children for a significant residual leak at 1-year follow up. CONCLUSIONS: Transcatheter patent ductus arteriosus closure is a low risk and usually effective alternative to surgical closure for the majority of patients beyond infancy.     

Dynamic three-dimensional display of common congenital cardiac defects from reconstruction of two-dimensional echocardiographic images

PURPOSE: To investigate the effects of acetone or water based Gluma primers on bonding efficacy when applied to acid-etched wet, dry or rewetted dentin. MATERIALS AND METHODS: Shear bond strength (SBS, 24 hours) was measured on human dentin etched with 20% phosphoric acid gel and rinsed with water in the wet (blot dried), the conventional (2 seconds air blast), the dry (10 seconds air drying), and the rewetted stage (10 seconds air drying, remoistening and blot drying). The priming solution was either the original water based or an acetone based experimental Gluma primer. Cavity sealing performance and depth of resin impregnation were determined by solvent and by technique along the margins of 4.5 mm wide cylindrical dentin cavities with 90 degree cavosurface angle. RESULTS: The SBSs of the wet technique groups were approximately 18 MPa, irrespective of the primer solvent. Conventional drying gave an SBS almost as high (16.5 MPa). Rewetting was highly effective with acetone as the primer solvent. The dry techniques resulted in moderate (water) and poor (acetone) bond strengths. The cavity margins of acetone based primer treated specimens were consistently gap free with the wet technique. The other seven groups showed between two and six gaps in each group of six specimens. The resin impregnated layer (RIL) thicknesses were 12.5 microns approximately in the wet groups, and thus identical with the total depth of demineralization resulting from the 30-second etching. The alternative techniques showed significantly thinner RILs particularly in the dry groups (7.5 microns).     

Transcatheter closure of patent ductus arteriosus using controlled-release coils

Controlled-release coils have become available recently for the closure of patent ductus arteriosus (PDA). Transcatheter closure of patent arterial ducts was attempted in 13 patients, ranging in age from 5 months to 15 years, mean 4.1 years. Implantation of controlled-release PDA coils was attempted via the femoral artery through 5 Fr catheters in all cases except one, in whom both the femoral arterial and venous routes were used. The procedure was successful in 10 of the 13 patients. In these, the pulmonary artery systolic pressure ranged between 25 and 42 mmHg and the duct diameter varied from 1.5 to 6 mm at its narrowest point. Six of the patients received a single coil. Two coils were inserted in three patients and three coils in one patient. In three patients the ducts were too large for safe release of the coils, despite attempted implantation of up to three coils simultaneously. These coils were easily withdrawn into the catheter. Immediately at the end of the procedure, the duct was completely occluded in nine of the 10 patients, and in one patient there was a small residual flow. The procedure time varied between 35 min and 2.5 h, mean 81 min and the fluoroscopy time varied from 5 to 78 min, mean 25 min. None of the patients experienced hemorrhage, diminished lower extremity pulse, hemolysis or infection. In one patient, a 5 mm coil embolized into the right pulmonary artery soon after release. It was retrieved with a snare, then 8 mm and a 5 mm coil were implanted satisfactorily in the arterial duct. At follow-up by color Doppler echocardiography, the duct was completely occluded in all patients. Transcatheter closure of patent arterial ducts by controlled-release PDA coils is effective and safe. Even when more than one coil is inserted, it is still cheaper than transcatheter umbrella closure. This method is therefore of great value, particularly in less affluent countries.     

Transcatheter closure of a residual postmyocardial infarction ventricular septal defect with the Amplatzer septal occluder

Acute ventricular septal rupture following myocardial infarction carries a high mortality. Early surgery improves survival but long term outcome depends on residual shunting and left ventricular function. Residual shunting is common despite apparently successful closure and may require reoperation. Transcatheter closure is an established method of treating selected congenital defects but clinical experience of transcatheter closure in postinfarction ventricular septal rupture is minimal. Transcatheter closure of a residual ventricular septal defect was successfully done using a new device, the Amplatzer septal occluder, in a 50 year old Indian man who had previously undergone emergency surgical repair for postinfarction acute ventricular septal rupture. The technique is described and its potential as a treatment in postinfarction ventricular septal rupture, its possible complications, and the important aspects of case selection and device design are discussed.     

Neonates with congenital heart disease, Part II: Congenital cardiac defects with increased pulmonary blood flow

Generally, cardiac lesions with increased pulmonary blood flow demonstrate cardiomegaly, increased pulmonary vascular markings, and pulmonary congestion on the chest x-ray. These findings occur as a result of the following: 1. A left-to-right shunt or mixing lesion in which excess volume of blood flow causes dilation of cardiac chambers, resulting in the appearance of cardiomegaly, and in which increased pulmonary artery blood flow causes increased pulmonary vascular markings 2. Obstruction of blood flow that produces pulmonary venous hypertension and resultant pulmonary edema The next article in this series will address cardiac lesions with decreased pulmonary blood flow.     

Surgery in congenital heart defects: current developments and a few case examples

Congenital heart surgery includes the palliative treatment and surgical complete repair of cardiac malformations in newborns, children and adolescents. Palliative surgery allows early or long-term survival, depending on the primary malformation and the condition of the patient. Confection of a systemic-to-pulmonary shunt (the modified Blalock-Taussig shunt) allows in general recovery from severe cyanosis and leads to development of the hypoplastic pulmonary vascular tree in newborns with severe pulmonary stenosis. Longterm palliation can be applied to all patients in whom establishment of a biventricular heart can not be realized. The total cavo-pulmonary connection represents one possibility to bypass a single ventricle in these complex cases. Total repair allows the restitution of a completely normal anatomy and physiology after surgery; usually, this type of surgery is followed by a normalization of life expectancy with minimal pharmacotherapy. Preoperative diagnosis of congenital heart disease is reasonably performed by transthoracic echocardiography in the majority of cases. Cardiac catheterism is reserved for complex cases and those in which full hemodynamic evaluation is required for proper planning of surgery. Continuous improvement has been realized in the fields of cardiac anesthesiology and pediatric intensive care during the last decade; hence more and more complex cases have been accepted without any negative effect on the operative mortality. Additionally there has been a number of improvements in surgical and perfusion techniques, thus allowing open heart surgery in newborns with a minimal weight of 2000 g. Intraoperative transesophageal echocardiography is performed routinely and allows the proper control of surgical repair; furthermore this examination may be helpful during the weaning period from the extracorporeal circulation. There is a number of interesting topics that will take importance or will be developed in the near future: the role of interventional cardiology in pediatric patients gains more and more importance. There is a potential for minimally-invasive surgery and the number of potential candidates for heart transplantation may increase, due to the fate of long-term survivors after palliative surgery.     

Development of Ce-based sintered magnets: review and prospect

Ce-based magnets have attracted extensive attention in both academia and industry due to their excellent property-price ratio and distinctive phase structures.Characteristically,Ce-based sintered magnets have widely tunable magnetic properties with changing Ce contents.Therefore,they can be used to meet many different application requirements from packaging market to driving motors,etc.The intrinsic magnetic properties,phase composition,and microstructures of the Ce-based sintered magnets with different Ce contents have been summarized.The service performances such as temperature stability,corrosion resistance,mechanical properties and thermal expansion of commercial Ce-based sintered magnets are introduced.The research and development trends of the Ce-based magnets in the future are pointed out.     

Dental defects of congenital syphilis

Emotionally focused marital therapy (EFT), a marital therapy that particularly focuses on the creation of secure attachment, has proven in empirical studies to be effective for distressed couples. This paper discusses the application of EFT in couples where one or both of the partners have experienced significant trauma. EFT, in this context of trauma, incorporates the nine steps of conventional EFT and also encompasses the three stages of the "constructivist" self development theory of trauma treatment. This paper illustrates how the integration of EFT and trauma treatment can prove effective in treating not only relationship distress but also the individual symptoms of posttraumatic stress disorder (PTSD).     

Transcatheter embolization of a ruptured superior gluteal artery aneurysm: case report and review of the literature

PURPOSE: To report the successful coil embolization of a true gluteal artery aneurysm and review therapeutic options for this rare condition. METHODS AND RESULTS: A ruptured superior gluteal artery aneurysm in a symptomatic 80-year-old man was successfully thrombosed by embolization using a combination of Gianturco coils and helical platinum microcoils. Six-month computed tomography demonstrated persistent thrombosis of the aneurysm and resolution of the perivascular blood. CONCLUSIONS: This report offers support for the use of catheter-based techniques as an alternative to standard surgical repair of gluteal artery aneurysms.     

Percutaneous closure of congenital and iatrogenic coronary arterial fistulas

Coronary arteriovenous fistulas (CAF) are the most common hemodinamically significant congenital coronary anomalies. Surgery has been the only therapeutic option for ages. We describe three cases of percutaneous occlusion of CAF, congenital and iatrogenic, that we treated with different devices, to fit their different anatomic and functional characteristics. Case 1). Male patient (pt) 20 years old, asymptomatic, affected with CAF between the right coronary artery and the right ventricle, with aneurysmatic vessel dilatation and occlusion of the posterolateral branches. CAF has been occluded with a detachable, valvulated latex balloon, wedged into the proximal neck of the aneurysm. Case 2). Female pt 63 years old, who was symptomatic for exertion angina, affected with multiple CAF which originated from proximal and distal circumflex artery, proximal left anterior descending artery (LAD), all of which flowed into the left inferior lobar pulmonary artery. The fistulas have been occluded with steel and tungsten coils. Case 3). Male pt 62 years old, who underwent orthotopic cardiac transplantation in 1990 for dilated cardiomyopathy. Coronary angiogram at one year was normal, but subsequently a multilocular CAF between LAD in the middle portion and the right ventricle became evident. During angiographic follow-up an increase of the size of the fistula was observed, together with a reduction of that of distal LAD. For this reason a percutaneous occlusion with multiple tungsten coil has been performed. The three procedures have had a favorable outcome and we did not observe any acute or late complications; clinical and angiographic follow-up confirmed this satisfactory results at six months. Based on the data of the literature and on this experience, we conclude that percutaneous occlusion is the first line therapy of CAF and that the different devices can be tailored to meet different anatomic and functional characteristics.     

Folate supplementation and neural tube defects: a review of a public health issue

OBJECTIVE: To examine the causes and mortality of poisoning in Tehran. METHODS: The 7000 poisoning cases referred to Loghman-Hakim Hospital in Tehran over six months in 1994 were evaluated retrospectively. RESULTS: The overall female to male ratio was 1.8:1. Most poisonings occurred in the age range 2-6 y for children and 21-40 y for adults. Oral ingestion was the most common route of intoxication. In children, boys had a higher frequency of poisonings than girls. Most cases of children were referred to the hospital between 8 am and 8 pm. In adults referred to the hospital, there was little diurnal variation in poisoning presentations. In adults, drugs were the most common cause of intoxication (60.2%). Of these, benzodiazepines (24.5%) were the most frequent, followed by antidepressants (20.5%) and analgesics (18%). Pesticide and opiate intoxications were also commonly observed. In children, after drugs (32.1%), hydrocarbons were the most frequent cause of poisoning (19.2%). Pesticide poisonings were most often fatal (19.2%), followed by barbiturates (18.6%) and opiates (16.2%). Organophosphate insecticides were responsible for 57% of total pesticide poisoning cases. Of the deaths, 87.5% were attributed to suicide. CONCLUSION: The majority of poisoning cases in adults occur intentionally and in children accidentally.     

Neurally mediated syncope: a review of cardiac and arterial receptors

This article reviews the basic physiology of the reflexogenic areas of the heart and the mechano- and baroreceptors that regulate cardiovascular and autonomic homeostasis, all of which contribute to our understanding of the pathogenesis of neurally mediated syncope. The mechanisms of neurally mediated syncope may involve excessive activation of ventricular receptors that trigger severe hypotension and bradycardia. Thus, neurally mediated syncope may be the clinical expression of the Bezold-Jarisch reflex, which occurs in situations of increased sympathetic activity, perhaps as a result of heightened cardiac receptor sensitivity. The arterial baroreceptors exert a ubiquitous influence on the heart and circulation, and serve primarily to buffer transient changes in arterial pressure by transmitting sensory information regarding their stretch to the central nervous system. This information, in conjunction with cardiac receptor input, elicits alterations in neural efferent output from sympathetic and parasympathetic fibers to provide subtle, continuous regulation of beat-to-beat cardiovascular hemodynamics to an array of physiologic and psychological stressors.     

Distraction osteogenesis in congenital limb length discrepancy: a review

This paper reviews the technique of callotasis used to correct limb length discrepancy due to congenital causes. Many more lower than upper limb lengthening procedures have been reported. Despite the low complication rate reported by the originators of the technique, patients undergoing limb lengthening because of congenital problems are at significant risk of pin tract sepsis, joint contracture, nerve palsies, angular deformities and fracture through the regenerate bone. A minority of studies focus specifically on limb lengthening for congenital defects. Most series simply include some congenital patients, but it is difficult to retrieve the data, and to generalize from them. The amount of lengthening with an acceptable complication rate should not exceed 25%; of the initial bone length. Even using circular frames with small pins, practically all patients may be expected to develop at least one complication each, ranging from pin tract infection to the necessity of carrying out additional unplanned operative procedures either during or after the treatment period. The prevalence of major complications seems to be correlated with the complexity and the duration of the treatment. The functional outcome and the psychological problems associated with a lengthy procedure, which may require long periods of repeated hospitalization, have only rarely been studied. However, it appears that prolonged strength loss is frequent, and that significant psychological morbidity is experienced. Patients and their families should be counselled before and during the procedure on these lesser known aspects of callotasis lengthening.