Secundum Type Atrial Septal Defect Research Articles

Clinical experiences on correction of congenital heart diseases with robotic technology: a report of 160 cases

To summarize the clinical experiences on correction of congenital heart disease with robotic technology at a single center. Between January 2007 and May 2012, this retrospective study recruited 160 consecutive patients undergoing robotic surgery for congenital heart diseases. There were 74 males and 86 females with a median age of 35 years (range: 11-62). The procedures included secundum-type atrial septal defect repair (n = 130), ostium primum defect repair (n = 1), perimembranous ventricular septal defect repair (n = 21), mitral valve repair for anterior leaflet cleft (n = 7) and mitral valve repair plus left atrial myxoma resection (n = 1). Cardiopulmonary bypass graft was established through cannulation of right femoral artery, vein and right internal jugular vein under the guidance of transesophageal ultrasound. Myocardial protection was performed with cold blood cardioplegic solution or HTK solution and a transthoracic Chitwood clamp was used to occlude ascending aorta. Via three 8-mm ports and one 15-mm port in right chest, the microscopic instruments were manipulated to complete defect closure or mitral valve plasty, utilizing da Vinci S or da Vinci SI robotic system. Echocardiography was performed intraoperatively and at pre-discharge. Routine follow-ups were conducted. The clinical data of operating time, cardiopulmonary bypass time and follow-up examinations were retrospectively analyzed. All cases were treated successfully without a conversion into median sternotomy. No operative mortality or severe surgical complications were observed. Seventy-six cases of secundum-type atrial septal defect were completed on beating heart. The learning curves were noted for operating time of beating heart group and cross clamp time of arrest heart group. No residual shunt, malignant arrhythmia or mitral valve regurgitation was detected on intraoperative or postoperative echocardiography and during a median follow-up period of (29.1 ± 16.3) months. Robotic minimal access is technically feasible and it may be applied in selective patients with atrial septal defect, perimembranous ventricular septal defect and mitral valve cleft.

Two-dimensional speckle-tracking echocardiography is more accurate than tissue Doppler imaging in assessing regional atrial deformation: A study in patients after transcatheter atrial septal defect closure

There is currently no optimal method for quantifying left atrial (LA) mechanical function. Tissue Doppler (TD) and two-dimensional speckle-tracking (2DST) strains are 2 new echocardiographic tools for non-invasive assessment of LA global and regional deformation [1]. Although myocardial deformation indices measured by these 2 methods have been increasingly reported in studies, the precision of these measurements is largely unknown mainly due to the lack of a good reference standard. Amplatzer septal occluder (ASO) is a bulky device implanted at the inter-atrial septum in patient with a secundum-type atrial septal defect (ASD). It is non-contractile and only moves passively due to tethering effect of surrounding cardiac structures. These 2 characteristics can serve as an “ideal reference” to validate the accuracy of TD or 2DST strain in evaluating LA regional myocardial deformation. We prospectively studied 44 adult ASD patients 3 months after successful percutaneous implantation of ASO devices and 4 patients with atrial fibrillation or pacemaker, 5with poor 2D or TD image quality were excluded. Finally, the data of 35 patients (age 43±14 years, 25 females, heart rate 64±8 bpm) in sinus rhythm were analyzed. Thirty-five age-, genderand heart rate-matched normal controls (NC, age 48±7 years, 17 females, heart rate 67±9 bpm) were enrolled in the same period. Transthoracic echocardiography (Vivid 7, Vingmed-General Electric, Horten, Norway) was performed and both 2D (frame rate>50/min) and color TD (frame rate>100/min) images with 5 consecutive beats were digitally recorded. One optimal cardiac cycle was selected for quantitative off-line analysis using 2D strain software (EchoPac PC, version 7.0.0, Vingmed-General Electric) to obtain strain parameters. The size of the sample volume was set to 6×20 mm. It covered the whole atrial segment and can be positioned at the middle portion of the ASO compatible to 2D strain sample volume (Fig. 1). The total segmental longitudinal strain was measured at the peak points of both 2DSTor TD-derived strain curves during systolic phase. Categorical and continuous variableswere expressed as percentage andmean±SD, respectively. Chi-square test and independent/ paired t test were used for comparisons as appropriate. A p valueb0.05 was considered significant.

Transcatheter embolization of multiple intra-pulmonary arterio-venous fistulae with Amplatzer vascular plugs

A 56-year-old male was referred for percutaneous treatment of multiple-symptomatic persistent pulmonary arterio-venous fistulae (PAVFs). The patient's history included surgical repair of a secundum-type atrial septal defect with closure of right lung PAVFs in 1961, repeat transcatheter radiofrequency ablations for recurrent episodes of intra-atrial re-entrant tachycardia, and implantation of a transvenous dual-chamber pacemaker for sick sinus syndrome in 2002. Over the …

Early‐Mid Term Follow‐Up Results of Percutaneous Closure of the Interatrial Septal Defects with Occlutech Figulla Devices: A Single Center Experience

Percutaneous closure of secundum type atrial septal defect (ASD) and patent foramen ovale (PFO) has gained widespread use in recent years. Herein, we evaluated the safety and efficacy of the Occlutech® Figulla devices for PFO and ASD closure in a reference tertiary center. All 143 patients (46.9% male, mean age 39.3 ± 12.2 years) who underwent transcatheter PFO (n = 85) and ASD (n = 58) closure with Occlutech® Figulla devices between February 2009 and October 2011 were included in this study. An echocardiographic follow-up examination was performed at the 1st, 6th, and 12th month visits. The devices were successfully implanted in all 143 patients (100%). In-hospital periprocedural complications were device embolization (0.7%; 1 ASD patient), atrial fibrillation (1.4%; 1 ASD and 1 PFO patients), supraventricular tachycardia (0.7%; 1 PFO patient), and vascular access hematoma (0.7%; 1 ASD patient). Among ASD patients, 2 patients had trivial (jet width <1 mm in diameter) and 1 patient had small (1-2 mm) residual shunts before hospital discharge, which disappeared after the 6-month visit. During the mean 15.4 ± 9.6 months follow-up, all patients were asymptomatic and no ischemic stroke, cardiac perforation, device erosion, embolization, thrombus formation, or malposition of the device was observed. Percutaneous PFO and secundum type ASD closure with the novel Occlutech® Figulla Occluder devices without left atrial central pin and with significantly reduced meshwork was safe, feasible, and effective.

Surgical Strategy in Patients with Atrial Septal Defect and Severe Pulmonary Hypertension

The aim of the study was to review our experience with atrial septal defect (ASD) closure with a fenestrated patch in patients with severe pulmonary hypertension. Between July 2004 and February 2009, 16 patients with isolated ASD underwent closure with a fenestrated patch. All patients had a secundum type ASD and severe pulmonary hypertension. Patients ranged in age from 6 to 57 years (mean ± SD, 34.9 ± 13.5 years). The follow-up period was 9 to 59 months (mean, 34.5 ± 13.1 months). The ranges of preoperative systolic and pulmonary arterial pressures were 63 to 119 mm Hg (mean, 83.8 ± 13.9 mm Hg) and 37 to 77 mm Hg (mean, 51.1 ± 10.1 mm Hg). The ranges of preoperative values for the ratio of the pulmonary flow to the systemic flow and for pulmonary arterial resistance were 1.1 to 2.7 (mean, 1.95 ± 0.5) and 3.9 to 16.7 Wood units (mean, 9.8 ± 2.9 Wood units), respectively. There was no early or late mortality. Tricuspid annuloplasty was performed in 14 patients (87.5%). The peak tricuspid regurgitation gradient and the ratio of the systolic pulmonary artery pressure to the systemic arterial pressure were decreased in all patients. The New York Heart Association class and the grade of tricuspid regurgitation were improved in 13 patients (81.2%) and 15 patients (93.7%), respectively. ASD closure in patients with severe pulmonary hypertension can be performed safely if we create fenestration. Tricuspid annuloplasty and a Cox maze procedure may improve the clinical result. Close observation and follow-up will be needed to validate the long-term benefits.

Enlarged right ventricular size at 11 years’ follow-up after closure of secundum-type atrial septal defect in children

The fate of right ventricular dimensions after surgical closure of secundum-type atrial septal defects remains unclear. The objectives of this study were to assess ventricular dimensions, exercise capability, and arrhythmias of patients operated for secundum-type atrial septal defect and compare the results with those in healthy references. A total of 78 consecutive patients underwent surgical closure for a secundum-type atrial septal defect between 1990 and 1995. In all, 42 patients were included and underwent a cross-sectional evaluation including echocardiography, magnetic resonance imaging, exercise testing, and 24-hour ambulatory electrocardiography. Patients were matched with healthy controls for gender, body surface area, and age. The mean age at surgery was 4.6 plus or minus 2.8 years, and the mean age at follow-up was 16 plus or minus 3 years. There were no residual intracardiac lesions. The mean right ventricular endsystolic volume was significantly larger in patients (142 ± 26 millilitres) than in references (137 ± 28 millilitres; p = 0.04). In 25% of the patients, right ventricular end-systolic volume was larger than the 95th percentile for references. No relevant arrhythmias were detected. Exercise testing did not reveal differences with healthy references: maximal power (169 ± 43 Watt patients versus 172 ± 53 controls; p = 0.8), maximal oxygen uptake (38 ± 8 versus 41 ± 13 millilitres per minute per kilogram; p = 0.1). After surgical closure of secundum-type atrial septal defect, right ventricular end-systolic volume is increased. These findings have no impact on rhythm status or exercise capacity at this stage of follow-up, but may have implications for the timing of surgery or the technique of closure if confirmed in longer follow-up.

Right ventricular load and function during exercise in patients with open and closed atrial septal defect type secundum

This study aimed at evaluating (1) right ventricular (RV) mean power during exercise, (2) the contribution of flow and pressure to RV mean power, and (3) the impact of pulmonary artery pressure on RV function during exercise. Fifty patients with atrial septal defect (ASD) type secundum (20 open, 30 closed) were enrolled. All underwent standard echocardiography, a bicycle stress echocardiography, and symptom-limited cardiopulmonary exercise testing. RV mean power was calculated as the product of RV cardiac output and mean pulmonary artery pressure (mPAP). RV function was assessed using RV fractional area change (FAC) at rest and at peak exercise. RV mean power was linearly related with oxygen uptake (VO₂) in patients with open (R (2)= 0.88; p < 0.0001) and closed ASD (R(2)= 0.90; p < 0.0001). The increase in RV mean power was steeper in open than in closed ASD patients (p < 0.0001). The change in RV cardiac output (7.1 ± 3.4 vs. 5.7 ± 2.4 l/min; p = 0.132) was not statistically different, but the change in mPAP (21.7 ± 9.6 vs. 12.8 ± 4.6 mmHg; p < 0.0001) and RV mean power (0.97 ± 0.56 vs. 0.53 ± 0.22 W; p = 0.009) were higher in patients with an open ASD. The change in RV FAC from rest to peak exercise was related to peak mPAP in open (R = -0.589; p = 0.010) and closed (R = -0.450; p = 0.021) ASD patients. RV mean power during exercise is higher in patients with an open than in patients with a closed ASD. The workload of the RV in patients with an open ASD is higher at rest due to a left-to-right shunt, at peak exercise due to an additional increase in mPAP. A higher increase in afterload may affect RV function during exercise.

Pulmonary arteriovenous fistula coexisting with secundum atrial septal defect

Pulmonary arteriovenous malformations (PAVM) consist of an abnormal connection between the pulmonary artery and vein bypassing the pulmonary capillary bed. Pulmonary arteriovenous fistulae are characterized by a right-to-left shunt of variable magnitude, and they may be accompanied by other congenital anomalies. We describe a case of pulmonary arteriovenous fistula with a secundum type atrial septal defect (ASD) in a 38-year-old woman, who underwent successful transcatheter closure of both the ASD and PAVM.

Index of Suspicion * Case 1: Irritability and Signs of Peritonitis in a Neonate * Case 2: Red Eye, Excessive Tearing, Photophobia, Irritability, and Splenomegaly in an Infant * Case 3: 2-year-old Girl Who Has Cough, Right Pulmonary Abnormalities

* ALL: : acute lymphoblastic leukemia CT: : computed tomography IVC: : inferior vena cava NA: : neonatal appendicitis NEC: : necrotizing enterocolitis WBC: : white blood cell A 7-day-old boy born at term is brought to the emergency department by his foster mother for refusal to feed for ∼20 hours and increased crying, although he is intermittently consolable. When given his bottle, the infant starts to suck but then cries as though in pain. He has not vomited, and his last bowel movement was yesterday. The stool has been moderately well formed without blood or mucus, and wet diapers have continued. There is no history of respiratory symptoms, lethargy, rashes, or jaundice. The biological mother is a 27-year-old woman with a known history of previous drug abuse; she had received some prenatal care. This infant was born by scheduled cesarean delivery. Initial physical examination reveals a crying but consolable neonate. His temperature is 37.7°C, heart rate is 170 beats/minute, and respiratory rate is 56 breaths/minute; the remainder of his findings are normal. His complete blood count (white blood cell [WBC] 11.7 × 109/L, 78.5% neutrophils, 11.4% monocytes, 9.8% lymphocytes), serum concentrations of electrolytes and glucose, urinalysis, and cerebrospinal fluid studies are normal. Cultures are obtained. An abdominal radiograph is normal and abdominal ultrasonography reveals trace pelvic fluid. He is given a bolus of normal saline and is started on antibiotics to treat possible sepsis. A few hours after admission, repeat examination is concerning for inconsolability, poor suck reflex, and lethargy. His abdomen is distended, firm, and tender to palpation. Bowel sounds are normal. Further studies are performed that reveal the diagnosis. A previously healthy 10-month-old boy is seen for a 2-week history of an erythematous left eye with tearing. Earlier, he was diagnosed as having conjunctivitis at an urgent care clinic and was treated with a 10-day course of polymyxin B/trimethoprim eye drops without improvement. He has felt warm intermittently but has not had a …

Thrombosis on implanted device for atrial septal defect closure or echocardiographic beam width artifact? a diagnostic enigma!

A 29 year old woman with NYHA functional class II and large secundum type atrial septal defect (ASD) underwent successfully percutaneous ASD closure with Figula ASD occluder (no. 30) without any peri-procedural complication. After 2 days she underwent transthoracic echocardiography and a large hypo-echoic mass was seen on left atrial side of implanted device in multiple views, suggestive of thrombosis or echocardiographic beam width artifact? A diagnostic enigma!

Chromosome 4q deletion syndrome: Narrowing the cardiovascular critical region to 4q32.2–q34.3

The 4q deletion syndrome is a rare chromosome deletion syndrome with a wide range of clinical phenotypes. There is limited clinical phenotype and molecular correlation for congenital heart defects (CHDs) reported so far for this region primarily because many cases are large deletions, often terminal, and because high-resolution array has not been reported in the evaluation of this group of patients. CHDs are reported in about 60% of patients with 4q deletion syndrome, occurring in the presence or absence of dHAND deletion, implying the existence of additional genes in 4q whose dosage influences cardiac development. We report an 8-month-old patient with a large mid-muscular to outlet ventricular septal defect (VSD), moderate-sized secundum-type atrial septal defect (ASD), thickened, dysplastic pulmonary valve with mild stenosis and moderate pulmonic regurgitation, and patent ductus arteriosus (PDA). Illumina CytoSNP array analysis disclosed a de novo, heterozygous, interstitial deletion of 11.6 Mb of genomic material from the long arm of chromosome 4, at 4q32.3-q34.3 (Chr4:167236114-178816031; hg18). The deleted region affects 37 RefSeq genes (hg18), including two provisional microRNA stemloops. Three genes in this region, namely TLL1 (Tolloid-like-1), HPGD (15-hydroxyprostaglandin dehydrogenase), and HAND2 (Heart and neural crest derivatives-expressed protein 2), are known to be involved in cardiac morphogenesis. This report narrows the critical region responsible for CHDs seen in 4q deletion syndrome.

Transcatheter therapies for congenital heart disease in Taiwan

The heart is made up of many different cell types, including myocytes, fibroblasts and vascular cells. The cardiac myocyte, although not likely to divide, may respond to gross organ injury by a process of growth or hypertrophy. Cellular hypertrophy, though a normal biological adaptation, has the potential to contribute to the change in the shape and the size of the heart, such as occurs in chronic heart failure. We are now just beginning to understand the signals and early pathways involved in the cardiac myocyte growth response, some of which are reviewed herein.

Percutaneous closure of multiple atrial septal defects and patent ductus arteriosus during the same session

An alternative to the surgical repair of secundum type atrial septal defects (ASD) and of patent ductus arteriosus (PDA) is transcatheter closure. However, there is limited information about the efficacy of using percutaneous devices to close multiple ASDs. An 8-year-old female patient was admitted to our hospital with a cardiac murmur. A large secundum multi-fenestrated ASD (17 mm, 4.5 mm, 3 mm) and PDA (3 mm) were diagnosed upon echocardiographic examination. During cardiac catheterization, the PDA was closed with an Amplatzer Duct Occluder (6x4 mm) followed by the closure of the ASD with an Amplatzer septal occluder (22 mm) with no residual shunting. The percutaneous closure of multi-fenestrated ASD with PDA in pediatric patients may be considered as a first-choice treatment with minimal complications.

Cardiac Alpha-Myosin (MYH6) Is the Predominant Sarcomeric Disease Gene for Familial Atrial Septal Defects

Secundum-type atrial septal defects (ASDII) account for approximately 10% of all congenital heart defects (CHD) and are associated with a familial risk. Mutations in transcription factors represent a genetic source for ASDII. Yet, little is known about the role of mutations in sarcomeric genes in ASDII etiology. To assess the role of sarcomeric genes in patients with inherited ASDII, we analyzed 13 sarcomeric genes (MYH7, MYBPC3, TNNT2, TCAP, TNNI3, MYH6, TPM1, MYL2, CSRP3, ACTC1, MYL3, TNNC1, and TTN kinase region) in 31 patients with familial ASDII using array-based resequencing. Genotyping of family relatives and control subjects as well as structural and homology analyses were used to evaluate the pathogenic impact of novel non-synonymous gene variants. Three novel missense mutations were found in the MYH6 gene encoding alpha-myosin heavy chain (R17H, C539R, and K543R). These mutations co-segregated with CHD in the families and were absent in 370 control alleles. Interestingly, all three MYH6 mutations are located in a highly conserved region of the alpha-myosin motor domain, which is involved in myosin-actin interaction. In addition, the cardiomyopathy related MYH6-A1004S and the MYBPC3-A833T mutations were also found in one and two unrelated subjects with ASDII, respectively. No mutations were found in the 11 other sarcomeric genes analyzed. The study indicates that sarcomeric gene mutations may represent a so far underestimated genetic source for familial recurrence of ASDII. In particular, perturbations in the MYH6 head domain seem to play a major role in the genetic origin of familial ASDII.

Pregnancy with both secundum type atrial septal defect and pulmonary hypertension

Atrial septal defect (ASD) is the most common congenital heart disease in adulthood. Although usually clinically asymptomatic in adult patients, it may become symptomatic with rhythm disorders and shortness of breath. Prognosis of pregnancy with congenital heart disease and health of infant were affected by several factors such as location of cardiac defect, presence or absence of cyanosis, degree of pulmonary vascular resistance, hemoglobin level, functional capacity and history of surgical repair. In this case, we presented a 29 years old, 15 weeks pregnant women with previously unknown congenital heart disease who had complaints of shortness of breath and palpitations. In physical examination, we found a grade 2/6 systolic murmur on mezocardiyak focus and 3/6 on tricuspid focus. Transthoracic echocardiography showed secundum type ASD (3 cm), severe right ventricular enlargement, moderate tricuspid regurgitation and increased pulmonary artery systolic pressure (60 mmHg). Pregnancy was terminated and the ASD was occluded surgically in elective conditions.

Evaluation of Right Ventricular Function in Early Period Following Transcatheter Closure of Atrial Septal Defect

There is limited data on alterations in novel right ventricular (RV) function indices like tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (TASV) after transcatheter atrial septal defect (ASD) closure. We aimed to evaluate RV function by echocardiography (ECG) with these novel indices in early period in patients with secundum-type ASD that was closed percutaneously. Patients were enrolled to study if they had secundum-type ASD that was suitable for percutaneous closure. Patient population consisted of 4 men and 16 women. Echocardiography was performed before and 1 month after closure. Mean age was 37 ± 16. Mean diameter of ASD and total atrial septum length measured by ECG were 19 ± 6 mm and 49 ± 7 mm, respectively. Mean diameter of defect in transesophageal echocardiography was 20 ± 6 mm. Stretched mean diameter in catheterization was 23 ± 6 mm. One month after closure, there were statistically significant decreases in RV end-diastolic diameters (43.3 ± 10.7 mm vs. 34.9 ± 5.5 mm; P < 0.001), RV/left ventricular (LV) end-diastolic diameter ratio (1.1 ± 0.3 vs. 0.87 ± 0.1; P < 0.001), TASV (16.9 ± 3.2 cm/sec vs. 14.3 ± 3.3 cm/sec; P < 0.05), early diastolic tricuspid annular velocity (15.3 ± 3.1 cm/sec vs. 13.4 ± 2.4 cm/sec P <0.05), late diastolic tricuspid annular velocity (16.2 ± 5.4 cm/sec vs. 14.3 ± 6.3 cm/sec; P < 0.05), and TAPSE (29.9 ± 6.2 mm vs. 22.4 ± 7.4 mm; P < 0.001). LV end-diastolic diameter (38.0 ± 6.9 mm and 40.0 ± 4.5 P < 0.05) was increased, whereas there was no change in LV ejection fraction. Closure of ASD by using Amplatzer devices led to decrease in right heart chamber size, tissue Doppler-derived tricuspid annular velocities and TAPSE in early period.

Neurohormonal and cytokine fluctuations following transcatheter closure for an atrial septal defect

IntroductionInflammation and neurohormonal activation are considered to be involved in the development of earlier and/or later complications in congenital heart disease patients, even after a successful repair of the lesion. It is not yet clarified what is the role of the therapeutic interventions in the occurrence of such a response and how it could be associated with possible postoperative complications. AimWe sought to assess the inflammatory and neurohormonal response to transcatheter closure of secundum type atrial septal defects (ASD) over a six-month follow-up period. We also evaluated the association between the respective markers and catheterization data as well as echocardiographic measurements. MethodsPlasma concentrations of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), interleukin-10 (IL-10), N-terminal-proatrial natriuretic peptide (NT-proANP) and N-terminal-probrain natriuretic peptide (NT-proBNP) were assessed and echocardiographic measurements were performed in twenty-eight patients with atrial septal defect prior to, and at the first, second and sixth months post transcatheter closure. Thirty-three age-matched healthy volunteers were also enrolled. ResultsIL-6 plasma levels, although higher preoperatively, [physical logarithm (ln) IL-6: 3.37±0.66 vs 2.92±0.44pg/ml, p=0.015], reached control levels postoperatively, at the end of the third month, whereas TNF-α and IL-10 were not influenced by the procedure. NT-proANP levels were elevated preoperatively compared to the control group (ln NT-proANP 3.78±0.572 vs 3.48±0.30, p=0.031), with a further significant increase during the 1st month (ln NT-proANP 3.78±0.572 vs 4.2±0.42, p=0.006), following the pattern of the left atrial volume enlargement, and remained high even 6months after the procedure .On the other hand, the initially normal concentrations of NT-proBNP, after a transient significant increase during the first month postoperatively (ln NT-proBNP 3.56±0.94 vs 4.58±0.91, p<0.0001) returned to the controls’ levels at the end of the third month. Preoperative concentrations of NT-proANP positively correlated with NT-proBNP concentrations and pulmonary to systemic flow ratio (Qp/Qs). ConclusionsTranscatheter closure could improve, on a mid- term basis, the inflammatory process but natriuretic peptides’ secretion continues in parallel with left atrial volume increase. Further follow up is required to determine the long-term progress of the inflammatory and neurohormonal response to the procedure.

Acute thrombus formation on an Amplatzer device during transcatheter closure of an atrial septal defect in a patient with homozygous factor V Leiden mutation

A 32-year-old woman underwent transcatheter closure of a secundum type atrial septal defect with the Amplatzer device. The procedure was started under premedication with aspirin, clopidogrel, and heparin. During the procedure, a highly mobile thrombus attached to the left atrial disc of the device was detected by transesophageal echocardiography (TEE). The device and the associated thrombus were successfully withdrawn and the patient was started on a combination of heparin and tirofiban infusion. The procedure was successfully completed without any recurrent thrombus formation or residual shunt. Further investigation for thrombophilia revealed homozygous factor V Leiden mutation and the patient was started on a life-long warfarin therapy. Follow-up TEE showed proper device position with no recurrent thrombus and the follow-up was uneventful.

Interatrial shunt: diagnosis of patent foramen ovale and atrial septal defect with 64-row coronary computed tomography angiography

The aim of this study was to investigate the frequency with which interatrial shunts are found during routine coronary computed tomography (CT) angiography and to describe imaging characterizations of patent foramen ovale (PFO), atrial septal defect (ASD), and atrial septal aneurysm (ASA). A total of 1081 adult patients were evaluated retrospectively for interatrial shunting; 77 were excluded from the study. CT diagnosis of PFO was defined as (1) a channel-like appearance of the interatrial septum (IAS) and (2) a contrast agent jet flow from the left atrium (LA) to the right atrium (RA). ASD was defined as (1) the IAS resembling a membrane with a hole and (2) a contrast jet flow between the two atria. ASA was identified by detecting a minimum 10-mm protrusion of the LA beyond the IAS into the RA. Among 1004 patients, 86 patients (8.6%) were diagnosed to have PFO. Another 23 patients (2.3%) had a hole in the IAS and were diagnosed as having ASD: 21 with an ostium secundum-type ASD and 2 with the sinus venosus type. ASA accompanied ASD in three patients. Electrocardiography-gated CT using the saline-chaser contrast injection technique that is routinely used for coronary arterial imaging can be used to detect interatrial shunts. The technique can also serve as a method for differentiating PFO, ASD, and ASA.

Cardiopulmonary Exercise Testing and SF-36 in Patients With Atrial Septal Defect Type Secundum

Although exercise capacity is impaired, atrial septal defect (ASD) patients report satisfactory exercise tolerance. This study aimed at (1) evaluating cardiopulmonary exercise testing (CPX) and (2) evaluating the impact of exercise capacity on perceived health status using a self-reported health questionnaire (SF-36) in patients with open and closed ASD. Seventeen patients (mean age 37 ± 17, 9 males) with open ASD and 24 (mean age 37 ± 14, 6 male) with closed ASD were included. All underwent CPX and completed a SF-36 questionnaire. Age- and gender-matched controls were selected for comparison of CPX variables and SF-36 was compared with results from a general population. Patients with open ASD had lower peak oxygen uptake (VO(2)) (27.9 ± 9.7 vs 38.5 ± 9.5 mL · kg(-1) · min(-1). P = .009) and higher VE/VCO(2) slope (31.0 ± 7.7 vs 24.1 ± 4.8; P = .004) than controls. Patients with closed ASD had lower peak VO(2) (26.2 ± 8.4 vs 34.8 ± 9.7 mL · kg(-1) · min(-1). P = .014) and peak heart rate (163 ± 25 vs 178 ± 16 bpm; P = .035) than controls. Perceived health-status was lower in patients with open ASD than the general population. Peak VO(2) correlated significantly with physical functioning, emotional functioning, and bodily pain in open ASD and with physical functioning, bodily pain, role limitation, vitality, and mental health in closed ASD patients. Patients with open and closed ASD had decreased peak VO(2). Patients with open ASD had lower ventilatory efficiency. Closed ASD patients had chronotropic incompetence because of β-blockers. SF-36 was reduced in patients with open ASD but not closed ASD. Reduced exercise capacity affected several domains of perceived health-status in ASD patients.