Systemic Desaturation Research Articles

Asymptomatic ventricular septal rupture following inferior wall myocardial infarction

A 60-year-old male was diagnosed as having inferior wall myocardial infarction 20 days back before admission to our tertiary care institute. He was referred to us for evaluation. Patient was not having any chest pain & was hemodynamically stable on admission to our centre. Patient was found to have ventricular septal defect in basal septum with left to right shunt through the defect. Coronary angiogram revealed single vessel disease (RCA). Although ventricular septal rupture following MI, are mostly symptomatic due to altered hemodynamics, heart failure or systemic desaturation if large; but our patient was asymptomatic surprisingly. As post MI ventricular septal rupture can progress at any point of time, closure is the treatment of choice-either surgical or percutaneous. Our patient underwent CABG with surgical closure as in our centre we usually do surgical closure of post MI VSRs. Patient is doing well on follow up.

(625) - Veno-arterial Shunting Is Tolerated in a Canine Model of Partial Ventricular Assist

The etiology of worsening renal function in chronic heart failure is incompletely understood. Chronic left ventricular failure, the resulting right ventricular fluid overload and elevated central venous pressure (CVP) have been implicated in deteriorating renal function. We hypothesized that shunting of right sided blood into the arterial system by using a peripherally inserted centrifugal pump (active shunting) would decrease right sided pressures, augment afterload and improve renal function. The amount of blood as percent of cardiac output that can be shunted without significant systemic desaturation was investigated in this study.

Persistent Left Superior Vena Cava Draining into Left Atrium as a Cause of Persistent Systemic Desaturation after Surgery

Persistent left superior vena cava (LSVC) is a rare congenital anomaly which usually produces no physiologic derangements if it drains into the right atrium via the coronary sinus, but it may cause significant desaturation when it drains into the left atrium (LA). Failure to diagnose LSVC communicating with the LA preoperatively may lead to serious consequences. We are describing an interesting case of a boy who presented with systemic desaturation due to an undetected LSVC after having undergone corrective surgery for atrioventricular canal defect. We have demonstrated that echocardiography with agitated saline contrast is a simple, accurate, and inexpensive diagnostic modality.

Cerebral Blood Flow and Oxygen Delivery In Response To Hyperoxia In Sickle Cell Anemia

Neurovascular sequalae are a common occurrence in Sickle Cell Anemia (SCA), with 11% of patients suffering cerebral vascular accident (CVA), or overt stroke by their twentieth birthday and 40% of patients developing silent cerebral infarcts (SCI) by age 14. Elevated transcranial Doppler (TCD) velocity of the middle cerebral artery identifies patients at risk for stroke, and this risk can be reduced by chronic transfusion therapy. However, the specificity of TCD is low causing many patients to be transfused unnecessarily. To further refine cerebrovascular risk stratification, we are studying factors responsible for normal and pathophysiologic cerebral blood flow (CBF) in SCD patients. Cerebral blood flow is increased in SCA patients compared to controls, but is believed to be a compensatory mechanism for chronic anemia and systemic desaturation. In order to test this hypothesis, we studied whole CBF and oxygen delivery (DO2) at rest and in response to hyperoxia in subjects with SCA and sickle cell trait (SCT).All patients were recruited at Children's Hospital Los Angeles through an IRB approved protocol. Informed consent was obtained for all patients. Exclusion criteria included pregnancy, previous stroke, acute chest or pain crisis hospitalization within one month. EKG, peripheral arterial oxygen saturation (SaO2), and fractional inspired oxygen (fiO2) were measured continuously throughout the study. Imaging consisted of a survey, reference scan, angiography localization, and nine axial phase contrast (PC) images. PC slices were placed inferior to the Circle of Willis, perpendicular to the carotids and basilar arteries. Participants received room air and 100% O2 through a non rebreathing respiratory circuit at 10 L/m. Room air exposure 20 minutes with six PC images collected throughout. Oxygen was delivered for 5 minutes followed by three more PC images. Blood for hemoglobin (HGB) and hematocrit (HCT) were drawn prior to MRI testing. No adverse events were reported upon follow up.Nine patients with SCA (5 male, 22.5 ± 6.7 yo p<0.05) and 3 with sickle cell trait (2 male, 36.7 ± 8.7 yo p<0.05) were studied. Baseline HGB was 25% lower (9.7 ± 1.3 versus 12.9 ± 0.1) and baseline HCT was 41% lower (28.0 ± 3.6 versus 47.3 ± 0.14 SCT) in SCA patients (p<0.05). Baseline whole brain CBF was elevated in SCA (1398 ± 400 ml/min versus 700 ± 172 ml/min). After correcting for HGB and SaO2, DO2 remained higher in SCA (192 ± 75 ml/min versus 105 ± 1.4 ml/min, p<0.05). During hyperoxia, whole brain CBF decreased by 10-15%, but the change was proportional to increased oxygen carrying capacity such that there was no change in DO2 in either populations.The increase in CBF we observed in SCA patients has been described using other modalities. However, we are the first to demonstrate that the increased flow observed is almost double what can be explained by their anemia and arterial desaturation alone. There are several possibilities for this observation. 1) SCA patients could have increased cerebral metabolic rate. If so, their mixed cerebral venous saturation will be normal and the flow is appropriate; 2) SCA patients have a mismatch between cerebral perfusion and metabolic demand, whether much of the increased flow does not effectively unload oxygen. If so, cerebral venous saturation would be high. We are currently optimizing MRI and NIR's technologies to estimate cerebrovascular metabolic rate, mixed cerebral venous saturation, and local supply-demand balance. [Display omitted] [Display omitted] Disclosures:Coates:Novartis Inc.: Honoraria, Speakers Bureau; Apopharma: Honoraria, Speakers Bureau; Shire: Speakers Bureau. Wood:Shire: Consultancy, Research Funding; Apopharma: Honoraria, Patents & Royalties; Novartis: Honoraria.

Transcatheter occlusion of a persistent left superior vena cava to the left atrium using the transseptal approach

A persistent left superior vena cava (LSVC) is a common venous anomaly, occurring in up to 10% of patients with congenital heart defects. Usually, a LSVC drains into the coronary sinus, then to the right atrium. The LSVC can drain directly to the left atrium, resulting in a right-to-left shunt and systemic desaturation. Historically, surgery has been used to address this lesion. Transcatheter occlusion of the LSVC is an alternative to surgery. We report the novel use of the transseptal approach to access the LSVC, and device occlusion using the Amplatzer Vascular Plug-II.

EComment. The challenges of surgical management of lung pathologies with an anomalous pulmonary vein

I read with great interest the work of Schiavon et al. in which they re-anastomosed the posterior segmental vein of the right upper lobe draining into the lower pulmonary vein during a right lower bilobectomy for lung cancer in other to avoid performing a pneumonectomy, should the vascular element be wrongfully sectioned at the surgery [1]. They went further to state that the risk of serious complications during pulmonary resection in patients with anomalous pulmonary venous connection is high and included bleeding and postoperative oedema in the residual lung amongst other complications. It is noteworthy to state that anomalous pulmonary venous connections can also occur in Sinus venosus atrial septal defects (SV-ASD) with equal challenges during surgeries for lung pathologies in these patients. An anomalous pulmonary vein with SV-ASD is defined as an interatrial defect with the right pulmonary vein draining directly into the right atrium or from the superior vena cava (SVC) or the inferior vena cava into the right atrium [2]. Besides the enumerated complications, other complications that could present a serious challenge to the thoracic surgeon are the complete transposition of the remaining pulmonary veins converting an initial acyanotic congenital cardiac problem to cyanotic one. This can occur when a left pneumonectomy is done in a patient with uncorrected SV-ASD for conditions such as tuberculosis or traumatic shattered lung. Furthermore, pulmonary venous collaterals may subsequently form, leading to systemic desaturation in the years following this surgical option [3,4]. So, for the aforementioned reasons, it is important to be watchful when considering surgical management of pulmonary pathologies in the setting of anomalous pulmonary venous connection (with or without SV-ASD) by re-implantation or re-anastomosing of the anomalous pulmonary vein to the common pulmonary vein instead of merely transecting or ligating the vessel. Conflict of Interest: None declared

EComment. An oval-shaped unidirectional check-valved patch for treating ventricular septal defects

We read with great interest the manuscript of Talwar et al. [1], in which the authors presented their experience of ventricular septal defect (VSD) closure with a unidirectional valved patch in patients with severe pulmonary hypertension. We would like to comment on a few points of the authors' paper. As a referral centre for the region, we receive similar patients, i.e. who are still operable but are high risk candidates for VSD closure due to increased pulmonary vascular resistance, and we use a similar technique. All patients receive detailed echocardiographic examinations and cardiac catheterization studies preoperatively. As soon as the patients are prepared for operation, a transoesophageal echocardiography probe is inserted. The dimensions, shape, and boundaries of the VSD are once again verified. A surgeon prepares the valved patch while the other starts the operation so that the delay during cardiac arrest is minimized. A hole is created on a square Dacron patch with an aortic punch. Another ‘U’ shaped Dacron patch is sewn on this patch 4-5 mm away from the margins of the fenestration. The open end of the ‘U’ is left unsewn. The exact size of the patch is adjusted when the VSD is explored. Most often, although three-dimensional, the VSDs are round or oval. An oval-shaped patch has smooth edges and is also easy for VSD closure. Thus we usually trim the reconstructed patch into a round or oval-shape. The authors used a folded, fenestrated patch [1]. Although it seems easier and faster to construct such a patch, size adjustment, if needed, does not seem easy, since trimming may encounter the suture lines. Moreover, since the fenestration is directed at the left ventricular apex, the sharp margin of the patch may be faced towards the tricuspid or semilunar valves, which may perhaps have valvular consequences. Additionally, when open, the valve of the patch may lead to outflow tract obstruction and leaflet damage in the long term. Another point is regarding the postoperative management of the patients. Authors stated that none of their patients had required nitric oxide during the intensive care unit stay [1]. In our practice we routinely administer inhaled nitric oxide to facilitate postoperative recovery in pulmonary hypertensive patients. In the manuscript, mean systemic saturation was 96.3 ± 4% (87% being the lowest) and 18% of the patients had episodes of systemic desaturation indicating a right-to-left shunt due to increased pulmonary pressure [1]. We believe that nitric oxide would have been very beneficial, especially in those patients. We would like to congratulate the authors for their successful management strategy of such a high risk patient group and for stressing once again the importance of unidirectional valved patches in treating patients with increased pulmonary vascular resistance.

Effect of Endovascular Stenting of Right Ventricle to Pulmonary Artery Conduit Stenosis in Infants With Hypoplastic Left Heart Syndrome on Stage II Outcomes

There is growing awareness that the Norwood procedure with the Sano modification is prone to early right ventricular to pulmonary artery (RV-PA) conduit stenosis resulting in systemic oxygen desaturation, increased interstage morbidity, and death. We report our experience with endovascular stent placement for conduit stenosis and compare the outcomes at stage II surgery between stented and nonstented infants. The medical records of all patients with hypoplastic left heart syndrome who received an RV-PA conduit at Norwood palliation from May 2005 to January 2010 were reviewed. The preoperative anatomy, demographics, operative variables, and outcomes pertaining to the Norwood and subsequent stage II surgeries were obtained and compared between stented and nonstented infants. The pre- and post-stent oxygen saturation, stenosis location, type and number of stents implanted, concomitant interventions, procedure-related complications, and reinterventions were collected. Of the 66 infants who underwent the Norwood procedure with RV-PA conduit modification, 16 (24%) received stents. The anatomy, demographics, and outcome variables after the Norwood procedure were similar between the stented and nonstented infants. The age at catheterization was 93 ± 48 days, and the weight was 4.9 ± 1.2 kg. The oxygen saturation increased from 66 ± 9% before intervention to 82 ± 6% immediately after stenting (p <0.0001). No interstage surgical shunt revisions were performed in either group. Age, weight, pre-stage II echocardiographic variables, oxygen saturation, and operative and outcome variables, including mortality, were similar between the 2 groups. In conclusion, endovascular stent placement for RV-PA conduit stenosis after the Norwood procedure leads to improved systemic oxygen levels and prevents early performance of stage II surgery without compromising stage II outcomes.

An Unusual Presentation of Necrotizing Enterocolitis on an Echocardiogram

This report describes the spontaneous intracardiac air contrast found on the echocardiogram of a 5 day-old term neonate with Down syndrome and a complete atrioventricular septal defect who had experienced sudden-onset tachypnea and systemic desaturation. The stream of air contrast was tracked coming from the hepatic veins, and a diagnosis of necrotizing enterocolitis was suspected. An abdominal radiograph and ultrasound confirmed the diagnosis.

Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients

IntroductionDaily interruption of sedation (IS) has been implemented in 30 to 40% of intensive care units worldwide and may improve outcome in medical intensive care patients. Little is known about the benefit of IS in acutely brain-injured patients.MethodsThis prospective observational study was performed in a neuroscience intensive care unit in a tertiary-care academic center. Twenty consecutive severely brain-injured patients with multimodal neuromonitoring were analyzed for levels of brain lactate, pyruvate and glucose, intracranial pressure (ICP), cerebral perfusion pressure (CPP) and brain tissue oxygen tension (PbtO2) during IS trials.ResultsOf the 82 trial days, 54 IS-trials were performed as interruption of sedation and analgesics were not considered safe on 28 days (34%). An increase in the FOUR Score (Full Outline of UnResponsiveness score) was observed in 50% of IS-trials by a median of three (two to four) points. Detection of a new neurologic deficit occurred in one trial (2%), and in one-third of IS-trials the trial had to be stopped due to an ICP-crisis (> 20 mmHg), agitation or systemic desaturation. In IS-trials that had to be aborted, a significant increase in ICP and decrease in PbtO2 (P < 0.05), including 67% with critical values of PbtO2 < 20 mmHg, a tendency to brain metabolic distress (P < 0.07) was observed.ConclusionsInterruption of sedation revealed new relevant clinical information in only one trial and a large number of trials could not be performed or had to be stopped due to safety issues. Weighing pros and cons of IS-trials in patients with acute brain injury seems important as related side effects may overcome the clinical benefit.

Arterial Switch Operation With Unidirectional Valved Patch Closure of Ventricular Septal Defect in Patients With Transposition of Great Arteries and Severe Pulmonary Hypertension

For patients with dextro-transposition of great arteries (d-TGAs), ventricular septal defect (VSD), and severe pulmonary arterial hypertension (PAH), the common surgical options are palliative arterial switch operation (ASO) or palliative atrial switch operation leaving the VSD open. We evaluated the role of ASO with VSD closure using a fenestrated unidirectional valved patch (UVP). Between July 2009 and February 2011, six patients with TGAs, VSD, and severe PAH (mean age 39.8 ± 47.4 months, median 21, range 8-132 months), weighing 10.7 ± 9.2 kg (median 8.6, range 4.3-29 kg), underwent ASO with VSD closure using our simple technique of UVP. Mean pulmonary artery systolic pressure before the operation was 106 ± 12.7 mm Hg (median 107.5, range 95-126 mm Hg) and pulmonary vascular resistance was 9.5 ± 4.22 units (median 9.5, range 6.6-17.1 Wood units). There were no deaths. All patients had a postoperative systemic arterial saturation of more than 95%, although there were frequent episodes of systemic desaturation due to right-to-left shunt across the valved VSD patch (as seen on transesophageal and transthoracic echocardiograms). Mean follow-up was 10 ± 7.6 months (median 7.5, range 1-22 months). At most recent follow-up, all patients had systemic arterial saturation of more than 95% and no right-to-left shunt through the VSD patch. In one patient, the follow-up cardiac catheterization showed a fall in pulmonary artery systolic pressure to 49 mm Hg. Arterial switch operation with UVP VSD closure is feasible with acceptable early results. It avoids complications of palliative atrial switch (arrhythmia and baffle obstruction) and partially or completely open VSD.

Oclusão percutânea da fenestração no pós-operatório tardio da cirurgia de Fontan

INTRODUCAO: A fenestracao na cirurgia de Fontan (CF) melhora o resultado imediato no pos-operatorio, por descompressao do circuito venoso-pulmonar e aumento do debito cardiaco, a despeito da dessaturacao arterial de oxigenio e do risco de embolia paradoxal. Geralmente as fenestracoes sao ocluidas percutaneamente no seguimento a medio prazo. Este estudo teve como objetivo relatar a experiencia institucional na oclusao percutânea da fenestracao. METODOS: Estudo descritivo longitudinal, observacional, retrospectivo, de uma coorte nao-consecutiva de pacientes. O procedimento foi realizado sob anestesia geral com a ajuda de ecocardiograma transesofagico. O teste de oclusao da fenestracao com cateter Bermann angiografico foi realizado antes da intervencao. Diferentes tecnicas e dispositivos foram empregados para a oclusao da fenestracao. RESULTADOS: Entre abril de 2004 e dezembro de 2010, 12 pacientes (media de idade, 103,1 ± 88,6 meses; peso, 29,9 ± 12,7 kg) submetidos a CF (10 tubos extracardiacos, 2 tuneis intra-atriais) foram tratados 44,1 ± 26,7 meses apos a CF. Um paciente nao tolerou o teste de oclusao com o balao, sendo contraindicado o procedimento. As proteses utilizadas foram: HelexTM (4 pacientes), AmplatzerTM (2 pacientes), Cardia AtriaseptTM (2 pacientes), FigullaTM (1 paciente), CeraTM (1 paciente), e 1 stent coberto Cheatham-PlatinumTM. Apos a oclusao da fenestracao, a saturacao de oxigenio aumentou significativamente (82,1 ± 6,5% para 95,2 ± 3,2%), sem aumento significativo da pressao venosa central (12,4 ± 2,6 mmHg para 14,5 ± 2,3 mmHg) nem queda do debito cardiaco. Apos o procedimento foi observado shunt residual imediato em 5 pacientes, que desapareceu antes da alta. CONCLUSOES: A oclusao percutânea das fenestracoes apos CF pode ser realizada com varias opcoes de proteses e tecnicas, sendo um procedimento seguro e efetivo e que resulta em normalizacao dos niveis de saturacao.

Hybrid Therapy for Pulmonary Atresia With Intact Ventricular Septum

In patients with pulmonary atresia with intact ventricular septum without right ventricular-dependent coronary circulation, catheter techniques, including the use of a stiff wire, lasers, and radiofrequency, have been most widely used for initial therapy; however, percutaneous perforation and balloon valvuloplasty have been associated with higher rates of procedural failure and serious complications. We report our experience with a hybrid approach involving the combination of surgery and interventional catheterization techniques for right ventricular decompression. Between March 2005 and April 2010, we performed a hybrid procedure in 30 newborns and infants (age, 1 day to 2 years; median age, 3 months) with favorable anatomy. The heart was exposed by performing midline sternotomy. A purse-string suture was placed in the right ventricular outflow tract 2 cm away from the pulmonary trunk. Then, a 16-gauge intravenous catheter was placed periventricular with the guidance of echocardiography to perforate the atretic pulmonary ventricle. Subsequently, a guide wire was inserted into the sheath and used to guide a balloon across the pulmonary ventricle. Sequential dilations were performed under the guidance of epicardial echocardiography until full opening of the pulmonary ventricle was obtained. In newborns, ductal ligation was performed, followed by modified Blalock-Taussig (mBT) shunt placement. Patients aged greater than 1 month were treated mostly with ductal ligation, and an mBT shunt was inserted if severe systemic oxygen desaturation occurred after ductal ligation; bidirectional Glenn shunt placement was performed if a patient showed severe hypoplasia. The hybrid procedure was successfully performed in all patients. Patent ductus arteriosus ligation was simultaneously performed in 27 cases. Six newborns were treated with mBT shunt placement after pulmonary valvuloplasty and patent ductus arteriosus ligation, and 2 patients aged greater than 1 month were treated with mBT shunt placement alone. Another 2 patients were selected for univentricular palliation with bidirectional Glenn procedure because of a diminutive monopartite right ventricle. No pericardial effusion or cardiac tamponade was observed. One patient in whom ductal ligation could not be performed was treated with mBT shunt placement because of hypoxemia 3 days after the hybrid procedure; the other patients were discharged without any further surgical intervention. During the follow-up period of 1.5 months to 5 years, 5 patients died; 25 (83.3%) survived and all were in New York Heart Association functional class 1. Saturation of peripheral oxygen in the survivors increased from 73.1±8.5% to 94±3.5% (p<001). Two-ventricle circulation was achieved in 24 patients, whereas 1 patient had a single-ventricle pathway. In conclusion, periventricular balloon pulmonary valvuloplasty using a hybrid approach was safe and feasible for patients with pulmonary atresia with intact ventricular septum.

Fenestrated ASD Closure in a Child with Idiopathic Pulmonary Hypertension and Exercise Desaturation

Pulmonary arterial hypertension is a progressive disorder that may result in right heart failure and death. Atrial level shunts in the presence of pulmonary hypertension may allow right-to-left mixing with maintenance of cardiac output and improved survival. However, excessive mixing at the atrial level can cause undue systemic desaturation, increased fatigue and decreased exercise tolerance even in the presence of adequate cardiac output. A 5½-year-old was diagnosed with pulmonary hypertension, a large atrial septal defect and right-to-left shunting. Medical therapy over an 18-month period was successful in decreasing pulmonary artery pressure and pulmonary vascular resistance. However, because of the size and position of the intracardiac defect, symptoms of fatigue, and severe systemic desaturation with only minor activities persisted. Fenestrated surgical closure of the defect was thus undertaken to decrease the degree of atrial mixing, but still allow atrial decompression if necessary. Subsequent hemodynamic evaluation has demonstrated continued improvement, and all previous symptoms have resolved. Repeated echocardiography has confirmed patency of the atrial fenestration with left-to-right atrial flow.

Rescue treatment by percutaneous closure of interatrial septal defect or PFO in infants with Berlin heart

During the past two decades, important progress has been achieved in the treatment of end-stage congestive heart failure in newborns and infants. The use of ventricular assist devices (VAD) in these patients is now available as a bridge to heart transplantation. The use of a VAD may reveal the presence of a silent interatrial septal defect or a patent foramen ovale (PFO), inducing a right to left shunt resulting in systemic desaturation and hemodynamic instability. We present two cases of low weight infants on circulatory support with VADs and right to left shunt through interatrial septum that were successfully treated by percutaneous intervention with an occlusion device.

Critical Pulmonary Stenosis

A 20-day-old girl was diagnosed with critical pulmonary valvular stenosis with patent ductus arteriosus (PDA). She underwent surgical pulmonary valvotomy and infundibular resection. A trial snaring of the PDA resulted in significant systemic desaturation, and the PDA was left undivided. A continuous infusion of prostaglandin was used to keep the PDA open for the next 8 days. The PDA acted as a "natural systemic-to-pulmonary shunt" to provide pulmonary blood flow until right ventricular compliance and function improved. The various causes of persistent desaturation following pulmonary valvotomy are discussed.

Venovenous malformation: a common finding after Kawashima operation

It has been reported that systemic venovenous malformation (VVM) can develop in patients with interrupted inferior vena cava (IVC) and univentricular type of congenital heart disease who undergo superior vena cava to pulmonary artery connection (Kawashima operation). These malformations can lead to profound systemic desaturation postoperatively. However, there have been few reports that characterise the prevalence, anatomic details and clinical correlations of these systemic VVM arising after Kawashima operation. In this study, we describe our experience with VVM after Kawashima operation, and discuss issues regarding their evaluation and postoperative management. Eight patients with median age 19 months (range: 5-238) who underwent Kawashima operation were subjected to postoperative angiography, prospectively. Sites of VVM origin and entry, as well as their course, were documented. The presence of pulmonary arteriovenous malformations (AVMs) was also documented. At median follow-up of 31 months (range: 16-72 months), a total of 14 VVM were found in different supra- and infra-diaphragmatic sites in six patients (75%); four of them had concomitant pulmonary AVM while the remaining two patients had only pulmonary AVM. Our findings suggest that systemic VVM can occur frequently after Kawashima operation and can produce significant desaturation postoperatively, and hence we support hepatic incorporation. Performing detailed angiographic studies of the supra- and infra-diaphragmatic systemic veins in routine assessment of patients before Kawashima operation is, probably, warranted.

Repair of Ventricular Aneurysm After Stage I Modified Sano-Norwood Procedure

Repair of Ventricular Aneurysm After Stage I Modified Sano-Norwood Procedure

SHA 27. Vacuum-assisted closure as a treatment modality for sternal wound complications after coronary artery bypass surgery

Objectives/Background: It has been reported that systemic venovenous malformation (VVM) can develop in patients with interrupted inferior vena cava (IVC) and univentricular type of congenital heart disease who undergo superior vena cava to pulmonary artery connection (Kawashima operation). These malformations can lead to profound systemic desaturation postoperatively. However, there have been few reports that characterize the prevalence, anatomic details and clinical correlations of these systemic VVM arising after Kawashima operation. In this study, we describe our experience with VVM after Kawashima operation and discuss issues regarding their preoperative evaluation and postoperative management. Methods: Eight patients (median age 19 months) who underwent Kawashima operation were subjected to postoperative angiography, prospectively. Sites of VVM origin and entry as well as their course were documented. The presence of arteriovenous malformations (AVM) was also documented. Results: During follow-up (16–72 months), a total of 14 VVM were found in different supra and infradiaphragmatic sites in six patients (75%); two of them had concomitant AVM. The remaining two patients had only AVM. Conclusion: Our findings suggest that Systemic VVM can occur frequently after Kawashima operation and can produce significant desaturation postoperatively. Performing detailed angiographic studies of the supra and infradiaphragmatic systemic veins in routine assessment of patients with interrupted IVC before Kawashima operation is probably warranted. Tracks: Adult Cardiology.

An Update on Patent Foramen Ovale Closure

The patent foramen ovale is an intra-cardiac right-to-left shunt that is thought to have an important role in a number of disease processes, including stroke, peripheral embolism, systemic oxygen desaturation (i.e. hypoxaemia) and migraine. A wide variety of percutaneous devices to close congenital heart defects are currently commercially available or in clinical trials. The trend in percutaneous closure of patent foramen ovales is shifting towards defect-tailored devices and new strategies that minimise the amount of foreign material left in the atria. This article focuses on the latest technologies available for closure of patent foramen ovales and on experimental devices currently under investigation.